[Congressional Bills 103th Congress]
[From the U.S. Government Publishing Office]
[H.R. 2138 Introduced in House (IH)]

103d CONGRESS
  1st Session
                                H. R. 2138

  To provide for budget reconciliation with respect to part B of the 
   medicare program, the medicaid program, and other health programs 
    within the jurisdiction of the Committee on Energy and Commerce.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                              May 17, 1993

Mr. Waxman introduced the following bill; which was referred jointly to 
        the Committees on Energy and Commerce and Ways and Means

_______________________________________________________________________

                                 A BILL


 
  To provide for budget reconciliation with respect to part B of the 
   medicare program, the medicaid program, and other health programs 
    within the jurisdiction of the Committee on Energy and Commerce.

    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

                          TITLE I--SHORT TITLE

SEC. 101. SHORT TITLE.

    This Act may be cited as the ``Medicare and Medicaid Budget 
Reconciliation Act of 1993''.

                      TITLE II--TABLE OF CONTENTS

SEC. 201. TABLE OF CONTENTS.

    The table of contents of this Act is as follows:

                          TITLE I--SHORT TITLE

Sec. 101. Short title.
                      TITLE II--TABLE OF CONTENTS

Sec. 201. Table of contents.
   TITLE III--REFERENCES TO OMNIBUS BUDGET RECONCILIATION ACT OF 1993

Sec. 302. References to Omnibus Budget Reconciliation Act of 1993.
                   TITLE IV--OTHER REFERENCES IN ACT

Sec. 401. Other references in act.
TITLE V--RECONCILIATION PROVISIONS RELATING TO MEDICARE, MEDICAID, AND 
                         OTHER HEALTH PROGRAMS

                Chasubchapter a--physicians' servicest B
Sec. 5001. Reduction in default update for conversion factor for 1994.
Sec. 5002. Reduction in performance standard rate of increase and 
                            increase in maximum reduction permitted in 
                            default update.
Sec. 5003. Classification of primary care services as a separate 
                            category of services.
Sec. 5004. Phased-in reduction in practice expense relative value units 
                            for certain services.
Sec. 5005. Limitation on payment for the anesthesia care team.
Sec. 5006. Basing payments for anesthesia services on actual time.
Sec. 5007. Separate payment for interpretation of electrocardiograms.
Sec. 5008. Payments for new physicians and practitioners.
Sec. 5009. Geographic adjustment factors for medicare physicians' 
                            services.
Sec. 5010. Extra-billing limits.
Sec. 5011. Relative values for pediatric services.
Sec. 5012. Antigens under physician fee schedule.
Sec. 5013. Administration of claims relating to physicians' services.
Sesubchapter b--outpatient hospital services and ambulatory surgical 
                                services
Sec. 5021. Extension of 10 percent reduction in payments for capital-
                            related costs of outpatient hospital 
                            services.
Sec. 5022. Extension of current reduction in payments for other costs 
                            of outpatient hospital services.
Sec. 5023. 1-year freeze in ambulatory surgery rates.
Sec. 5024. Eye or eye and ear hospitals. 
Sec. 5025. Extension of cap on payments for intraocular lenses.
Sec. 5026. Miscesubchapter c--durable medical equipment
Sec. 5031. Revisions to payment rules for durable medical equipment.
Sec. 5032. Payment for parenteral and enteral nutrients, supplies, and 
                            equipment during 1994.
Sec. 5033. Treatment of nebulizers and aspirators.
Sec. 5034. Certification of suppliers.
Sec. 5035. Prohibition against carrier forum shopping.
Sec. 5036. Restrictions on certain marketing and sales activities.
Sec. 5037. Kickback clarification.
Sec. 5038. Beneficiary liability for noncovered services.
Sec. 5039. Adjustments for inherent reasonableness.
Sec. 5040. Payment for surgical dressings.
Sec. 5041. Payments for tens devices.
Sec. 5042. Miscellaneosubchapter d--part b premium.
Sec. 5051. Part B presubchapter e--other provisions
Sec. 5061. Payments for clinical diagnostic laboratory tests.
Sec. 5062. Treatment of inpatients and provision of diagnostic and 
                            therapeutic X-ray services by rural health 
                            clinics and Federally qualified health 
                            centers.
Sec. 5063. Application of mammography certification requirements.
Sec. 5064. Extension of Alzheimer's disease demonstration.
Sec. 5065. Oral cancer drugs.
Sec. 5066. Extension of municipal health service demonstration 
                            projects.
Sec. 5067. Treatment of certain Indian health programs and facilities 
                            as Federally-qualified health centers.
Sec. 5068. Interest payments.
Sec. 5069. Clarification of coverage of certified nurse-midwife 
                            services performed outside the maternity 
                            cycle.
Sec. 5069A. Increase in, and study of, annual cap on amount of medicare 
                            payment for outpatient physical therapy and 
                            occupational therapy services.
Sec. 5070. Miscellaneous and technical corrections.
            Chapter 2--Provisions Relating to Parts A and B

Sec. 5071. Elimination of add-on for overhead of hospital-based home 
                            health agencies.
Sec. 5072. Study and report on medicare GME payments.
Sec. 5073. Medicare as secondary payer.
Sec. 5074. Extension of self-referral ban to additional specified 
                            services.
Sec. 5075. Reduction in payment for erythropoietin.
Sec. 5076. Medicare hospital agreements with organ procurement 
                            organizations.
Sec. 5077. Extension of waiver for Watts Health Foundation.
Sec. 5078. Improved outreach for qualified medicare beneficiaries.
Sec. 5079. Social health maintenance organizations.
Sec. 5080. Peer review organizations.
Sec. 5081. Hospice information to home health beneficiaries.
Sec. 5082. Health maintenance organizations.
Sec. 5083. Miscellaneous and technical corrections.
   Chapter 3--Provisions Relating to Medicare Supplemental Insurance 
                                Policies

Sec. 5091. Standards for medicare supplemental insurance policies.
     Subtitle B--Medicaid Program and Other Health Care Provisions

                subchapter a--program savings provisions
                       Part I--Repeal of Mandate

Sec. 5101. Personal care services furnished outside the home as 
                            optional benefit.
                 Part II--Outpatient Prescription Drugs

Sec. 5106. Permitting prescription drug formularies under State plans.
Sec. 5107. Elimination of special exemption from prior authorization 
                            for new drugs.
Sec. 5108. Technical corrections relating to section 4401 of OBRA-1990.
  Part III--Restrictions on Divestiture of Assets and Estate Recovery

Sec. 5111. Transfer of assets.
Sec. 5112. Medicaid estate recoveries.
Sec. 5113. Closing loophole permitting wealthy individuals to qualify 
                            for medicaid.
 Part IV--Improvement in Identification and Collection of Third Party 
                                Payments

Sec. 5116. Liability of third parties to pay for care and services.
Sec. 5117. Health Coverage Clearinghouse.
               ``TITLE XXI--HEALTH COVERAGE CLEARINGHOUSE

        ``Sec. 2101. Establishment of clearinghouse.
        ``Sec. 2102. Provision of information.
        ``Sec. 2103. Requirement that employers furnish information.
        ``Sec. 2104. Data bank.

Sec. 5118. Medical child support.
  Part V--Assuring Proper Payments to Disproportionate Share Hospitals

Sec. 5121. Assuring proper payments to disproportionate share 
                 subchapter b--miscellaneous provisions
                Part I--Anti-fraud and Abuse Provisions

Sec. 5131. Application of medicare rules limiting certain physician 
                            referrals.
Sec. 5132. Intermediate sanctions for kickback violations.
Sec. 5133. Requiring maintenance of effort for State medicaid fraud 
                            control units.
                    Part II--Managed Care Provisions

Sec. 5135. Medicaid managed care anti-fraud provisions.
Sec. 5136. Clarification of treatment of HMO enrollees in computing the 
                            medicaid inpatient utilization rate in 
                            qualifying hospitals as disproportionate 
                            share hospitals.
Sec. 5137. Extension of period of applicability of enrollment mix 
                            requirement to certain health maintenance 
                            organizations providing services under 
                            Dayton Area Health Plan.
Sec. 5138. Extension of medicaid waiver for Tennessee Primary Care 
                            Network.
Sec. 5139. Waiver of application of medicaid enrollment mix requirement 
                            to District of Columbia Chartered Health 
                            Plan, Inc.
Sec. 5140. Extension of Minnesota Prepaid Medicaid Demonstration 
                            Project.
          Part III--Emergency Services to Undocumented Aliens

Sec. 5141. Increase in Federal financial participation for emergency 
                            medical assistance to undocumented aliens.
Sec. 5142. Limiting Federal medicaid matching payment to bona fide 
                            emergency services for undocumented aliens.
                   Part IV--Miscellaneous Provisions

Sec. 5144. Increase in limit on Federal medicaid matching payments to 
                            Puerto Rico and other territories.
Sec. 5145. Criteria for making determinations of denial of Federal 
                            medicaid matching payments to States.
Sec. 5146. Renewal of unfunded demonstration project for low-income 
                            pregnant women and children.
Sec. 5147. Optional medicaid coverage of TB-related services for 
                            certain TB-infected individuals.
Sec. 5148. Application of mammography certification requirements under 
                            the medicaid program.
Sec. 5149. Removal of sunset on extension of eligibility for working 
                            families.
Sec. 5150. Extension of moratorium on treatment of certain facilities 
                            as institutions for mental diseases.
Sec. 5150A. Treatment of certain clinics as federally-qualified health 
                            centers.
subchapter c--miscellaneous and technical corrections relating to obra-
                                  1990
Sec. 5151. Effective date.
Sec. 5152. Corrections relating to section 4402 (enrollment under group 
                            health plans).
Sec. 5153. Corrections relating to section 4501 (low-income medicare 
                            beneficiaries).
Sec. 5154. Corrections relating to section 4601 (child health).
Sec. 5155. Corrections relating to section 4602 (outreach locations).
Sec. 5156. Corrections relating to section 4604 (payment for hospital 
                            services for children under 6 years of 
                            age).
Sec. 5157. Corrections relating to section 4703 (payment adjustments 
                            for disproportionate share hospitals).
Sec. 5158. Corrections relating to section 4704 (Federally-qualified 
                            health centers).
Sec. 5159. Corrections relating to section 4708 (substitute 
                            physicians).
Sec. 5160. Corrections relating to section 4711 (home and community 
                            care for frail elderly).
Sec. 5161. Corrections relating to section 4712 (community supported 
                            living arrangements services).
Sec. 5162. Correction relating to section 4713 (COBRA continuation 
                            coverage).
Sec. 5163. Correction relating to section 4716 (medicaid transition for 
                            family assistance).
Sec. 5164. Corrections relating to section 4723 (medicaid spenddown 
                            option).
Sec. 5165. Corrections relating to section 4724 (optional State 
                            disability determinations).
Sec. 5166. Correction relating to section 4732 (special rules for 
                            health maintenance organizations).
Sec. 5167. Corrections relating to section 4741 (home and community-
                            based waivers).
Sec. 5168. Corrections relating to section 4744 (frail elderly 
                            waivers).
Sec. 5169. Corrections relating to section 4747 (coverage of HIV-
                            positive individuals).
Sec. 5170. Correction relating to section 4751 (advance directives).
Sec. 5171. Corrections relating to section 4752 (physicians' services).
Sec. 5172. Corrections relating to section 4801 (nursing home reform).
Sec. 5173. Other technical corrections.
Sec. 5174. Corrections to designations of new provisions.
         Chapter 2--Universal Access to Childhood Immunizations

Sec. 5181. Establishment of entitlement and monitoring programs with 
                            respect to childhood immunizations.
   ``Subtitle 3--Entitlement and Monitoring Programs With Respect to 
                        Childhood Immunizations

                     ``Part A--Entitlement Program

        ``Sec. 2151. Delivery to States of sufficient quantities of 
                            pediatric vaccines.
        ``Sec. 2152. Entitlements.
        ``Sec. 2153. Voluntary participation of health care providers.
        ``Sec. 2154. Intrastate distribution of pediatric vaccines.
        ``Sec. 2155. General provisions.
        ``Sec. 2156. State option regarding immunization of additional 
                            categories of children.
        ``Sec. 2157. State application for vaccines.
        ``Sec. 2158. Contracts with manufacturers of pediatric 
                            vaccines.
        ``Sec. 2159. Certain administrative variations.
        ``Sec. 2160. List of pediatric vaccines; schedule for 
                            administration.
        ``Sec. 2161. Childhood Immunization Trust Fund.
        ``Sec. 2162. Definitions.
        ``Sec. 2163. Termination of program.
    ``Part B--National System for Monitoring Immunization Status of 
                                Children

        ``Sec. 2171. Formula grants for State registries with respect 
                            to monitoring.
        ``Sec. 2172. Registry data.
        ``Sec. 2173. General provisions.
        ``Sec. 2174. Application for grant.
        ``Sec. 2175. Determination of amount of allotment.
        ``Sec. 2176. Definitions.
        ``Sec. 2177. Authorization of appropriations.
 ``Part C--Funding for Other Purposes Regarding Childhood Immunizations

        ``Sec. 2181. Grants regarding Year 2000 health objectives.

Sec. 5182. National Vaccine Injury Compensation Program amendments.
Sec. 5183. Medicaid immunization provisions.
Sec. 5184. Availability of medicaid payments for childhood vaccine 
                            replacement programs.
Sec. 5185. Healthy start for infants.
Sec. 5186. Increase in authorization of appropriations for the Maternal 
                            and Child Health Services Block Grant 
                            Program.
Sec. 5187. Miscellaneous technical corrections to Public Health Service 
                            Act provisions.

   TITLE III--REFERENCES TO OMNIBUS BUDGET RECONCILIATION ACT OF 1993

SEC. 302. REFERENCES TO OMNIBUS BUDGET RECONCILIATION ACT OF 1993.

    Any reference in this Act (or in any amendment made by this Act) to 
the Omnibus Budget Reconciliation Act of 1993 shall be deemed to be a 
reference to this Act.

                   TITLE IV--OTHER REFERENCES IN ACT

SEC. 401. OTHER REFERENCES IN ACT.

    (a) Amendments to Social Security Act.--Except as otherwise 
specifically provided, whenever in this Act an amendment is expressed 
in terms of an amendment to or repeal of a section or other provision, 
the reference shall be considered to be made to that section or other 
provision of the Social Security Act.
    (b) References to OBRA.--In this Act, the terms ``OBRA-1986'', 
``OBRA-1987'', ``OBRA-1989'', and ``OBRA-1990'' refer to the Omnibus 
Budget Reconciliation Act of 1986 (Public Law 99-509), the Omnibus 
Budget Reconciliation Act of 1987 (Public Law 100-203), the Omnibus 
Budget Reconciliation Act of 1989 (Public Law 101-239), and the Omnibus 
Budget Reconciliation Act of 1990 (Public Law 101-508), respectively.

TITLE V--RECONCILIATION PROVISIONS RELATING TO MEDICARE, MEDICAID, AND 
                         OTHER HEALTH PROGRAMS

                      Subtitle A--Medicare Program

                CHAPTER 1--PROVISIONS RELATING TO PART B

                   Subchapter A--Physicians' Services

SEC. 5001. REDUCTION IN DEFAULT UPDATE FOR CONVERSION FACTOR FOR 1994.

    Section 1848(d)(3)(A) (42 U.S.C. 1395w-4(d)(3)(A)) is amended--
            (1) in clause (i), by striking ``clause (iii)'' and 
        inserting ``clauses (iii) and (iv)'', and
            (2) by adding at the end the following new clause:
                            ``(iv) Adjustment in percentage increase 
                        for 1994.--In applying clause (i) for services 
                        (other than primary care services) furnished in 
                        1994, the percentage increase in the 
                        appropriate update index shall be reduced by--
                                    ``(I) 3 percentage points for 
                                surgical services (as defined for 
                                purposes of subsection (j)(1)), and
                                    ``(II) 2 percentage points for 
                                other services.''.

SEC. 5002. REDUCTION IN PERFORMANCE STANDARD RATE OF INCREASE AND 
              INCREASE IN MAXIMUM REDUCTION PERMITTED IN DEFAULT 
              UPDATE.

    (a) Reduction in Performance Standard Factor.--Section 
1848(f)(2)(B) (42 U.S.C. 1395w-4(f)(2)(B)) is amended--
            (1) by striking ``and'' at the end of clause (ii), and
            (2) by striking clause (iii) and inserting the following:
                            ``(iii) for 1993 is 2 percentage points,
                            ``(iv) for 1994 is 3\1/2\ percentage 
                        points, and
                            ``(v) for each succeeding year is 4 
                        percentage points.''.
    (b) Increase in Maximum Reduction Permitted in Default Update.--
Section 1848(d)(3)(B)(ii) (42 U.S.C. 1395w-4(d)(3)(B)(ii)) is amended--
            (1) in subclause (II), by striking ``or 1995'', and
            (2) in subclause (III), by striking ``3'' and inserting 
        ``5''.

SEC. 5003. CLASSIFICATION OF PRIMARY CARE SERVICES AS A SEPARATE 
              CATEGORY OF SERVICES.

    (a) In General.--Section 1848(j)(1) (42 U.S.C. 1395w-4(j)(1)) is 
amended by inserting ``, primary care services (as defined in section 
1842(i)(4)),'' after ``Secretary)''.
    (b) Effective Date.--The amendment made by subsection (a) shall 
apply--
            (1) to volume performance standard rates of increase 
        established under section 1848(f) of the Social Security Act 
        for fiscal years beginning with fiscal year 1994, and
            (2) to updates in the conversion factors for physicians' 
        services established under section 1848(d) of such Act for 
        physicians' services to be furnished in calendar years 
        beginning with 1996.

SEC. 5004. PHASED-IN REDUCTION IN PRACTICE EXPENSE RELATIVE VALUE UNITS 
              FOR CERTAIN SERVICES.

    (a) In General.--Section 1848(c)(2) (42 U.S.C. 1395w-4(c)(2)) is 
amended by adding at the end the following new subparagraph:
                    ``(E) Reduction in practice expense relative value 
                units for certain services.--
                            ``(i) In general.--Subject to clause (ii), 
                        the Secretary shall reduce the practice expense 
                        relative value units applied to services 
                        described in clause (iii) furnished in--
                                    ``(I) 1994, by 25 percent of the 
                                number by which the number of practice 
                                expense relative value units 
                                (determined for 1994 without regard to 
                                this subparagraph) exceeds the number 
                                of work relative value units determined 
                                for 1994,
                                    ``(II) 1995, by an additional 25 
                                percent of such excess, and
                                    ``(III) 1996 and subsequent years, 
                                by an additional 25 percent of such 
                                excess.
                            ``(ii) Floor on reductions.--The practice 
                        expense relative value units for a physicians' 
                        service shall not be reduced under this 
                        subparagraph to a number less than 110 percent 
                        of the number of work relative value units.
                            ``(iii) Services covered.--For purposes of 
                        clause (i), the services described in this 
                        clause are physicians' services that are not 
                        described in clause (iv) and for which--
                                    ``(I) there are work relative value 
                                units, and
                                    ``(II) the number of practice 
                                expense relative value units 
                                (determined for 1994) exceeds 110 
                                percent of the number of work relative 
                                value units (determined for such year).
                            ``(iv) Excluded services.--For purposes of 
                        clause (iii), the services described in this 
                        clause are--
                                    ``(I) anesthesia services,
                                    ``(II) radiology services, and
                                    ``(III) services which the 
                                Secretary determines at least 75 
                                percent of which are provided under 
                                this title in an office setting.''.
    (b) Development of Resource-Based Methodology for Practice 
Expenses.--
            (1) The Secretary of Health and Human Services shall 
        develop a methodology for implementing in 1997 a resource-based 
        system for determining practice expense relative value units 
        for each physician's service.
            (2) The Secretary shall transmit a report by June 30, 1996, 
        on the methodology developed under paragraph (1) to the 
        Committees on Ways and Means and Energy and Commerce of the 
        House of Representatives and the Committee on Finance of the 
        Senate. The report shall include a presentation of data 
        utilized in developing the methodology and an explanation of 
        the methodology.

SEC. 5005. LIMITATION ON PAYMENT FOR THE ANESTHESIA CARE TEAM.

    (a) Limit on Payment to a Physician for Medical Direction.--
            (1) In general.--Section 1848(a) (42 U.S.C. 1395w-4(a)) is 
        amended by adding at the end the following new paragraph:
            ``(5) Special rule for medical direction.--
                    ``(A) In general.--With respect to physicians' 
                services furnished on or after January 1, 1994, and 
                consisting of medical direction of two, three, or four 
                concurrent anesthesia cases, the fee schedule amount to 
                be applied shall not exceed one-half of the amount 
                described in subparagraph (B).
                    ``(B) Amount.--The amount described in this 
                subparagraph, for a physician's medical direction of 
                the performance of anesthesia services, is the 
                following percentage of the fee schedule amount 
                otherwise applicable under this section if the 
                anesthesia services were personally performed by the 
                physician alone:
                            ``(i) For services furnished during 1994, 
                        120 percent.
                            ``(ii) For services furnished during 1995, 
                        115 percent.
                            ``(iii) For services furnished during 1996, 
                        110 percent.
                            ``(iv) For services furnished during 1997, 
                        105 percent.
                            ``(v) For services furnished after 1997, 
                        100 percent.''.
            (2) Elimination of reduction for medical direction of 
        multiple nurse anesthetists.--Section 1842(b) (42 U.S.C. 
        1395u(b)) is amended by striking paragraph (13).
    (b) Payment to a Certified Registered Nurse Anesthetist for 
Medically Directed Services.--Subparagraph (B) of section 1833(l)(4) 
(42 U.S.C. 1395l(l)(4)) is amended--
            (1) in clause (i), by inserting ``and before January 1, 
        1994,'' after ``1991,'';
            (2) in clause (ii)--
                    (A) by adding ``and'' at the end of subclause (II),
                    (B) by striking the comma at the end of subclause 
                (III) and inserting a period, and
                    (C) by striking subclauses (IV) through (VII); and
            (3) by adding at the end the following new clause:
    ``(iii) In the case of services of a certified registered nurse 
anesthetist who is medically directed by a physician and that are 
furnished on or after January 1, 1994, the fee schedule amount shall be 
one-half of the amount described in section 1848(a)(5)(B) with respect 
to the physician.''.

SEC. 5006. BASING PAYMENTS FOR ANESTHESIA SERVICES ON ACTUAL TIME.

    (a) Physicians' Services.--Section 1848(b)(2)(B) (42 U.S.C. 1395w-
4(b)(2)(B)) is amended by adding at the end the following: ``For 
anesthesia services furnished on or after January 1, 1994, the 
Secretary may not modify the methodology in effect as of January 1, 
1993, for determining the amount of time that may be billed for such 
services under this section.''.
    (b) Services of Certified Registered Nurse Anesthetists.--Section 
1833(l)(1)(B) (42 U.S.C. 1395l(l)(1)(B)) is amended by adding at the 
end the following: ``For anesthesia services furnished on or after 
January 1, 1994, the Secretary may not modify the methodology in effect 
as of January 1, 1993, for determining the amount of time that may be 
billed for such services under this section.''.

SEC. 5007. SEPARATE PAYMENT FOR INTERPRETATION OF ELECTROCARDIOGRAMS.

    (a) In General.--Paragraph (3) of section 1848(b) (42 U.S.C. 1395w-
4(b)) is amended to read as follows:
            ``(3) Treatment of interpretation of electrocardiograms.--
        The Secretary--
                    ``(A) shall make separate payment under this 
                section for the interpretation of electrocardiograms 
                performed or ordered to be performed as part of or in 
                conjunction with a visit to or a consultation with a 
                physician, and
                    ``(B) shall adjust the relative values established 
                for visits and consultations under subsection (c) so as 
                not to include relative value units for interpretations 
                of electrocardiograms in the relative value for visits 
                and consultations.''.
    (b) Assuring Budget Neutrality.--Section 1848(c)(2) (42 U.S.C. 
1395w-4(c)(2)) is amended by adding at the end the following new 
subparagraph:
                    ``(E) Budget neutrality adjustments.--The 
                Secretary--
                            ``(i) shall reduce the relative values for 
                        all services (other than anesthesia services) 
                        established under this paragraph (and, in the 
                        case of anesthesia services, the conversion 
                        factor established by the Secretary for such 
                        services) by such percentage as the Secretary 
                        determines to be necessary so that, beginning 
                        in 1996, the amendment made by section 5007(a) 
                        of the Omnibus Budget Reconciliation Act of 
                        1993 would not result in expenditures under 
                        this section that exceed the amount of such 
                        expenditures that would have been made if such 
                        amendment had not been made, and
                            ``(ii) shall reduce the amounts determined 
                        under subsection (a)(2)(B)(ii)(I) by such 
                        percentage as the Secretary determines to be 
                        required to assure that, taking into account 
                        the reductions made under clause (i), the 
                        amendment made by section 5007(a) of the 
                        Omnibus Budget Reconciliation Act of 1993 would 
                        not result in expenditures under this section 
                        in 1994 that exceed the amount of such 
                        expenditures that would have been made if such 
                        amendment had not been made.''.
    (c) Conforming Amendments.--Section 1848 (42 U.S.C. 1395w-4) is 
amended--
            (1) in subsection (a)(2)(B)(ii)(I), by inserting ``and as 
        adjusted under subsection (c)(2)(E)(ii)'' after ``for 1994'';
            (2) in subsection (c)(2)(A)(i), by adding at the end the 
        following: ``Such relative values are subject to adjustment 
        under subparagraph (E)(i).''; and
            (3) in subsection (i)(1)(B), by adding at the end 
        ``including adjustments under subsection (c)(2)(E),''.
    (d) Effective Date.--The amendments made by this section shall 
apply to services furnished on or after January 1, 1994.

SEC. 5008. PAYMENTS FOR NEW PHYSICIANS AND PRACTITIONERS.

    (a) Equal Treatment of New Physicians and Practitioners.--(1) 
Section 1848(a) (42 U.S.C. 1395w-4(a)) is amended by striking paragraph 
(4).
    (2) Section 1842(b)(4) (42 U.S.C. 1395u(b)(4)) is amended by 
striking subparagraph (F).
    (b) Budget Neutrality Adjustment.--Notwithstanding any other 
provision of law, the Secretary of Health and Human Services shall 
reduce the following values and amounts for 1994 (to be applied for 
that year and subsequent years) by such uniform percentage as the 
Secretary determines to be required to assure that the amendments made 
by subsection (a) will not result in expenditures under part B of title 
XVIII of the Social Security Act in 1994 that exceed the amount of such 
expenditures that would have been made if such amendments had not been 
made:
            (1) The relative values established under section 1848(c) 
        of such Act for services (other than anesthesia services) and, 
        in the case of anesthesia services, the conversion factor 
        established under section 1848 of such Act for such services.
            (2) The amounts determined under section 
        1848(a)(2)(B)(ii)(I) of such Act.
            (3) The prevailing charges or fee schedule amounts to be 
        applied under such part for services of a health care 
        practitioner (as defined in section 1842(b)(4)(F)(ii)(I) of 
        such Act, as in effect before the date of the enactment of this 
        Act).
    (c) Conforming Amendments.--Section 1848 (42 U.S.C. 1395w-4), as 
amended by section 5007(c), is amended--
            (1) in subsection (a)(2)(B)(ii)(I), by inserting ``and 
        section 5008(b) of the Omnibus Budget Reconciliation Act of 
        1993'' after ``for 1994'';
            (2) in subsection (c)(2)(A)(i), by inserting ``and section 
        5008(b) of the Omnibus Budget Reconciliation Act of 1993'' 
        after ``under subparagraph (E)(i)''; and
            (3) in subsection (i)(1)(B), by inserting ``and section 
        5008(b) of the Omnibus Budget Reconciliation Act of 1993'' 
        after ``under subsection (c)(2)(E)''.
    (d) Effective Date.--The amendments made by subsection (a) shall 
apply to services furnished on or after January 1, 1994.

SEC. 5009. GEOGRAPHIC ADJUSTMENT FACTORS FOR MEDICARE PHYSICIANS' 
              SERVICES.

    (a) Requiring Consultation with Representatives of Physicians in 
Reviewing Geographic Adjustment Factors.--Section 1848(e)(1)(C) (42 
U.S.C. 1395w-4(e)(1)(C)) is amended by striking ``shall review'' and 
inserting ``shall, in consultation with appropriate representatives of 
physicians, review''.
    (b) Use of Most Recent Data In Geographic Adjustment.--Section 
1848(e)(1) (42 U.S.C. 1395w-4(e)(1)) is amended by adding at the end 
the following new subparagraph:
                    ``(D) Use of recent data.--In establishing indices 
                and index values under this paragraph, the Secretary 
                shall use the most recent data available relating to 
                practice expenses, malpractice expenses, and physician 
                work effort in different fee schedule areas.''.
    (c) Deadline for Initial Review and Revision.--The Secretary of 
Health and Human Services shall first review and revise geographic 
adjustment factors under section 1848(e)(1)(C) of the Social Security 
Act by not later than January 1, 1995.
    (d) Report on Review Process.--Not later than 1 year after the date 
of the enactment of this Act, the Secretary of Health and Human 
Services shall study and report to the Committee on Finance of the 
Senate and the Committee on Ways and Means and the Committee on Energy 
and Commerce of the House of Representatives on--
            (1) the data necessary to review and revise the indices 
        established under section 1848(e)(1)(A) of the Social Security 
        Act, including--
                    (A) the shares allocated to physicians' work 
                effort, practice expenses (other than malpractice 
                expenses), and malpractice expenses;
                    (B) the weights assigned to the input components of 
                such shares; and
                    (C) the index values assigned to such components;
            (2) any limitations on the availability of data necessary 
        to review and revise such indices at least every three years;
            (3) ways of addressing such limitations, with particular 
        attention to the development of alternative data sources for 
        input components for which current index values are based on 
        data collected less frequently than every three years; and
            (4) the costs of developing more accurate and timely data.

SEC. 5010. EXTRA-BILLING LIMITS.

    (a) Enforcement and Uniform Application.--
            (1) Enforcement.--Paragraph (1) of section 1848(g) (42 
        U.S.C. 1395w-4(g)) is amended to read as follows:
            ``(1) Limitation on actual charges.--
                    ``(A) In general.--In the case of a 
                nonparticipating physician or nonparticipating supplier 
                or other person (as defined in section 1842(i)(2)) who 
                does not accept payment on an assignment-related basis 
                for a physician's service furnished with respect to an 
                individual enrolled under this part, the following 
                rules apply:
                            ``(i) Application of limiting charge.--No 
                        person may bill or collect an actual charge for 
                        the service in excess of the limiting charge 
                        described in paragraph (2) for such service.
                            ``(ii) No liability for excess charges.--No 
                        person is liable for payment of any amounts 
                        billed for the service in excess of such 
                        limiting charge.
                            ``(iii) Correction of excess charges.--If 
                        such a physician, supplier, or other person 
                        bills, but does not collect, an actual charge 
                        for a service in violation of clause (i), the 
                        physician, supplier, or other person shall 
                        reduce on a timely basis the actual charge 
                        billed for the service to an amount not to 
                        exceed the limiting charge for the service.
                            ``(iv) Refund of excess collections.--If 
                        such a physician, supplier, or other person 
                        collects an actual charge for a service in 
                        violation of clause (i), the physician, 
                        supplier, or other person shall provide on a 
                        timely basis a refund to the individual charged 
                        in the amount by which the amount collected 
                        exceeded the limiting charge for the service. 
                        The amount of such a refund shall be reduced to 
                        the extent the individual has an outstanding 
                        balance owed by the individual to the 
                        physician.
                    ``(B) Sanctions.--If a physician, supplier, or 
                other person--
                            ``(i) knowingly and willfully bills or 
                        collects for services in violation of 
                        subparagraph (A)(i) on a repeated basis, or
                            ``(ii) fails to comply with clause (iii) or 
                        (iv) of subparagraph (A) on a timely basis,
                the Secretary may apply sanctions against the 
                physician, supplier, or other person in accordance with 
                paragraph (2) of section 1842(j). In applying this 
                subparagraph, paragraph (4) of such section applies in 
                the same manner as such paragraph applies to such 
                section and any reference in such section to a 
                physician is deemed also to include a reference to a 
                supplier or other person under this subparagraph.
                    ``(C) Timely basis.--For purposes of this 
                paragraph, a correction of a bill for an excess charge 
                or refund of an amount with respect to a violation of 
                subparagraph (A)(i) in the case of a service is 
                considered to be provided `on a timely basis', if the 
                reduction or refund is made not later than 30 days 
                after the date the physician, supplier, or other person 
                is notified by the carrier under this part of such 
                violation and of the requirements of subparagraph 
                (A).''.
            (2) Uniform application of extra-billing limits to 
        physicians' services.--
                    (A) In general.--Section 1848(g)(2)(C) (42 U.S.C. 
                1395w-4(g)(2)(C)) is amended by inserting ``or for 
                nonparticipating suppliers or other persons'' after 
                ``nonparticipating physicians''.
                    (B) Conforming definition.--Section 1842(i)(2) (42 
                U.S.C. 1395u(i)(2)) is amended--
                            (i) by striking ``, and the term'' and 
                        inserting ``; the term'', and
                            (ii) by inserting before the period at the 
                        end the following: ``; and the term 
                        `nonparticipating supplier or other person' 
                        means a supplier or other person (excluding a 
                        provider of services) that is not a 
                        participating physician or supplier (as defined 
                        in subsection (h)(1))''.
            (3) Additional conforming amendments.--Section 1848 (42 
        U.S.C. 1395w-4) is amended--
                    (A) in subsection (a)(3)--
                            (i) by inserting ``and suppliers'' after 
                        ``physicians'',
                            (ii) by inserting ``or a nonparticipating 
                        supplier or other person'' after 
                        ``nonparticipating physician'', and
                            (iii) by adding at the end the following: 
                        ``In the case of physicians' services 
                        (including services which the Secretary 
                        excludes pursuant to subsection (j)(3)) of a 
                        nonparticipating physician, supplier, or other 
                        person for which payment is made under this 
                        part on a basis other than the fee schedule 
                        amount, the payment shall be based on 95 
                        percent of the payment basis for such services 
                        furnished by a participating physician, 
                        supplier, or other person.'';
                    (B) in subsection (g)(1)(A), as amended by 
                subsection (a), in the matter before clause (i), by 
                inserting ``(including services which the Secretary 
                excludes pursuant to subsection (j)(3))'' after ``a 
                physician's service'';
                    (C) in subsection (g)(2)(D), by inserting ``(or, if 
                payment under this part is made on a basis other than 
                the fee schedule under this section, 95 percent of the 
                other payment basis)'' after ``subsection (a)'';
                    (D) in subsection (g)(3)(B)--
                            (i) by inserting after the first sentence 
                        the following: `` No person is liable for 
                        payment of any amounts billed for such a 
                        service in violation of the previous 
                        sentence.'', and
                            (ii) in the last sentence, by striking 
                        ``previous sentence'' and inserting ``first 
                        sentence'';
                    (E) in subsection (h)--
                            (i) by inserting ``or nonparticipating 
                        supplier or other person furnishing physicians' 
                        services (as defined in section 1848(j)(3))'' 
                        after ``physician'' the first place it appears,
                            (ii) by inserting ``, supplier, or other 
                        person'' after ``physician'' the second place 
                        it appears, and
                            (iii) by inserting ``, suppliers, and other 
                        persons'' after ``physicians'' the second place 
                        it appears; and
                    (F) in subsection (j)(3), by inserting ``, except 
                for purposes of subsections (a)(3), (g), and (h)'' 
                after ``tests and''.
    (b) Clarification of Mandatory Assignment Rules for Certain 
Practitioners.--
            (1) In general.--Section 1842(b) (42 U.S.C. 1395u(b)) is 
        amended by adding at the end the following new paragraph:
    ``(19)(A) Payment for any service furnished by a practitioner 
described in subparagraph (C) and for which payment may be made under 
this part on a reasonable charge or fee schedule basis may only be made 
under this part on an assignment-related basis.
    ``(B) A practitioner described in subparagraph (C) or other person 
may not bill (or collect any amount from) the individual or another 
person for any service described in subparagraph (A), except for 
deductible and coinsurance amounts applicable under this part. No 
person is liable for payment of any amounts billed for such a service 
in violation of the previous sentence. If a practitioner or other 
person knowingly and willfully bills (or collects an amount) for such a 
service in violation of such sentence, the Secretary may apply 
sanctions against the practitioner or other person in the same manner 
as the Secretary may apply sanctions against a physician in accordance 
with section 1842(j)(2) in the same manner as such section applies with 
respect to a physician. Paragraph (4) of section 1842(j) shall apply in 
this subparagraph in the same manner as such paragraph applies to such 
section.
    ``(C) A practitioner described in this subparagraph is any of the 
following:
            ``(i) A physician assistant, nurse practitioner, or 
        clinical nurse specialist (as defined in section 1861(aa)(5)).
            ``(ii) A certified registered nurse anesthetist (as defined 
        in section 1861(bb)(2)).
            ``(iii) A certified nurse-midwife (as defined in section 
        1861(gg)(2)).
            ``(iv) A clinical social worker (as defined in section 
        1861(hh)(1)).
            ``(v) A clinical psychologist (as defined by the Secretary 
        for purposes of section 1861(ii)).
    ``(D) For purposes of this paragraph, a service furnished by a 
practitioner described in subparagraph (C) includes any services and 
supplies furnished as incident to the service as would otherwise be 
covered under this part if furnished by a physician or as incident to a 
physician's service.''.
            (2) Conforming amendments.--
                    (A) Section 1833 (42 U.S.C. 1395l) is amended--
                            (i) in subsection (l)(5), by striking 
                        subparagraph (B) and redesignating subparagraph 
                        (C) as subparagraph (B);
                            (ii) by striking subsection (p); and
                            (iii) in subsection (r), by striking 
                        paragraph (3) and redesignating paragraph (4) 
                        as paragraph (3).
                    (B) Section 1842(b)(12) (42 U.S.C. 1395u(b)(12)) is 
                amended by striking subparagraph (C).
    (c) Information on Extra-Billing Limits.--
            (1) Part of explanation of medicare benefits.--Section 
        1842(h)(7) (42 U.S.C. 1395u(h)(7)) is amended--
                    (A) by striking ``and'' at the end of subparagraph 
                (B),
                    (B) in subparagraph (C), by striking ``shall 
                include'',
                    (C) in subparagraph (C), by striking the period at 
                the end and inserting ``, and'', and
                    (D) by adding at the end the following new 
                subparagraph:
            ``(D) in the case of services for which the billed amount 
        exceeds the limiting charge imposed under section 1848(g), 
        information regarding such applicable limiting charge 
        (including information concerning the right to a refund under 
        section 1848(g)(1)(A)(iv)).''.
            (2) Determinations by carriers.--Subparagraph (G) of 
        section 1842(b)(3) (42 U.S.C. 1395u(b)(3)) is amended to read 
        as follows:
            ``(G) will, for a service that is furnished with respect to 
        an individual enrolled under this part, that is not paid on an 
        assignment-related basis, and that is subject to a limiting 
        charge under section 1848(g)--
                    ``(i) determine, prior to making payment, whether 
                the amount billed for such service exceeds the limiting 
                charge applicable under section 1848(g)(2);
                    ``(ii) notify the physician, supplier, or other 
                person periodically (but not less often than once every 
                30 days) of determinations that amounts billed exceeded 
                such applicable limiting charges; and
                    ``(iii) provide for prompt response to inquiries of 
                physicians, suppliers, and other persons concerning the 
                accuracy of such limiting charges for their 
                services;''.
    (d) Report on Charges in Excess of Limiting Charge.--Section 
1848(g)(6)(B) (42 U.S.C. 1395w-4(g)(6)(B)) is amended by inserting 
``the extent to which actual charges exceed limiting charges, the 
number and types of services involved, and the average amount of excess 
charges and'' after ``report to the Congress''.
    (e) Miscellaneous and Technical Amendments.--Section 1833 (42 
U.S.C. 1395l) is amended--
            (1) in subsection (a)(1), as amended by section 
        5070(e)(2)--
                    (A) by striking ``and'' before ``(O)'', and
                    (B) by inserting before the semicolon at the end 
                the following: ``, and (P) with respect to services 
                described in clauses (i), (ii) and (iv) of section 
                1861(s)(2)(K), the amounts paid are subject to the 
                provisions of section 1842(b)(12)''; and
            (2) in subsection (h)(5)(D)--
                    (A) by striking ``paragraphs (2) and (3)'' and by 
                inserting ``paragraph (2)'', and
                    (B) by adding at the end the following: ``Paragraph 
                (4) of such section shall apply in this subparagraph in 
                the same manner as such paragraph applies to such 
                section.''.
    (f) Effective Dates.--
            (1) Enforcement and uniform application; miscellaneous and 
        technical amendments.--The amendments made by subsections (a) 
        and (e) shall apply to services furnished on or after the date 
        of the enactment of this Act; except that the amendments made 
        by subsection (a) shall not apply to services of a 
        nonparticipating supplier or other person furnished before 
        January 1, 1994.
            (2) Practitioners.--The amendments made by subsection (b) 
        shall apply to services furnished on or after January 1, 1994.
            (3) EOMBs.--The amendments made by subsection (c)(1) shall 
        apply to explanations of benefits provided on or after January 
        1, 1994.
            (4) Carrier determinations.--The amendments made by 
        subsection (c)(2) shall apply to contracts as of January 1, 
        1994.
            (5) Report.--The amendment made by subsection (d) shall 
        apply to reports for years beginning with 1994.

SEC. 5011. RELATIVE VALUES FOR PEDIATRIC SERVICES.

    (a) In General.--The Secretary of Health and Human Services shall 
fully develop, by not later than July 1, 1994, relative values for the 
full range of pediatric physicians' services which are consistent with 
the relative values developed for other physicians' services under 
section 1848(c) of the Social Security Act. In developing such values, 
the Secretary shall conduct such refinements as may be necessary to 
produce appropriate estimates for such relative values.
    (b) Study.--
            (1) In general.--The Secretary shall conduct a study of the 
        relative values for pediatric and other services to determine 
        whether there are significant variations in the resources used 
        in providing similar services to different populations. In 
        conducting such study, the Secretary shall consult with 
        appropriate organizations representing pediatricians and other 
        physicians and physical and occupational therapists.
            (2) Report.--Not later than July 1, 1994, the Secretary 
        shall submit to Congress a report on the study conducted under 
        paragraph (1). Such report shall include any appropriate 
        recommendations regarding needed changes in coding or other 
        payment policies to ensure that payments for pediatric services 
        appropriately reflect the resources required to provide these 
        services.

SEC. 5012. ANTIGENS UNDER PHYSICIAN FEE SCHEDULE.

    (a) In General.--Section 1848(j)(3) (42 U.S.C. 1395w-4(j)(3)) is 
amended by inserting ``(2)(G),'' after ``(2)(D),''.
    (b) Effective Date.--The amendment made by subsection (a) shall 
apply to services furnished on or after January 1, 1994.

SEC. 5013. ADMINISTRATION OF CLAIMS RELATING TO PHYSICIANS' SERVICES.

    (a) Limitation on Carrier User Fees.--Section 1842(c) (42 U.S.C. 
1395u(c)) is amended by adding at the end the following new paragraph:
    ``(4) Neither a carrier nor the Secretary may impose a fee under 
this title--
            ``(A) for the filing of claims related to physicians' 
        services,
            ``(B) for an error in filing a claim relating to 
        physicians' services or for such a claim which is denied,
            ``(C) for any appeal under this title with respect to 
        physicians' services,
            ``(D) for applying for (or obtaining) a unique identifier 
        under subsection (r), or
            ``(E) for responding to inquiries respecting physicians' 
        services or for providing information with respect to medical 
        review of such services.''.
    (b) Clarification of Permissible Substitute Billing Arrangements.--
            (1) In general.--Clause (D) of section 1842(b)(6) (42 
        U.S.C. 1395u(b)(6)) is amended to read as follows: ``(D) 
        payment may be made to a physician for physicians' services 
        (and services furnished incident to such services) furnished by 
        a second physician to patients of the first physician if (i) 
        the first physician is unavailable to provide the services; 
        (ii) the services are furnished pursuant to an arrangement 
        between the two physicians that (I) is informal and reciprocal, 
        or (II) involves per diem or other fee-for-time compensation 
        for such services; (iii) the services are not provided by the 
        second physician over a continuous period of more than 60 days; 
        and (iv) the claim form submitted to the carrier for such 
        services includes the second physician's unique identifier 
        (provided under the system established under subsection (r)) 
        and indicates that the claim meets the requirements of this 
        clause for payment to the first physician''.
            (2) Effective date.--The amendment made by paragraph (1) 
        shall apply to services furnished on or after the first day of 
        the first month beginning more than 60 days after the date of 
        the enactment of this Act.

SEC. 5014. MISCELLANEOUS AND TECHNICAL CORRECTIONS.

    (a) Overvalued Procedures (Section 4101 of OBRA-1990).--(1) Section 
1842(b)(16)(B)(iii) (42 U.S.C. 1395u(b)(16)(B)(iii)) is amended--
            (A) by striking ``, simple and subcutaneous'',
            (B) by striking ``; small'' and inserting ``and small'',
            (C) by striking ``treatments;'' the first place it appears 
        and inserting ``and'',
            (D) by striking ``lobectomy;'',
            (E) by striking ``enterectomy; colectomy; 
        cholecystectomy;'',
            (F) by striking ``; transurerethral resection'' and 
        inserting ``and resection'', and
            (G) by striking ``sacral laminectomy;''.
    (2) Section 4101(b)(2) of OBRA-1990 is amended--
            (A) in the matter before subparagraph (A), by striking 
        ``1842(b)(16)'' and inserting ``1842(b)(16)(B)'', and
            (B) in subparagraph (B)--
                    (i) by striking ``, simple and subcutaneous'',
                    (ii) by striking ``(HCPCS codes 19160 and 19162)'' 
                and inserting ``(HCPCS code 19160)'', and
                    (iii) by striking all that follows ``(HCPCS codes 
                92250'' and inserting ``and 92260).''.
    (b) Radiology Services (Section 4102 of OBRA-1990).--(1) Section 
1834(b)(4) (42 U.S.C. 1395m(b)(4)) is amended by redesignating 
subparagraphs (E) and (F) as subparagraphs (F) and (G), respectively.
    (2) Section 1834(b)(4)(D) (42 U.S.C. 1395m(b)(4)(D)) is amended--
            (A) in the matter before clause (i), by striking ``shall be 
        determined as follows:'' and inserting ``shall, subject to 
        clause (vii), be reduced to the adjusted conversion factor for 
        the locality determined as follows:'',
            (B) in clause (iv), by striking ``Local adjustment.--
        Subject to clause (vii), the conversion factor to be applied 
        to'' and inserting ``Adjusted conversion factor.--The adjusted 
        conversion factor for'',
            (C) in clause (vii), by striking ``under this 
        subparagraph'', and
            (D) in clause (vii), by inserting ``reduced under this 
        subparagraph by'' after ``shall not be''.
    (3) Section 4102(c)(2) of OBRA-1990 is amended by striking 
``radiology services'' and all that follows and inserting ``nuclear 
medicine services''.
    (4) Section 4102(d) of OBRA-1990 is amended by striking ``new 
paragraph'' and inserting ``new subparagraph''.
    (5) Section 1834(b)(4)(E) (42 U.S.C. 1395m(b)(4)(E)) is amended by 
inserting ``Rule for certain scanning services.--'' after ``(E)''.
    (6) Section 1848(a)(2)(D)(iii) (42 U.S.C. 1395w-4(a)(2)(D)(iii)) is 
amended by striking ``that are subject to section 6105(b) of the 
Omnibus Budget Reconciliation Act of 1989'' and by striking ``provided 
under such section'' and inserting ``provided under section 6105(b) of 
the Omnibus Budget Reconciliation Act of 1989''.
    (c) Anesthesia Services (Section 4103 of OBRA-1990).--(1) Section 
4103(a) of OBRA-1990 is amended by striking ``Reduction in Fee 
Schedule'' and inserting ``Reduction in Prevailing Charges''.
    (2) Section 1842(q)(1)(B) (42 U.S.C. 1395u(q)(1)(B)) is amended--
            (A) in the matter before clause (i), by striking ``shall be 
        determined as follows:'' and inserting ``shall, subject to 
        clause (iv), be reduced to the adjusted prevailing charge 
        conversion factor for the locality determined as follows:'', 
        and
            (B) in clause (iii), by striking ``Subject to clause (iv), 
        the prevailing charge conversion factor to be applied in'' and 
        inserting ``The adjusted prevailing charge conversion factor 
        for''.
    (d) Assistants at Surgery (Section 4107 of OBRA-1990).--(1) Section 
4107(c) of OBRA-1990 is amended by inserting ``(a)(1)'' after 
``subsection''.
    (2) Section 4107(a)(2) of OBRA-1990 is amended by adding at the end 
the following: ``In applying section 1848(g)(2)(D) of the Social 
Security Act for services of an assistant-at-surgery furnished during 
1991, the recognized payment amount shall not exceed the maximum amount 
specified under section 1848(i)(2)(A) of such Act (as applied under 
this paragraph in such year).''.
    (e) Technical Components of Diagnostic Services (Section 4108 of 
OBRA-1990).--Section 1842(b) (42 U.S.C. 1395u(b)) is amended by 
redesignating paragraph (18), as added by section 4108(a) of OBRA-1990, 
as paragraph (17) and, in such paragraph, by inserting ``, tests 
specified in paragraph (14)(C)(i),'' after ``diagnostic laboratory 
tests''.
    (f) Statewide Fee Schedules (Section 4117 of OBRA-1990).--Section 
4117 of OBRA-1990 is amended--
            (1) in subsection (a)--
                    (A) by striking ``In General.--'', and
                    (B) by striking ``, if the'' and all that follows 
                through ``1991, ''; and
            (2) by striking subsections (b), (c), and (d).
    (g) Study of Aggregation Rule for Claims of Similar Physician 
Services (Section 4113 of OBRA-1990).--Section 4113 of OBRA-1990 is 
amended--
            (1) by inserting ``of the Social Security Act'' after 
        ``1869(b)(2)''; and
            (2) by striking ``December 31, 1992'' and inserting 
        ``December 31, 1993''.
    (h) Other Miscellaneous and Technical Amendments.--(1) The heading 
of section 1834(f) (42 U.S.C. 1395m(f)) is amended by striking ``Fiscal 
Year''.
    (2)(A) Section 4105(b) of OBRA-1990 is amended--
            (i) in paragraph (2), by striking ``amendments'' and 
        inserting ``amendment'', and
            (ii) in paragraph (3), by striking ``amendments made by 
        paragraphs (1) and (2)'' and inserting ``amendment made by 
        paragraph (1)''.
    (B) Section 1848(f)(2)(C) (42 U.S.C. 1395w-4(f)(2)(C)) is amended 
by inserting ``Performance standard rates of increase for fiscal year 
1991.--'' after ``(C)''.
    (C) Section 4105(d) of OBRA-1990 is amended by inserting 
``Publication of Performance Standard Rates.--'' after ``(d)''.
    (3) Section 1842(b)(4)(F) (42 U.S.C. 1395u(b)(4)(F)) is amended--
            (A) in clause (i), by striking ``prevailing charge'' the 
        first place it appears and inserting ``customary charge''; and
            (B) in clause (ii)(III), by striking ``second, third, and 
        fourth'' and inserting ``first, second, and third''.
    (4) Section 1842(b)(4)(F)(ii)(I) (42 U.S.C. 1395u(b)(4)(F)(ii)(I)) 
is amended by striking ``respiratory therapist,''.
    (5) Section 4106(c) of OBRA-1990 is amended by inserting ``of the 
Social Security Act'' after ``1848(d)(1)(B)''.
    (6) Section 4114 of OBRA-1990 is amended by striking ``patients'' 
the second place it appears.
    (7) Section 1848(e)(1)(C) (42 U.S.C. 1395w-4(e)(1)(C)) is amended 
by inserting ``date of the'' after ``since the''.
    (8) Section 4118(f)(1)(D) of OBRA-1990 is amended by striking ``is 
amended''.
    (9) Section 4118(f)(1)(N)(ii) of OBRA-1990 is amended by striking 
``subsection (f)(5)(A)'' and inserting ``subsection (f)(5)(A))''.
    (10) Section 1845(e) (42 U.S.C. 1395w-1(e)) is amended--
            (A) by striking paragraph (2); and
            (B) by redesignating paragraphs (3), (4), and (5) as 
        paragraphs (2), (3), and (4).
    (11) Section 4118(j)(2) of OBRA-1990 is amended by striking ``In 
section'' and inserting ``Section''.
    (12)(A) Section 1848(i)(3) (42 U.S.C. 1395w-4(i)(3)) is amended by 
striking the space before the period at the end.
    (B) Section 1834(a)(10)(B) (42 U.S.C. 1395m(a)(10)(B)) is amended 
by striking ``as such provisions apply to physicians' services and 
physicians and a reasonable charge under section 1842(b)''.
    (i) Other Corrections.--(1) Effective on the date of the enactment 
of this Act, section 6102(d)(4) of OBRA-1989 is amended by striking all 
that follows the first sentence.
    (2) Effective for payments for fiscal years beginning with fiscal 
year 1994, section 1842(c)(1) (42 U.S.C. 1395u(c)(1)) is amended--
            (A) in subparagraph (A), by striking ``(A) Any contract'' 
        and inserting ``Any contract''; and
            (B) by striking subparagraph (B).
    (j) Effective Date.--Except as provided in subsection (i), the 
amendments made by this section and the provisions of this section 
shall take effect as if included in the enactment of OBRA-1990.

  Subchapter B--Outpatient Hospital Services and Ambulatory Surgical 
                                Services

SEC. 5021. EXTENSION OF 10 PERCENT REDUCTION IN PAYMENTS FOR CAPITAL-
              RELATED COSTS OF OUTPATIENT HOSPITAL SERVICES.

    Section 1861(v)(1)(S)(ii)(I) (42 U.S.C. 1395x(v)(1)(S)(ii)(I)) is 
amended by striking ``fiscal year 1992, 1993, 1994, or 1995'' and 
inserting ``fiscal years 1992 through 1998''.

SEC. 5022. EXTENSION OF CURRENT REDUCTION IN PAYMENTS FOR OTHER COSTS 
              OF OUTPATIENT HOSPITAL SERVICES.

    Section 1861(v)(1)(S)(ii)(II) (42 U.S.C. 1395x(v)(1)(S)(ii)(II)) is 
amended by striking ``1991'' and all that follows and inserting ``1991 
through 1998''.

SEC. 5023. 1-YEAR FREEZE IN AMBULATORY SURGERY RATES.

    The Secretary of Health and Human Services shall not provide for 
any update in the amounts of payment described in paragraphs (2)(A) and 
(2)(B) of section 1833(i)(2) of the Social Security Act that otherwise 
would occur in fiscal year 1994.

SEC. 5024. EYE OR EYE AND EAR HOSPITALS.

    (a) In General.--Section 1833(i) (42 U.S.C. 1395l(i)) is amended--
            (1) in paragraph (3)(B)(ii)--
                    (A) by striking ``the last sentence of this 
                clause'' and inserting ``paragraph (4)'', and
                    (B) by striking the last sentence; and
            (2) by inserting after paragraph (3) the following new 
        paragraph:
    ``(4)(A) In the case of a hospital that--
            ``(i) makes application to the Secretary and demonstrates 
        that it specializes in eye services or eye and ear services (as 
        determined by the Secretary),
            ``(ii) receives more than 30 percent of its total revenues 
        from outpatient services, and
            ``(iii) on October 1, 1987--
                    ``(I) was an eye specialty hospital or an eye and 
                ear specialty hospital, or
                    ``(II) was operated as an eye or eye and ear unit 
                (as defined in subparagraph (B)) of a general acute 
                care hospital which, on the date of the application 
                described in clause (i), operates less than 20 percent 
                of the beds that the hospital operated on October 1, 
                1987, and has sold or otherwise disposed of a 
                substantial portion of the hospital's other acute care 
                operations,
the cost proportion and ASC proportion in effect under subclauses (I) 
and (II) of paragraph (3)(B)(ii) for cost reporting periods beginning 
in fiscal year 1988 shall remain in effect for cost reporting periods 
beginning on or after October 1, 1988, and before January 1, 1995.
    ``(B) For purposes of this subparagraph (A)(iii)(II), the term `eye 
or eye and ear unit' means a physically separate or distinct unit 
containing separate surgical suites devoted solely to eye or eye and 
ear services.''.
    (b) Effective Date.--The amendments made by subsection (a) shall 
apply to portions of cost reporting periods beginning on or after 
January 1, 1994.

SEC. 5025. EXTENSION OF CAP ON PAYMENTS FOR INTRAOCULAR LENSES.

    (a) In General.--Section 4151(c)(3) of OBRA-1990 is amended by 
striking ``December 31, 1992'' and inserting ``December 31, 1994''.
    (b) Effective Date.--The amendment made by subsection (a) shall be 
effective as if included in the enactment of OBRA-1990.

SEC. 5026. MISCELLANEOUS AND TECHNICAL CORRECTIONS.

    (a) Payment Amounts for Services Furnished in Ambulatory Surgical 
Centers.--(1)(A) Section 1833(i)(2)(A)(i) (42 U.S.C. 1395l(i)(2)(A)(i)) 
is amended by striking the comma at the end and inserting the 
following: ``, as determined in accordance with a survey (based upon a 
representative sample of procedures and facilities) taken not later 
than January 1, 1995, and every 5 years thereafter, of the actual 
audited costs incurred by such centers in providing such services,''.
    (B) Section 1833(i)(2) (42 U.S.C. 1395l(i)(2)) is amended--
            (i) in the second sentence of subparagraph (A) and the 
        second sentence of subparagraph (B), by striking ``and may be 
        adjusted by the Secretary, when appropriate,''; and
            (ii) by adding at the end the following new subparagraph:
    ``(C) Notwithstanding the second sentence of subparagraph (A) or 
the second sentence of subparagraph (B), if the Secretary has not 
updated amounts established under such subparagraphs with respect to 
facility services furnished during a fiscal year (beginning with fiscal 
year 1996), such amounts shall be increased by the percentage increase 
in the consumer price index for all urban consumers (U.S. city average) 
as estimated by the Secretary for the 12-month period ending with the 
midpoint of the fiscal year involved.''.
    (C) The second sentence of section 1833(i)(1) (42 U.S.C. 
1395l(i)(1)) is amended by striking the period and inserting the 
following: ``, in consultation with appropriate trade and professional 
organizations.''.
    (2) Section 4151(c)(3) of OBRA-1990 is amended by striking ``for 
the insertion of an intraocular lens'' and inserting ``for an 
intraocular lens inserted''.
    (b) Adjustments to Payment Amounts for New Technology Intraocular 
Lenses.--(1) Not later than 1 year after the date of the enactment of 
this Act, the Secretary of Health and Human Services (in this 
subsection referred to as the ``Secretary'') shall develop and 
implement a process under which interested parties may request review 
by the Secretary of the appropriateness of the reimbursement amount 
provided under section 1833(i)(2)(A)(iii) of the Social Security Act 
with respect to a class of new technology intraocular lenses. For 
purposes of the preceding sentence, an intraocular lens may not be 
treated as a new technology lens unless it has been approved by the 
Food and Drug Administration.
    (2) In determining whether to provide an adjustment of payment with 
respect to a particular lens under paragraph (1), the Secretary shall 
take into account whether use of the lens is likely to result in 
reduced risk of intraoperative or postoperative complication or trauma, 
accelerated postoperative recovery, reduced induced astigmatism, 
improved postoperative visual acuity, more stable postoperative vision, 
or other comparable clinical advantages.
    (3) The Secretary shall publish notice in the Federal Register from 
time to time (but no less often than once each year) of a list of the 
requests that the Secretary has received for review under this 
subsection, and shall provide for a 30-day comment period on the lenses 
that are the subjects of the requests contained in such notice. The 
Secretary shall publish a notice of his determinations with respect to 
intraocular lenses listed in the notice within 90 days after the close 
of the comment period.
    (4) Any adjustment of a payment amount (or payment limit) made 
under this subsection shall become effective not later than 30 days 
after the date on which the notice with respect to the adjustment is 
published under paragraph (3).
    (c) Blend Amounts for Ambulatory Surgical Center Payments.--
            (1) In general.--Subclauses (I) and (II) of section 
        1833(i)(3)(B)(ii) (42 U.S.C. 1395l(i)(3)(B)(ii)) are each 
        amended--
                    (A) by striking ``for reporting'' and inserting 
                ``for portions of cost reporting''; and
                    (B) by striking ``and on or before'' and inserting 
                ``and ending on or before''.
            (2) Effective date.--The amendments made by paragraph (1) 
        shall take effect as if included in the enactment of OBRA-1990.

                Subchapter C--Durable Medical Equipment

SEC. 5031. REVISIONS TO PAYMENT RULES FOR DURABLE MEDICAL EQUIPMENT.

    (a) Basing National Payment Limits on Median of Local Payment 
Amounts.--
            (1) Inexpensive and routinely purchased items; items 
        requiring frequent and substantial servicing.--(A) Paragraphs 
        (2)(C)(i)(II) and (3)(C)(i)(II) of section 1834(a) (42 U.S.C. 
        1395m(a)) are each amended--
                    (i) by striking ``1992'' the first place it appears 
                and inserting ``1992, 1993, and 1994''; and
                    (ii) by striking ``1992'' the second place it 
                appears and inserting ``the year''.
            (B) Paragraphs (2)(C)(ii) and (3)(C)(ii) of section 1834(a) 
        (42 U.S.C. 1395m(a)) are each amended--
                    (i) by striking ``and'' at the end of subclause 
                (I);
                    (ii) by redesignating subclause (II) as (IV); and
                    (iii) by inserting after subclause (I) the 
                following new subclauses:
                                    ``(II) for 1992 and 1993, the 
                                amount determined under this clause for 
                                the preceding year increased by the 
                                covered item update for such subsequent 
                                year,
                                    ``(III) for 1994, the local payment 
                                amount determined under clause (i) for 
                                such item or device for that year, 
                                except that the national limited 
                                payment amount may not exceed 100 
                                percent of the median of all local 
                                payment amounts determined under such 
                                clause for such item for that year and 
                                may not be less than 85 percent of the 
                                median of all local payment amounts 
                                determined under such clause for such 
                                item or device for that year, and''.
            (2) Miscellaneous devices and items.--Section 1834(a)(8) 
        (42 U.S.C. 1395m(a)(8)) is amended--
                    (A) in subparagraph (A)(ii)(III), by striking 
                ``1992'' and inserting ``1992, 1993, and 1994''; and
                    (B) in subparagraph (B)--
                            (i) by striking ``and'' at the end of 
                        clause (i),
                            (ii) by redesignating clause (ii) as (iv), 
                        and
                            (iii) by inserting after clause (i) the 
                        following new clauses:
                            ``(ii) for 1992 and 1993, the amount 
                        determined under this subparagraph for the 
                        preceding year increased by the covered item 
                        update for such subsequent year;
                            ``(iii) for 1994, the local purchase price 
                        computed under subparagraph (A)(ii) for the 
                        item for the year, except that such national 
                        limited purchase price may not exceed 100 
                        percent of the median of all local purchase 
                        prices computed for the item under such 
                        subparagraph for the year and may not be less 
                        than 85 percent of the median of all local 
                        purchase prices computed under such 
                        subparagraph for the item for the year; and''.
            (3) Oxygen and oxygen equipment.--Section 1834(a)(9) (42 
        U.S.C. 1395m(a)(9)) is amended--
                    (A) in subparagraph (A)(ii)(II), by striking ``1991 
                and 1992'' and inserting ``1991, 1992, 1993, and 
                1994''; and
                    (B) in subparagraph (B)--
                            (i) by striking ``and'' at the end of 
                        clause (i),
                            (ii) by redesignating clause (ii) as (iv), 
                        and
                            (iii) by inserting after clause (i) the 
                        following new clauses:
                            ``(ii) for 1992 and 1993, the amount 
                        determined under this subparagraph for the 
                        preceding year increased by the covered item 
                        update for such subsequent year;
                            ``(iii) for 1994, the local monthly payment 
                        rate computed under subparagraph (A)(ii) for 
                        the item for the year, except that such 
                        national limited monthly payment rate may not 
                        exceed 100 percent of the median of all local 
                        monthly payment rates computed for the item 
                        under such subparagraph for the year and may 
                        not be less than 85 percent of the median of 
                        all local monthly payment rates computed for 
                        the item under such subparagraph for the year; 
                        and''.
    (b) Payment for Prosthetic Devices and Orthotics and Prosthetics.--
            (1) In general.--Section 1834(h)(2) (42 U.S.C. 1395m(h)(2)) 
        is amended--
                    (A) in subparagraph (A)(ii)(II), by striking ``1992 
                or 1993'' and inserting ``1992, 1993, or 1994'';
                    (B) in subparagraph (B)(ii), by striking ``each 
                subsequent year'' and inserting ``1993'';
                    (C) in subparagraph (C)(iv), by striking ``regional 
                purchase price computed under subparagraph (B)'' and 
                inserting ``national limited purchase price computed 
                under subparagraph (E)'';
                    (D) in subparagraph (D)(ii), by striking ``a 
                subsequent year'' and inserting ``1993''; and
                    (E) by adding at the end the following new 
                subparagraph:
                    ``(E) Computation of national limited purchase 
                price.--With respect to the furnishing of a particular 
                item in a year, the Secretary shall compute a national 
                limited purchase price--
                            ``(i) for 1994, equal to the local purchase 
                        price computed under subparagraph (A)(ii)(II) 
                        for the item for the year, except that such 
                        national limited purchase price may not exceed 
                        100 percent of the median of all local purchase 
                        prices for the item computed under such 
                        subparagraph for the year, and may not be less 
                        than 85 percent of the median of all local 
                        purchase prices for the item computed under 
                        such subparagraph for the year; and
                            ``(ii) for each subsequent year, equal to 
                        the amount determined under this subparagraph 
                        for the preceding year increased by the 
                        applicable percentage increase for such 
                        subsequent year.''.
            (2) Exception for certain items.--Section 1834(h) (42 
        U.S.C. 1395m(h)), as amended by paragraph (1), is further 
        amended--
                    (A) in paragraph (1)(B), by striking ``subparagraph 
                (C),'' and inserting ``subparagraphs (C) and (F),''; 
                and
                    (B) by adding at the end of paragraph (2) the 
                following new subparagraph:
                    ``(F) Exception for certain items.--Payment for 
                ostomy supplies, tracheostomy supplies, and urologicals 
                shall be made in accordance with subparagraphs (B) and 
                (C) of section 1834(a)(2).''.
    (c) Effective Date.--The amendments made by this section shall 
apply to items furnished on or after January 1, 1994.

SEC. 5032. PAYMENT FOR PARENTERAL AND ENTERAL NUTRIENTS, SUPPLIES, AND 
              EQUIPMENT DURING 1994.

    In determining the amount of payment under part B of title XVIII of 
the Social Security Act during 1994, the charges determined to be 
reasonable with respect to parenteral and enteral nutrients, supplies, 
and equipment may not exceed the charges determined to be reasonable 
with respect to such nutrients, supplies, and equipment during 1993.

SEC. 5033. TREATMENT OF NEBULIZERS AND ASPIRATORS.

    (a) In General.--Section 1834(a)(3)(A) (42 U.S.C. 1395m(a)(3)(A)) 
is amended by striking ``ventilators, aspirators, IPPB machines, and 
nebulizers'' and inserting ``ventilators and IPPB machines''.
    (b) Payment for Accessories Relating to Nebulizers and 
Aspirators.--Section 1834(a)(2)(A) (42 U.S.C. 1395m(a)) is amended--
            (1) by striking ``or'' at the end of clause (i),
            (2) by adding ``or'' at the end of clause (ii), and
            (3) by inserting after clause (ii) the following new 
        clause:
                            ``(iii) which is an accessory used in 
                        conjunction with a nebulizer or aspirator,''.
    (c) Effective Date.--The amendments made by this section shall 
apply to items furnished on or after January 1, 1994.

SEC. 5034. CERTIFICATION OF SUPPLIERS.

    (a) Requirements.--
            (1) In general.--Section 1834 (42 U.S.C. 1395m) is amended 
        by adding at the end the following new subsection:
    ``(i) Requirements for Suppliers of Medical Equipment and 
Supplies.--
            ``(1) Issuance and renewal of supplier number.--
                    ``(A) Payment.--Except as provided in subparagraph 
                (C), no payment may be made under this part after 
                October 1, 1994, for items furnished by a supplier of 
                medical equipment and supplies unless such supplier 
                obtains (and renews at such intervals as the Secretary 
                may require) a supplier number.
                    ``(B) Standards for possessing a supplier number.--
                A supplier may not obtain a supplier number unless--
                            ``(i) for medical equipment and supplies 
                        furnished on or after October 1, 1994, and 
                        before January 1, 1996, the supplier meets 
                        standards prescribed by the Secretary; and
                            ``(ii) for medical equipment and supplies 
                        furnished on or after January 1, 1996, the 
                        supplier meets revised standards prescribed by 
                        the Secretary (in consultation with 
                        representatives of suppliers of medical 
                        equipment and supplies, carriers, and 
                        consumers) that shall include requirements that 
                        the supplier--
                                    ``(I) comply with all applicable 
                                State and Federal licensure and 
                                regulatory requirements;
                                    ``(II) maintain a physical facility 
                                on an appropriate site;
                                    ``(III) have proof of appropriate 
                                liability insurance; and
                                    ``(IV) meet such other requirements 
                                as the Secretary may specify.
                    ``(C) Exception for items furnished as incident to 
                a physician's service.--Subparagraph (A) shall not 
                apply with respect to medical equipment and supplies 
                furnished as an incident to a physician's service.
                    ``(D) Prohibition against multiple supplier 
                numbers.--The Secretary may not issue more than one 
                supplier number to any supplier of medical equipment 
                and supplies unless the issuance of more than one 
                number is appropriate to identify subsidiary or 
                regional entities under the supplier's ownership or 
                control.
                    ``(E) Prohibition against delegation of supplier 
                determinations.--The Secretary may not delegate (other 
                than by contract under section 1842) the responsibility 
                to determine whether suppliers meet the standards 
                necessary to obtain a supplier number.
            ``(2) Certificates of medical necessity.--
                    ``(A) Standardized certificates.--Not later than 
                October 1, 1994, the Secretary shall, in consultation 
                with carriers under this part, develop one or more 
                standardized certificates of medical necessity (as 
                defined in subparagraph (C)) for medical equipment and 
                supplies for which the Secretary determines that such a 
                certificate is necessary.
                    ``(B) Prohibition against distribution by suppliers 
                of certificates of medical necessity.--
                            ``(i) In general.--Except as provided in 
                        clause (ii), a supplier of medical equipment 
                        and supplies may not distribute to physicians 
                        or to individuals entitled to benefits under 
                        this part for commercial purposes any completed 
                        or partially completed certificates of medical 
                        necessity on or after October 1, 1994.
                            ``(ii) Exception for certain billing 
                        information.--Clause (i) shall not apply with 
                        respect to a certificate of medical necessity 
                        for any item that is not contained on the list 
                        of potentially overused items developed by the 
                        Secretary under subsection (a)(15)(A) to the 
                        extent that such certificate contains only 
                        information completed by the supplier of 
                        medical equipment and supplies identifying such 
                        supplier and the beneficiary to whom such 
                        medical equipment and supplies are furnished, a 
                        description of such medical equipment and 
                        supplies, any product code identifying such 
                        medical equipment and supplies, and any other 
                        administrative information (other than 
                        information relating to the beneficiary's 
                        medical condition) identified by the Secretary. 
                        In the event a supplier provides a certificate 
                        of medical necessity containing information 
                        permitted under this clause, such certificate 
                        shall also contain the fee schedule amount and 
                        the supplier's charge for the medical equipment 
                        or supplies being furnished prior to 
                        distribution of such certificate to the 
                        physician.
                            ``(iii) Penalty.--Any supplier of medical 
                        equipment and supplies who knowingly and 
                        willfully distributes a certificate of medical 
                        necessity in violation of clause (i) is subject 
                        to a civil money penalty in an amount not to 
                        exceed $1,000 for each such certificate of 
                        medical necessity so distributed. The 
                        provisions of section 1128A (other than 
                        subsections (a) and (b)) shall apply to civil 
                        money penalties under this subparagraph in the 
                        same manner as they apply to a penalty or 
                        proceeding under section 1128A(a).
                    ``(C) Definition.--For purposes of this paragraph, 
                the term `certificate of medical necessity' means a 
                form or other document containing information required 
                by the Secretary to be submitted to show that a covered 
                item is reasonable and necessary for the diagnosis or 
                treatment of illness or injury or to improve the 
                functioning of a malformed body member.
    ``(3) Coverage and review criteria.--
                    ``(A) Development and establishment.--Not later 
                than January 1, 1996, the Secretary, in consultation 
                with representatives of suppliers of medical equipment 
                and supplies, individuals enrolled under this part, and 
                appropriate medical specialty societies, shall develop 
                and establish uniform national coverage and utilization 
                review criteria for 200 items of medical equipment and 
                supplies selected in accordance with the standards 
                described in subparagraph (B). The Secretary shall 
                publish the criteria as part of the instructions 
                provided to fiscal intermediaries and carriers under 
                this part and no further publication, including 
                publication in the Federal Register, shall be required.
                    ``(B) Standards for selecting items subject to 
                criteria.--The Secretary may select an item for 
                coverage under the criteria developed and established 
                under subparagraph (A) if the Secretary finds that--
                            ``(i) the item is frequently purchased or 
                        rented by beneficiaries;
                            ``(ii) the item is frequently subject to a 
                        determination that such item is not medically 
                        necessary; or
                            ``(iii) the coverage or utilization 
                        criteria applied to the item (as of the date of 
                        the enactment of this subsection) is not 
                        consistent among carriers.
                    ``(C) Annual review and expansion of items subject 
                to criteria.--The Secretary shall annually review the 
                coverage and utilization of items of medical equipment 
                and supplies to determine whether items not included 
                among the items selected under subparagraph (A) should 
                be made subject to uniform national coverage and 
                utilization review criteria, and, if appropriate, shall 
                develop and apply such criteria to such additional 
                items.
            ``(4) Definition.--The term `medical equipment and 
        supplies' means--
                    ``(A) durable medical equipment (as defined in 
                section 1861(n));
                    ``(B) prosthetic devices (as described in section 
                1861(s)(8));
                    ``(C) orthotics and prosthetics (as described in 
                section 1861(s)(9));
                    ``(D) surgical dressings (as described in section 
                1861(s)(5));
                    ``(E) such other items as the Secretary may 
                determine; and
                    ``(F) for purposes of paragraphs (1) and (3)--
                            ``(i) home dialysis supplies and equipment 
                        (as described in section 1861(s)(2)(F)), and
                            ``(ii) immunosuppressive drugs (as 
                        described in section 1861(s)(2)(J)).''.
            (2) Conforming amendment.--Effective October 1, 1994, 
        paragraph (16) of section 1834(a) (42 U.S.C. 1395m(a)) is 
        repealed.
    (b) Report on effect of uniform criteria on utilization of items.--
Not later than July 1, 1996, the Secretary shall submit a report to the 
Committee on Ways and Means and the Committee on Energy and Commerce of 
the House of Representatives and the Committee on Finance of the Senate 
analyzing the impact of the uniform criteria established under section 
1834(i)(3)(A) of the Social Security Act (as added by subsection (a)) 
on the utilization of items of medical equipment and supplies by 
individuals enrolled under part B of the medicare program.
    (c) Use of Covered Items by Disabled Beneficiaries.--
            (1) In general.--The Secretary of Health and Human 
        Services, in consultation with representatives of suppliers of 
        durable medical equipment under part B of the medicare program 
        and individuals entitled to benefits under such program on the 
        basis of disability, shall conduct a study of the effects of 
        the methodology for determining payments for items of such 
        equipment under such part on the ability of such individuals to 
        obtain items of such equipment, including customized items.
            (2) Report.--Not later than one year after the date of the 
        enactment of this Act, the Secretary shall submit a report to 
        Congress on the study conducted under paragraph (1), and shall 
        include in the report such recommendations as the Secretary 
        considers appropriate to assure that disabled medicare 
        beneficiaries have access to items of durable medical 
        equipment.
    (d) Criteria for Treatment of Items as Prosthetics Devices or 
Orthotics and Prosthetics.--Not later than one year after the date of 
the enactment of this Act, the Secretary of Health and Human Services 
shall submit a report to the Committees on Ways and Means and Energy 
and Commerce of the House of Representatives and the Committee on 
Finance of the Senate describing prosthetic devices or orthotics and 
prosthetics covered under part B of the medicare program that do not 
require individualized or custom fitting and adjustment to be used by a 
patient. Such report shall include recommendations for an appropriate 
methodology for determining the amount of payment for such items under 
such program.

SEC. 5035. PROHIBITION AGAINST CARRIER FORUM SHOPPING.

    (a) In General.--Section 1834(a)(12) (42 U.S.C. 1395m(a)(12)) is 
amended to read as follows:
            ``(12) Use of carriers to process claims.--
                    ``(A) Designation of regional carriers.--The 
                Secretary may designate, by regulation under section 
                1842, one carrier for one or more entire regions to 
                process all claims within the region for covered items 
                under this section.
                    ``(B) Prohibition against carrier shopping.--(i) No 
                supplier of a covered item may present or cause to be 
                presented a claim for payment under this part unless 
                such claim is presented to the appropriate regional 
                carrier (as designated by the Secretary).
                    ``(ii) For purposes of clause (i), the term 
                `appropriate regional carrier' means the carrier having 
                jurisdiction over the geographic area that includes the 
                permanent residence of the patient to whom the item is 
                furnished.''.
    (b) Effective Date.--The amendment made by subsection (a) shall 
apply to items furnished on or after October 1, 1993.
    (c) Clarification of Authority to Designate Carriers for Other 
Items and Services.--Nothing in this subsection or the amendment made 
by this subsection may be construed to restrict the authority of the 
Secretary of Health and Human Services to designate regional carriers 
or modify claims jurisdiction rules with respect to items or services 
under part B of the medicare program that are not covered items under 
section 1834(a) of the Social Security Act or prosthetic devices or 
orthotics and prosthetics under section 1834(h) of such Act.

SEC. 5036. RESTRICTIONS ON CERTAIN MARKETING AND SALES ACTIVITIES.

    (a) Prohibiting Unsolicited Telephone Contacts From Suppliers of 
Durable Medical Equipment to Medicare Beneficiaries.--
            (1) In general.--Section 1834(a) (42 U.S.C. 1395m(a)) is 
        amended by adding at the end the following new paragraph:
            ``(17) Prohibition against unsolicited telephone contacts 
        by suppliers.--
                    ``(A) In general.--A supplier of a covered item 
                under this subsection may not contact an individual 
                enrolled under this part by telephone regarding the 
                furnishing of a covered item to the individual (other 
                than a covered item the supplier has already furnished 
                to the individual) unless--
                            ``(i) the individual gives permission to 
                        the supplier to make contact by telephone for 
                        such purpose; or
                            ``(ii) the supplier has furnished a covered 
                        item under this subsection to the individual 
                        during the 15-month period preceding the date 
                        on which the supplier contacts the individual 
                        for such purpose.
                    ``(B) Prohibiting payment for items furnished 
                subsequent to unsolicited contacts.--If a supplier 
                knowingly contacts an individual in violation of 
                subparagraph (A), no payment may be made under this 
                part for any item subsequently furnished to the 
                individual by the supplier.
                    ``(C) Exclusion from program for suppliers engaging 
                in pattern of unsolicited contacts.--If a supplier 
                knowingly contacts individuals in violation of 
                subparagraph (A) to such an extent that the supplier's 
                conduct establishes a pattern of contacts in violation 
                of such subparagraph, the Secretary shall exclude the 
                supplier from participation in the programs under this 
                Act, in accordance with the procedures set forth in 
                subsections (c), (f), and (g) of section 1128.''.
            (2) Requiring refund of amounts collected for disallowed 
        items.--Section 1834(a) (42 U.S.C. 1395m(a)), as amended by 
        paragraph (1), is amended by adding at the end the following 
        new paragraph:
            ``(18) Refund of amounts collected for certain disallowed 
        items.--
                    ``(A) In general.--If a nonparticipating supplier 
                furnishes to an individual enrolled under this part a 
                covered item for which no payment may be made under 
                this part by reason of paragraph (17)(B), the supplier 
                shall refund on a timely basis to the patient (and 
                shall be liable to the patient for) any amounts 
                collected from the patient for the item, unless--
                            ``(i) the supplier establishes that the 
                        supplier did not know and could not reasonably 
                        have been expected to know that payment may not 
                        be made for the item by reason of paragraph 
                        (17)(B), or
                            ``(ii) before the item was furnished, the 
                        patient was informed that payment under this 
                        part may not be made for that item and the 
                        patient has agreed to pay for that item.
                    ``(B) Sanctions.--If a supplier knowingly and 
                willfully fails to make refunds in violation of 
                subparagraph (A), the Secretary may apply sanctions 
                against the supplier in accordance with section 
                1842(j)(2).
                    ``(C) Notice.--Each carrier with a contract in 
                effect under this part with respect to suppliers of 
                covered items shall send any notice of denial of 
                payment for covered items by reason of paragraph 
                (17)(B) and for which payment is not requested on an 
                assignment-related basis to the supplier and the 
                patient involved.
                    ``(D) Timely basis defined.--A refund under 
                subparagraph (A) is considered to be on a timely basis 
                only if--
                            ``(i) in the case of a supplier who does 
                        not request reconsideration or seek appeal on a 
                        timely basis, the refund is made within 30 days 
                        after the date the supplier receives a denial 
                        notice under subparagraph (C), or
                            ``(ii) in the case in which such a 
                        reconsideration or appeal is taken, the refund 
                        is made within 15 days after the date the 
                        supplier receives notice of an adverse 
                        determination on reconsideration or appeal.''.
    (b) Conforming Amendment.--Section 1834(h)(3) (42 U.S.C. 
1395m(h)(3)) is amended by striking ``Paragraph (12)'' and inserting 
``Paragraphs (12) and (17)''.
    (c) Effective Date.--The amendments made by subsections (a) and (b) 
shall apply to items furnished after the expiration of the 60-day 
period that begins on the date of the enactment of this Act.

SEC. 5037. KICKBACK CLARIFICATION.

    (a) In General.--Section 1128B(b)(3)(B) (42 U.S.C. 1320a-
7b(b)(3)(B)) is amended by inserting before the semicolon the 
following: ``(except that in the case of a contract supply arrangement 
between any entity and a supplier of medical supplies and equipment (as 
defined in section 1834(i)(4), but not including items described in 
subparagraph (F) of such section), such employment shall not be 
considered bona fide to the extent that it includes tasks of a clerical 
and cataloging nature in transmitting to suppliers assignment rights of 
individuals eligible for benefits under part B of title XVIII, or 
performance of warehousing or stock inventory functions)''.
    (b) Effective Date.--The amendment made by subsection (a) shall 
apply with respect to services furnished on or after the first day of 
the first month that begins after the expiration of the 60-day period 
beginning on the date of the enactment of this Act.

SEC. 5038. BENEFICIARY LIABILITY FOR NONCOVERED SERVICES.

    (a) Unassigned Claims.--
            (1) In general.--Section 1834(i) (42 U.S.C. 1395m(i)), as 
        added by section 5034(a)(1), is amended--
                    (A) by redesignating paragraph (4) as paragraph 
                (5), and
                    (B) by inserting after paragraph (3) the following 
                new paragraph:
            ``(4) Limitation on patient liability.--If a supplier of 
        medical equipment and supplies (as defined in paragraph (5))--
                    ``(A) furnishes an item or service to a beneficiary 
                for which no payment may be made by reason of paragraph 
                (1);
                    ``(B) furnishes an item or service to a beneficiary 
                for which payment is denied in advance under subsection 
                (a)(15); or
                    ``(C) furnishes an item or service to a beneficiary 
                for which payment is denied under section 1862(a)(1);
        any expenses incurred for items and services furnished to an 
        individual by such a supplier not on an assigned basis shall be 
        the responsibility of such supplier. The individual shall have 
        no financial responsibility for such expenses and the supplier 
        shall refund on a timely basis to the individual (and shall be 
        liable to the individual for) any amounts collected from the 
        individual for such items or services. The provisions of 
        subsection (a)(18) shall apply to refunds required under the 
        previous sentence in the same manner as such provisions apply 
        to refunds under such subsection.''.
            (2) Conforming amendment.--Section 1128B(b)(3)(B) (42 
        U.S.C. 1320a-7b(b)(3)(B)), as amended by section 5037(a), is 
        amended by striking ``1834(i)(4)'' and inserting 
        ``1834(i)(5)''.
    (b) Assigned Claims.--Section 1879 (42 U.S.C. 1395pp) is amended by 
adding at the end the following new subsection:
    ``(h) If a supplier of medical equipment and supplies (as defined 
in section 1834(i)(4))--
            ``(1) furnishes an item or service to a beneficiary for 
        which no payment may be made by reason of section 1834(i)(1); 
        or
            ``(2) furnishes an item or service to a beneficiary for 
        which payment is denied in advance under section 1834(a)(15);
any expenses incurred for items and services furnished to an individual 
by such a supplier on an assignment-related basis shall be the 
responsibility of such supplier. The individual shall have no financial 
responsibility for such expenses and the supplier shall refund on a 
timely basis to the individual (and shall be liable to the individual 
for) any amounts collected from the individual for such items or 
services. The provisions of section 1834(a)(18) shall apply to refunds 
required under the previous sentence in the same manner as such 
provisions apply to refunds under such section.''.
    (c) Effective Date.--The amendments made by this section shall 
apply to items or services furnished on or after October 1, 1994.

SEC. 5039. ADJUSTMENTS FOR INHERENT REASONABLENESS.

    (a) Adjustments Made to Final Payment Amounts.--
            (1) In general.--Section 1834(a)(10)(B) (42 U.S.C. 
        1395m(a)(10)(B)) is amended by adding at the end the following: 
        ``In applying such provisions to payments for an item under 
        this subsection, the Secretary shall make adjustments to the 
        payment basis for the item described in paragraph (1)(B) if the 
        Secretary determines (in accordance with such provisions and on 
        the basis of prices and costs applicable at the time the item 
        is furnished) that such payment basis is not inherently 
        reasonable.''.
            (2) Effective date.--The amendment made by paragraph (1) 
        shall take effect on the date of the enactment of this Act.
    (b) Adjustment Required for Certain Items.--
            (1) In general.--In accordance with section 1834(a)(10)(B) 
        of the Social Security Act (as amended by subsection (a)), the 
        Secretary of Health and Human Services shall determine whether 
        the payment amounts for the items described in paragraph (2) 
        are not inherently reasonable, and shall adjust such amounts in 
        accordance with such section if the amounts are not inherently 
        reasonable.
            (2) Items described.--The items referred to in paragraph 
        (1) are decubitus care equipment, transcutaneous electrical 
        nerve stimulators, and any other items considered appropriate 
        by the Secretary.

SEC. 5040. PAYMENT FOR SURGICAL DRESSINGS.

    (a) In General.--Section 1834 (42 U.S.C. 1395m), as amended by 
section 5034(a)(1), is amended by adding at the end the following new 
subsection:
    ``(j) Payment for Surgical Dressings.--
            ``(1) In general.--Payment under this subsection for 
        surgical dressings (described in section 1861(s)(5)) shall be 
        made in a lump sum amount for the purchase of the item in an 
        amount equal to 80 percent of the lesser of--
                    ``(A) the actual charge for the item; or
                    ``(B) a payment amount determined in accordance 
                with the methodology described in subparagraphs (B) and 
                (C) of subsection (a)(2) (except that in applying such 
                methodology, the national limited payment amount 
                referred to in such subparagraphs shall be initially 
                computed based on local payment amounts using average 
                reasonable charges for the 12-month period ending 
                December 31, 1992, increased by the covered item 
                updates described in such subsection for 1993 and 1994)
            ``(2) Exceptions.--Paragraph (1) shall not apply to 
        surgical dressings that are--
                    ``(A) furnished as an incident to a physician's 
                professional service; or
                    ``(B) furnished by a home health agency.''.
    (b) Conforming Amendment.--Section 1833(a)(1) (42 U.S.C. 
1395l(a)(1)), as amended by sections 5070(e)(2) and 5010(e)(1), is 
amended--
            (1) by striking ``and'' before ``(P)'', and
            (2) by inserting before the semicolon at the end the 
        following: ``, and (Q) with respect to surgical dressings, the 
        amounts paid shall be the amounts determined under section 
        1834(j);''.
    (c) Effective Date.--The amendments made by this section shall 
apply to items furnished on or after January 1, 1994.

SEC. 5041. PAYMENTS FOR TENS DEVICES.

    (a) In General.--Section 1834(a)(1)(D) (42 U.S.C. 1395m(a)(1)(D)) 
is amended by striking ``15 percent'' the second place it appears and 
inserting ``45 percent''.
    (b) Effective Date.--The amendment made by subsection (a) shall 
apply to items furnished on or after January 1, 1994.

SEC. 5042. MISCELLANEOUS AND TECHNICAL CORRECTIONS.

    (a) Updates to Payment Amounts.--Subparagraph (A) of section 
1834(a)(14) (42 U.S.C. 1395m(a)(14)) is amended to read as follows:
                    ``(A) for 1991 and 1992, the percentage increase in 
                the consumer price index for all urban consumers (U.S. 
                city average) for the 12-month period ending with June 
                of the previous year reduced by 1 percentage point; 
                and''.
    (b) Treatment of Potentially Overused Items and Advanced 
Determinations of Coverage.--(1) Effective on the date of the enactment 
of this Act, section 1834(a)(15) (42 U.S.C. 1395m(a)(15)) is amended to 
read as follows:
            ``(15) Special treatment for potentially overused items.--
                    ``(A) Development of list of items by secretary.--
                The Secretary shall develop and periodically update a 
                list of items for which payment may be made under this 
                subsection that are potentially overused, and shall 
                include in such list seat-lift mechanisms, 
                transcutaneous electrical nerve stimulators, motorized 
                scooters, decubitus care mattresses, and any such other 
                item determined by the Secretary to be potentially 
                overused on the basis of any of the following 
                criteria--
                            ``(i) the item is marketed directly to 
                        potential patients;
                            ``(ii) the item is marketed with an offer 
                        to potential patients to waive the costs of 
                        coinsurance associated with the item or is 
                        marketed as being available at no cost to 
                        policyholders of a medicare supplemental policy 
                        (as defined in section 1882(g)(1));
                            ``(iii) the item has been subject to a 
                        consistent pattern of overutilization; or
                            ``(iv) a high proportion of claims for 
                        payment for such item under this part may not 
                        be made because of the application of section 
                        1862(a)(1).
                    ``(B) Items subject to special carrier scrutiny.--
                Payment may not be made under this part for any item 
                contained in the list developed by the Secretary under 
                subparagraph (A) unless the carrier has subjected the 
                claim for payment for the item to special scrutiny or 
                has followed the procedures described in paragraph 
                (11)(C) with respect to the item.''.
    (2) Effective January 1, 1994, section 1834(a)(11) (42 U.S.C. 
1395m(a)) is amended by adding at the end the following new 
subparagraph:
                    ``(C) Carrier determinations for certain items in 
                advance.--A carrier shall determine in advance whether 
                payment for an item may not be made under this 
                subsection because of the application of section 
                1862(a)(1) if--
                            ``(i) the item is a customized item (other 
                        than inexpensive items specified by the 
                        Secretary); or
                            ``(ii) the item is a specified covered item 
                        under subparagraph (B).''.
    (3) Effective for standards applied for contract years beginning 
after the date of the enactment of this Act, section 1842(c) (42 U.S.C. 
1395u(c)), as amended by section 5013(a), is amended by adding at the 
end the following new paragraph:
    ``(5) Each contract under this section which provides for the 
disbursement of funds, as described in subsection (a)(1)(B), shall 
require the carrier to meet criteria developed by the Secretary to 
measure the timeliness of carrier responses to requests for payment of 
items described in section 1834(a)(11)(C).''.
    (4) Section 1834(h)(3) (42 U.S.C. 1395m(h)(3)) is amended by 
striking ``paragraph (10) and paragraph (11)'' and inserting 
``paragraphs (10) and (11)''.
    (c) Study of Variations in Durable Medical Equipment Supplier 
Costs.--
            (1) Collection and analysis of supplier cost data.--The 
        Administrator of the Health Care Financing Administration 
        shall, in consultation with appropriate organizations, collect 
        data on supplier costs of durable medical equipment for which 
        payment may be made under part B of the medicare program, and 
        shall analyze such data to determine the proportions of such 
        costs attributable to the service and product components of 
        furnishing such equipment and the extent to which such 
        proportions vary by type of equipment and by the geographic 
        region in which the supplier is located.
            (2) Development of geographic adjustment index; reports.--
        Not later than January 1, 1995--
                    (A) the Administrator shall submit a report to the 
                Committees on Energy and Commerce and Ways and Means of 
                the House of Representatives and the Committee on 
                Finance of the Senate on the data collected and the 
                analysis conducted under paragraph (1), and shall 
                include in such report the Administrator's 
                recommendations for a geographic cost adjustment index 
                for suppliers of durable medical equipment under the 
                medicare program and an analysis of the impact of such 
                proposed index on payments under the medicare program; 
                and
                    (B) the Comptroller General shall submit a report 
                to the Committees on Energy and Commerce and Ways and 
                Means of the House of Representatives and the Committee 
                on Finance of the Senate analyzing on a geographic 
                basis the supplier costs of durable medical equipment 
                under the medicare program.
    (d) Oxygen Retesting.--Section 1834(a)(5)(E) (42 U.S.C. 
1395m(a)(5)(E)) is amended by striking ``55'' and inserting ``56''.
    (e) Other Miscellaneous and Technical Amendments.--(1) Section 
4152(a)(3) of OBRA-1990 is amended by striking ``amendment made by 
subsection (a)'' and inserting ``amendments made by this subsection''.
    (2) Section 4152(c)(2) of OBRA-1990 is amended by striking 
``1395m(a)(7)(A)'' and inserting ``1395m(a)(7)''.
    (3) Section 1834(a)(7)(A)(iii)(II) (42 U.S.C. 
1395m(a)(7)(A)(iii)(II)) is amended by striking ``clause (v)'' and 
inserting ``clause (vi)''.
    (4) Section 1834(a)(7)(C)(i) (42 U.S.C. 1395m(a)(7)(C)(i)) is 
amended by striking ``or paragraph (3)''.
    (5) Section 1834(a)(3) (42 U.S.C. 1395m(a)(3)) is amended by 
striking subparagraph (D).
    (6) Section 4153(c)(1) of OBRA-1990 is amended by striking 
``1834(a)'' and inserting ``1834(h)''.
    (7) Section 4153(d)(2) of OBRA-1990 is amended by striking 
``Reconiliation'' and inserting ``Reconciliation''.
    (8)(A) Section 1834(a) (42 U.S.C. 1395m(a)) is amended by striking 
paragraph (6).
    (B) Section 1834(a) (42 U.S.C. 1395m(a)) is amended--
            (i) in subparagraphs (A) and (B) of paragraph (1), by 
        striking ``(2) through (7)'' each place it appears and 
        inserting ``(2) through (5) and (7)'';
            (ii) in paragraph (7), by striking ``(2) through (6)'' and 
        inserting ``(2) through (5)'';
            (iii) in paragraph (8), by striking ``paragraphs (6) and 
        (7)'' each place it appears in the matter preceding 
        subparagraph (A) and in subparagraph (C) and inserting 
        ``paragraph (7)''; and
            (iv) in paragraph (8)(A)(i), by striking ``described--'' 
        and all that follows and inserting ``described in paragraph (7) 
        equal to the average of the purchase prices on the claims 
        submitted on an assignment-related basis for the unused item 
        supplied during the 6-month period ending with December 
        1986.''.
    (9) The amendments made by this subsection shall take effect as if 
included in the enactment of OBRA-1990.

                      Subchapter D--Part B Premium

SEC. 5051. PART B PREMIUM.

    Section 1839(e) (42 U.S.C. 1395r(e)) is amended--
            (1) in paragraph (1)(A), by inserting ``and for each month 
        in 1996 and 1997'' after ``January 1991'', and
            (2) in paragraph (2), by striking ``1991'' and inserting 
        ``1998''.

                     Subchapter E--Other Provisions

SEC. 5061. PAYMENTS FOR CLINICAL DIAGNOSTIC LABORATORY TESTS.

    (a) Lower Cap.--Section 1833(h)(4)(B) (42 U.S.C. 1395l(h)(4)(B)) is 
amended--
            (1) by striking ``and'' at the end of clause (iii),
            (2) in clause (iv), by inserting ``and before January 1, 
        1994,'' after ``1990,'',
            (3) by striking the period at the end of clause (iv) and 
        inserting ``, and'', and
            (4) by adding at the end the following:
            ``(v) after December 31, 1993, is equal to 76 percent of 
        the median of all the fee schedules established for that test 
        for that laboratory setting under paragraph (1).''.
    (b) Two Percent Update for 1994 Through 1998.--Section 
1833(h)(2)(A)(ii)(III) (42 U.S.C. 1395l(h)(2)(A)(ii)(III)) is amended 
by striking ``1991, 1992, and 1993'' and inserting ``1991 through 
1998''.

SEC. 5062. TREATMENT OF INPATIENTS AND PROVISION OF DIAGNOSTIC AND 
              THERAPEUTIC X-RAY SERVICES BY RURAL HEALTH CLINICS AND 
              FEDERALLY QUALIFIED HEALTH CENTERS.

    (a) Treatment of Inpatients.--Section 1861(aa) (42 U.S.C. 
1395x(aa)) is amended--
            (1) in paragraph (1), in the matter following subparagraph 
        (C), by striking ``as an outpatient'' and inserting ``as a 
        patient'';
            (2) in paragraph (2)(A), by striking ``furnishing to 
        outpatients'' and inserting ``furnishing to patients''; and
            (3) in paragraph (3), in the matter following subparagraph 
        (B), by striking ``as an outpatient'' and inserting ``as a 
        patient''.
    (b) Treatment of Diagnostic and Therapeutic X-Ray Services.--
Section 1861(aa) (42 U.S.C. 1395x(aa)) is further amended--
            (1) in paragraph (1)(A), by inserting ``(i)'' after ``(A)'' 
        and by adding at the end the following: ``and (ii) diagnostic 
        and therapeutic x-ray services,'', and
            (2) in paragraph (2)(A), by striking ``(A)'' and inserting 
        ``(A)(i)''.
    (c) Conforming Amendment.--Section 1862(a)(14) (42 U.S.C. 
1395y(a)(14)) is amended by striking ``and services of a certified 
registered nurse anesthetist'' and inserting ``services of a certified 
registered nurse anesthetist, rural health clinic services, and 
Federally-qualified health center services''.
    (d) Effective Date.--The amendments made by this section shall take 
effect on January 1, 1994, and shall apply to services furnished on or 
after such date.

SEC. 5063. APPLICATION OF MAMMOGRAPHY CERTIFICATION REQUIREMENTS.

    (a) Screening Mammography.--Section 1834(c) (42 U.S.C. 1395m(c)) is 
amended--
            (1) in paragraph (1)(B), by striking ``meets the quality 
        standards established under paragraph (3)'' and inserting ``is 
        conducted by a facility that has a certificate (or provisional 
        certificate) issued under section 354 of the Public Health 
        Service Act'';
            (2) in paragraph (1)(C)(iii), by striking ``paragraph (4)'' 
        and inserting ``paragraph (3)'';
            (3) by striking paragraph (3); and
            (4) by redesignating paragraphs (4) and (5) as paragraphs 
        (3) and (4).
    (b) Diagnostic Mammography.--Section 1861(s)(3) (42 U.S.C. 
1395x(s)(3)) is amended by inserting ``and including diagnostic 
mammography if conducted by a facility that has a certificate (or 
provisional certificate) issued under section 354 of the Public Health 
Service Act'' after ``necessary''.
    (c) Conforming Amendments.--(1) Section 1862(a)(1)(F) (42 U.S.C. 
1395y(a)(1)(F)) is amended by striking ``or which does not meet the 
standards established under section 1834(c)(3)'' and inserting ``or 
which is not conducted by a facility described in section 
1834(c)(1)(B)''.
    (2) Section 1863 (42 U.S.C. 1395z) is amended by striking ``or 
whether screening mammography meets the standards established under 
section 1834(c)(3),''.
    (3) The first sentence of section 1864(a) (42 U.S.C. 1395aa(a)) is 
amended by striking ``, or whether screening mammography meets the 
standards established under section 1834(c)(3)''.
    (4) The third sentence of section 1865(a) (42 U.S.C. 1395bb(a)) is 
amended by striking ``1834(c)(3),''.
    (d) Effective Date.--The amendments made by this section shall 
apply to mammography furnished by a facility on and after the first 
date that the certificate requirements of section 354(b) of the Public 
Health Service Act apply to such mammography conducted by such 
facility.

SEC. 5064. EXTENSION OF ALZHEIMER'S DISEASE DEMONSTRATION.

    Section 9342 of OBRA-1986, as amended by section 4164(a)(2) of 
OBRA-1990, is amended--
            (1) in subsection (c)(1), by striking ``4 years'' and 
        inserting ``5 years''; and
            (2) in subsection (f)--
                    (A) by striking ``$55,000,000'' and inserting 
                ``$60,000,000'', and
                    (B) by striking ``$3,000,000'' and inserting 
                ``$5,000,000''.

SEC. 5065. ORAL CANCER DRUGS.

    (a) Coverage of Certain Self-Administered Anticancer Drugs.--
Section 1861(s)(2) (42 U.S.C. 1395(s)(2)), as amended by section 
5070(f)(7)(B), is amended--
            (1) by striking ``and'' at the end of subparagraph (N);
            (2) by adding ``and'' at the end of subparagraph (O); and
            (3) by adding at the end the following new subparagraph:
            ``(P) an oral drug (which is approved by the Federal Food 
        and Drug Administration) prescribed for use as an anticancer 
        chemotherapeutic agent for a given indication, and containing 
        an active ingredient (or ingredients), which is the same 
        indication and active ingredient (or ingredients) as a drug 
        which the carrier determines would be covered pursuant to 
        subparagraph (A) or (B) if the drug could not be self-
        administered;''.
    (b) Effective Date.--The amendments made by this section shall 
apply to items furnished on or after January 1, 1994.

SEC. 5066. EXTENSION OF MUNICIPAL HEALTH SERVICE DEMONSTRATION 
              PROJECTS.

    Section 9215 of the Consolidated Omnibus Budget Reconciliation Act 
of 1985, as amended by section 6135 of OBRA-1989, is amended--
            (1) by striking ``December 31, 1993'' and inserting 
        ``December 31, 1997'', and
            (2) in the second sentence, by inserting after 
        ``beneficiary costs,'' the following: ``costs to the medicaid 
        program and other payors, access to care, outcomes, beneficiary 
        satisfaction, utilization differences among the different 
        populations served by the projects,''.

SEC. 5067. TREATMENT OF CERTAIN INDIAN HEALTH PROGRAMS AND FACILITIES 
              AS FEDERALLY-QUALIFIED HEALTH CENTERS.

    (a) In General.--Section 1861(aa)(4) (42 U.S.C. 1395x(aa)(4)) is 
amended--
            (1) by striking ``or'' at the end of subparagraph (B);
            (2) by striking the period at the end of subparagraph (C) 
        and inserting ``; or''; and
            (3) by adding at the end the following new subparagraph:
            ``(D) is an outpatient health program or facility operated 
        by a tribe or tribal organization under the Indian Self-
        Determination Act or by an urban Indian organization receiving 
        funds under title V of the Indian Health Care Improvement 
        Act.''.
    (b) Effective Date.--The amendment made by subsection (a) shall 
take effect as if included in the enactment of section 4161(a)(2)(C) of 
OBRA-1990.

SEC. 5068. INTEREST PAYMENTS.

    (a) In General.--Section 1842(c)(2)(B)(ii)(IV) of the Social 
Security Act shall be applied with respect to paper claims received in 
the 9-month period beginning January 1, 1993, by substituting ``27 
calendar days'' for ``24 calendar days'' and ``17 calendar days''.
    (b) Prohibiting Payment of Interest During Mandatory Payment Delay 
Period.--Section 1842(c)(2)(C) (42 U.S.C. 1395u(c)(2)(C)) is amended by 
adding at the end the following: ``Notwithstanding any other provision 
of law, no interest may be paid with respect to a claim pursuant to the 
preceding sentence within any period following the submission of the 
claim during which no payment may be issued, mailed, or otherwise 
transmitted with respect to the claim.''.

SEC. 5069. CLARIFICATION OF COVERAGE OF CERTIFIED NURSE-MIDWIFE 
              SERVICES PERFORMED OUTSIDE THE MATERNITY CYCLE.

    (a) In General.--Section 1861(gg)(2) (42 U.S.C. 1395x(gg)(2)) is 
amended by striking ``, and performs services'' and all that follows 
and inserting a period.
    (b) Effective Date.--The amendment made by subsection (a) shall 
apply to services furnished on or after January 1, 1994.

SEC. 5069A. INCREASE IN, AND STUDY OF, ANNUAL CAP ON AMOUNT OF MEDICARE 
              PAYMENT FOR OUTPATIENT PHYSICAL THERAPY AND OCCUPATIONAL 
              THERAPY SERVICES.

    (a) Increase in Annual Limitation.--Section 1833(g) (42 U.S.C. 
1395l(g)) is amended by striking ``$750'' and inserting ``$900'' each 
place it appears.
    (b) Study.--(1) The Physician Payment Review Commission shall 
conduct a study of the appropriateness of continuing an annual 
limitation on the amount of payment for outpatient services of 
independently practicing physical and occupational therapists under the 
medicare program.
    (2) By not later than January 1, 1995, the Commission shall submit 
to the Committees on Energy and Commerce and Ways and Means of the 
House of Representatives and the Committee on Finance of the Senate a 
report on the study conducted under paragraph (1). Such report shall 
include such recommendations for changes in such annual limitation as 
the Commission finds appropriate.
    (c) Effective Date.--The amendment made by subsection (a) shall 
apply to services furnished on or after January 1, 1994.

SEC. 5070. MISCELLANEOUS AND TECHNICAL CORRECTIONS.

    (a) Revision of Information on Part B Claims Forms.--Section 
1833(q)(1) (42 U.S.C. 1395l(q)(1)) is amended--
            (1) by striking ``provider number'' and inserting ``unique 
        physician identification number''; and
            (2) by striking ``and indicate whether or not the referring 
        physician is an interested investor (within the meaning of 
        section 1877(h)(5))''.
    (b) Consultation for Social Workers.--Effective with respect to 
services furnished on or after January 1, 1991, section 6113(c) of 
OBRA-1989 is amended--
            (1) by inserting ``and clinical social worker services'' 
        after ``psychologist services''; and
            (2) by striking ``psychologist'' the second and third place 
        it appears and inserting ``psychologist or clinical social 
        worker''.
    (c) Reports on Hospital Outpatient Payment.--(1) OBRA-1989 is 
amended by striking section 6137.
    (2) Section 1135(d) (42 U.S.C. 1320b-5(d)) is amended--
            (A) by striking paragraph (6); and
            (B) in paragraph (7)--
                    (i) by striking ``systems'' each place it appears 
                and inserting ``system''; and
                    (ii) by striking ``paragraphs (1) and (6)'' and 
                inserting ``paragraph (1)''.
    (d) Radiology and Diagnostic Services Provided in Hospital 
Outpatient Departments.--(1) Effective as if included in the enactment 
of OBRA-1989, section 1833(n)(1)(B)(i)(II) (42 U.S.C. 
1395l(n)(1)(B)(i)(II)) is amended--
            (A) by striking ``1989'' and inserting ``1989 and for 
        services described in subsection (a)(2)(E)(ii) furnished on or 
        after January 1, 1992''; and
            (B) by striking ``1842(b)'' and inserting ``1842(b) (or, in 
        the case of services furnished on or after January 1, 1992, 
        under section 1848)''.
    (2) Effective as if included in the enactment of OBRA-1989, section 
1833(n)(1)(B)(i)(II) (42 U.S.C. 1395l(n)(1)(B)(i)(II)) is amended by 
striking ``January 1, 1989'' and inserting ``April 1, 1989''.
    (e) Payments to Nurse Practitioners in Rural Areas (Section 4155 of 
OBRA-1990).--(1) Section 1861(s)(2)(K)(iii) (42 U.S.C. 
1395x(s)(2)(K)(iii)) is amended--
            (A) by striking ``subsection (aa)(3)'' and inserting 
        ``subsection (aa)(5)''; and
            (B) by striking ``subsection (aa)(4)'' and inserting 
        ``subsection (aa)(6)''.
    (2) Section 1833(a)(1) (42 U.S.C. 1395l(a)(1)) is amended--
            (A) by striking ``and'' before ``(N)''; and
            (B) with respect to the matter inserted by section 
        4155(b)(2)(B) of OBRA-1990--
                    (i) by striking ``(M)'' and inserting ``, and 
                (O)'', and
                    (ii) by transferring and inserting it (as amended) 
                immediately before the semicolon at the end.
    (3) Section 1833(r)(1) (42 U.S.C. 1395l(r)(1)) is amended--
            (A) by striking ``ambulatory'' each place it appears and 
        inserting ``or ambulatory''; and
            (B) by striking ``center,'' and inserting ``center''.
    (4) Section 1833(r)(2)(A) (42 U.S.C. 1395l(r)(2)(A)) is amended by 
striking ``subsection (a)(1)(M)'' and inserting ``subsection 
(a)(1)(O)''.
    (5) Section 1861(b)(4) (42 U.S.C. 1395x(b)(4)) is amended by 
striking ``subsection (s)(2)(K)(i)'' and inserting ``clauses (i) or 
(iii) of subsection (s)(2)(K)''.
    (6) Section 1861(aa)(5) (42 U.S.C. 1395x(aa)(5)) is amended by 
striking ``this Act'' and inserting ``this title''.
    (7) Section 1862(a)(14) (42 U.S.C. 1395y(a)(14)) is amended by 
striking ``1861(s)(2)(K)(i)'' and inserting ``1861(s)(2)(K)(i) or 
1861(s)(2)(K)(iii)''.
    (8) Section 1866(a)(1)(H) (42 U.S.C. 1395cc(a)(1)(H)) is amended by 
striking ``1861(s)(2)(K)(i)'' and inserting ``1861(s)(2)(K)(i) or 
1861(s)(2)(K)(iii)''.
    (f) Other Miscellaneous and Technical Amendments.--
            (1) Immediate enrollment in part b by individuals covered 
        by an employment-based plan.--(A) Subparagraphs (A) and (B) of 
        section 1837(i)(3) (42 U.S.C. 1395p(i)(3)) are each amended--
                    (i) by striking ``beginning with the first day of 
                the first month in which the individual is no longer 
                enrolled'' and inserting ``including each month during 
                any part of which the individual is enrolled''; and
                    (ii) by striking ``and ending seven months later'' 
                and inserting ``ending with the last day of the eighth 
                consecutive month in which the individual is at no time 
                so enrolled''.
            (B) Paragraphs (1) and (2) of section 1838(e) (42 U.S.C. 
        1395q(e)) are amended to read as follows:
            ``(1) in any month of the special enrollment period in 
        which the individual is at any time enrolled in a plan 
        (specified in subparagraph (A) or (B), as applicable, of 
        section 1837(i)(3)) or in the first month following such a 
        month, the coverage period shall begin on the first day of the 
        month in which the individual so enrolls (or, at the option of 
        the individual, on the first day of any of the following three 
        months), or
            ``(2) in any other month of the special enrollment period, 
        the coverage period shall begin on the first day of the month 
        following the month in which the individual so enrolls.''.
            (C) The amendments made by subparagraphs (A) and (B) shall 
        take effect on the first day of the first month that begins 
        after the expiration of the 120-day period that begins on the 
        date of the enactment of this Act.
            (2) Blend amounts for ambulatory surgical center 
        payments.--Subclauses (I) and (II) of section 1833(i)(3)(B)(ii) 
        (42 U.S.C. 1395l(i)(3)(B)(ii)) are each amended--
                    (A) by striking ``for reporting'' and inserting 
                ``for portions of cost reporting''; and
                    (B) by striking ``and on or before'' and inserting 
                ``and ending on or before''.
            (3) Clinical diagnostic laboratory tests (section 4154 of 
        obra-1990).--Section 4154(e)(5) of OBRA-1990 is amended by 
        striking ``(1)(A)'' and inserting ``(1)(A),''.
            (4) Separate payment under part b for certain services 
        (section 4157 of obra-1990).--Section 4157(a) of OBRA-1990 is 
        amended by striking ``(a) Services of'' and all that follows 
        through ``Section'' and inserting ``(a) Treatment of Services 
        of Certain Health Practitioners.--Section''.
            (5) Community health centers and rural health clinics 
        (section 4161 of obra-1990).--(A) The fourth sentence of 
        section 1861(aa)(2) (42 U.S.C. 1395x(aa)(2)) is amended--
                    (i) by striking ``certification'' the first place 
                it appears and inserting ``approval''; and
                    (ii) by striking ``the Secretary's approval or 
                disapproval of the certification'' and inserting 
                ``Secretary's approval or disapproval''.
            (B) Section 4161(a)(7)(B) of OBRA-1990 is amended by 
        inserting ``and to the Committee on Finance of the Senate'' 
        after ``Representatives''.
            (6) Screening mammography (section 4163 of obra-1990).--
        Section 4163 of OBRA-1990 is amended--
                    (A) by adding at the end of subsection (d) the 
                following new paragraph:
            ``(3) The amendment made by paragraph (2)(A)(iv) shall 
        apply to screening pap smears performed on or after July 1, 
        1990.''; and
                    (B) in subsection (e), by striking ``The 
                amendments'' and inserting ``Except as provided in 
                subsection (d)(3), the amendments.''.
            (7) Injectable drugs for treatment of osteoporosis.--
                    (A) Clarification of drugs covered.--The section 
                1861(jj) (42 U.S.C. 1395x(jj)) inserted by section 
                4156(a)(2) of OBRA-1990 is amended--
                            (i) in the matter preceding paragraph (1), 
                        by striking ``a bone fracture related to''; and
                            (ii) in paragraph (1), by striking 
                        ``patient'' and inserting ``individual has 
                        suffered a bone fracture related to post-
                        menopausal osteoporosis and that the 
                        individual''.
                    (B) Limiting coverage to drugs provided by home 
                health agencies.--(i) The section 1861(jj) (42 U.S.C. 
                1395x(jj)) inserted by section 4156(a)(2) of OBRA-1990 
                is amended by striking ``if'' and inserting ``by a home 
                health agency if''.
                    (ii) Section 1861(m)(5) (42 U.S.C. 1395x(m)(5)) is 
                amended by striking ``but excluding'' and inserting 
                ``and a covered osteoporosis drug (as defined in 
                subsection (kk), but excluding other''.
                    (iii) Section 1861(s)(2) (42 U.S.C. 1395x(s)(2)) is 
                amended--
                            (I) by adding ``and'' at the end of 
                        subparagraph (N), and
                            (II) by striking subparagraph (O) and 
                        redesignating subparagraph (P) as subparagraph 
                        (O).
                    (C) Payment based on reasonable cost.--Section 
                1833(a)(2) (42 U.S.C. 1395l(a)(2)) is amended--
                            (i) in subparagraph (A), by striking 
                        ``health services'' and inserting ``health 
                        services (other than covered osteoporosis drug 
                        (as defined in section 1861(kk)))'';
                            (ii) by striking ``and'' at the end of 
                        subparagraph (D);
                            (iii) by striking the semicolon at the end 
                        and inserting ``; and''; and
                            (iv) by adding at the end the following new 
                        subparagraph:
                    ``(F) with respect to covered osteoporosis drug (as 
                defined in section 1861(kk)) furnished by a home health 
                agency, 80 percent of the reasonable cost of such 
                service, as determined under section 1861(v);''.
                    (D) Application of part b deductible.--Section 
                1833(b)(2) (42 U.S.C. 1395l(b)(2)) is amended by 
                striking ``services'' and inserting ``services (other 
                than covered osteoporosis drug (as defined in section 
                1861(kk)))''.
                    (E) Covered osteoporosis drug (section 4156 of 
                obra-1990).--Section 1861 (42 U.S.C. 1395x) is amended, 
                in the subsection (jj) inserted by section 4156(a)(2) 
                of OBRA-1990, by striking ``(jj) The term'' and 
                inserting ``(kk) The term''.
            (8) Other miscellaneous and technical corrections (section 
        4164 of obra-1990).--
                    (A) Ownership disclosure requirements.--(i) Section 
                1124A(a)(2)(A) (42 U.S.C. 1320a-3a(a)(2)(A)) is amended 
                by striking ``of the Social Security Act''.
                    (ii) Section 4164(b)(4) of OBRA-1990 is amended by 
                striking ``paragraph'' and inserting ``paragraphs''.
                    (B) Directory of unique physician identifier 
                numbers.--Section 4164(c) of OBRA-1990 is amended by 
                striking ``publish'' and inserting ``publish, and shall 
                periodically update,''.
    (g) Effective Date.--Except as otherwise provided in this section, 
the amendments made by this section shall take effect as if included in 
the enactment of OBRA-1990.

            CHAPTER 2--PROVISIONS RELATING TO PARTS A AND B

SEC. 5071. ELIMINATION OF ADD-ON FOR OVERHEAD OF HOSPITAL-BASED HOME 
              HEALTH AGENCIES.

    (a) General Rule.--The first sentence of section 1861(v)(1)(L)(ii) 
(42 U.S.C. 1395x(v)(1)(L)(ii)) is amended by striking ``, with 
appropriate adjustment for administrative and general costs of 
hospital-based agencies''.
    (b) Effective Date.--The amendment made by subsection (a) applies 
to cost reporting periods beginning after fiscal year 1993.

SEC. 5072. STUDY AND REPORT ON MEDICARE GME PAYMENTS.

    (a) Study.--The Secretary of Health and Human Services shall 
conduct a study of the methodology used to determine payments to 
hospitals under the medicare program for the costs of medical residency 
training programs and shall include in the study an analysis of the 
causes of variation among such programs in the per resident costs of 
direct graduate medical education, including the extent of support for 
such programs from non-hospital sources.
    (b) Report.--Not later than 1 year after the date of the enactment 
of this Act, the Secretary shall submit a report to Congress on the 
study conducted under subsection (a), and shall include in the report 
any recommendations considered appropriate by the Secretary for 
modifications to the methodology used to determine payments to 
hospitals under the medicare program for the costs of medical residency 
training programs that will encourage greater uniformity among medical 
residency training programs in the per resident costs of direct 
graduate medical education.

SEC. 5073. MEDICARE AS SECONDARY PAYER.

    (a) Extension of Data Match Program.--Section 1862(b)(5)(C)(iii) 
(42 U.S.C. 1395y(b)(5)(C)(iii)) is amended by striking ``1995'' and 
inserting ``1998''.
    (b) Permanent Application to Disabled Individuals.--Section 
1862(b)(1)(B) (42 U.S.C. 1395y(b)(1)(B)) is amended by striking clause 
(iii).
    (c) Application of ESRD Rules to Certain Aged and Disabled 
Beneficiaries and Extension of Application of 18-Month Rule.--
            (1) Subparagraphs (A)(iv) and (B)(ii) of section 1862(b)(1) 
        (42 U.S.C. 1395y(b)(1)) are each amended--
                    (A) by striking ``Clause (i) shall not apply'' and 
                inserting ``Subparagraph (C) shall apply instead of 
                clause (i)'', and
                    (B) by inserting ``(without regard to entitlement 
                under section 226)'' after ``or'' the second place it 
                appears.
            (2) The second sentence of section 1862(b)(1)(C) is amended 
        by striking ``on or before January 1, 1996'' and inserting 
        ``before October 1, 1998''.
    (d) Uniform Rules for Size of Employer.--
            (1) In general.--Section 1862(b)(1) (42 U.S.C. 1395y(b)(1)) 
        is amended by adding at the end the following:
                    ``(E) General provisions.--
                            ``(i) Exclusion of group health plan of a 
                        small employer.--Subparagraphs (A) through (C) 
                        do not apply to a group health plan unless the 
                        plan is a plan of, or contributed to by, an 
                        employer or employee organization that has 20 
                        or more individuals in current employment 
                        status for each working day in each of 20 or 
                        more calendar weeks in the current calendar 
                        year or the preceding calendar year.
                            ``(ii) Exception for small employers in 
                        multiemployer or multiple employer group health 
                        plans.--Subparagraphs (A) through (C) also do 
                        not apply with respect to individuals enrolled 
                        in a multiemployer or multiple employer group 
                        health plan if the coverage of the individuals 
                        under the plan is by virtue of current 
                        employment status with an employer that does 
                        not have 20 or more individuals in current 
                        employment status for each working day in each 
                        of 20 or more calendar weeks in the current 
                        calendar year and the preceding calendar year; 
                        but the exception provided in this clause 
                        applies only if the plan elects treatment under 
                        this clause.
                            ``(iii) Application of controlled group 
                        rules.--For purposes of clauses (i) and (ii)--
                                    ``(I) all employees of corporations 
                                which are members of a controlled group 
                                of corporations (within the meaning of 
                                section 1563(a) of the Internal Revenue 
                                Code of 1986, determined without regard 
                                to subsection (a)(4) or (e)(3)(C)), 
                                shall be treated as employed by a 
                                single employer,
                                    ``(II) all employees of trades or 
                                businesses (whether or not 
                                incorporated) which are under common 
                                control (under regulations prescribed 
                                by the Secretary of the Treasury under 
                                section 414(c) of that Code) shall be 
                                treated as employed by a single 
                                employer,
                                    ``(III) all employees of the 
                                members of an affiliated service group 
                                (as defined in section 414(m) of that 
                                Code) shall be treated as employed by a 
                                single employer, and
                                    ``(IV) leased employees (as defined 
                                in section 414(n)(2) of that Code) 
                                shall be treated as employees of the 
                                person for whom they perform services 
                                to the extent they are so treated under 
                                section 414(n) of that Code.
                        In applying sections of the Internal Revenue 
                        Code of 1986 under this clause, the Secretary 
                        shall rely upon the regulations and decisions 
                        of the Secretary of the Treasury respecting 
                        such sections.
                            ``(iv) Group health plan defined.--For 
                        purposes of this subsection, the term `group 
                        health plan' has the meaning given such term in 
                        section 5000(b) of the Internal Revenue Code of 
                        1986, without regard to section 5000(d) of such 
                        Code.
                            ``(v) Current employment status defined.--
                        For purposes of this subsection, an individual 
                        has `current employment status' with an 
                        employer if the individual is an employee, is 
                        the employer, or is associated with the 
                        employer in a business relationship.
                            ``(vi) Treatment of self-employed persons 
                        as employers.--For purposes of this subsection, 
                        the term `employer' includes a self-employed 
                        person.''.
            (2) Conforming amendments for working aged.--Section 
        1862(b)(1)(A) (42 U.S.C. 1395y(b)(1)(A)) is amended--
                    (A) by amending subclauses (I) and (II) of clause 
                (i) to read as follows:
                                    ``(I) may not take into account 
                                that an individual (or the individual's 
                                spouse) who is covered under the plan 
                                by virtue of the individual's current 
                                employment status with an employer is 
                                entitled to benefits under this title 
                                under section 226(a), and
                                    ``(II) shall provide that any 
                                individual age 65 or over (and the 
                                individual's spouse age 65 or older) 
                                who is covered under the plan by virtue 
                                of the individual's current employment 
                                status with an employer shall be 
                                entitled to the same benefits under the 
                                plan under the same conditions as any 
                                such individual (or spouse) under age 
                                65.'';
                    (B) by striking clauses (ii), (iii), and (v), and
                    (C) by redesignating clause (iv) as clause (ii).
            (3) Amendments for disabled individuals.--Section 1862(b) 
        (42 U.S.C. 1395y(b)) is amended--
                    (A) by amending the heading and clause (i) of 
                paragraph (1)(B) to read as follows:
                    ``(B) Disabled individuals under group health 
                plans.--
                            ``(i) In general.--A group health plan may 
                        not take into account that an individual (or a 
                        member of the individual's family) who is 
                        covered under the plan by virtue of the 
                        individual's current employment status with an 
                        employer is entitled to benefits under this 
                        title under section 226(b).'';
                    (B) by striking clause (iv) of paragraph (1)(B); 
                and
                    (C) in the second sentence of paragraph (2)(A), by 
                striking ``or large group health plan''.
            (4) Amendments for individuals with esrd.--Section 
        1862(b)(1)(C) (42 U.S.C. 1395y(b)(1)(C)) is amended--
                    (A) in the matter preceding clause (i), by striking 
                ``(as defined in paragraph (A)(v))'',
                    (B) by striking ``solely'' each place it appears,
                    (C) by striking ``by reason of'' and inserting 
                ``under'' each place it appears, and
                    (D) by inserting ``or eligible for'' after 
                ``entitled to'' each place it appears.
    (e) Secondary Payer Exemption for Members of Religious Orders.--
Effective as if included in the enactment of OBRA-1989, section 
6202(e)(2) of such Act is amended by adding at the end the following: 
``Such amendment also shall apply to items and services furnished 
before such date with respect to secondary payor cases which the 
Secretary of Health and Human Services had not identified as of such 
date.''.
    (f) Improving Identification of Medicare Secondary Payer 
Situations.--
            (1) Survey of beneficiaries.--
                    (A) In general.--Section 1862(b)(5) (42 U.S.C. 
                1395y(b)(5)) is amended by adding at the end the 
                following new subparagraph:
                    ``(D) Obtaining information from beneficiaries.--
                Before an individual applies for benefits under part A 
                or enrolls under part B, the Administrator shall mail 
                the individual a questionnaire to obtain information on 
                whether the individual is covered under a primary plan 
                and the nature of the coverage provided under the plan, 
                including the name, address, and identifying number of 
                the plan.''.
                    (B) Distribution of questionnaire by contractor.--
                The Secretary of Health and Human Services shall enter 
                into an agreement with an entity not later than April 
                1, 1994, to distribute the questionnaire described in 
                section 1862(b)(5)(D) of the Social Security Act (as 
                added by subparagraph (A)).
                    (C) No medicare secondary payor denial based on 
                failure to complete questionnaire.--Section 1862(b)(2) 
                (42 U.S.C. 1395y(b)(2)) is amended by adding at the end 
                the following new subparagraph:
                    ``(C) Treatment of questionnaires.--The Secretary 
                may not fail to make payment under subparagraph (A) 
                solely on the ground that an individual failed to 
                complete a questionnaire concerning the existence of a 
                primary plan.''.
            (2) Mandatory screening by providers and suppliers under 
        part b.--
                    (A) In general.--Section 1862(b) (42 U.S.C. 
                1395y(b)) is amended by adding at the end the following 
                new paragraph:
            ``(6) Screening requirements for providers and suppliers.--
                    ``(A) In general.--Notwithstanding any other 
                provision of this title, no payment may be made for any 
                item or service furnished under part B unless the 
                entity furnishing such item or service completes (to 
                the best of its knowledge and on the basis of 
                information obtained from the individual to whom the 
                item or service is furnished) the portion of the claim 
                form relating to the availability of other health 
                benefit plans.
                    ``(B) Penalties.--An entity that knowingly, 
                willfully, and repeatedly fails to complete a claim 
                form in accordance with subparagraph (A) or provides 
                inaccurate information relating to the availability of 
                other health benefit plans on a claim form under such 
                subparagraph shall be subject to a civil money penalty 
                of not to exceed $2,000 for each such incident. The 
                provisions of section 1128A (other than subsections (a) 
                and (b)) shall apply to a civil money penalty under the 
                previous sentence in the same manner as such provisions 
                apply to a penalty or proceeding under section 
                1128A(a).''.
                    (B)  Effective date.--The amendment made by 
                subparagraph (A) shall apply with respect to items and 
                services furnished on or after January 1, 1994.
    (g) Improvements in Recovery of Payments From Primary Payers.--
            (1) Submission of reports on efforts to recover erroneous 
        payments.--Section 1842(b)(3) (42 U.S.C. 1395u(b)(3)) is 
        amended--
                    (A) by striking ``and'' at the end of subparagraphs 
                (G) and (H); and
                    (B) by inserting after subparagraph (H) the 
                following new subparagraph:
            ``(I) will submit annual reports to the Secretary 
        describing the steps taken to recover payments made under this 
        part for items or services for which payment has been or could 
        be made under a primary plan (as defined in section 
        1862(b)(2)(A)).''.
            (2) Requirements under carrier performance evaluation 
        program.--Section 1842(b)(2) (42 U.S.C. 1395u(b)(2)) is amended 
        by adding at the end the following new subparagraph:
    ``(D) In addition to any other standards and criteria established 
by the Secretary for evaluating carrier performance under this 
paragraph relating to avoiding erroneous payments, the Secretary shall 
establish standards and criteria relating to the carrier's success in 
recovering payments made under this part for items or services for 
which payment has been or could be made under a primary plan (as 
defined in section 1862(b)(2)(A)).''.
            (3) Deadline for reimbursement by primary plans.--
                    (A) In general.--Section 1862(b)(2)(B)(i) (42 
                U.S.C. 1395y(b)(2)(B)(i)) is amended by adding at the 
                end the following sentence: ``If reimbursement is not 
                made to the appropriate Trust Fund before the 
                expiration of the 60-day period that begins on the date 
                such notice or other information is received, the 
                Secretary may charge interest (beginning with the date 
                on which the notice or other information is received) 
                on the amount of the reimbursement until reimbursement 
                is made (at a rate determined by the Secretary in 
                accordance with regulations of the Secretary of the 
                Treasury applicable to charges for late payments).''.
                    (B) Conforming amendment.--The heading of clause 
                (i) of section 1862(b)(2)(B) is amended to read as 
                follows: ``Repayment required.--''.
                    (C) Effective date.--The amendments made by this 
                paragraph shall apply to payments for items and 
                services furnished on or after the date of the 
                enactment of this Act.
            (4) Effective date.--The amendments made by paragraphs (1) 
        and (2) shall apply to contracts with fiscal intermediaries and 
        carriers under title XVIII of the Social Security Act for years 
        beginning with 1994.
    (h) Miscellaneous and Technical Corrections.--
            (1) The sentence in section 1862(b)(1)(C) added by section 
        4203(c)(1)(B) of OBRA-1990 is amended by striking ``clauses (i) 
        and (ii)'' and inserting ``this subparagraph''.
            (2) Effective as if included in the enactment of OBRA-1989, 
        section 1862(b)(1) is amended--
                    (A) in subparagraphs (A)(v) and (B)(iv)(II), by 
                inserting ``, without regard to section 5000(d) of such 
                Code'' before the period at the end of each 
                subparagraph;
                    (B) in subparagraph (A)(iii), by striking ``current 
                calendar year or the preceding calendar year'' and 
                inserting ``current calendar year and the preceding 
                calendar year''; and
                    (C) in the matter in subparagraph (C) after clause 
                (ii), by striking ``taking into account that'' and 
                inserting ``paying benefits secondary to this title 
                when''.
            (3) Section 1862(b)(5)(C)(i) (42 U.S.C. 1395y(b)(5)(C)(i)) 
        is amended by striking ``6103(l)(12)(D)(iii)'' and inserting 
        ``6103(l)(12)(E)(iii)''.
            (4) Section 4203(c)(2) of OBRA-1990 is amended--
                    (A) by striking ``the application of clause (iii)'' 
                and inserting ``the second sentence'';
                    (B) by striking ``on individuals'' and all that 
                follows through ``section 226A of such Act'';
                    (C) in clause (ii), by striking ``clause'' and 
                inserting ``sentence'';
                    (D) in clause (v), by adding ``and'' at the end; 
                and
                    (E) in clause (vi)--
                            (i) by inserting ``of such Act'' after 
                        ``1862(b)(1)(C)'', and
                            (ii) by striking the period at the end and 
                        inserting the following: ``, without regard to 
                        the number of employees covered by such 
                        plans.''.
            (5) Section 4203(d) of OBRA-1990 is amended by striking 
        ``this subsection'' and inserting ``this section''.
            (6) Except as provided in paragraph (2), the amendments 
        made by this subsection shall be effective as if included in 
        the enactment of OBRA-1990 and shall be executed before the 
        amendments made by subsections (a) through (d) of this section.
    (i) Effective Date.--
            (1) In general.--Except as otherwise provided in this 
        section, the amendments made by this section shall take effect 
        on the date of the enactment of this Act.
            (2) ESRD and uniform size rules.--The amendments made by 
        subsections (c) and (d) apply to items and services furnished 
        on or after January 1, 1994.

SEC. 5074. EXTENSION OF SELF-REFERRAL BAN TO ADDITIONAL SPECIFIED 
              SERVICES.

    (a) Extension to Designated Health Services.--
            (1) In general.--Section 1877 (42 U.S.C. 1395nn) is 
        amended--
                    (A) by striking ``clinical laboratory services'' 
                and ``clinical laboratory services'' and inserting 
                ``designated health services'' and ``designated health 
                services'', respectively, each place either appears in 
                subsections (a)(1), (b)(2)(A)(ii), (b)(4), (d)(1), 
                (d)(2), and (d)(3); and
                    (B) by adding at the end the following new 
                subsection:
    ``(i) Designated Health Services Defined.--In this section, the 
term `designated health services' means--
            ``(1) clinical laboratory services;
            ``(2) physical or occupational therapy services;
            ``(3) radiology or other diagnostic services;
            ``(4) radiation therapy services;
            ``(5) the furnishing of durable medical equipment;
            ``(6) the furnishing of parenteral and enteral nutrition 
        nutrients, supplies, and equipment;
            ``(7) home health services; and
            ``(8) home infusion therapy services.''.
            (2) Conforming amendments.--Section 1877 is further 
        amended--
                    (A) in subsection (g)(1), by striking ``clinical 
                laboratory service'' and inserting ``designated health 
                service'', and
                    (B) in subsection (h)(7)(B), by striking ``clinical 
                laboratory service'' and inserting ``designated health 
                service''.
    (b) Multiple Locations for Group Practices.--Section 
1877(b)(2)(A)(ii)(II) (42 U.S.C. 1395nn(b)(2)(A)(ii)(II)) is amended by 
striking ``centralized provision'' and inserting ``provision of some or 
all''.
    (c) Treatment of Compensation Arrangements.--
            (1) Rental of office space and equipment.--Paragraph (1) of 
        section 1877(e) (42 U.S.C. 1395nn(e)) is amended to read as 
        follows:
            ``(1) Rental of office space; rental of equipment.--
                    ``(A) Office space.--Payments made by a lessee to a 
                lessor for the use of premises if--
                            ``(i) the lease is set out in writing, 
                        signed by the parties, and specifies the 
                        premises covered by the lease,
                            ``(ii) the aggregate space rented or leased 
                        is reasonable and necessary for the legitimate 
                        business purposes of the lease or rental and is 
                        used exclusively by the lessee when being used 
                        by the lessee,
                            ``(iii) the lease provides for a term of 
                        rental or lease for at least one year,
                            ``(iv) the rental charges over the term of 
                        the lease are set in advance, are consistent 
                        with fair market value, and are not determined 
                        in a manner that takes into account the volume 
                        or value of any referrals or other business 
                        generated between the parties,
                            ``(v) the lease would be commercially 
                        reasonable even if no referrals were made 
                        between the parties,
                            ``(vi) the lease covers all of the premises 
                        leased between the parties for the period of 
                        the lease, and
                            ``(vii) the compensation arrangement meets 
                        such other requirements as the Secretary may 
                        impose by regulation as needed to protect 
                        against program or patient abuse.
                    ``(B) Equipment.--Payments made by a lessee of 
                equipment to the lessor of the equipment for the use of 
                the equipment if--
                            ``(i) the lease is set out in writing, 
                        signed by the parties, and specifies the 
                        equipment covered by the lease,
                            ``(ii) the equipment rented or leased is 
                        reasonable and necessary for the legitimate 
                        business purposes of the lease or rental and is 
                        used exclusively by the lessee when being used 
                        by the lessee,
                            ``(iii) the lease provides for a term of 
                        rental or lease of at least one year,
                            ``(iv) the rental charges over the term of 
                        the lease are set in advance, are consistent 
                        with fair market value, and are not determined 
                        in a manner that takes into account the volume 
                        or value of any referrals or other business 
                        generated between the parties,
                            ``(v) the lease would be commercially 
                        reasonable even if no referrals were made 
                        between the parties,
                            ``(vi) the lease covers all of the 
                        equipment leased between the parties for the 
                        period of the lease, and
                            ``(vii) the compensation arrangement meets 
                        such other requirements as the Secretary may 
                        impose by regulation as needed to protect 
                        against program or patient abuse.''.
            (2) Bona fide employment relationships.--Section 1877(e)(2) 
        (42 U.S.C. 1395nn(e)(2)) is amended--
                    (A) by striking ``and service'' and ``with 
                hospitals'';
                    (B) by striking ``An arrangement'' and all that 
                follows through ``if'' and inserting ``Any amount paid 
                by an employer to a physician (or immediate family 
                member) who has a bona fide employment relationship 
                with the employer for the provision of services if'';
                    (C) in subparagraphs (A), (B), and (D), by striking 
                ``arrangement'' and inserting ``employment'';
                    (D) in subparagraph (C), by striking ``to the 
                hospital''; and
                    (E) by adding at the end the following:
        ``Subparagraph (B)(ii) shall not be construed as prohibiting 
        the payment of remuneration in the form of shares of overall 
        profits or in the form of a productivity bonus based on 
        services performed personally by the physician or member, if 
        the amount of the remuneration is not determined in a manner 
        that takes into account directly the volume or value of any 
        referrals by the referring physician.''.
            (3) Personal service arrangements.--Section 1877(e) is 
        further amended by adding at the end the following new 
        paragraph:
            ``(7) Personal service arrangements.--Remuneration from an 
        entity under an arrangement if--
                    ``(A) the arrangement is set out in writing, signed 
                by the parties, and specifies the services covered by 
                the arrangement,
                    ``(B) the arrangement covers all of the services to 
                be provided,
                    ``(C) the aggregate services contracted for do not 
                exceed those that are reasonable and necessary for the 
                legitimate business purposes of the arrangement,
                    ``(D) the term of the arrangement is for at least 
                one year,
                    ``(E) the compensation to be paid over the term of 
                the arrangement is set in advance, does not exceed fair 
                market value, and is not determined in a manner that 
                takes into account the volume or value of any referrals 
                or other business generated between the parties,
                    ``(F) the services to be performed under the 
                arrangement do not involve the counseling or promotion 
                of a business arrangement of other activity that 
                violates any State or Federal law, and
                    ``(G) the arrangement meets such other requirements 
                as the Secretary may impose by regulation as needed to 
                protect against program or patient abuse.''.
            (4) Additional exceptions.--Section 1877(e) is further 
        amended by adding at the end the following new paragraphs:
            ``(8) Payments by a physician for items and services.--
        Payments made by a physician--
                    ``(A) to a laboratory in exchange for the provision 
                of clinical laboratory services, or
                    ``(B) to an entity as compensation for other items 
                or services if the items or services are furnished at a 
                price that is consistent with fair market value.
            ``(9) Payments for pathology services of a group 
        practice.--Payments made to a group practice for pathology 
        services under an agreement if--
                    ``(A) the agreement is set out in writing and 
                specifies the services to be provided by the parties 
                and the compensation for services provided under the 
                agreement,
                    ``(B) the compensation paid over the term of the 
                agreement is consistent with fair market value and is 
                not determined in a manner that takes into account the 
                volume or value of any referrals or other business 
                generated between the parties,
                    ``(C) the compensation is provided pursuant to an 
                agreement which would be commercially reasonable even 
                if no referrals were made to the entity, and
                    ``(D) the compensation arrangement between the 
                parties meets such other requirements as the Secretary 
                may impose by regulation as needed to protect against 
                program or patient abuse.''.
            (4) Referring physicians.--Section 1877(h)(7)(C) (42 U.S.C. 
        1395nn(h)(7)(C)) is amended--
                    (A) by inserting ``a request by a radiologist for 
                diagnostic radiology services, and a request by a 
                radiation oncologist for radiation therapy,'' after 
                ``examination services,'', and
                    (B) by inserting ``, radiologist, or radiation 
                oncologist'' after ``pathologist'' the second place it 
                appears.
    (d) Treatment of Group Practices.--
            (1) Use of billing numbers, etc.--Section 1877 is amended--
                    (A) in subsection (b)(2)(B), by inserting ``under a 
                billing number assigned to the group practice'' after 
                ``member'',
                    (B) in subsection (h)(4)(B), by inserting ``and 
                under a billing number assigned to the group'' after 
                ``in the name of the group'', and
                    (C) in subsection (h)(4)(C), by striking ``by 
                members of the group''.
            (2) Treatment of services under arrangements between 
        hospitals and group practices.--
                    (A) In general.--Section 1877(h)(4) (42 U.S.C. 
                1395nn(h)(4)) is amended--
                            (i) in subparagraph (B) (as amended by 
                        paragraph (1)(B)), by inserting ``(or are 
                        billed in the name of a hospital for which the 
                        group provides designated health services 
                        pursuant to an arrangement that meets the 
                        requirements of subparagraph (B))'' after 
                        ``assigned to the group'';
                            (ii) by redesignating subparagraphs (A) 
                        through (D) as clauses (i) through (iv), 
                        respectively;
                            (iii) by inserting ``(A)'' after ``.--''; 
                        and
                            (iv) by adding at the end the following new 
                        subparagraph:
            ``(B) The requirements of this subparagraph, with respect 
        to an arrangement for designated health services provided by 
        the group and billed in the name of a hospital, are that--
                    ``(i) with respect to services provided to an 
                inpatient of the hospital, the arrangement is pursuant 
                to the provision of inpatient hospital services under 
                section 1861(b)(3);
                    ``(ii) the arrangement began before December 19, 
                1989, and has continued in effect without interruption 
                since such date;
                    ``(iii) the group provides substantially all of the 
                designated health services to the hospital's patients;
                    ``(iv) the arrangement is pursuant to an agreement 
                that is set out in writing and that specifies the 
                services to be provided by the parties and the 
                compensation for services provided under the agreement;
                    ``(v) the compensation paid over the term of the 
                agreement is consistent with fair market value and the 
                compensation per unit of services is fixed in advance 
                and is not determined in a manner that takes into 
                account the volume or value of any referrals or other 
                business generated between the parties;
                    ``(vi) the compensation is provided pursuant to an 
                agreement which would be commercially reasonable even 
                if no referrals were made to the entity; and
                    ``(vii) the arrangement between the parties meets 
                such other requirements as the Secretary may impose by 
                regulation as needed to protect against program or 
                patient abuse.''.
                    (B) Conforming amendment.--Section 1877(b)(2)(B) 
                (42 U.S.C. 1395nn(b)(2)(B)) is amended by inserting 
                ``(or by a hospital for which such a group practice 
                provides designated health services pursuant to an 
                arrangement that meets the requirements of subsection 
                (h)(4)(B))'' after ``by a group practice of which such 
                physician is a member''.
            (3) Treatment of certain faculty practice plans.--The last 
        sentence of section 1877(h)(4)(A) (42 U.S.C. 1395nn(h)(4)(A)), 
        as redesignated by paragraph (1)(A), is amended by inserting 
        ``, institution of higher education, or medical school'' after 
        ``hospital''.
    (e) Expanding Rural Provider Exception To Cover Compensation 
Arrangements.--
            (1) In general.--Section 1877(b) (42 U.S.C. 1395nn(b)) is 
        amended--
                    (A) by redesignating paragraph (5) as paragraph 
                (7), and
                    (B) by inserting after paragraph (4) the following 
                new paragraph:
            ``(5) Rural providers.--In the case of designated services 
        if--
                    ``(A) the entity furnishing the services is in a 
                rural area (as defined in section 1886(d)(2)(D)), and
                    ``(B) substantially all of the services furnished 
                by the entity to individuals entitled to benefits under 
                this title are furnished to such individuals who reside 
                in such a rural area.''.
            (2) Conforming amendments.--Section 1877(d) (42 U.S.C. 
        1395nn(d)) is amended--
                    (A) by striking paragraph (2), and
                    (B) by redesignating paragraph (3) as paragraph 
                (2).
    (f) Exception for Shared Facility Laboratory Services.--
            (1) In general.--Section 1877 is amended--
                    (A) in subsection (b), as amended by subsection 
                (e)(1), by inserting after paragraph (5) the following 
                new paragraph:
            ``(6) Shared facility laboratory services.--
                    ``(A) In general.--In the case of shared facility 
                laboratory services of a shared facility--
                            ``(i) that are furnished--
                                    ``(I) personally by the referring 
                                physician who is a shared facility 
                                physician or personally by an 
                                individual supervised by such a 
                                physician or by another shared facility 
                                physician and employed under the shared 
                                facility arrangement,
                                    ``(II) by a shared facility in a 
                                building in which the referring 
                                physician furnishes physician's 
                                services unrelated to the furnishing of 
                                shared facility laboratory services, 
                                and
                                    ``(III) to a patient of a shared 
                                facility physician; and
                            ``(ii) that are billed by the referring 
                        physician or by an entity that is wholly owned 
                        by such physician.
                    ``(B) Limitation.--The exception under this 
                paragraph shall only apply to a shared facility only if 
                the facility and the shared facility arrangement were 
                established as of June 26, 1992.''; and
                    (B) in subsection (h), by adding at the end the 
                following new paragraph:
            ``(8) Shared facility related definitions.--
                    ``(A) Shared facility laboratory services.--The 
                term `shared facility laboratory services' means, with 
                respect to a shared facility, clinical laboratory 
                services furnished by the facility to patients of 
                shared facility physicians.
                    ``(B) Shared facility.--The term `shared facility' 
                means an entity that furnishes shared facility 
                laboratory services under a shared facility 
                arrangement.
                    ``(C) Shared facility physician.--The term `shared 
                facility physician' means, with respect to a shared 
                facility, a physician who has a financial relationship 
                under a shared facility arrangement with the facility.
                    ``(D) Shared facility arrangement.--The term 
                `shared facility arrangement' means, with respect to 
                the provision of shared facility laboratory services in 
                a building, a financial arrangement--
                            ``(i) which is only between physicians who 
                        are providing services (unrelated to shared 
                        facility laboratory services) in the same 
                        building,
                            ``(ii) in which the overhead expenses of 
                        the facility are shared, in accordance with 
                        methods previously determined by the physicians 
                        in the arrangement, among the physicians in the 
                        arrangement, and
                            ``(iii) which, in the case of a 
                        corporation, is wholly owned and controlled by 
                        shared facility physicians.''.
            (2) GAO study of shared facility arrangements.--
                    (A) In general.--The Comptroller General shall 
                analyze the effect on the utilization of health 
                services of shared facility arrangements for which an 
                exception is provided under the amendments made by 
                paragraph (1). The analysis shall include a review of 
                the effect of the limitation, described in section 
                1877(b)(6)(B) of the Social Security Act (as added by 
                paragraph (1)), with respect to such exception and on 
                the availability of services (including hematology 
                services).
                    (B) Report.--Not later than January 1, 1995, the 
                Comptroller General shall submit a report to Congress 
                on the analysis conducted under subparagraph (A). The 
                report shall include recommendations with respect to 
                changing the limitation.
    (g) Exemption of Compensation Arrangements Involving Certain Types 
of Remuneration.--Section 1877(h)(1) (42 U.S.C. 1395nn(h)(1)) is 
amended--
            (1) by striking subparagraph (B);
            (2) in subparagraph (A), by inserting before the period the 
        following: ``(other than an arrangement involving only 
        remuneration described in subparagraph (B))''; and
            (3) by adding at the end the following new subparagraph:
            ``(B) Remuneration described in this subparagraph is any 
        remuneration consisting of any of the following:
                    ``(i) The forgiveness of amounts owed for 
                inaccurate tests or procedures, mistakenly performed 
                tests or procedures, or the correction of minor billing 
                errors.
                    ``(ii) The provision of items, devices, or supplies 
                that are used solely to--
                            ``(I) collect, transport, process, or store 
                        specimens for the entity providing the item, 
                        device, or supply, or
                            ``(II) communicate the results of tests or 
                        procedures for such entity.''.
    (h) Exception for Publicly-Traded Securities.--Section 1877(c)(2) 
(42 U.S.C. 1395nn(d)(2)) is amended by striking ``total assets 
exceeding $100,000,000'' and inserting ``stockholder equity exceeding 
$75,000,000''.
    (i) Miscellaneous and Technical Corrections.--Section 1877 (42 
U.S.C. 1395nn) is amended--
            (1) in subsection (b)(2)(A)(i), in subparagraph (A)(i), by 
        striking ``who are employed by such physician or group practice 
        and who are personally'' and inserting ``who are directly'';
            (2) in the fourth sentence of subsection (f)--
                    (A) by striking ``provided'' and inserting 
                ``furnished'', and
                    (B) by striking ``provides'' and inserting 
                ``furnish'';
            (3) in the fifth sentence of subsection (f)--
                    (A) by striking ``providing'' each place it appears 
                and inserting ``furnishing'',
                    (B) by striking ``with respect to the providers'' 
                and inserting ``with respect to the entities'', and
                    (C) by striking ``diagnostic imaging services of 
                any type'' and inserting ``magnetic resonance imaging, 
                computerized axial tomography scans, and ultrasound 
                services''; and
            (4) in subsection (a)(2)(B), by striking ``subsection 
        (h)(1)(A)'' and inserting ``subsection (h)(1)''.
    (j) Effective Dates.--
            (1) The amendments made by subsection (a) apply with 
        respect to a referral by a physician for designated health 
        services (as described in section 1877(i) of the Social 
        Security Act) made after December 31, 1994.
            (2) The amendments made by this section (other than 
        subsection (a)) shall apply to referrals made on or after 
        January 1, 1992.

SEC. 5075. REDUCTION IN PAYMENT FOR ERYTHROPOIETIN.

    (a) In General.--Section 1881(b)(11)(B)(ii)(I) (42 U.S.C. 
1395rr(b)(11)(B)(ii)(I)) is amended--
            (1) by striking ``1991'' and inserting ``1994'', and
            (2) by striking ``$11'' and inserting ``$10''.
    (b) Effective Date.--The amendments made by subsection (a) apply to 
erythropoietin furnished after 1993.

SEC. 5076. MEDICARE HOSPITAL AGREEMENTS WITH ORGAN PROCUREMENT 
              ORGANIZATIONS.

    (a) In General.--Section 1138(a)(1) (42 U.S.C. 1320b-8(a)(1)) is 
amended--
            (1) by striking ``and'' at the end of subparagraph (A),
            (2) by striking the period at the end of subparagraph (B) 
        and inserting ``; and'', and
            (3) by adding at the end the following new subparagraph:
            ``(C) in the case of a hospital or rural primary care 
        hospital that has in effect an agreement (described in section 
        371(b)(3)(A) of the Public Health Service Act) with an organ 
        procurement organization, the agreement is with such 
        organization for the service area in which the hospital is 
        located (as established under such section).''.
    (b) Effective Date.--The amendments made by subsection (a) shall 
apply to hospitals participating in the programs under titles XVIII and 
XIX of the Social Security Act as of January 1, 1994.

SEC. 5077. EXTENSION OF WAIVER FOR WATTS HEALTH FOUNDATION.

    Section 9312(c)(3)(D) of OBRA-1986, as added by section 4018(d) of 
OBRA-1987 and as amended by section 6212(a)(1) of OBRA-1989, is amended 
by striking ``1994'' and inserting ``1996''.

SEC. 5078. IMPROVED OUTREACH FOR QUALIFIED MEDICARE BENEFICIARIES.

    The Secretary of Health and Human Services shall establish and 
implement a method for obtaining information from newly eligible 
medicare beneficiaries that may be used to determine whether such 
beneficiaries may be eligible for medical assistance for medicare cost-
sharing under State medicaid plans as qualified medicare beneficiaries, 
and for transmitting such information to the State in which such a 
beneficiary resides.

SEC. 5079. SOCIAL HEALTH MAINTENANCE ORGANIZATIONS.

    (a) Extension of Current Waivers.--Section 4018(b) of OBRA-1987, as 
amended by section 4207(b)(4) of OBRA-1990, is amended--
            (1) in paragraph (1) by striking ``December 31, 1995'' and 
        inserting ``December 31, 1997''; and
            (2) in paragraph (4) by striking ``March 31, 1996'' and 
        inserting ``March 31, 1998''.
    (b) Expansion of Demonstrations.--Section 2355 of the Deficit 
Reduction Act of 1984, as amended by section 4207(b)(4)(B) of OBRA-
1990, is amended--
            (1) in the last sentence of subsection (a) by striking ``12 
        months'' and inserting ``36 months''; and
            (2) in subsection (b)(1)(B)--
                    (A) by striking ``or'' at the end of clause (iii), 
                and
                    (B) by redesignating clause (iv) as clause (v) and 
                inserting after clause (iii) the following new clause:
                            ``(iv) integrating acute and chronic care 
                        management for patients with end-stage renal 
                        disease through expanded community care case 
                        management services (and for purposes of a 
                        demonstration project conducted under this 
                        clause, any requirement under a waiver granted 
                        under this section that a project disenroll 
                        individuals who develop end-stage renal disease 
                        shall not apply); or''.
    (c) Expansion of Number of Members Per Site.--The Secretary of 
Health and Human Services may not impose a limit of less than 12,000 on 
the number of individuals that may participate in a project conducted 
under section 2355 of the Deficit Reduction Act of 1984.
    (d) Miscellaneous and Technical Corrections.--
            (1) The section following section 4206 of OBRA-1990 is 
        amended by striking ``Sec. 4027.'' and inserting ``Sec. 
        4207.'', and in this subtitle is referred to as section 4207 of 
        OBRA-1990.
            (2) Section 2355(b)(1)(B) of the Deficit Reduction Act of 
        1984, as amended by section 4207(b)(4)(B)(ii) of OBRA-1990, is 
        amended--
                    (A) by striking ``12907(c)(4)(A)'' and inserting 
                ``4207(b)(4)(B)(i)'', and
                    (B) by striking ``feasibilitly'' and inserting 
                ``feasibility''.
            (3) Section 4207(b)(4)(B)(iii)(III) of OBRA-1990 is amended 
        by striking the period at the end and inserting a semicolon.
            (4) Subsections (c)(3) and (e) of section 2355 of the 
        Deficit Reduction Act of 1984, as amended by section 
        4207(b)(4)(B) of OBRA-1990, are each amended by striking 
        ``12907(c)(4)(A)'' each place it appears and inserting 
        ``4207(b)(4)(B)''.
            (5) Section 4207(c)(2) of OBRA-1990 is amended by striking 
        ``the Committee on Ways and Means'' each place it appears and 
        inserting ``the Committees on Ways and Means and Energy and 
        Commerce''.
            (6) Section 4207(d) of OBRA-1990 is amended by 
        redesignating the second paragraph (3) (relating to effective 
        date) as paragraph (4).
            (7) Section 4207(i)(2) of OBRA-1990 is amended--
                    (A) by striking the period at the end of clause 
                (iii) and inserting a semicolon, and
                    (B) in clause (v), by striking ``residents'' and 
                inserting ``patients''.
            (8) Section 4207(j) of OBRA-1990 is amended by striking 
        ``title'' each place it appears and inserting ``subtitle''.
    (e) Effective Date.--The amendments made by this section shall take 
effect as if included in the enactment of OBRA-90.

SEC. 5080. PEER REVIEW ORGANIZATIONS.

    (a) Repeal Of PRO Precertification Requirement for Certain Surgical 
Procedures.--
            (1) In general.--Section 1164 (42 U.S.C. 1320c-13) is 
        repealed.
            (2) Conforming amendments.--
                    (A) Section 1154 (42 U.S.C. 1320c-3) is amended--
                            (i) in subsection (a), by striking 
                        paragraph (12), and
                            (ii) in subsection (d), by striking ``(and 
                        except as provided in section 1164)''.
                    (B) Section 1833 (42 U.S.C. 1395l) is amended--
                            (i) in subsection (a)(1)(D)(i), by striking 
                        ``, or for tests furnished in connection with 
                        obtaining a second opinion required under 
                        section 1164(c)(2) (or a third opinion, if the 
                        second opinion was in disagreement with the 
                        first opinion)'';
                            (ii) in subsection (a)(1), by striking 
                        clause (G);
                            (iii) in subsection (a)(2)(A), by striking 
                        ``to items and services (other than clinical 
                        diagnostic laboratory tests) furnished in 
                        connection with obtaining a second opinion 
                        required under section 1164(c)(2) (or a third 
                        opinion, if the second opinion was in 
                        disagreement with the first opinion),'';
                            (iv) in subsection (a)(2)(D)(i)--
                                    (I) by striking ``related basis,'' 
                                and inserting ``related basis or'', and
                                    (II) by striking ``, or for tests 
                                furnished in connection with obtaining 
                                a second opinion required under section 
                                1164(c)(2) (or a third opinion, if the 
                                second opinion was in disagreement with 
                                the first opinion))'';
                            (v) in subsection (a)(3), by striking ``and 
                        for items and services furnished in connection 
                        with obtaining a second opinion required under 
                        section 1164(c)(2), or a third opinion, if the 
                        second opinion was in disagreement with the 
                        first opinion)''; and
                            (vi) in the first sentence of subsection 
                        (b), by striking ``(4)'' and all that follow 
                        through ``and (5)'' and inserting ``and (4)''.
                    (C) Section 1834(g)(1)(B) (42 U.S.C. 
                1395m(g)(1)(B)) is amended by striking ``and for items 
                and services furnished in connection with obtaining a 
                second opinion required under section 1164(c)(2), or a 
                third opinion, if the second opinion was in 
                disagreement with the first opinion)''.
                    (D) Section 1862(a) (42 U.S.C. 1395y(a)) is 
                amended--
                            (i) by adding ``or'' at the end of 
                        paragraph (14),
                            (ii) by striking ``; or'' at the end of 
                        paragraph (15) and inserting a period, and
                            (iii) by striking paragraph (16).
                    (E) The third sentence of section 1866(a)(2)(A) (42 
                U.S.C. 1395w(a)(2)(A)) is amended by striking ``, with 
                respect to items and services furnished in connection 
                with obtaining a second opinion required under section 
                1164(c)(2) (or a third opinion, if the second opinion 
                was in disagreement with the first opinion),''.
            (3) Effective date.--The amendments made by this subsection 
        shall apply to services provided on or after the date of the 
        enactment of this Act.
    (b) Miscellaneous and Technical Corrections.--(1) The third 
sentence of section 1156(b)(1) (42 U.S.C. 1320c-5(b)(1)) is amended by 
striking ``whehter'' and inserting ``whether''.
    (2)(A) Subparagraph (B) of section 1154(a)(9) (42 U.S.C. 1320c-
3(a)(9)) is amended to read as follows:
            ``(B) If the organization finds, after reasonable notice 
        and opportunity for discussion with the physician or 
        practitioner concerned, that the physician or practitioner has 
        furnished services in violation of section 1156(a), the 
        organization shall notify the State board or boards responsible 
        for the licensing or disciplining of the physician or 
        practitioner of its finding and of any action taken as a result 
        of the finding.''.
    (B) Subparagraph (D) of section 1160(b)(1) (42 U.S.C. 1320c-
9(b)(1)) is amended to read as follows:
                    ``(D) to provide notice in accordance with section 
                1154(a)(9)(B);''.
    (3) Section 4205(d)(2)(B) of OBRA-1990 is amended by striking 
``amendments'' and inserting ``amendment''.
    (4) Section 1160(d) (42 U.S.C. 1320c-9(d)) is amended by striking 
``subpena'' and inserting ``subpoena''.
    (5) Section 4205(e)(2) of OBRA-1990 is amended by striking 
``amendments'' and inserting ``amendment'' and by striking ``all''.
    (6)(A) Except as provided in subparagraph (B), the amendments made 
by this subsection shall take effect as if included in the enactment of 
OBRA-1990.
    (B) The amendments made by paragraph (2) (relating to the 
requirement on reporting of information to State boards) shall take 
effect on the date of the enactment of this Act.

SEC. 5081. HOSPICE INFORMATION TO HOME HEALTH BENEFICIARIES.

    (a) In General.--Section 1891(a)(1) (42 U.S.C. 1395bbb(a)(1)) is 
amended by adding at the end the following new subparagraph:
                    ``(H) The right, in the case of a resident who is 
                entitled to benefits under this title, to be fully 
                informed orally and in writing (at the time of coming 
                under the care of the agency) of the entitlement of 
                individuals to hospice care under section 1812(a)(4) 
                (unless there is no hospice program providing hospice 
                care for which payment may be made under this title 
                within the geographic area of the facility and it is 
                not the common practice of the agency to refer patients 
                to hospice programs located outside such geographic 
                area).''.
    (b) Effective Date.--The amendment made by subsection (a) shall 
apply to services furnished on or after the first day of the first 
month beginning more than one year after the date of the enactment of 
this Act.

SEC. 5082. HEALTH MAINTENANCE ORGANIZATIONS.

    (a) Adjustment In Medicare Capitation Payments To Account For 
Regional Variations In Application of Secondary Payor Provisions.--
            (1) In general.--Section 1876(a)(4) (42 U.S.C. 
        1395mm(a)(4)) is amended by adding at the end the following new 
        sentence: ``In establishing the adjusted average per capita 
        cost for a geographic area, the Secretary shall take into 
        account the differences between the proportion of individuals 
        in the area with respect to whom there is a group health plan 
        that is a primary payor (within the meaning of section 
        1862(b)(2)(A)) compared to the proportion of all such 
        individuals with respect to whom there is such a group health 
        plan.''.
            (2) Effective date.--The amendment made by paragraph (1) 
        shall apply to contracts entered into for years beginning with 
        1994.
    (b) Revisions in the Payment Methodology for Risk Contractors.--
Section 4204(b) of OBRA-1990 is amended to read as follows:
    ``(b) Revisions in the Payment Methodology for Risk Contractors.--
(1)(A) Not later than January 1, 1995, the Secretary of Health and 
Human Services (in this subsection referred to as the ``Secretary'') 
shall submit a proposal to the Congress that provides for revisions to 
the payment method to be applied in years beginning with 1996 for 
organizations with a risk-sharing contract under section 1876(g) of the 
Social Security Act.
    ``(B) In proposing the revisions required under subparagraph (A) 
the Secretary shall consider--
            ``(i) the difference in costs associated with medicare 
        beneficiaries with differing health status and demographic 
        characteristics; and
            ``(ii) the effects of using alternative geographic 
        classifications on the determinations of costs associated with 
        beneficiaries residing in different areas.
    ``(2) Not later than 3 months after the date of submittal of the 
proposal made pursuant to paragraph (1), the Comptroller General shall 
review the proposal and shall report to Congress on the appropriateness 
of the proposed modifications.''.
    (c) Miscellaneous and Technical Corrections.--(1) Section 
1876(a)(3) (42 U.S.C. 1395mm(a)(3)) is amended by striking ``subsection 
(c)(7)'' and inserting ``subsections (c)(2)(B)(ii) and (c)(7)''.
    (2) Section 4204(c)(3) of OBRA-1990 is amended by striking ``for 
1991'' and inserting ``for years beginning with 1991''.
    (3) Section 4204(d)(2) of OBRA-1990 is amended by striking 
``amendment'' and inserting ``amendments''.
    (4) Section 1876(a)(1)(E)(ii)(I) (42 U.S.C. 1395mm(a)(1)(E)(ii)(I)) 
is amended by striking the comma after ``contributed to''.
    (5) Section 4204(e)(2) of OBRA-1990 is amended by striking ``(which 
has a risk-sharing contract under section 1876 of the Social Security 
Act)''.
    (6) Section 4204(f)(4) of OBRA-1990 is amended by striking 
``final''.
    (7) Section 1862(b)(3)(C) (42 U.S.C. 1395y(b)(3)(C)) is amended--
            (A) in the heading, by striking ``plan'' and inserting 
        ``plan or a large group health plan'';
            (B) by striking ``group health plan'' and inserting ``group 
        health plan or a large group health plan'';
            (C) by striking ``, unless such incentive is also offered 
        to all individuals who are eligible for coverage under the 
        plan''; and
            (D) by striking ``the first sentence of subsection (a) and 
        other than subsection (b)'' and inserting ``subsections (a) and 
        (b)''.
    (8) The amendments made by this subsection shall take effect as if 
included in the enactment of OBRA-1990.

SEC. 5083. MISCELLANEOUS AND TECHNICAL CORRECTIONS.

    (a) Survey and Certification Requirements.--(1) Section 1864 (42 
U.S.C. 1395aa) is amended--
            (A) in subsection (e), by striking ``title'' and inserting 
        ``title (other than any fee relating to section 353 of the 
        Public Health Service Act)''; and
            (B) in the first sentence of subsection (a), by striking 
        ``1861(s) or'' and all that follows through ``Service Act,'' 
        and inserting ``1861(s),''.
    (2) An agreement made by the Secretary of Health and Human Services 
with a State under section 1864(a) of the Social Security Act may 
include an agreement that the services of the State health agency or 
other appropriate State agency (or the appropriate local agencies) will 
be utilized by the Secretary for the purpose of determining whether a 
laboratory meets the requirements of section 353 of the Public Health 
Service Act.
    (b) Other Miscellaneous and Technical Provisions.--(1) Section 1833 
(42 U.S.C. 1395l) is amended by redesignating the subsection (r) added 
by section 4206(b)(2) of OBRA-1990 as subsection (s).
    (2) Section 1866(f)(1) (42 U.S.C. 1395cc(f)(1)) is amended by 
striking ``1833(r)'' and inserting ``1833(s)''.
    (3) Section 1861(s)(2) (42 U.S.C. 1395x(s)(2)) is amended by moving 
subparagraph (O), as redesignated by section 5070(f)(7)(B)(iii)(II) of 
this subtitle, two ems to the left.
    (4) Section 1881(b)(1)(C) (42 U.S.C. 1395rr(b)(1)(C)) is amended by 
striking ``1861(s)(2)(Q)'' and inserting ``1861(s)(2)(P)''.
    (5) Section 4201(d)(2) of OBRA-1990 is amended by striking ``(B) by 
striking'', ``(C) by striking'', and ``(3) by adding'' and inserting 
``(i) by striking'', ``(ii) by striking'', and ``(B) by adding'', 
respectively.
    (6)(A) Section 4207(a)(1) of OBRA-1990 is amended by adding closing 
quotation marks and a period after ``such review.''.
    (B) Section 4207(a)(4) of OBRA-1990 is amended by striking ``this 
subsection'' and inserting ``paragraphs (2) and (3)''.
    (C) Section 4207(b)(1) of OBRA-1990 is amended by striking 
``section 3(7)'' and inserting ``section 601(a)(1)''.
    (7) Section 4202 of OBRA-1990 is amended--
            (A) in subsection (b)(1)(A), by striking ``home 
        hemodialysis staff assistant'' and inserting ``qualified home 
        hemodialysis staff assistant (as described in subsection 
        (d))'';
            (B) in subsection (b)(2)(B)(ii)(I), by striking ``(as 
        adjusted to reflect differences in area wage levels)'';
            (C) in subsection (c)(1)(A), by striking ``skilled''; and
            (D) in subsection (c)(1)(E), by striking ``(b)(4)'' and 
        inserting ``(b)(2)''.
    (c) Effective Date.--The amendments made by this section shall take 
effect as if included in the enactment of OBRA-1990.

   CHAPTER 3--PROVISIONS RELATING TO MEDICARE SUPPLEMENTAL INSURANCE 
                                POLICIES

SEC. 5091. STANDARDS FOR MEDICARE SUPPLEMENTAL INSURANCE POLICIES.

    (a) Simplification of Medicare Supplemental Policies.--
            (1) Section 4351 of OBRA-1990 is amended by striking ``(a) 
        In General.--''.
            (2) Section 1882(p) (42 U.S.C. 1395ss(p)) is amended--
                    (A) in paragraph (1)(A)--
                            (i) by striking ``promulgates'' and 
                        inserting ``changes the revised NAIC Model 
                        Regulation (described in subsection (m)) to 
                        incorporate'',
                            (ii) by striking ``(such limitations, 
                        language, definitions, format, and standards 
                        referred to collectively in this subsection as 
                        `NAIC standards')'', and
                            (iii) by striking ``included a reference to 
                        the NAIC standards'' and inserting ``were a 
                        reference to the revised NAIC Model Regulation 
                        as changed under this subparagraph (such 
                        changed regulation referred to in this section 
                        as the `1991 NAIC Model Regulation')'';
                    (B) in paragraph (1)(B)--
                            (i) by striking ``promulgate NAIC 
                        standards'' and inserting ``make the changes in 
                        the revised NAIC Model Regulation'',
                            (ii) by striking ``limitations, language, 
                        definitions, format, and standards described in 
                        clauses (i) through (iv) of such subparagraph 
                        (in this subsection referred to collectively as 
                        `Federal standards')'' and inserting ``a 
                        regulation'', and
                            (iii) by striking ``included a reference to 
                        the Federal standards'' and inserting ``were a 
                        reference to the revised NAIC Model Regulation 
                        as changed by the Secretary under this 
                        subparagraph (such changed regulation referred 
                        to in this section as the `1991 Federal 
                        Regulation')'';
                    (C) in paragraph (1)(C)(i), by striking ``NAIC 
                standards or the Federal standards'' and inserting 
                ``1991 NAIC Model Regulation or 1991 Federal 
                Regulation'';
                    (D) in paragraphs (1)(C)(ii)(I), (1)(E), (2), and 
                (9)(B), by striking ``NAIC or Federal standards'' and 
                inserting ``1991 NAIC Model Regulation or 1991 Federal 
                Regulation'';
                    (E) in paragraph (2)(C), by striking ``(5)(B)'' and 
                inserting ``(4)(B)'';
                    (F) in paragraph (4)(A)(i), by inserting ``or 
                paragraph (6)'' after ``(B)'';
                    (G) in paragraph (4), by striking ``applicable 
                standards'' each place it appears and inserting 
                ``applicable 1991 NAIC Model Regulation or 1991 Federal 
                Regulation'';
                    (H) in paragraph (6), by striking ``in regard to 
                the limitation of benefits described in paragraph (4)'' 
                and inserting ``described in clauses (i) through (iii) 
                of paragraph (1)(A)'';
                    (I) in paragraph (7), by striking ``policyholder'' 
                and inserting ``policyholders'';
                    (J) in paragraph (8), by striking ``after the 
                effective date of the NAIC or Federal standards with 
                respect to the policy, in violation of the previous 
                requirements of this subsection'' and inserting ``on 
                and after the effective date specified in paragraph 
                (1)(C) (but subject to paragraph (10)), in violation of 
                the applicable 1991 NAIC Model Regulation or 1991 
                Federal Regulation insofar as such regulation relates 
                to the requirements of subsection (o) or (q) or clause 
                (i), (ii), or (iii) of paragraph (1)(A)'';
                    (K) in paragraph (9), by adding at the end the 
                following new subparagraph:
    ``(D) Subject to paragraph (10), this paragraph shall apply to 
sales of policies occurring on or after the effective date specified in 
paragraph (1)(C).''; and
                    (L) in paragraph (10), by striking ``this 
                subsection'' and inserting ``paragraph (1)(A)(i)''.
    (b) Guaranteed Renewability.--Section 1882(q) (42 U.S.C. 1395ss(q)) 
is amended--
            (1) in paragraph (2), by striking ``paragraph (2)'' and 
        inserting ``paragraph (4)'', and
            (2) in paragraph (4), by striking ``the succeeding issuer'' 
        and inserting ``issuer of the replacement policy''.
    (c) Enforcement of Standards.--
            (1) Section 1882(a)(2) (42 U.S.C. 1395ss(a)(2)) is 
        amended--
                    (A) in subparagraph (A), by striking ``NAIC 
                standards or the Federal standards'' and inserting 
                ``1991 NAIC Model Regulation or 1991 Federal 
                Regulation'', and
                    (B) by striking ``after the effective date of the 
                NAIC or Federal standards with respect to the policy'' 
                and inserting ``on and after the effective date 
                specified in subsection (p)(1)(C)''.
            (2) The sentence in section 1882(b)(1) added by section 
        4353(c)(5) of OBRA-1990 is amended--
                    (A) by striking ``The report'' and inserting ``Each 
                report'',
                    (B) by inserting ``and requirements'' after 
                ``standards'',
                    (C) by striking ``and'' after ``compliance,'', and
                    (D) by striking the comma after ``Commissioners''.
            (3) Section 1882(g)(2)(B) (42 U.S.C. 1395ss(g)(2)(B)) is 
        amended by striking ``Panel'' and inserting ``Secretary''.
            (4) Section 1882(b)(1) (42 U.S.C. 1395ss(b)(1)) is amended 
        by striking ``the the Secretary'' and inserting ``the 
        Secretary''.
    (d) Preventing Duplication.--
            (1) Section 1882(d)(3)(A) (42 U.S.C. 1395ss(d)(3)(A)) is 
        amended--
                    (A) by amending the first sentence to read as 
                follows:
    ``(i) It is unlawful for a person to sell or issue to an individual 
entitled to benefits under part A or enrolled under part B of this 
title--
            ``(I) a health insurance policy with knowledge that the 
        policy duplicates health benefits to which the individual is 
        otherwise entitled under this title or title XIX,
            ``(II) a medicare supplemental policy with knowledge that 
        the individual is entitled to benefits under another medicare 
        supplemental policy, or
            ``(III) a health insurance policy (other than a medicare 
        supplemental policy) with knowledge that the policy duplicates 
        health benefits to which the individual is otherwise entitled, 
        other than benefits to which the individual is entitled under a 
        requirement of State or Federal law.'';
                    (B) by designating the second sentence as clause 
                (ii) and, in such clause, by striking ``the previous 
                sentence'' and inserting ``clause (i)'';
                    (C) by designating the third sentence as clause 
                (iii) and, in such clause--
                            (i) by striking ``the previous sentence'' 
                        and inserting ``clause (i) with respect to the 
                        sale of a medicare supplemental policy'', and
                            (ii) by striking ``and the statement'' and 
                        all that follows up to the period at the end; 
                        and
                    (D) by striking the last sentence.
            (2) Section 1882(d)(3)(B) (42 U.S.C. 1395ss(d)(3)(B)) is 
        amended--
                    (A) in clause (ii)(II), by striking ``65 years of 
                age or older'',
                    (B) in clause (iii)(I), by striking ``another 
                medicare'' and inserting ``a medicare'',
                    (C) in clause (iii)(I), by striking ``such a 
                policy'' and inserting ``a medicare supplemental 
                policy'',
                    (D) in clause (iii)(II), by striking ``another 
                policy'' and inserting ``a medicare supplemental 
                policy'', and
                    (E) by amending subclause (III) of clause (iii) to 
                read as follows:
    ``(III) If the statement required by clause (i) is obtained and 
indicates that the individual is entitled to any medical assistance 
under title XIX, the sale of the policy is not in violation of clause 
(i) (insofar as such clause relates to such medical assistance), if a 
State medicaid plan under such title pays the premiums for the policy, 
or, in the case of a qualified medicare beneficiary described in 
section 1905(p)(1), if the State pays less than the full amount of 
medicare cost-sharing as described in subparagraphs (B), (C), and (D) 
of section 1905(p)(3) for such individual.''.
            (3)(A) Section 1882(d)(3)(C) (42 U.S.C. 1395ss(d)(3)(C)) is 
        amended--
                    (i) by striking ``the selling'' and inserting ``(i) 
                the sale or issuance'', and
                    (ii) by inserting before the period at the end the 
                following: ``, (ii) the sale or issuance of a policy or 
                plan described in subparagraph (A)(i)(I) (other than a 
                medicare supplemental policy to an individual entitled 
                to any medical assistance under title XIX) under which 
                all the benefits are fully payable directly to or on 
                behalf of the individual without regard to other health 
                benefit coverage of the individual but only if (for 
                policies sold or issued more than 60 days after the 
                date the statements are published or promulgated under 
                subparagraph (D)) there is disclosed in a prominent 
                manner as part of (or together with) the application 
                the applicable statement (specified under subparagraph 
                (D)) of the extent to which benefits payable under the 
                policy or plan duplicate benefits under this title, or 
                (iii) the sale or issuance of a policy or plan 
                described in subparagraph (A)(i)(III) under which all 
                the benefits are fully payable directly to or on behalf 
                of the individual without regard to other health 
                benefit coverage of the individual''.
            (B) Section 1882(d)(3) (42 U.S.C. 1395ss(d)(3)) is amended 
        by adding at the end the following:
    ``(D)(i) If--
            ``(I) within the 90-day period beginning on the date of the 
        enactment of this subparagraph, the National Association of 
        Insurance Commissioners develops (after consultation with 
        consumer and insurance industry representatives) and submits to 
        the Secretary a statement for each of the types of health 
        insurance policies (other than medicare supplemental policies 
        and including, as separate types of policies, policies paying 
        directly to the beneficiary fixed, cash benefits) which are 
        sold to persons entitled to health benefits under this title, 
        of the extent to which benefits payable under the policy or 
        plan duplicate benefits under this title, and
            ``(II) the Secretary approves all the statements submitted 
        as meeting the requirements of subclause (I),
each such statement shall be (for purposes of subparagraph (C)) the 
statement specified under this subparagraph for the type of policy 
involved. The Secretary shall review and approve (or disapprove) all 
the statements submitted under subclause (I) within 30 days after the 
date of their submittal. Upon approval of such statements, the 
Secretary shall publish such statements.
    ``(ii) If the Secretary does not approve the statements under 
clause (i) or the statements are not submitted within the 90-day period 
specified in such clause, the Secretary shall promulgate (after 
consultation with consumer and insurance industry representatives and 
not later than 90 days after the date of disapproval or the end of such 
90-day period (as the case may be)) a statement for each of the types 
of health insurance policies (other than medicare supplemental policies 
and including, as separate types of policies, policies paying directly 
to the beneficiary fixed, cash benefits) which are sold to persons 
entitled to health benefits under this title, of the extent to which 
benefits payable under the policy or plan duplicate benefits under this 
title, and each such statement shall be (for purposes of subparagraph 
(C)) the statement specified under this subparagraph for the type of 
policy involved.''.
            (C) The requirement of a disclosure under section 
        1882(d)(3)(C)(ii) of the Social Security Act shall not apply to 
        an application made for a policy or plan before 60 days after 
        the date the Secretary of Health and Human Services publishes 
        or promulgates all the statements under section 1882(d)(3)(D) 
        of such Act.
            (4) Subparagraphs (A) and (B) of section 1882(q)(5)(A) (42 
        U.S.C. 1395ss(q)(5)(A)) are amended by striking ``of the Social 
        Security Act''.
            (5) The second subsection (b) of section 4354 of OBRA-1990 
        (relating to effective date) is amended by redesignating such 
        subsection as subsection (c).
    (e) Loss Ratios and Refunds of Premiums.--
            (1) Section 1882(r) (42 U.S.C. 1395ss(r)) is amended--
                    (A) in paragraph (1), by striking ``or sold'' and 
                inserting ``or renewed (or otherwise provide coverage 
                after the date described in subsection (p)(1)(C))'';
                    (B) in paragraph (1)(A), by inserting ``for periods 
                after the effective date of these provisions'' after 
                ``the policy can be expected'';
                    (C) in paragraph (1)(A), by striking 
                ``Commissioners,'' and inserting ``Commissioners)'';
                    (D) in paragraph (1)(B), by inserting before the 
                period at the end the following: ``, treating policies 
                of the same type as a single policy for each standard 
                package'';
                    (E) by adding at the end of paragraph (1) the 
                following: ``For the purpose of calculating the refund 
                or credit required under paragraph (1)(B) for a policy 
                issued before the date specified in subsection 
                (p)(1)(C), the refund or credit calculation shall be 
                based on the aggregate benefits provided and premiums 
                collected under all such policies issued by an insurer 
                in a State (separated as to individual and group 
                policies) and shall be based only on aggregate benefits 
                provided and premiums collected under such policies 
                after the date specified in section 5091(m)(4) of the 
                Omnibus Budget Reconciliation Act of 1993.'';
                    (F) in the first sentence of paragraph (2)(A), by 
                striking ``by policy number'' and inserting ``by 
                standard package'';
                    (G) by striking the second sentence of paragraph 
                (2)(A) and inserting the following: ``Paragraph (1)(B) 
                shall not apply to a policy until 12 months following 
                issue.'';
                    (H) in the last sentence of paragraph (2)(A), by 
                striking ``in order'' and all that follows through 
                ``are effective'';
                    (I) by adding at the end of paragraph (2)(A), the 
                following new sentence: ``In the case of a policy 
                issued before the date specified in subsection 
                (p)(1)(C), paragraph (1)(B) shall not apply until 1 
                year after the date specified in section 5091(m)(4) of 
                the Omnibus Budget Reconciliation Act of 1993.'';
                    (J) in paragraph (2), by striking ``policy year'' 
                each place it appears and inserting ``calendar year'';
                    (K) in paragraph (4), by striking ``February'', 
                ``disllowance'', ``loss-ratios'' each place it appears, 
                and ``loss-ratio'' and inserting ``October'', 
                ``disallowance'', ``loss ratios'', and ``loss ratio'', 
                respectively;
                    (L) in paragraph (6)(A), by striking ``issues a 
                policy in violation of the loss ratio requirements of 
                this subsection'' and ``such violation'' and inserting 
                ``fails to provide refunds or credits as required in 
                paragraph (1)(B)'' and ``policy issued for which such 
                failure occurred'', respectively; and
                    (M) in paragraph (6)(B), by striking ``to 
                policyholders'' and inserting ``to the policyholder or, 
                in the case of a group policy, to the certificate 
                holder''.
            (2) Section 1882(b)(1) (42 U.S.C. 1395ss(b)(1)) is amended, 
        in the matter after subparagraph (H), by striking ``subsection 
        (F)'' and inserting ``subparagraph (F)''.
            (3) Section 4355(d) of OBRA-1990 is amended by striking 
        ``sold or issued'' and all that follows and inserting ``issued 
        or renewed (or otherwise providing coverage after the date 
        described in section 1882(p)(1)(C) of the Social Security Act) 
        on or after the date specified in section 1882(p)(1)(C) of such 
        Act.''.
    (f) Treatment of HMO's.--
            (1) Section 1882(g)(1) (42 U.S.C. 1395ss(g)(1)) is amended 
        by striking ``a health maintenance organization or other direct 
        service organization'' and all that follows through ``1833'' 
        and inserting ``an eligible organization (as defined in section 
        1876(b)) if the policy or plan provides benefits pursuant to a 
        contract under section 1876 or an approved demonstration 
        project described in section 603(c) of the Social Security 
        Amendments of 1983, section 2355 of the Deficit Reduction Act 
        of 1984, or section 9412(b) of the Omnibus Budget 
        Reconciliation Act of 1986 or, during the period beginning on 
        the date specified in subsection (p)(1)(C) and ending on 
        December 31, 1994, a policy or plan of an organization if the 
        policy or plan provides benefits pursuant to an agreement under 
        section 1833(a)(1)(A)''.
            (2) Section 4356(b) of OBRA-1990 is amended by striking 
        ``on the date of the enactment of this Act'' and inserting ``on 
        the date specified in section 1882(p)(1)(C) of the Social 
        Security Act''.
    (g) Pre-Existing Condition Limitations.--Section 1882(s) (42 U.S.C. 
1395ss(s)) is amended--
            (1) in paragraph (2)(A), by striking ``for which an 
        application is submitted'' and inserting ``in the case of an 
        individual for whom an application is submitted prior to or'',
            (2) in paragraph (2)(A), by striking ``in which the 
        individual (who is 65 years of age or older) first is enrolled 
        for benefits under part B'' and inserting ``as of the first day 
        on which the individual is 65 years of age or older and is 
        enrolled for benefits under part B'', and
            (3) in paragraph (2)(B), by striking ``before it'' and 
        inserting ``before the policy''.
    (h) Medicare Select Policies.--
            (1) Section 1882(t) (42 U.S.C. 1395ss(t)) is amended--
                    (A) in paragraph (1), by inserting ``medicare 
                supplemental'' after ``If a'',
                    (B) in paragraph (1), by striking ``NAIC Model 
                Standards'' and inserting ``1991 NAIC Model Regulation 
                or 1991 Federal Regulation'',
                    (C) in paragraph (1)(A), by inserting ``or 
                agreements'' after ``contracts'',
                    (D) in subparagraphs (E)(i) and (F) of paragraph 
                (1), by striking ``NAIC standards'' and inserting 
                ``standards in the 1991 NAIC Model Regulation or 1991 
                Federal Regulation'', and
                    (E) in paragraph (2), by inserting ``the issuer'' 
                before ``is subject to a civil money penalty''.
            (2) Section 1154(a)(4)(B) (42 U.S.C. 1320c-3(a)(4)(B)) is 
        amended--
                    (A) by inserting ``that is'' after ``(or'', and
                    (B) by striking ``1882(t)'' and inserting 
                ``1882(t)(3)''.
    (i) Health Insurance Counseling.--Section 4360 of OBRA-1990 is 
amended--
            (1) in subsection (b)(2)(A)(ii), by striking ``Act'' and 
        inserting ``Act)'';
            (2) in subsection (b)(2)(D), by striking ``services'' and 
        inserting ``counseling'';
            (3) in subsection (b)(2)(I), by striking ``assistance'' and 
        inserting ``referrals'';
            (4) in subsection (c)(1), by striking ``and that such 
        activities will continue to be maintained at such level'';
            (5) in subsection (d)(3), by striking ``to the rural 
        areas'' and inserting ``eligible individuals residing in rural 
        areas'';
            (6) in subsection (e)--
                    (A) by striking ``subsection (c) or (d)'' and 
                inserting ``this section'',
                    (B) by striking ``and annually thereafter, issue an 
                annual report'' and inserting ``and annually thereafter 
                during the period of the grant, issue a report'',
                    (C) in paragraph (1), by striking ``State-wide'', 
                and
                    (D) in subsection (f), by striking paragraph (2) 
                and by redesignating paragraphs (3) through (5) as 
                paragraphs (2) through (4), respectively; and
            (7) by redesignating the second subsection (f) (relating to 
        authorization of appropriations for grants) as subsection (g).
    (j) Telephone Information System.--
            (1) Section 1804 (42 U.S.C. 1395b-2) is amended--
                    (A) by adding at the end of the heading the 
                following: ``; medicare and medigap information'',
                    (B) by inserting ``(a)'' after ``1804.'', and
                    (C) by adding at the end the following new 
                subsection:
    ``(b) The Secretary shall provide information via a toll-free 
telephone number on the programs under this title.''.
            (2) Section 1882(f) (42 U.S.C. 1395ss(f)) is amended by 
        adding at the end the following new paragraph:
    ``(3) The Secretary shall provide information via a toll-free 
telephone number on medicare supplemental policies (including the 
relationship of State programs under title XIX to such policies).''.
            (3) Section 1889 (42 U.S.C. 1395zz) is repealed.
    (k) Mailing of Policies.--Section 1882(d)(4) (42 U.S.C. 
1395ss(d)(4)) is amended--
            (1) in subparagraph (D), by striking ``, if such policy'' 
        and all that follows up to the period at the end, and
            (2) by adding at the end the following new subparagraph:
    ``(E) Subparagraph (A) shall not apply in the case of an issuer who 
mails or causes to be mailed a policy, certificate, or other matter 
solely to comply with the requirements of subsection (q).''.
    (l) Effective Date.--The amendments made by this section shall be 
effective as if included in the enactment of OBRA-1990; except that--
            (1) the amendments made by subsection (d)(1) shall take 
        effect on the date of the enactment of this Act, but no penalty 
        shall be imposed under section 1882(d)(3)(A) of the Social 
        Security Act (for an action occurring after the effective date 
        of the amendments made by section 4354 of OBRA-1990 and before 
        the date of the enactment of this Act) with respect to the sale 
        or issuance of a policy which is not unlawful under section 
        1882(d)(3)(A)(i)(II) of the Social Security Act (as amended by 
        this section);
            (2) the amendments made by subsection (d)(2)(A) and by 
        subparagraphs (A), (B), and (E) of subsection (e)(1) shall be 
        effective on the date specified in subsection (m)(4); and
            (3) the amendment made by subsection (g)(2) shall take 
        effect on January 1, 1994, and shall apply to individuals who 
        attain 65 years of age or older on or after the effective date 
        of section 1882(s)(2) of the Social Security Act (and, in the 
        case of individuals who attained 65 years of age after such 
        effective date and before January 1, 1994, and who were not 
        covered under such section before January 1, 1994, the 6-month 
        period specified in that section shall begin January 1, 1994).
    (m) Transition Provisions.--
            (1) In general.--If the Secretary of Health and Human 
        Services identifies a State as requiring a change to its 
        statutes or regulations to conform its regulatory program to 
        the changes made by this section, the State regulatory program 
        shall not be considered to be out of compliance with the 
        requirements of section 1882 of the Social Security Act due 
        solely to failure to make such change until the date specified 
        in paragraph (4).
            (2) NAIC Standards.--If, within 6 months after the date of 
        the enactment of this Act, the National Association of 
        Insurance Commissioners (in this subsection referred to as the 
        ``NAIC'') modifies its 1991 NAIC Model Regulation (adopted in 
        July 1991) to conform to the amendments made by this section 
        and to delete from section 15C the exception which begins with 
        ``unless'', such modifications shall be considered to be part 
        of that Regulation for the purposes of section 1882 of the 
        Social Security Act.
            (3) Secretary standards.--If the NAIC does not make the 
        modifications described in paragraph (2) within the period 
        specified in such paragraph, the Secretary of Health and Human 
        Services shall make the modifications described in such 
        paragraph and such modifications shall be considered to be part 
        of that Regulation for the purposes of section 1882 of the 
        Social Security Act.
            (4) Date specified.--
                    (A) In general.--Subject to subparagraph (B), the 
                date specified in this paragraph for a State is the 
                earlier of--
                            (i) the date the State changes its statutes 
                        or regulations to conform its regulatory 
                        program to the changes made by this section, or
                            (ii) 1 year after the date the NAIC or the 
                        Secretary first makes the modifications under 
                        paragraph (2) or (3), respectively.
                    (B) Additional legislative action required.--In the 
                case of a State which the Secretary identifies as--
                            (i) requiring State legislation (other than 
                        legislation appropriating funds) to conform its 
                        regulatory program to the changes made in this 
                        section, but
                            (ii) having a legislature which is not 
                        scheduled to meet in 1994 in a legislative 
                        session in which such legislation may be 
                        considered,
                the date specified in this paragraph is the first day 
                of the first calendar quarter beginning after the close 
                of the first legislative session of the State 
                legislature that begins on or after January 1, 1994. 
                For purposes of the previous sentence, in the case of a 
                State that has a 2-year legislative session, each year 
                of such session shall be deemed to be a separate 
                regular session of the State legislature.

     Subtitle B--Medicaid Program and Other Health Care Provisions

                      CHAPTER 1--MEDICAID PROGRAM

                Subchapter A--Program Savings Provisions

                       PART I--REPEAL OF MANDATE

SEC. 5101. PERSONAL CARE SERVICES FURNISHED OUTSIDE THE HOME AS 
              OPTIONAL BENEFIT.

    (a) In General.--Section 1905(a) (42 U.S.C. 1396d(a)), as amended 
by section 5174(c)(1), is further amended--
            (1) in paragraph (7), by striking ``including personal care 
        services'' and all that follows through ``nursing facility'';
            (2) in paragraph (23), by striking ``and'' at the end;
            (3) by redesignating paragraph (24) as paragraph (25); and
            (4) by inserting after paragraph (23) the following new 
        paragraph:
            ``(24) personal care services furnished to an individual 
        who is not an inpatient or resident of a nursing facility that 
        are (A) authorized by a physician for the individual in 
        accordance with a plan of treatment, (B) provided by an 
        individual who is qualified to provide such services and who is 
        not a member of the individual's family, (C) supervised by a 
        registered nurse, and (D) furnished in a home or other 
        location; and''.
    (b) Conforming Amendments.--(1) Section 1902(a)(10)(C)(iv) (42 
U.S.C. 1396a(a)(10)(C)(iv)), as amended by section 5174(c)(2)(A), is 
amended by striking ``through (23)'' and inserting ``through (24)''.
    (2) Section 1902(j) (42 U.S.C. 1396a(j)), as amended by section 
5174(c)(2)(B), is amended by striking ``through (24)'' and inserting 
``through (25)''.
    (c) Effective Date.--The amendments made by subsections (a) and (b) 
shall take effect as if included in the enactment of section 4721(a) of 
OBRA-90.

                 PART II--OUTPATIENT PRESCRIPTION DRUGS

SEC. 5106. PERMITTING PRESCRIPTION DRUG FORMULARIES UNDER STATE PLANS.

    (a) Elimination of Prohibition Against Use of Formularies.--
Paragraph (54) of section 1902(a)(54) (42 U.S.C. 1396a(a)(54)) is 
amended to read as follows:
            ``(54) in the case of a State plan that provides medical 
        assistance for covered outpatient drugs (as defined in section 
        1927(k)), comply with the applicable requirements of section 
        1927;''.
    (b) Standards for Formularies.--Section 1927(d) (42 U.S.C. 1396r-
8(d)), as amended by sections 5107(a) and 5108(b)(4)(A)(iii), is 
amended--
            (1) by adding at the end of paragraph (1) the following new 
        subparagraph:
            ``(C) In the case of a State that establishes a formulary 
        in accordance with paragraph (5), the State may exclude 
        coverage of a covered outpatient drug that is not included in 
        the formulary.''; and
            (2) by inserting after paragraph (4) the following new 
        paragraph:
            ``(5) Requirements for formularies.--A State may establish 
        a formulary only if the following requirements are met:
                    ``(A) The formulary is established by a committee 
                consisting of physicians, pharmacists, and other 
                appropriate individuals appointed by the Governor of 
                the State (or, at the option of the State, the State's 
                drug use review board established under subsection 
                (g)(3)).
                    ``(B) Except as provided in subparagraph (C), the 
                formulary includes the covered outpatient drugs of any 
                manufacturer which has entered into and complies with 
                an agreement under subsection (a).
                    ``(C) The committee may exclude a covered 
                outpatient drug with respect to the treatment of a 
                specific disease or condition for an identified 
                population (if any) only if the committee finds, based 
                on the drug's labeling (or, in the case of a drug whose 
                prescribed use is not approved under the Federal Food, 
                Drug, and Cosmetic Act but is a medically accepted 
                indication, based on information from the appropriate 
                compendia described in subsection (k)(6)), that the 
                excluded drug does not have a significant, clinically 
                meaningful therapeutic advantage in terms of safety, 
                effectiveness, or clinical outcome of such treatment 
                for such population over other drugs included in the 
                formulary.
                    ``(D) With respect to a decision to exclude a 
                covered outpatient drug from the formulary or a 
                prescribed use of such a drug, the committee issues a 
                written explanation of its decision that is available 
                to the public, unless the decision was made at a 
                meeting of the committee which was open to the public.
                    ``(E) The manufacturer of the drug, and any person 
                affected by the decision, may obtain a reversal of the 
                committee's decision to exclude a covered outpatient 
                drug from the formulary under subparagraph (C) on the 
                ground that the decision was arbitrary and capricious, 
                in accordance with an appeals process that is 
                established by the State and that provides an 
                opportunity for judicial review of such decision.
                    ``(F) The State plan permits coverage of a drug 
                excluded from the formulary pursuant to a prior 
                authorization program that is consistent with paragraph 
                (4).
                    ``(G) The formulary meets such other requirements 
                as the Secretary may impose.''.
    (c) Effective Date.--The amendments made by this section shall 
apply to calendar quarters beginning on or after October 1, 1993, 
without regard to whether or not regulations to carry out such 
amendments have been promulgated by such date.

SEC. 5107. ELIMINATION OF SPECIAL EXEMPTION FROM PRIOR AUTHORIZATION 
              FOR NEW DRUGS.

    (a) In General.--Section 1927(d) (42 U.S.C. 1396r-8(d)), as amended 
by section 5108(b)(4)(A)(iii), is amended by striking paragraph (5).
    (b) Conforming Amendment.--Section 1927(d)(3) (42 U.S.C. 1396r-
8(d)(3)) is amended by striking ``(except with respect'' and all that 
follows through ``of this paragraph)''.
    (c) Effective Date.--The amendments made by this section shall 
apply to calendar quarters beginning on or after October 1, 1993, 
without regard to whether or not regulations to carry out such 
amendments have been promulgated by such date.

SEC. 5108. TECHNICAL CORRECTIONS RELATING TO SECTION 4401 OF OBRA-1990.

    (a) Section 1903, SSA.--Paragraph (10) of section 1903(i), as 
inserted by section 4401(a)(1)(B) of OBRA-1990, is amended to read as 
follows:
            ``(10) with respect to covered outpatient drugs unless 
        there is a rebate agreement in effect under section 1927 with 
        respect to such drugs or unless section 1927(a)(3) applies;''.
    (b) Section 1927, SSA.--(1) Section 1927(a) (42 U.S.C. 1396r-8(a)) 
is amended--
            (A) in paragraph (1)--
                    (i) by amending the second sentence to read as 
                follows: ``Any such agreement entered into prior to 
                April 1, 1991, shall be deemed to have been entered 
                into on January 1, 1991, and the amount of the rebate 
                under such agreement shall be calculated as if the 
                agreement had been entered into on January 1, 1991.'', 
                and
                    (ii) in the third sentence, by striking ``March'' 
                and inserting ``April'';
            (B) in paragraph (2)--
                    (i) by striking ``first'', and
                    (ii) by striking the period at the end and 
                inserting the following: ``, except that such paragraph 
                (and section 1903(i)(10)(A)) shall not apply to the 
                dispensing of such a drug before April 1, 1991, if the 
                Secretary determines that there were extenuating 
                circumstances with respect to the first calendar 
                quarter of 1991.'';
            (C) in paragraph (3), by striking ``single source'' and all 
        that follows and inserting the following: ``covered outpatient 
        drugs if--
                    ``(A) based on information provided by a 
                beneficiary's physician, the State has made a 
                determination that the availability of the drug is 
                essential to the health of the beneficiary under the 
                State plan, and the Secretary has reviewed and approved 
                such determination; and
                    ``(B) the drug has been given a rating of 1-A by 
                the Food and Drug Administration.'';
                    (D) in paragraph (4)--
                            (i) by striking ``in compliance with'' and 
                        inserting ``in effect under'', and
                            (ii) by striking ``coverage of the 
                        manufacturer's drugs'' and inserting 
                        ``ingredient costs of the manufacturer's 
                        covered outpatient drugs covered''; and
                    (E) by adding at the end the following new 
                paragraph:
            ``(5) Application in certain states and territories.--
                    ``(A) Application in states operating under 
                demonstration projects.--In the case of any State which 
                is providing medical assistance to its residents under 
                a waiver granted under section 1115, the Secretary 
                shall require the State to meet the requirements of 
                section 1902(a)(54) and of this section in the same 
                manner as the State would be required to meet such 
                requirements if the State had in effect a plan approved 
                under this title.
                    ``(B) No application in commonwealths and 
                territories.--This section, and sections 1902(a)(54) 
                and 1903(i)(10), shall only apply to a State that is 
                one of the 50 States or the District of Columbia.''.
    (2) Section 1927(b) (42 U.S.C. 1396r-8(b)) is amended--
            (A) in paragraph (1)(A)--
                    (i) by striking ``(or periodically in accordance 
                with a schedule specified by the Secretary)'' and 
                inserting ``(or other period specified by the 
                Secretary)'', and
                    (ii) by inserting ``after December 31, 1990, for 
                which payment was made'' after ``dispensed'';
            (B) in paragraph (2)(A)--
                    (i) by striking ``calendar quarter'' and ``the 
                quarter'' and inserting ``rebate period'' and ``the 
                period'', respectively,
                    (ii) by striking ``dosage units'' and inserting 
                ``units of each dosage form and strength'', and
                    (iii) by inserting ``after December 31, 1990, for 
                which payment was made'' after ``dispensed'';
            (C) in paragraph (3)(A)--
                    (i) in clause (i), by striking ``quarter'' each 
                place it appears and inserting ``calendar quarter or 
                other rebate period under the agreement'',
                    (ii) in clause (i), by striking the open 
                parenthesis before ``for'' and the close parenthesis 
                after ``drugs'',
                    (iii) in clause (i), by striking ``subsection 
                (c)(2)(B)) for covered outpatient drugs'' and inserting 
                ``subsection (c)(1)(C) for each covered outpatient 
                drug'', and
                    (iv) in clause (ii), by inserting a comma after 
                ``this section'' and after ``1990'';
            (D) in paragraph (3)(B)--
                    (i) by striking ``$100,000'' and inserting 
                ``$10,000'',
                    (ii) by striking ``if the wholesaler'' and 
                inserting ``for each instance in which the 
                wholesaler'',
                    (iii) by inserting ``in response to such a 
                request'' after ``false information'', and
                    (iv) by striking ``(with respect to amounts of 
                penalties or additional assessments)'';
            (E) in paragraph (3)(C)--
                    (i) in clause (i), by striking ``the penalty'' and 
                inserting ``the rebate next required to be paid'',
                    (ii) in clause (i), by striking ``and such amount 
                shall be paid to the Treasury, and, if'' and inserting 
                ``. If'',
                    (iii) in clause (ii), by inserting ``under 
                subparagraph (A)'' after ``provides false 
                information'', and
                    (iv) in clause (ii), by striking ``Such civil money 
                penalties are'' and inserting ``Any such civil money 
                penalty shall be'';
            (F) in paragraph (3)(D), by striking ``wholesaler,'' and 
        inserting ``wholesaler or the''; and
            (G) in paragraph (4)(B)(iii), by adding at the end the 
        following: ``In the case of such a termination, a State may 
        terminate coverage of the drugs affected by such termination as 
        of the effective date of such termination without providing any 
        advance notice otherwise required by regulation.''.
    (3) Section 1927(c) (42 U.S.C. 1396r-8(c)) is amended--
            (A) in paragraph (1) in the matter preceding subparagraph 
        (A)--
                    (i) by striking the first sentence,
                    (ii) in the second sentence, by striking ``Except 
                as otherwise provided'' and all that follows through 
                ``the Secretary)'' and inserting the following: ``For 
                purposes of this section, the amount of the rebate 
                under this subsection for a rebate period'', and
                    (iii) by inserting ``(except as provided in 
                subsection (b)(3)(C) and paragraph (2))'' after ``drugs 
                shall'';
            (B) in paragraph (1)(A), by striking ``the quarter (or 
        other period)'' and inserting ``the rebate period'';
            (C) in subparagraph (C)--
                    (i) by striking ``For purposes of this paragraph'' 
                and inserting ``Best price defined.--For purposes of 
                this section'',
                    (ii) by inserting ``provider,'' after 
                ``retailer,'', and
                    (iii) by striking the semicolon at the end and 
                inserting a period; and
            (D) by striking subparagraph (D) and inserting the 
        following:
                    ``(D) Use of estimated best prices during initial 
                year of availability of drug.--If the Secretary 
                determines that a manufacturer cannot determine the 
                best price for rebate periods during the first year in 
                which an agreement is in effect until after the end of 
                the year, as part of the agreement the Secretary may 
                require the manufacturer to estimate the best price for 
                rebate periods during the year and provide an 
                adjustment to the rebate paid to the State to take into 
                account the difference (if any) between the best price 
                and the estimated best price.''.
    (4)(A) Section 1927(d) (42 U.S.C. 1396r-8(d)) is amended--
            (i) in paragraph (2)--
                    (I) in subparagraph (A), by inserting ``or loss'' 
                after ``gain'',
                    (II) by striking subparagraph (I), and
                    (III) by redesignating subparagraphs (J) and (K) as 
                subparagraphs (I) and (J);
            (ii) in paragraph (3)--
                    (I) by striking ``described in paragraph (2)'', and
                    (II) by inserting ``described in paragraph (2)'' 
                after ``classes of drugs,'';
            (iii) by striking paragraph (4) and by redesignating 
        paragraphs (5) through (7) as paragraphs (4) through (6);
            (iv) in paragraph (6), as so redesignated, by striking 
        ``provided'' and inserting ``if''; and
            (v) by striking the second sentence of paragraph (6), as so 
        redesignated, and paragraph (8) and inserting the following:
            ``(7) Construction with respect to fraud and abuse.--
        Nothing in this section shall be construed to restrict the 
        authority of a State to apply sanctions under this Act against 
        any person for fraud or abuse.''.
    (B) Section 1927(d)(4) of the Social Security Act, as redesignated 
by subparagraph (A)(iii), shall first apply to drugs dispensed on or 
after July 1, 1991.
    (5)(A) Section 1927(f) (42 U.S.C. 1396r-8(f)) is amended to read as 
follows:
    ``(f) No Reductions in Pharmacy Reimbursement Limits.--
            ``(1) In general.--During the period beginning on November 
        5, 1990, and ending on December 31, 1994--
                    ``(A) a State may not reduce the amount paid by the 
                State under this title with respect to the ingredient 
                cost of a covered outpatient drug or the dispensing fee 
                for such a drug below the amount in effect as of 
                November 5, 1990, and
                    ``(B) the Secretary may not change the regulations 
                in effect on November 5, 1990, governing the amounts 
                described in subparagraph (A) which are eligible for 
                Federal financial participation, to reduce the 
                reimbursement limits described in such regulations.
            ``(2) Construction.--If the Secretary notified a State 
        before November 5, 1990, that its payment amounts under this 
        title with respect to the ingredient cost of a covered 
        outpatient drug or the dispensing fee for such a drug were in 
        excess of those permitted under regulations in effect on such 
        date, paragraph (1)(B) shall not be construed as preventing a 
        State from reducing payment amounts or dispensing fee in order 
        to comply with such regulations.''.
    (B) Not later than April 1, 1994, the Secretary of Health and Human 
Services shall establish an upper limit on the amount of payment which 
is eligible for Federal financial participation under title XIX of the 
Social Security Act for each multiple source drug (as defined in 
section 1927(k)(7)(A)(i) of such Act) for which the Food and Drug 
Administration has rated at least 3 formulations of such drug as 
therapeutically and pharmaceutically equivalent, regardless of whether 
all the formulations of such drug are rated as so equivalent. In 
establishing such a limit for a drug, the Secretary shall take into 
account only those formulations of the drug which the Food and Drug 
Administration has rated as therapeutically and pharmaceutically 
equivalent.
    (6) Section 1927(g) (42 U.S.C. 1396r-8(g)) is amended--
            (A) by amending paragraph (1) to read as follows:
            ``(1) Requirement for drug use review program.--Each State 
        shall provide, by not later than January 1, 1993, for a drug 
        use review program for covered outpatient drugs (other than 
        drugs dispensed to residents of nursing facilities) that--
                            ``(i) meets the requirements of paragraph 
                        (2), and
                            ``(ii) is intended to assure that 
                        prescriptions for such drugs are appropriate, 
                        medically necessary, and not likely to lead to 
                        adverse medical results.'';
            (B) in paragraph (2)--
                    (i) by amending the matter before subparagraph (A) 
                to read as follows:
            ``(2) Requirements.--'',
                    (ii) by amending subparagraph (A) to read as 
                follows:
                    ``(A) Prospective drug use review.--Each drug use 
                review program shall provide for a review of drug 
                therapy before each prescription is filled or delivered 
                to an individual receiving benefits under this title 
                (including counseling by pharmacists) consistent with 
                standards established by the Secretary. Nothing in this 
                paragraph shall be construed as requiring a pharmacist 
                to provide consultation when an individual receiving 
                benefits under this title or caregiver of such 
                individual refuses such consultation.'',
                    (iii) in subparagraph (C)--
                            (I) by striking ``Application of 
                        standards.--'' and inserting ``Standards.--
                        (i)'',
                            (II) by striking ``and literature referred 
                        to in subsection (1)(B)'' and inserting 
                        ``described in clause (ii)'',
                            (III) by striking ``including but not 
                        limited to'' and inserting ``. Such assessment 
                        shall include'',
                            (IV) by striking ``abuse/misuse and, as 
                        necessary, introduce remedial strategies,'' and 
                        inserting ``abuse or misuse and introduce 
                        remedial strategies'', and
                            (V) by adding at the end the following new 
                        clause:
                    ``(ii) The compendia described in this clause are 
                the American Hospital Formulary Service Drug 
                Information, the United States Pharmacopeia-Drug 
                Information, and the American Medical Association Drug 
                Evaluations.'', and
                    (iv) by amending subparagraph (D) to read as 
                follows:
                    ``(D) Educational program.--The program shall 
                educate (directly or by contract) pharmacists, 
                physicians, and other individuals prescribing or 
                dispensing covered outpatient drugs under the State 
                plan on common drug therapy problems in order to 
                improve prescribing or dispensing practices.'';
            (C) in paragraph (3)--
                    (i) in subparagraph (A), by striking 
                ``(hereinafter'' and all that follows and inserting 
                ``(in this paragraph referred to as the `DUR 
                Board').'',
                    (ii) in subparagraph (B), by striking ``51 
                percent'' and all that follows and inserting ``50 
                percent licensed and actively practicing physicians and 
                at least 1/3 but not more than 50 percent licensed and 
                actively practicing pharmacists.'',
                    (iii) by amending subparagraph (C) to read as 
                follows:
                    ``(C) Responsibilities.--The responsibilities of 
                the DUR Board shall include the following:
                            ``(i) Carrying out retrospective drug use 
                        review pursuant to paragraph (2)(B).
                            ``(ii) Establishing and applying standards 
                        for drug use review described in paragraph 
                        (2)(C).
                            ``(iii) Implementing educational programs 
                        described in paragraph (2)(D).
                            ``(iv) Conducting ongoing evaluations of 
                        the effectiveness of its programs and 
                        activities in improving the quality and safety 
                        of drug therapy for individuals receiving 
                        benefits under the State plan.''; and
            (D) by amending subparagraph (D) to read as follows:
            ``(4) Annual report.--Each State shall submit a report each 
        year to the Secretary on the nature and scope of the drug use 
        review program under this subsection. Such report shall include 
        an estimate of cost savings resulting from operation of such 
        program.''.
    (7) Section 1927(h) (42 U.S.C. 1396r-8(h)) is amended to read as 
follows:
    ``(h) Encouraging Electronic Claims Management.--The Secretary 
shall encourage each single State agency under this title to establish, 
as its principal means of processing claims for covered outpatient 
drugs, a point-of-sale electronic claims management system for the 
purpose of verifying eligibility, transmitting data on claims, and 
assisting pharmacists and other authorized persons in applying for and 
receiving payment under the State plan.''.
    (8) Section 1927(i) (42 U.S.C. 1396r-8(i)) is amended to read as 
follows:
    ``(i) Annual Report on Rebate Program.--Not later than May 1 of 
each year, the Secretary shall submit to the Committee on Finance of 
the Senate, the Committee on Energy and Commerce of the House of 
Representatives, and the Committee on Aging of the Senate a report on 
the operation of the rebate agreements required for covered outpatient 
drugs under this section in the preceding fiscal year, and shall 
include in the report such information in addition to the information 
required to be reported under section 601(d) of the Veterans Health 
Care Act of 1992 as the Secretary considers appropriate.''.
    (9) Section 1927(j) (42 U.S.C. 1396r-8(j)) is amended to read as 
follows:
    ``(j) Exemption From Certain Requirements for Certain Health 
Maintenance Organizations and Hospitals.--
            ``(1) Certain health maintenance organizations and 
        pharmacies.--The requirements of subsections (g) and (h) shall 
        not apply with respect to covered outpatient drugs dispensed 
        by--
                    ``(A) an entity which receives payment under a 
                prepaid capitation basis or under any other risk basis 
                in accordance with section 1903(m)(2)(A) for services 
                provided under the State plan; or
                    ``(B) a pharmacy that is owned or operated by a 
                qualified health maintenance organization (as defined 
                in section 1310(d) of the Public Health Service Act) 
                that operates its own prospective drug use review 
                program.
            ``(2) Hospitals with independent formulary systems.--
                    ``(A) In general.--The requirements of subsections 
                (g) and (h) shall not apply with respect to covered 
                outpatient drugs dispensed by a hospital providing 
                medical assistance under the State plan that dispenses 
                such drugs under a drug formulary system.
                    ``(B) Application of state formulary.--Nothing in 
                subparagraph (A) shall be construed to permit payment 
                to be made under the State plan for a covered 
                outpatient drug that is included in a drug formulary 
                but that is not included in the State formulary under 
                subsection (d)(5).
            ``(3) Construction in determining best price.--Nothing in 
        this subsection shall be construed to exclude any covered 
        outpatient drugs subject to the provisions of this subsection 
        from the determination of the best price (as defined in 
        subsection (c)(1)(C)) for such drugs.''.
    (10) Section 1927(k) (42 U.S.C. 1396r-8(k)) is amended--
            (A) in paragraph (1), by striking ``calendar quarter'' and 
        inserting ``rebate period'';
            (B) in paragraph (2)--
                    (i) in the matter before clause (i) of subparagraph 
                (A), strike ``paragraph (5)'' and insert ``subparagraph 
                (D)'',
                    (ii) by striking ``and'' at the end of subparagraph 
                (A),
                    (iii) by striking the period at the end of 
                subparagraph (C) and inserting ``; and'', and
                    (iv) by adding at the end the following new 
                subparagraph:
                    ``(D) a drug which may be sold without a 
                prescription (commonly referred to as an `over-the-
                counter drug'), if the drug is prescribed by a 
                physician (or other person authorized to prescribe 
                under State law).'';
            (C) in paragraph (3)--
                    (i) in subparagraph (E), by striking ``**** 
                emergency room visits'',
                    (ii) in subparagraph (F), by striking ``sevices'' 
                and inserting ``services'', and
                    (iii) in subparagraph (H), by inserting 
                ``services'' after ``dialysis'';
            (D) by striking paragraph (4);
            (E) by amending paragraph (5) to read as follows:
            ``(5) Manufacturer.--The term `manufacturer' means, with 
        respect to a covered outpatient drug--
                    ``(A) the entity (if any) that both manufactures 
                and distributes the drug, or
                    ``(B) if no such entity exists, the entity that 
                distributes the drug.
        Such term does not include a wholesale distributor of the drug 
        that does not hold a National Drug Code number for the drug or 
        a retail pharmacy licensed under State law.'';
            (F) in paragraph (6), by striking ``, which appears'' and 
        all that follows and inserting ``which is accepted by any of 
        the compendia described in subsection (g)(2)(C)(ii).'';
            (G) in paragraph (7)--
                    (i) in subparagraph (A)(i), by striking ``calendar 
                quarter'' and inserting ``rebate period'',
                    (ii) in subparagraph (A)(i), by striking 
                ``paragraph (5)'' and inserting ``paragraph (2)(D)'',
                    (iii) in subparagraph (A)(ii), by inserting ``or 
                product licensing application'' after ``application'',
                    (iv) in subparagraph (C)(i), by striking 
                ``pharmaceuutically'' and inserting 
                ``pharmaceutically'', and
                    (v) in subparagraph (C)(iii), by striking ``, 
                provided that'' and inserting ``and''; and
            (H) by redesignating paragraph (8) as paragraph (9) and by 
        inserting after paragraph (7) the following new paragraph:
            ``(8) Rebate period.--The term `rebate period' means, with 
        respect to an agreement under subsection (a), a calendar 
        quarter or other period specified with respect to the agreement 
        under subsection (b)(1)(A) for the payment of rebates.''.
    (d) Funding.--Section 4401(b)(2) of OBRA-1990 is amended by 
striking ``75 percent,'' and all that follows and inserting ``75 
percent.''.
    (e) Demonstration Projects.--Section 4401(c)(1) of OBRA-1990 is 
amended--
            (A) in subparagraph (A), by striking ``10'' and inserting 
        ``5''; and
            (B) in subparagraph (C), by striking ``regiment'' and 
        inserting ``regimen''.
    (f) Studies.--Section 4401(d) of OBRA-1990 is amended--
            (1) in paragraph (1)(A), by striking ``other institutional 
        facilities, and managed care plans'' and inserting ``nursing 
        facilities, intermediate care facilities for the mentally 
        retarded, and health maintenance organizations'';
            (2) in paragraph (1)(B), by striking ``under this 
        subsection'' and inserting ``under this paragraph'';
            (3) in paragraph (1)(B)(i), by striking ``under this 
        section'' and inserting ``under section 1927 of the Social 
        Security Act'';
            (4) in paragraph (1)(B)(ii)--
                    (A) by striking ``drug use review'' and inserting 
                ``the type of drug use review that is'', and
                    (B) by striking ``under this section'' and 
                inserting ``under such section'';
            (5) in paragraph (1)(B)(iii), by striking ``under this 
        title'' and inserting ``under title XIX of the Social Security 
        Act'';
            (6) in paragraph (1)(C)--
                    (A) by striking ``May 1, 1991'' and inserting ``May 
                1, 1992'', and
                    (B) by striking ``hereafter'';
            (7) in paragraph (2), by striking ``the Committees on Aging 
        of the Senate and House of Representatives an annual report and 
        inserting ``the Committee on Aging of the Senate a report'';
            (8) in paragraph (3)--
                    (A) in subparagraph (A), by striking ``, acting in 
                consultation with the Comptroller General,'',
                    (B) by indenting subparagraph (B) an additional 2 
                ems, and
                    (C) in subparagraph (B)--
                            (i) by striking ``December 31, 1991, the 
                        Secretary and the Comptroller General'' and 
                        inserting ``June 1, 1993, the Secretary'', and
                            (ii) by striking ``the Committees on Aging 
                        of the Senate and the House of 
                        Representatives'' and inserting ``the Committee 
                        on Aging of the Senate'';
            (9) in paragraph (4)(A), by striking ``each'' and by 
        striking the semicolon and inserting a comma; and
            (10) by striking paragraphs (5) and (6).

  PART III--RESTRICTIONS ON DIVESTITURE OF ASSETS AND ESTATE RECOVERY

SEC. 5111. TRANSFER OF ASSETS.

    (a) Period of Ineligibility.--
            (1) Extending look-back period to 36 months.--Section 
        1917(c)(1) (42 U.S.C. 1396p(c)(1)) is amended by striking ``30-
        month period'' and inserting ``36-month period''.
            (2) Eliminating 30-month limit on period of 
        ineligibility.--The second sentence of such section is amended 
        by striking ``equal to'' and all that follows and inserting the 
        following: ``equal to--
            ``(A) the total uncompensated value of the resources so 
        transferred; divided by
            ``(B) the average monthly cost, to a private patient at the 
        time of the application, of nursing facility services in the 
        State or, at State option, in the community in which the 
        individual is institutionalized.''.
            (3) Cumulative periods of ineligibility in the case of 
        multiple transfers.--Such sentence is further amended by 
        inserting ``(or, in the case of a transfer which occurs during 
        a period of ineligibility attributable to a previous transfer, 
        the first month after the end of all periods of ineligibility 
        attributable to any previous transfer)'' after ``shall begin 
        with the month in which such resources were transferred''.
    (b) Criteria for Undue Hardship Exception.--Section 1917(c)(2)(D) 
(42 U.S.C. 1396p(c)(2)(D)) is amended to read as follows:
            ``(D) the State agency determines, under procedures 
        established by the State (in accordance with standards 
        specified by the Secretary) that the denial of eligibility 
        would work an undue hardship (in accordance with criteria 
        established by the Secretary).''.
    (c) Treatment of Jointly Held Assets.--Section 1917(c) (42 U.S.C. 
1936p(c)) is further amended by adding at the end the following new 
paragraph:
    ``(6) For purposes of this subsection, in the case of an asset held 
by an individual in common with another person or persons in a joint 
tenancy or a similar arrangement, the asset (or the affected portion 
thereof) shall be considered to be transferred by such individual when 
any action is taken, either by such individual or by any other person, 
that reduces or eliminates such individual's ownership or control of 
such asset.''.
    (d) Medicaid Qualifying Trusts.--Section 1902(k) (42 U.S.C. 
1396a(k)) is amended to read as follows:
    ``(k) Treatment of Trust Amounts.--
            ``(1) In General.--For purposes of determining an 
        individual's eligibility for or amount of benefits under a 
        State plan under this title, subject to paragraph (4), the 
        following rules shall apply to a trust (which term includes, 
        for purposes of this subsection, any similar legal instrument 
        or device, such as an annuity) established by such individual:
                    ``(A) Revocable trusts.--In the case of a revocable 
                trust--
                            ``(i) the corpus of the trust shall be 
                        considered resources available to the 
                        individual,
                            ``(ii) payments from the trust to or for 
                        the benefit of the individual shall be 
                        considered income of the individual, and
                            ``(iii) any other payments from the trust 
                        shall be considered a transfer of assets by the 
                        individual subject to section 1917(c).
                    ``(B) Irrevocable trusts which may benefit 
                grantor.--In the case of an irrevocable trust, if there 
                are any circumstances under which payment from the 
                trust could be made to or for the benefit of the 
                individual--
                            ``(i) the corpus of the trust (or that 
                        portion of the corpus from which, or from the 
                        increase whereof, payment to the individual 
                        could be made) shall be considered resources 
                        available to the individual, and payments from 
                        that portion of the corpus (or increase)--
                                    ``(I) to or for the benefit of the 
                                individual, shall be considered income 
                                of the individual, and
                                    ``(II) for any other purpose, shall 
                                be considered a transfer of assets by 
                                the individual subject to the 
                                provisions of section 1917(c); and
                            ``(ii) any portion of the trust from which 
                        (or from the income whereof) no payment could 
                        under any circumstances be made to the 
                        individual shall be considered, as of the date 
                        of establishment of the trust (or, if later, 
                        the date on which payment to the individual was 
                        foreclosed), a transfer of assets by the 
                        individual subject to section 1917(c), and 
                        payments from such portion of the trust after 
                        such date shall be disregarded.
                    ``(C) Irrevocable trusts which cannot benefit 
                grantor.--In the case of an irrevocable trust, if no 
                payment may be made from the trust under any 
                circumstances to or for the benefit of the individual--
                            ``(i) the corpus of the trust shall be 
                        considered, as of the date of establishment of 
                        the trust (or, if later, the date on which 
                        payment to the individual was foreclosed), a 
                        transfer of assets subject to section 1917(c), 
                        and
                            ``(ii) payments from the trust after the 
                        date specified in clause (i) shall be 
                        disregarded.
            ``(2) Determination of grantor.--
                    ``(A) Treatment of acts by individual and others.--
                For purposes of this subsection, an individual shall be 
                considered to have established a trust if--
                            ``(i) the individual (or the individual's 
                        spouse), or a person (including a court or 
                        administrative body) with legal authority to 
                        act in place of or on behalf of such individual 
                        (or spouse), or any person (including any court 
                        or administrative body) acting at the direction 
                        or upon the request of such individual (or 
                        spouse), established (other than by will) such 
                        a trust, and
                            ``(ii) assets of the individual (as defined 
                        in subparagraph (B)) were used to form all or 
                        part of the corpus of such trust.
                    ``(B) Assets.--For purposes of this paragraph, 
                assets of an individual include all income and 
                resources of the individual and of the individual's 
                spouse, including any income or resources which the 
                individual (or spouse) is entitled to but does not 
                receive because of action by the individual (or 
                spouse), by a person (including a court or 
                administrative body) with legal authority to act in 
                place of or on behalf of such individual (or spouse), 
                or by any person (including any court or administrative 
                body) acting at the direction or upon the request of 
                such individual (or spouse).
                    ``(C) Trusts containing assets of more than one 
                individual.--In the case of a trust whose corpus 
                includes assets of an individual (as determined 
                pursuant to subparagraph (A)) and assets of any other 
                person or persons, the provisions of this subsection 
                shall apply to the portion of the trust attributable to 
                the assets of the individual.
            ``(3) Application; relation to other provisions.--Subject 
        to paragraph (4), this subsection shall apply without regard 
        to--
                    ``(A) the purposes for which the trust is 
                established,
                    ``(B) whether the trustees have or exercise any 
                discretion under the trust,
                    ``(C) any restrictions on when or whether 
                distributions may be made from the trust, or
                    ``(D) any restrictions on the use of distributions 
                from the trust.
            ``(4) Exceptions and hardship waiver.--
                    ``(A) Exception for certain trusts.--This 
                subsection shall not apply to any of the following 
                trusts:
                            ``(i) A trust established for the benefit 
                        of a disabled individual (as determined under 
                        section 1614(a)(3)) by a parent, grandparent, 
                        or other representative payee of the 
                        individual.
                            ``(ii) A trust established in a State for 
                        the benefit of an individual if--
                                    ``(I) the trust is composed only of 
                                pension, Social Security, and other 
                                income to the individual (and 
                                accumulated income in the trust),
                                    ``(II) the State will receive any 
                                amounts remaining in the trust upon the 
                                death of the individual, and
                                    ``(III) the State makes medical 
                                assistance available to individuals 
                                described in section 
                                1902(a)(10)(A)(ii)(V), but does not 
                                make such assistance available to any 
                                group of individuals under section 
                                1902(a)(10)(C).
                    ``(B) Special treatment of annuities.--In this 
                subsection, the term `trust' includes an annuity only 
                to such extent and in such manner as the Secretary 
                specifies.
                    ``(C) Hardship waiver.--The State agency shall 
                establish procedures (in accordance with standards 
                specified by the Secretary) under which the agency 
                waives the application of this subsection with respect 
                to an individual if the individual establishes (under 
                criteria established by the Secretary) that such 
                application would work an undue hardship on the 
                individual.''.
    (e) Effective Date.--(1) The amendments made by this section shall 
apply, except as provided in this subsection, to payments under title 
XIX of the Social Security Act for calendar quarters beginning on or 
after October 1, 1993, without regard to whether or not final 
regulations to carry out such amendments have been promulgated by such 
date.
    (2) The amendments made by this section shall not apply--
            (A) to medical assistance provided for services furnished 
        before October 1, 1993,
            (B) with respect to resources disposed of before May 11, 
        1993,
            (C) with respect to trusts established before May 11, 1993, 
        or
            (D) with respect to inter-spousal transfers.

SEC. 5112. MEDICAID ESTATE RECOVERIES.

    (a) Requiring Establishment of Estate Recovery Programs.--
            (1) In general.--Section 1902(a)(51) (42 U.S.C. 
        1396a(a)(51)) is amended by striking ``and (B)'' and inserting 
        ``(B) provide for an estate recovery program that meets the 
        requirements of section 1917(b)(1), and (C)''.
            (2) Requirements for estate recovery programs.--Section 
        1917(b) (42 U.S.C. 1396p(b)) is amended--
                    (A) in paragraph (1)--
                            (i) by striking ``(b)(1)'' and inserting 
                        ``(2)'', and
                            (ii) by striking ``(a)(1)(B)'' and 
                        inserting ``(a)(1)(B)(i)'';
                    (B) in paragraph (2), by striking ``(2) Any 
                adjustment or recovery under'' and inserting ``(3) Any 
                adjustment or recovery under an estate recovery program 
                under''; and
                    (C) by inserting before paragraph (2), as 
                designated by subparagraph (A), the following:
    ``(b)(1) For purposes of section 1902(a)(51)(B), the requirements 
for an estate recovery program of a State are as follows:
            ``(A) The program provides for identifying and tracking 
        (and, at the option of the State, preserving) resources 
        (whether excluded or not) of individuals who are furnished any 
        of the following long-term care services for which medical 
        assistance is provided under this title:
                    ``(i) Nursing facility services.
                    ``(ii) Home and community-based services (as 
                defined in section 1915(d)(5)(C)(i)).
                    ``(iii) Services described in section 1905(a)(14) 
                (relating to services in an institution for mental 
                diseases).
                    ``(iv) Home and community care provided under 
                section 1929.
                    ``(v) Community supported living arrangements 
                services provided under section 1930.
            ``(B) The program provides for promptly ascertaining--
                    ``(i) when such an individual dies;
                    ``(ii) in the case of such an individual who was 
                married at the time of death, when the surviving spouse 
                dies; and
                    ``(iii) at the option of the State, cases in which 
                adjustment or recovery may not be made at the time of 
                death because of the application of paragraph (3)(A) or 
                paragraph (3)(B).
            ``(C)(i) The program provides for the collection consistent 
        with paragraph (3) of an amount (not to exceed the amount 
        described in clause (ii)) from--
                    ``(I) the estate of the individual;
                    ``(II) in the case of an individual described in 
                subparagraph (B)(ii), from the estate of the surviving 
                spouse; or
                    ``(III) at the option of the State, in a case 
                described in subparagraph (B)(iii), from the 
                appropriate person.
            ``(ii) The amount described in this clause is the amount of 
        medical assistance correctly paid under this title for long-
        term care services described in subparagraph (A) furnished on 
        behalf of the individual.''.
    (b) Hardship Waiver.--Section 1917(b) (42 U.S.C. 1396p(b)) is 
further amended by adding at the end the following new paragraph:
    ``(4) The State agency shall establish procedures (in accordance 
with standards specified by the Secretary) under which the agency 
waives the application of this subsection if such application would 
work an undue hardship (in accordance with criteria established by the 
Secretary).''.
    (c) Definition of Estate.--Section 1917(b) (42 U.S.C. 1396(b)) is 
further amended by adding at the end the following new paragraph:
    ``(5) For purposes of this section, the term `estate', with respect 
to a deceased individual, includes all real and personal property and 
other assets in which the individual had any legally cognizable title 
or interest at the time of his death, including such assets conveyed to 
a survivor, heir, or assign of the deceased individual through joint 
tenancy, survivorship, life estate, living trust, or other 
arrangement.''.
    (d) Effective Date.--
            (1)(A) The amendments made by subsections (a) and (b) apply 
        (except as provided under subparagraph (B)) to payments under 
        title XIX of the Social Security Act for calendar quarters 
        beginning on or after October 1, 1993, without regard to 
        whether or not final regulations or standards to carry out such 
        amendments have been promulgated by such date.
            (B) In the case of a State plan for medical assistance 
        under title XIX of the Social Security Act which the Secretary 
        of Health and Human Services determines requires State 
        legislation (other than legislation appropriating funds) in 
        order for the plan to meet the additional requirements imposed 
        by the amendments made by subsections (a) and (b), the State 
        plan shall not be regarded as failing to comply with the 
        requirements of such title solely on the basis of its failure 
        to meet these additional requirements before the first day of 
        the first calendar quarter beginning after the close of the 
        first regular session of the State legislature that begins 
        after the date of the enactment of this Act. For purposes of 
        the previous sentence, in the case of a State that has a 2-year 
        legislative session, each year of such session shall be deemed 
        to be a separate regular session of the State legislature.
            (2) The amendments made by this section shall not apply to 
        individuals who died before October 1, 1993.

SEC. 5113. CLOSING LOOPHOLE PERMITTING WEALTHY INDIVIDUALS TO QUALIFY 
              FOR MEDICAID.

    (a) In General.--Section 1902(r)(2) (42 U.S.C. 1396a(r)(2)) is 
amended by adding at the end the following:
    ``(C)(i) Notwithstanding subparagraph (A), except as provided in 
clause (ii), a State plan may not provide pursuant to this paragraph 
for disregarding any assets--
            ``(I) to the extent that payments are made under a long-
        term care insurance policy; or
            ``(II) because an individual has received (or is entitled 
        to receive) benefits for a specified period of time under a 
        long-term care insurance policy.
    ``(ii) Clause (i) shall not apply to State plan provisions that are 
approved as of May 14, 1993.''.
    (b) Effective Date.--The amendment made by subsection (a) shall 
take effect on the date of the enactment of this Act.

 PART IV--IMPROVEMENT IN IDENTIFICATION AND COLLECTION OF THIRD PARTY 
                                PAYMENTS

SEC. 5116. LIABILITY OF THIRD PARTIES TO PAY FOR CARE AND SERVICES.

    (a) Liability of ERISA Plans.--(1) Section 1902(a)(25)(A) (42 
U.S.C. 1396a(a)(25)(A)) is amended by striking ``insurers)'' and 
inserting ``insurers and group health plans (as defined in section 
607(1) of the Employee Retirement Income Security Act of 1974) and 
including a service benefit plan and a health maintenance 
organization)''.
    (2) Section 1903(o) of such Act (42 U.S.C. 1396b(o)) is amended by 
striking ``regulation)'' and inserting ``regulation and including a 
group health plan (as defined in section 607(1) of the Employee 
Retirement Income Security Act of 1974)), a service benefit plan, and a 
health maintenance organization''.
    (b) Requiring State to Prohibit Insurers From Taking Medicaid 
Status Into Account.--Section 1902(a)(25) (42 U.S.C. 1396a(a)(25)) is 
amended--
            (1) by striking ``and'' at the end of subparagraph (F);
            (2) by adding ``and'' at the end of subparagraph (G); and
            (3) by adding after subparagraph (G) the following new 
        subparagraph:
                    ``(H) that the State prohibits any health insurer 
                (including a group health plan, as defined in section 
                607(1) of the Employee Retirement Income Security Act 
                of 1974, a service benefit plan, and a health 
                maintenance organization), in enrolling an individual 
                or in making any payments for benefits to the 
                individual or on the individual's behalf, from taking 
                into account that the individual is eligible for or is 
                provided medical assistance under a State plan;''.
    (c) State Right to Subrogation.--Section 1902(a)(25) (42 U.S.C. 
1396a(a)(25)), as amended by subsection (b), is further amended--
            (1) by striking ``and'' at the end of subparagraph (G);
            (2) by adding ``and'' at the end of subparagraph (H); and
            (3) by adding after subparagraph (H) the following new 
        subparagraph:
                    ``(I) that to the extent that payment has been made 
                under the State plan for medical assistance in any case 
                where a third party has a legal liability to make 
                payment for such assistance, the State is subrogated to 
                the right of any other party to payment for such 
                assistance;''.
    (d) Effective Date.--(1) Except as provided in paragraph (2), the 
amendments made by subsections (a)(1), (b), and (c) shall apply to 
calendar quarters beginning on or after October 1, 1993, without regard 
to whether or not final regulations to carry out such amendments have 
been promulgated by such date.
    (2) In the case of a State plan for medical assistance under title 
XIX of the Social Security Act which the Secretary of Health and Human 
Services determines requires State legislation (other than legislation 
appropriating funds) in order for the plan to meet the additional 
requirements imposed by the amendments made by subsections (a) and (b), 
the State plan shall not be regarded as failing to comply with the 
requirements of such title solely on the basis of its failure to meet 
these additional requirements before the first day of the first 
calendar quarter beginning after the close of the first regular session 
of the State legislature that begins after the date of the enactment of 
this Act. For purposes of the previous sentence, in the case of a State 
that has a 2-year legislative session, each year of such session shall 
be deemed to be a separate regular session of the State legislature.
    (3) The amendment made by subsection (a)(2) shall apply to items 
and services furnished on or after October 1, 1993.

SEC. 5117. HEALTH COVERAGE CLEARINGHOUSE.

    (a) In General.--The Social Security Act is amended by adding at 
the end the following new title:

               ``TITLE XXI--HEALTH COVERAGE CLEARINGHOUSE

                    ``establishment of clearinghouse

    ``Sec. 2101. (a) In General.--The Secretary shall establish and 
operate a Health Coverage Clearinghouse (in this title referred to as 
the `Clearinghouse') for the purpose of identifying, for beneficiaries 
of a covered health program (as defined in subsection (c)), third 
parties (which may include a covered health program) which may be 
liable for payment for health care items and services furnished to such 
beneficiaries under such program.
    ``(b) Director.--The Clearinghouse shall be headed by a Director 
(in this title referred to as the `Director') appointed by the 
Secretary.
    ``(c) Covered Health Program Defined.--In this title, the term 
`covered health program' means any of the following under which payment 
is made for health care items or services furnished to a beneficiary:
            ``(1) The medicare program under title XVIII.
            ``(2) A State plan for medical assistance under title XIX 
        (including a State plan operating under a Statewide waiver 
        under section 1115).
            ``(3) The Indian Health Service and any program under the 
        Indian Health Care Improvement Act.
            ``(4) A State program under title V that provides payment 
        for items or services.
    ``(d) Other Definitions.--In this title:
            ``(1) The term `administrator' means, with respect to the 
        covered health program described in--
                    ``(A) subsection (c)(1), the Administrator of the 
                Health Care Financing Administration;
                    ``(B) subsection (c)(2), the single State agency 
                referred to in section 1902(a)(5);
                    ``(C) subsection (c)(3), the Director of the Indian 
                Health Service; and
                    ``(D) subsection (c)(4), the State agency receiving 
                funds under title V.
            ``(2) The term `group health plan' has the meaning given 
        such term in section 6103(l)(12)(E)(ii) of such Code.
            ``(3) The term `qualified employer' has the meaning given 
        such term in section 6103(l)(12)(E)(iii) of the Internal 
        Revenue Code of 1986.

                       ``provision of information

    ``Sec. 2102. (a) Request for Information.--An administrator of a 
covered health program may request from the Director information 
concerning the employment and group health coverage of a program 
beneficiary, the beneficiary's spouse, and (if the beneficiary is a 
dependent child) the beneficiary's parents. The Director shall provide 
such information if the request--
            ``(1) is in such form and manner and at such a time as the 
        Director may require, and
            ``(2) specifies the name and tax identification number of 
        the beneficiary.
    ``(b) Data Matching Program.--
            ``(1) Request by director.--The Director shall, at such 
        intervals as the Director finds appropriate, transmit to the 
        Secretary of the Treasury the names and tax identification 
        numbers of beneficiaries with respect to whom a request has 
        been made pursuant to subsection (a), and request that such 
        Secretary disclose to the Commissioner of Social Security the 
        following information:
                    ``(A) Whether the beneficiary is married and, if 
                so, the name of the spouse and such spouse's tax 
                identification number.
                    ``(B) If the beneficiary is a dependent child, the 
                name of and tax identification numbers of the 
                beneficiary's parents.
            ``(2) Information from commissioner of social security.--
        The Secretary, acting through the Commissioner of Social 
        Security, shall, upon written request from the Director, 
        disclose to the Director, the following information:
                    ``(A) For each individual who is identified as 
                having received wages (as defined in section 3401(a) of 
                the Internal Revenue Code of 1986) from, and as having 
                available coverage under a group health plan of, an 
                employer in a previous year--
                            ``(i) the name and taxpayer identification 
                        number of the individual;
                            ``(ii) the name, address, and taxpayer 
                        identification number of the employer, and 
                        whether such employer is a qualified employer; 
                        and
                            ``(iii) whether the employer has made 
                        available a group health plan to the employee 
                        and the plan coverage provided (if any) with 
                        respect to the employee and family members of 
                        the employee under the group health plan.
                    ``(B) For each individual who is identified as 
                married and whose spouse is identified as having 
                received wages (as defined in section 3401(a) of the 
                Internal Revenue Code of 1986) from, and as having 
                available coverage under a group health plan of, an 
                employer in a previous year--
                            ``(i) the name and taxpayer identification 
                        number of the individual and of the 
                        individual's spouse;
                            ``(ii) the name, address, and taxpayer 
                        identification number of the spouse's employer, 
                        and whether such employer is a qualified 
                        employer; and
                            ``(iii) whether the spouse's employer has 
                        made available a group health plan to the 
                        spouse and the plan coverage provided (if any) 
                        with respect to the spouse and family members 
                        of the spouse under the group health plan.
                    ``(C) For each individual who is identified as a 
                dependent child and whose parent is identified as 
                having received wages (as defined in section 3401(a) of 
                the Internal Revenue Code of 1986) from, and as having 
                available coverage under a group health plan of, an 
                employer in a previous year--
                            ``(i) the name and taxpayer identification 
                        number of the individual and of the 
                        individual's parent;
                            ``(ii) the name, address, and taxpayer 
                        identification number of the parent's employer, 
                        and whether such employer is a qualified 
                        employer; and
                            ``(iii) whether the parent's employer has 
                        made available a group health plan to the 
                        parent and the plan coverage provided (if any) 
                        with respect to the parent and dependent 
                        children of the parent under the group health 
                        plan.
            ``(3) Information from employers.--The Director shall--
                    ``(A) request, from the employer of each individual 
                (including each spouse) with respect to whom 
                information was received from the Commissioner of 
                Social Security pursuant to paragraph (2), specific 
                information concerning coverage of such individual (and 
                of the individual's spouse and dependent children) 
                under the employer's group health plan (including the 
                period and nature of the coverage, and the name, 
                address, and identifying number of the plan), and
                    ``(B) furnish the information received in response 
                to such request with respect to an individual (or such 
                individual's spouse or dependent children) to the 
                administrator requesting such information pursuant to 
                subsection (a).

            ``requirement that employers furnish information

    ``Sec. 2103. (a) In General.--An employer shall furnish to the 
Director the information requested pursuant to section 2102(b)(3) 
within 30 days after receipt of such a request.
    ``(b) Sunset on Requirement.--Subsection (a) shall not apply to 
inquiries made after September 30, 1998.
    ``(c) Civil Money Penalty for Failure to Cooperate.--
            ``(1) In general.--An employer (other than a Federal or 
        other governmental entity) who willfully or repeatedly fails to 
        provide timely and accurate response to a request for 
        information pursuant to section 2102(b)(3) shall be subject, in 
        addition to any other penalties that may be prescribed by law, 
        to a civil money penalty of not to exceed $1,000 for each 
        individual with respect to whom such a request is made.
            ``(2) Enforcement authority.--In cases of failure to 
        respond to the Director in accordance with subsection (a) to 
        inquiries relating to requests pursuant to section 2102, the 
        provisions of section 1128A (other than subsections (a) and 
        (b)) shall apply to civil money penalties under paragraph (1) 
        in the same manner as such provisions apply to penalties or 
        proceedings under section 1128A(a).

                              ``data bank

    ``Sec. 2104. (a) Maintenance of Information.--The Clearinghouse 
shall maintain a data bank, containing information on individuals 
obtained pursuant to this title. Individual information in the data 
bank shall be retained for not less than one year after the date the 
information was obtained.
    ``(b) Disclosure of Information in Data Bank.--
            ``(1) In general.--The Director is authorized (subject to 
        paragraph (2)) to disclose any information in the data bank 
        established pursuant to subsection (a) with respect to an 
        individual (or an individual's spouse or parent)--
                    ``(A) to the Commissioner of Social Security, the 
                Secretary of the Treasury, administrators, employers, 
                and insurers, to the extent necessary to assist such 
                administrators;
                    ``(B) to Federal and State law enforcement 
                officials responsible for enforcement of civil or 
                criminal laws, in connection with investigations or 
                administrative or judicial law enforcement proceedings 
                relating to a covered health program; and
                    ``(C) for research or statistical purposes.
            ``(2) Restrictions on disclosure.--Information in the data 
        bank may be disclosed under this subsection only for purposes 
        of, and to the extent necessary in, determining the extent to 
        which an individual is covered under any group health plan.
    ``(c) Use of Contractors.--The responsibilities of the 
Clearinghouse under this section may be carried out by contract.
    ``(d) Fees.--The Clearinghouse shall--
            ``(1) establish fees for services under this section 
        designed to cover the full costs to the Clearinghouse of 
        providing such services, and
            ``(2) require the payment of such fees to provide such 
        services.''.
    (b) Conforming Medicare Amendments.--Section 1862(b)(5) (42 U.S.C. 
1395y(b)(5)) is amended--
            (1) in subparagraph (A)(i)--
                    (A) by striking ``Secretary of the Treasury'' and 
                inserting ``Director of the Health Coverage 
                Clearinghouse'',
                    (B) by striking ``(as defined in section 
                6103(l)(12) of the Internal Revenue Code of 1986)'' and 
                inserting ``(as defined in clause (iii))'', and
                    (C) by striking ``and request'' and all that 
                follows and inserting a period;
            (2) in subparagraph (A)(ii)--
                    (A) by striking ``the Commissioner of the Social 
                Security Administration'' and all that follows and 
                inserting ``the Director of the Health Coverage 
                Clearinghouse to obtain and disclose to the 
                Administrator, pursuant to section 2102(b) and to 
                subparagraph (C) of section 6103(l)(12) of the Internal 
                Revenue Code of 1986, the information described in 
                section 2102(b) and subparagraph (B) of such section 
                6103(l)(12).'', and
                    (B) by inserting ``, pursuant to section 1144(c),'' 
                after ``disclose to the Administrator''; and
            (3) by striking subparagraph (C).
    (c) Medicaid Use of Clearinghouse.--Section 1902(a)(25)(A) (42 
U.S.C. 1396a(a)(25)(A)) is amended by inserting ``(including making 
appropriate requests to the Director of the Health Coverage 
Clearinghouse under section 2102)'' after ``all reasonable measures''.
    (d) Collection of Third Party Payments Under Maternal and Child 
Health Block Grant Program.--Section 505(a) (42 U.S.C. 705(a)) is 
amended--
            (1) by striking ``and'' at the end of paragraph (4),
            (2) by striking the period at the end of paragraph (5) and 
        inserting ``; and'', and
            (3) by inserting after paragraph (5) the following new 
        paragraph:
            ``(6) provides for an entity providing health services with 
        assistance from the State under this title taking all 
        reasonable steps--
                    ``(A) to ascertain the legal liability of third 
                parties to pay for such services, and
                    ``(B) where such liability is found to exist, to 
                seek reimbursement for such services.''.
    (e) Effective Dates.--
            (1) The amendments made by subsections (a), (b), and (d) 
        shall take effect on April 1, 1995.
            (2) The amendments made by subsection (c) shall apply to 
        allotments for years beginning with fiscal year 1994.

SEC. 5118. MEDICAL CHILD SUPPORT.

    (a) State Plan Requirement.--Section 1902(a)(45) (42 U.S.C. 
1396a(a)(45)) is amended by striking ``owed to recipients'' and 
inserting ``and have in effect laws relating to medical child 
support''.
    (b) Medical Child Support Laws.--Section 1912 of such Act (42 
U.S.C. 1396k) is amended--
            (1) by adding at the end of the heading the following: ``; 
        required laws relating to medical child support''; and
            (2) by adding at the end the following new subsection:
    ``(c) The laws relating to medical child support, which a State is 
required to have in effect under section 1902(a)(45), are as follows:
            ``(1) A law that prohibits an insurer from denying 
        enrollment of a child under the health coverage of the child's 
        parent on the ground that the child was born out of wedlock, on 
        the ground that the child may not be claimed as a dependent on 
        the parent's Federal income tax return, or on the ground that 
        the child does not reside with the parent or in the insurer's 
        service area. In this subsection, the term `insurer' includes a 
        group health plan, as defined in section 607(1) of the Employee 
        Retirement Income Security Act of 1974, a health maintenance 
        organization, and an entity offering a service benefit plan.
            ``(2) A law that requires an insurer, in any case in which 
        a parent is required by court or administrative order to 
        provide health coverage for a child and the parent is eligible 
        for family health coverage through the insurer--
                    ``(A) to permit such parent, upon application and 
                without regard to any enrollment season restrictions, 
                to enroll the parent and such child under such family 
                coverage;
                    ``(B) if such a parent is enrolled but fails to 
                make application to obtain coverage of such child, to 
                enroll such child under such family coverage upon 
                application by the child's other parent or by the State 
                agency administering the program under this title or 
                part D of title IV; and
                    ``(C) not to disenroll (or eliminate coverage of) 
                such a child unless the insurer is provided 
                satisfactory written evidence that--
                            ``(i) such court or administrative order is 
                        no longer in effect, or
                            ``(ii) the child is or will be enrolled in 
                        comparable health coverage through another 
                        insurer which will take effect not later than 
                        the effective date of such disenrollment.
            ``(3) A law that requires an employer doing business in the 
        State, in the case of health coverage offered through 
        employment with the employer and providing coverage of a child 
        of an employee pursuant to a court or administrative order, to 
        withhold from such employee's compensation the employee's share 
        (if any) of premiums for health coverage (to the maximum amount 
        permitted under section 303(b) of the Consumer Credit 
        Protection Act) and to pay such share of premiums to the 
        insurer.
            ``(4) A law that prohibits an insurer from imposing 
        requirements upon a State agency, which is acting as an agent 
        or subrogee of an individual eligible for medical assistance 
        under this title and covered for health benefits from the 
        insurer, that are different from requirements applicable to an 
        agent or subrogee of any other individual so covered.
            ``(5) A law that requires an insurer, in any case in which 
        a child has health coverage through the insurer of a 
        noncustodial parent--
                    ``(A) to provide such information to the custodial 
                parent as may be necessary for the child to obtain 
                benefits through such coverage;
                    ``(B) to permit the custodial parent (or provider, 
                with the custodial parent's approval) to submit claims 
                for covered services without the approval of the 
                noncustodial parent; and
                    ``(C) to make payment on claims submitted in 
                accordance with subparagraph (B) directly to the 
                custodial parent or the provider.
            ``(6) A law that requires the State agency under this title 
        to garnish the wages, salary, or other employment income of, 
        and to withhold amounts from State tax refunds to, any person 
        who--
                    ``(A) is required by court or administrative order 
                to provide coverage of the costs of health services to 
                a child who is eligible for medical assistance under 
                this title,
                    ``(B) has received payment from a third party for 
                the costs of such services to such child, but
                    ``(C) has not used such payments to reimburse, as 
                appropriate, either the other parent or guardian of 
                such child or the provider of such services,
        to the extent necessary to reimburse the State agency for 
        expenditures for such costs under its plan under this title, 
        but any claims for current or past-due child support shall take 
        priority over any such claims for the costs of such 
        services.''.
    (c) Effective Date.--(1) Except as provided in paragraph (2), the 
amendments made by this section apply to calendar quarters beginning on 
or after April 1, 1994, without regard to whether or not final 
regulations to carry out such amendments have been promulgated by such 
date.
    (2) In the case of a State plan under title XIX of the Social 
Security Act which the Secretary of Health and Human Services 
determines requires State legislation in order for the plan to meet the 
additional requirements imposed by the amendments made by this section, 
the State plan shall not be regarded as failing to comply with the 
requirements of such title solely on the basis of its failure to meet 
these additional requirements before the first day of the first 
calendar quarter beginning after the close of the first regular session 
of the State legislature that begins after the date of enactment of 
this Act. For purposes of the previous sentence, in the case of a State 
that has a 2-year legislative session, each year of such session shall 
be deemed to be a separate regular session of the State legislature.

  PART V--ASSURING PROPER PAYMENTS TO DISPROPORTIONATE SHARE HOSPITALS

SEC. 5121. ASSURING PROPER PAYMENTS TO DISPROPORTIONATE SHARE 
              HOSPITALS.

    (a) Disproportionate Share Hospitals Required to Provide Minimum 
Level of Services to Medicaid Patients.--Section 1923 (42 U.S.C. 1396r-
4) is amended--
            (1) in subsection (a)(1)(A), by striking ``requirement'' 
        and inserting ``requirements'';
            (2) in subsection (b)(1), by striking ``requirement'' and 
        inserting ``requirements'';
            (3) in the heading to subsection (d), by striking 
        ``Requirement'' and inserting ``Requirements'';
            (4) by adding at the end of subsection (d) the following 
        new paragraph:
            ``(3) No hospital may be defined or deemed as a 
        disproportionate share hospital under a State plan under this 
        title 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.'';
            (5) in subsection (e)(1)--
                    (A) by striking ``and'' before ``(B)'', and
                    (B) by inserting before the period at the end the 
                following: ``, and (C) the plan meets the requirement 
                of subsection (d)(3) and such payment adjustments are 
                made consistent with the fourth sentence of subsection 
                (c)''; and
            (6) in subsection (e)(2)--
                    (A) in subparagraph (A), by inserting ``(other than 
                the fourth sentence of subsection (c))'' after ``(c)'',
                    (B) by striking ``and'' at the end of subparagraph 
                (A),
                    (C) by striking the period at the end of 
                subparagraph (B) and inserting ``, and'', and
                    (D) by adding at the end the following new 
                subparagraph:
            ``(C) subsection (d)(3) shall apply.''.
    (b) Limiting Amount of Payment Adjustments for State or County 
Hospitals to Uncovered Costs.--Subsection (c) of such section is 
amended by adding at the end the following: ``A payment adjustment 
during a year is not considered to be consistent with this subsection 
with respect to a hospital owned or operated by a State (or by an 
instrumentality or a unit of government within a State) if the payment 
adjustment exceeds the costs of furnishing hospital services (as 
determined by the Secretary and net of payments under this title, other 
than under this section, and by uninsured patients) by the hospital to 
individuals who either are eligible for medical assistance under the 
State plan or have no health insurance (or other source of third party 
payment) for such services during the year. For purposes of the 
preceding sentence, 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 
payment.''.
    (c) Effective Date.--The amendments made by 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--
            (1) the end of the State fiscal year that ends during 1994, 
        or
            (2) 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.

                 Subchapter B--Miscellaneous Provisions

                PART I--ANTI-FRAUD AND ABUSE PROVISIONS

SEC. 5131. APPLICATION OF MEDICARE RULES LIMITING CERTAIN PHYSICIAN 
              REFERRALS.

    (a) In General.--Section 1903(i) (42 U.S.C. 1396b(i)), as amended 
by section 5174(b), is amended--
                    (A) in paragraph (12), by striking or at the end,
                    (B) in paragraph (13), by striking the period at 
                the end and inserting ``; or'', and
                    (C) by inserting after paragraph (13) the following 
                new paragraph:
            ``(14) with respect to any amount expended for an item or 
        service for which payment would be denied under section 
        1877(g)(1) if the item or service were furnished to an 
        individual entitled to benefits under title XVIII.''.
    (b) Effective Date.--The amendment made by subsection (a) shall 
apply to items and services furnished on or after October 1, 1993.

SEC. 5132. INTERMEDIATE SANCTIONS FOR KICKBACK VIOLATIONS.

    (a) Penalty for Kickbacks.--Section 1128A(a) (42 U.S.C. 1320a-
7a(a)) is amended--
            (1) by striking ``or'' at the end of paragraphs (1) and 
        (2);
            (2) by adding ``or'' at the end of paragraph (3);
            (3) by inserting after paragraph (3) the following new 
        paragraph:
            ``(4) carries out any activity in violation of paragraph 
        (1) or (2) of section 1128B(b);'';
            (4) by striking ``given).'' at the end of the first 
        sentence and inserting ``given or, in cases under paragraph 
        (4), $50,000 for each such violation).'';
            (5) in the second sentence, by inserting ``in cases under 
        paragraphs (1), (2), and (3),'' after ``In addition,''; and
            (6) by inserting after the second sentence, the following 
        new sentence: ``In cases under paragraph (4), such a person 
        shall be subject to an assessment of not more than twice the 
        total amount of the remuneration offered, paid, solicited, or 
        received in violation of section 1128B(b), determined without 
        regard to whether a portion of such remuneration was offered, 
        paid, solicited, or received for a lawful purpose.''.
    (b) Authorization to Act.--The first sentence of section 
1128A(c)(1) (42 U.S.C. 1320a-7a(c)(1)) is amended by striking all that 
follows ``(b)'' and inserting the following: ``unless, within one year 
after the date the Secretary presents a case to the Attorney General 
for consideration, the Attorney General brings an action in a district 
court of the United States.''.
    (c) Effective Dates.--
            (1) The amendments made by subsection (a) shall apply to 
        remuneration offered, paid, solicited, or received before, on, 
        or after the date of the enactment of this Act.
            (2) The amendment made by subsection (b) shall apply to 
        cases presented by the Secretary of Health and Human Services 
        for consideration on or after the date of the enactment of this 
        Act.

SEC. 5133. REQUIRING MAINTENANCE OF EFFORT FOR STATE MEDICAID FRAUD 
              CONTROL UNITS.

    (a) In General.--Section 1902(a)(49) (42 U.S.C. 1396a(a)(49)) is 
amended--
            (1) by inserting ``(A)'' after ``(49)'', and
            (2) by adding at the end the following new subparagraph:
            ``(B) provide that the State will expend for its medicaid 
        fraud and abuse control unit (as defined in section 1903(q)), 
        for each State fiscal year, an amount that is not less than the 
        amount expended for such unit in the State fiscal year that 
        ended in 1992 adjusted to reflect the percentage increase in 
        total expenditures under the State plan between such State 
        fiscal year and the State fiscal year involved;''.
    (b) Effective Date.--The amendments made by subsection (a) shall 
apply to State fiscal years ending after 1993.

                    PART II--MANAGED CARE PROVISIONS

SEC. 5135. MEDICAID MANAGED CARE ANTI-FRAUD PROVISIONS.

    (a) Prohibiting Affiliations with Individuals Debarred by Federal 
Agencies.--
            (1) In general.--Section 1903(m) (42 U.S.C. 1396b(m)) is 
        amended--
                    (A) in paragraph (2)(A)--
                            (i) by striking ``and'' at the end of 
                        clause (x),
                            (ii) by striking the period at the end of 
                        clause (xi) and inserting ``; and'', and
                            (iii) by adding at the end the following 
                        new clause:
            ``(xii) the entity complies with the requirements of 
        paragraph (3) (relating to certain protections against fraud 
        and abuse).'';
                    (B) in paragraph (2)(B), as amended by section 
                5158(b), by striking ``clause (ix)'' and inserting 
                ``clauses (ix) and (xii)''; and
                    (C) by inserting after paragraph (2) the following 
                new paragraph:
    ``(3)(A)(i) A health maintenance organization may not have a person 
described in clause (iv) as a director, officer, partner, or person 
with beneficial ownership of more than 5 percent of organization's 
equity.
    ``(ii) A health maintenance organization may not have an 
employment, consulting, or other agreement with a person described in 
clause (iv) for the provision of goods and services that are 
significant and material to the organization's obligations under its 
contract with the State described in paragraph (2)(A)(iii).
    ``(iii) If a health maintenance organization is not in compliance 
with clause (i) or clause (ii)--
            ``(I) a State may continue an existing agreement with the 
        organization unless the Secretary (in consultation with the 
        Inspector General of the Department of Health and Human 
        Services) directs otherwise; and
            ``(II) a State may not renew or otherwise extend the 
        duration of an existing agreement with the organization unless 
        the Secretary (in consultation with the Inspector General of 
        the Department of Health and Human Services) provides a written 
        statement describing compelling reasons that exist for renewing 
        or extending the agreement.
    ``(iv) A person described in this clause is a person that--
            ``(I) is debarred or suspended by the Federal Government, 
        pursuant to the Federal acquisition regulation, from Government 
        contracting and subcontracting, or
            ``(II) is an affiliate (within the meaning of the Federal 
        acquisition regulation) of a person described in subclause 
        (I).''.
            (2) Effective date.--The amendments made by paragraph (1) 
        shall apply to agreements between a State and an entity under 
        section 1903(m) of the Social Security Act entered into or 
        renewed on or after October 1, 1993, without regard to whether 
        regulations to carry out such amendments are promulgated by 
        such date.
    (b) Requirement for State Conflict-of-Interest Safeguards in 
Medicaid Risk Contracting.--
            (1) In general.--Section 1903(m)(2)(A) (42 U.S.C. 
        1396b(m)(2)(A)), as amended by subsection (a)(1)(C), is 
        amended--
                    (A) by striking ``and'' at the end of clause (xi),
                    (B) by striking the period at the end of clause 
                (xii) and inserting ``; and'', and
                    (C) by adding at the end the following new clause:
            ``(xiii) the State certifies to the Secretary that it has 
        in effect conflict-of-interest safeguards with respect to 
        officers and employees of the State with responsibility with 
        respect to contracts with organizations under this subsection 
        that are at least as effective as the Federal safeguards, 
        provided under section 27 of the Office of Federal Procurement 
        Policy Act (41 U.S.C. 423), against conflicts of interest that 
        apply with respect to Federal procurement officials with 
        comparable responsibilities with respect to such contracts.''.
            (2) Effective date.--The amendments made by paragraph (1) 
        shall apply as of July 1, 1994, without regard to whether 
        regulations to carry out such amendments are promulgated by 
        such date.
    (c) Requiring Disclosure of Financial Information.--
            (1) In general.--Section 1903(m)(3), as inserted by 
        subsection (a)(1)(C), is amended by adding at the end the 
        following new subparagraph:
    ``(B) The contract between the State and an entity referred to in 
paragraph (2)(A)(iii) shall provide that--
            ``(i) the entity agrees to report to the State such 
        financial information as the Secretary or the State may require 
        to demonstrate that the entity has a fiscally sound operation; 
        and
            ``(ii) the entity agrees to make available to its enrollees 
        upon reasonable request--
                    ``(I) the information reported under paragraph (1),
                    ``(II) the information required to be disclosed 
                under sections 1124 and 1126, and
                    ``(III) a description of each transaction, 
                described in subparagraphs (A) through (C) of section 
                1318(a)(3) of the Public Health Service Act, between 
                the entity and a party in interest (as defined in 
                section 1318(b) of such Act).''.
            (2) Effective date.--The amendment made by paragraph (1) 
        shall apply to contract years beginning on or after October 1, 
        1993, without regard to whether regulations to carry out such 
        amendments are promulgated by such date, with respect to 
        information reported or required to be disclosed, or 
        transactions occurring, before, on, or after such date.
    (d) Prohibiting Marketing Fraud.--
            (1) In general.--Section 1903(m)(3), as inserted by 
        subsection (a)(1) and as amended by subsection (c)(1), is 
        amended by adding at the end the following new subparagraph:
    ``(C) The contract between the State and an entity referred to in 
paragraph (2)(A)(iii) shall provide that the entity agrees to comply 
with such procedures and conditions as the Secretary prescribes in 
order to ensure that, before an individual is enrolled with the entity, 
the individual is provided accurate and sufficient information to make 
an informed decision whether or not to enroll.''.
            (2) Effective date.--The amendment made by paragraph (1) 
        shall apply to contract years that begin on or after October 1, 
        1993, without regard to whether regulations to carry out such 
        amendment are promulgated by such date.
    (e) Requiring Adequate Equity for For-Profit Entities.--
            (1) In general.--Section 1903(m)(3), as previously amended 
        by this section, is further amended by adding at the end the 
        following new subparagraph:
    ``(D)(i) The contract between the State and an entity referred to 
in paragraph (2)(A)(iii) shall require, in the case of a for-profit 
entity, that the entity shall maintain an average ratio of--
            ``(I) equity capital to
            ``(II) payments made by the State to the entity under the 
        contract on a capitation basis or any other risk basis,
of not less than such minimum ratio as the Secretary shall specify.
    ``(ii) The contract between the State and a non-profit entity 
referred to in paragraph (2)(A)(iii) shall require that no payment 
shall be made directly or indirectly under an agreement between the 
non-profit entity and a related for-profit entity (as defined by the 
Secretary) unless the for-profit entity maintains an average ratio of 
equity capital to payments under such agreement of not less than such 
ratio as the Secretary shall specify.''.
            (2) Effective date.--The amendment made by paragraph (1) 
        shall apply to contract years beginning on or after July 1, 
        1994, without regard to whether regulations to carry out such 
        amendment are promulgated by such date.
    (f) Requiring Adequate Provision Against Risk of Insolvency.--
            (1) In general.--Section 1903(m)(1)(A)(ii) (42 U.S.C. 
        1396b(m)(1)(A)(ii)) is amended by inserting ``, which meets 
        such standards as the Secretary shall prescribe'' after 
        ``satisfactory to the State''.
            (2) Effective date and transition.--(A) The amendment made 
        by paragraph (1) shall apply to contract years beginning on or 
        after July 1, 1994, without regard to whether regulations to 
        carry out such amendments are promulgated by such date.
            (B) If the Secretary of Health and Human Services has not 
        promulgated standards to carry out the amendment made by 
        paragraph (1) by July 1, 1994, until such standards have been 
        promulgated a provision of a health maintenance organization 
        against the risk of insolvency shall not be considered to meet 
        standards prescribed by the Secretary, for purposes of section 
        1903(m)(1)(A)(ii) of the Social Security Act, unless such 
        provision has been found satisfactory by the Secretary under 
        section 1876(b)(2)(E) of such Act.
    (g) Requiring Report on Net Earnings and Additional Benefits.--
            (1) In general.--Section 1903(m)(3), as previously amended 
        by this section, is amended by adding at the end the following 
        new subparagraph:
    ``(E) The contract between the State and an entity referred to in 
paragraph (2)(A)(iii) shall provide that the entity shall submit a 
report to the State and the Secretary not later than 12 months after 
the close of a contract year containing--
            ``(i) a financial statement of the entity's net earnings 
        under the contract during the contract year, which statement 
        has been audited using auditing standards established by the 
        Secretary in consultation with the States; and
            ``(ii) a description of any benefits that are in addition 
        to the benefits required to be provided under the contract that 
        were provided during the contract year to members enrolled with 
        the entity and entitled to medical assistance under the 
        plan.''.
            (2) Effective date.--The amendment made by paragraph (1) 
        shall apply to contract years beginning on or after October 1, 
        1993, without regard to whether regulations to carry out such 
        amendments are promulgated by such date.
    (h) Report on Net Earnings of Contractors.--Not later than 6 months 
after the date of the enactment of this Act, the Secretary of Health 
and Human Services shall submit a report to Congress on the earnings of 
organizations with contracts to receive payment for providing medical 
assistance under title XIX of the Social Security Act on a prepaid 
capitation or any other risk basis. The report shall include the 
Secretary's recommendations on options for requiring such 
organizations, as a condition of participation under such title, to 
dedicate a portion of such earnings to the provision of additional 
benefits to individuals enrolled with the organization.

SEC. 5136. CLARIFICATION OF TREATMENT OF HMO ENROLLEES IN COMPUTING THE 
              MEDICAID INPATIENT UTILIZATION RATE IN QUALIFYING 
              HOSPITALS AS DISPROPORTIONATE SHARE HOSPITALS.

    (a) In General.--Section 1923(b)(2) (42 U.S.C. 1396r-4(b)(2)) is 
amended by inserting before the period at the end the following: ``and 
whether or not the individual is enrolled with an entity contracting 
with the State on a prepaid capitation basis or other risk basis under 
section 1903(m)''.
    (b) Effective Date.--The amendment made by subsection (a) shall 
apply to payments to States under section 1903(a) of the Social 
Security Act for payments to hospitals made under State plans on and 
after the first day of the first calendar quarter beginning after the 
date of the enactment of this Act.

SEC. 5137. EXTENSION OF PERIOD OF APPLICABILITY OF ENROLLMENT MIX 
              REQUIREMENT TO CERTAIN HEALTH MAINTENANCE ORGANIZATIONS 
              PROVIDING SERVICES UNDER DAYTON AREA HEALTH PLAN.

    Section 2 of Public Law 102-276 is amended by striking ``January 
31, 1994'' and inserting ``December 31, 1995''.

SEC. 5138. EXTENSION OF MEDICAID WAIVER FOR TENNESSEE PRIMARY CARE 
              NETWORK.

    Section 6411(f) of the Omnibus Budget Reconciliation Act of 1989, 
as amended by section 1 of Public Law 102-317, is amended by striking 
``January 31, 1994'' and inserting ``December 31, 1995''.

SEC. 5139. WAIVER OF APPLICATION OF MEDICAID ENROLLMENT MIX REQUIREMENT 
              TO DISTRICT OF COLUMBIA CHARTERED HEALTH PLAN, INC.

    (a) In General.--The Secretary of Health and Human Services shall 
waive the application of the requirement described in section 
1903(m)(2)(A)(ii) of the Social Security Act to the entity known as the 
District of Columbia Chartered Health Plan, Inc., for the period 
described in subsection (b), if the Secretary determines that the 
entity is making continuous efforts and progress toward achieving 
compliance with such requirement.
    (b) Period of Applicability.--The period referred to in subsection 
(a) is the period that begins on October 1, 1992, and ends on December 
31, 1995.

SEC. 5140. EXTENSION OF MINNESOTA PREPAID MEDICAID DEMONSTRATION 
              PROJECT.

    (a) In General.--Section 507 of the Family Support Act of 1988, as 
amended by section 6411(j) of OBRA-1989 and by section 4733 of OBRA-
1990, is amended by striking ``1996'' and inserting ``1998''.
    (b) Authority to Impose Premium.--
            (1) In general.--Notwithstanding section 1916 of the Social 
        Security Act and subject to paragraph (2), the State of 
        Minnesota may impose a premium on individuals receiving medical 
        assistance under the Minnesota Prepaid Demonstration Project 
        operated under a waiver granted by the Secretary of Health and 
        Human Services under section 1115(a) of the Social Security Act 
        and other individuals eligible under the State's plan for 
        medical assistance under title XIX of such Act.
            (2) Limitation on amount of premium.--In no case may the 
        amount of any premium imposed on an individual receiving 
        medical assistance under the State plan or under the 
        Demonstration Project described in paragraph (1) exceed 10 
        percent of the amount by which the family income (less expenses 
        for the care of a dependent child) of the individual exceeds 
        110 percent of the income official poverty line (as defined by 
        the Office of Management and Budget), and revised annually in 
        accordance with section 673(2) of the Omnibus Budget 
        Reconciliation Act of 1981) applicable to a family of the size 
        involved.

          PART III--EMERGENCY SERVICES TO UNDOCUMENTED ALIENS

SEC. 5141. INCREASE IN FEDERAL FINANCIAL PARTICIPATION FOR EMERGENCY 
              MEDICAL ASSISTANCE TO UNDOCUMENTED ALIENS.

    (a) In General.--Section 1905(b) (42 U.S.C. 1396d(b)) is amended by 
adding at the end the following: ``Notwithstanding the first sentence 
of this section, subject to 1903(v)(4), the Federal medical assistance 
percentage shall be 100 per centum with respect to amounts expended by 
an eligible State in a covered fiscal year (as defined in section 
1903(v)(4)(C)) as medical assistance for care and services described in 
section 1903(v)(2) to aliens described in section 1903(v)(1).''.
    (b) Limitation.--Section 1903(v) (42 U.S.C. 1396b(v)) is amended by 
adding at the end the following new paragraph:
    ``(4)(A) With respect to any eligible State (as defined in 
subparagraph (C)(i)), the amount of the increase in payments to a State 
under subsection (a) in a covered fiscal year (as defined in 
subparagraph (C)(ii)), resulting from the increase in the Federal 
medical assistance percentage under the fourth sentence of section 
1905(b), shall not exceed the State's allotment determined under 
subparagraph (B).
    ``(B)(i) The total of the allotments to all States for a covered 
fiscal year under this paragraph shall be $300,000,000.
    ``(ii) From the total allotment under clause (i) for a covered 
fiscal year, the Secretary shall determine the amount of the allotment 
for each eligible State. Subject to clause (iii), the amount of such 
allotment for such a fiscal year shall bear the same ratio to the total 
amount specified in clause (i) for the fiscal year as the ratio of--
            ``(I) the allotment to the State for fiscal year 1993 under 
        section 204 of the Immigration Reform and Control Act of 1986, 
        to
            ``(II) the total of such allotments for all such eligible 
        States for fiscal year 1993.
    ``(iii) In the case of an eligible State which notifies the 
Secretary that an amount of its allotment will not be used by the State 
under this paragraph, the State's allotment shall be reduced by such 
amount and such amount shall be redistributed among the other eligible 
States in proportion to the amount otherwise allotted to such State 
under clause (ii).
    ``(C) For purposes of this paragraph and the fourth sentence of 
section 1905(b):
            ``(i) The term `eligible State' means a State--
                    ``(I) with a plan approved under this title 
                (including a State which is providing medical 
                assistance to its residents under a statewide waiver 
                granted under section 1115), and
                    ``(II) for which its allotment for fiscal year 1993 
                under section 204 of the Immigration Reform and Control 
                Act of 1986 is at least 1 percent of the total of such 
                allotments for all the States for fiscal year 1993.
            ``(ii) The term `covered fiscal year' means only fiscal 
        year 1994.
    ``(D) Nothing in this paragraph or the fourth sentence of section 
1905(b) shall be construed as establishing entitlement authority 
(within the meaning of section 3(9) of the Congressional Budget Act of 
1974) for any fiscal year other than a covered fiscal year.''.

SEC. 5142. LIMITING FEDERAL MEDICAID MATCHING PAYMENT TO BONA FIDE 
              EMERGENCY SERVICES FOR UNDOCUMENTED ALIENS.

    (a) In General.--Section 1903(v)(2) (42 U.S.C. 1396b(v)(2)) is 
amended--
            (1) by striking ``and'' at the end of subparagraph (A),
            (2) by striking the period at the end of subparagraph (B) 
        and inserting ``, and'', and
            (3) by adding at the end the following new subparagraph:
            ``(C) such care and services are not related to an organ 
        transplant procedure.''.
    (b) Effective Date.--(1) Subject to paragraph (2), the amendments 
made by subsection (a) shall apply as if included in the enactment of 
OBRA-1986.
    (2) The Secretary of Health and Human Services shall not disallow 
expenditures made for the care and services described in section 
1903(v)(2)(C) of the Social Security Act, as added by subsection (a), 
furnished before the date of the enactment of this Act.

                   PART IV--MISCELLANEOUS PROVISIONS

SEC. 5144. INCREASE IN LIMIT ON FEDERAL MEDICAID MATCHING PAYMENTS TO 
              PUERTO RICO AND OTHER TERRITORIES.

    (a) In General.--Paragraphs (1) through (5) of section 1108(c) (42 
U.S.C. 1308(c)) are amended to read as follows:
            ``(1) Puerto Rico shall not exceed (A) $104,000,000 for 
        fiscal year 1994 and (B) for each succeeding fiscal year the 
        amount provided in this paragraph for the preceding fiscal year 
        increased by percentage increase in the medical care component 
        of the consumer price index for all urban consumers (as 
        published by the Bureau of Labor Statistics) for the twelve-
        month period ending in March preceding the beginning of the 
        fiscal year, rounded to the nearest $100,000;
            ``(2) the Virgin Islands shall not exceed (A) $3,425,000 
        for fiscal year 1994, and (B) for each succeeding fiscal year 
        the amount provided in this paragraph for the preceding fiscal 
        year increased by percentage increase referred to in paragraph 
        (1)(B), rounded to the nearest $10,000;
            ``(3) Guam shall not exceed (A) $3,290,000 for fiscal year 
        1994, and (B) for each succeeding fiscal year the amount 
        provided in this paragraph for the preceding fiscal year 
        increased by percentage increase referred to in paragraph 
        (1)(B), rounded to the nearest $10,000;
            ``(4) Northern Mariana Islands shall not exceed (A) 
        $990,000 for fiscal year 1994, and (B) for each succeeding 
        fiscal year the amount provided in this paragraph for the 
        preceding fiscal year increased by percentage increase referred 
        to in paragraph (1)(B), rounded to the nearest $10,000; and
            ``(5) American Samoa shall not exceed (A) $1,910,000 for 
        fiscal year 1994, and (B) for each succeeding fiscal year the 
        amount provided in this paragraph for the preceding fiscal year 
        increased by percentage increase referred to in paragraph 
        (1)(B), rounded to the nearest $10,000.''.
    (b) Effective Date.--The amendment made by subsection (a) shall 
apply beginning with fiscal year 1994.

SEC. 5145. CRITERIA FOR MAKING DETERMINATIONS OF DENIAL OF FEDERAL 
              MEDICAID MATCHING PAYMENTS TO STATES.

    (a) In General.--Section 1903 (42 U.S.C. 1396b) is amended by 
adding at the end the following new subsection:
    ``(x)(1) In any case in which the Secretary proposes to disallow 
under section 1116(d) a claim by a State under this section and the 
State exercises its right of reconsideration under section 1116(d), the 
Departmental Appeals Board established in the Department of Health and 
Human Services shall, if such Board upholds the basis for the 
disallowance, determine whether the amount of the disallowance should 
be reduced. In making this determination, the Board shall take into 
account (to the extent the State makes a showing) factors which shall 
include--
            ``(A) the nature of the basis for the disallowance;
            ``(B) whether the amount of the disallowance is 
        proportionate to the error or deficiency on which the 
        disallowance is based;
            ``(C) whether the basis of the disallowance constitutes 
        noncompliance that prevented or materially affected the 
        provision of appropriate services to individuals eligible under 
        this title; or
            ``(D) whether Federal guidance with respect to the action 
        that is the basis for the proposed disallowance was 
        insufficient and the State made good faith efforts to conform 
        its action to the intent of the applicable Federal statute or 
        regulation.
    ``(2) No disallowance shall be taken or upheld if the action of the 
State on which the disallowance would be based is consistent with its 
approved State plan.''.
    (b) Effective Date.--The amendment made by subsection (a) shall 
apply to disallowances made after the date of the enactment of this Act 
and shall take effect without regard to the promulgation of 
implementing regulations.

SEC. 5146. RENEWAL OF UNFUNDED DEMONSTRATION PROJECT FOR LOW-INCOME 
              PREGNANT WOMEN AND CHILDREN.

    (a) In General.--Section 6407 of OBRA-89 is amended--
            (1) in subsection (d), by striking ``3 years'' and 
        inserting ``5 years'';
            (2) in subsection (f), by striking ``$10,000,000 in each of 
        fiscal years 1990, 1991, and 1992'' and inserting 
        ``$30,000,000''; and
            (3) in subsection (g)(2), by striking ``January 1, 1994'' 
        and inserting ``one year after the termination of the 
        demonstration projects''.
    (b) Effective Date.--The amendments made by subsection (a) shall 
take effect as if included in the enactment of OBRA-89.

SEC. 5147. OPTIONAL MEDICAID COVERAGE OF TB-RELATED SERVICES FOR 
              CERTAIN TB-INFECTED INDIVIDUALS.

    (a) Coverage as Optional, Categorically Needy Group.--Section 
1902(a)(10)(A)(ii) (42 U.S.C. 1396a(a)(10)(A)(ii)) is amended--
            (1) by striking ``or'' at the end of subclause (X),
            (2) by adding ``or'' at the end of subclause (XI), and
            (3) by adding at the end the following new subclause:
                                    ``(XII) who are described in 
                                subsection (z)(1) (relating to certain 
                                TB-infected individuals);''.
    (b) Group and Benefit Described.--Section 1902 is amended by adding 
at the end the following new subsection:
    ``(z)(1) Individuals described in this paragraph are individuals 
not described in subsection (a)(10)(A)(i)--
            ``(A) who have tested positively to be infected with 
        tuberculosis;
            ``(B) whose income (as determined under the State plan 
        under this title with respect to disabled individuals) does not 
        exceed the maximum amount of income a disabled individual 
        described in subsection (a)(10)(A)(i) may have and obtain 
        medical assistance under the plan; and
            ``(C) whose resources (as determined under the State plan 
        under this title with respect to disabled individuals) do not 
        exceed the maximum amount of resources a disabled individual 
        described in subsection (a)(10)(A)(i) may have and obtain 
        medical assistance under the plan.
    ``(2) For purposes of subsection (a)(10), the term `TB-related 
services' means each of the following services relating to treatment of 
infection with tuberculosis:
            ``(A) Prescribed drugs.
            ``(B) Physicians' services and services described in 
        section 1905(a)(2).
            ``(C) Laboratory and X-ray services.
            ``(D) Clinic services and Federally-qualified health center 
        services.
            ``(E) Case management services (as defined in section 
        1915(g)(2)).
            ``(F) Services (other than room and board) designed to 
        encourage completion of regimens of prescribed drugs by 
        outpatients, including services to observe directly the intake 
        of prescribed drugs.''.
    (c) Limitation on Benefits.--Section 1902(a)(10), as amended by 
section 5162(a), is amended, in the matter following subparagraph (F)--
            (1) by striking ``, and (XII)'' and inserting ``, (XII)'', 
        and
            (2) by inserting before the semicolon at the end the 
        following: ``, and (XIII) the medical assistance made available 
        to an individual described in subsection (z)(1) who is eligible 
        for medical assistance only because of subparagraph 
        (A)(ii)(XII) shall be limited to medical assistance for TB-
        related services (as defined in subsection (z)(2))''.
    (d) Conforming Expansion of Case Management Services Option.--
Section 1915(g)(1) (42 U.S.C. 1396n(g)(1)) is amended by inserting ``or 
to individuals described in section 1902(z)(1)(A),'' after ``or with 
either,''.
    (e) Conforming Amendment.--Section 1905(a) (42 U.S.C. 1396d(a)) is 
amended--
            (1) by striking ``or'' at the end of clause (ix),
            (2) by adding ``or'' at the end of clause (x),
            (3) by inserting after clause (x) the following new clause:
            ``(xi) individuals described in section 1902(z)(1),'', and
            (4) by amending paragraph (19) to read as follows:
            ``(19) case management services (as defined in section 
        1915(g)(2)) and TB-related services described in section 
        1902(z)(2)(F);''.
    (f) Effective Date.--The amendments made by this section shall 
apply to medical assistance furnished on or after January 1, 1994, 
without regard to whether or not final regulations to carry out such 
amendments have been promulgated by such date.

SEC. 5148. APPLICATION OF MAMMOGRAPHY CERTIFICATION REQUIREMENTS UNDER 
              THE MEDICAID PROGRAM.

    (a) In General.--Section 1902(a)(9) (42 U.S.C. 1396a(a)(9)) is 
amended--
            (1) by striking ``and'' at the end of subparagraph (B),
            (2) by striking the semicolon at the end of subparagraph 
        (C) and inserting ``, and'', and
            (3) by adding at the end the following new subparagraph:
                    ``(D) that any mammography paid for under such plan 
                must be conducted by a facility that has a certificate 
                (or provisional certificate) issued under section 354 
                of the Public Health Service Act;''.
    (b) Effective Date.--(1) Except as provided in paragraph (2), the 
amendments made by subsection (a) shall apply to mammography furnished 
by a facility during calendar quarters beginning on or after the first 
date that the certificate requirements of section 354(b) of the Public 
Health Service Act apply to such mammography conducted by such 
facility, without regard to whether or not final regulations to carry 
out such amendments have been promulgated by such date.
    (2) In the case of a State plan for medical assistance under title 
XIX of the Social Security Act which the Secretary of Health and Human 
Services determines requires State legislation (other than legislation 
appropriating funds) in order for the plan to meet the additional 
requirement imposed by the amendment made by subsection (a)(3), the 
State plan shall not be regarded as failing to comply with the 
requirements of such title solely on the basis of its failure to meet 
this additional requirement before the first day of the first calendar 
quarter beginning after the close of the first regular session of the 
State legislature that begins after the date of the enactment of this 
Act. For purposes of the previous sentence, in the case of a State that 
has a 2-year legislative session, each year of such session shall be 
deemed to be a separate regular session of the State legislature.

SEC. 5149. REMOVAL OF SUNSET ON EXTENSION OF ELIGIBILITY FOR WORKING 
              FAMILIES.

    Subsection (f) of section 1925 (42 U.S.C. 1396r-6) is repealed.

SEC. 5150. EXTENSION OF MORATORIUM ON TREATMENT OF CERTAIN FACILITIES 
              AS INSTITUTIONS FOR MENTAL DISEASES.

    Effective as if included in the enactment of OBRA-1989, section 
6408(a)(3) of such Act is amended by striking ``180 days'' and all that 
follows and inserting ``December 31, 1995.''.

SEC. 5150A. TREATMENT OF CERTAIN CLINICS AS FEDERALLY-QUALIFIED HEALTH 
              CENTERS.

    (a) In General.--Section 1905(l)(2)(B) (42 U.S.C. 1396d(l)(2)(B)), 
as amended by section 5158(c), is amended--
            (1) by striking ``or'' at the end of clause (ii)(II),
            (2) by adding ``or'' at the end of clause (iii), and
            (3) by inserting after clause (iii) the following new 
        clause:
            ``(iv) was treated by the Secretary, for purposes of part B 
        of title XVIII, as a comprehensive Federally funded health 
        center as of January 1, 1990;''.
    (b) Effective Date.--The amendments made by subsection (a) shall 
apply to calendar quarters beginning on or after July 1, 1993.

SEC. 5150B. NURSING HOME REFORM.

    (a) Suspension of Decertification of Nurses Aide Training and 
Competency Evaluation Programs Based on Extended Surveys.--
            (1) In general.--Section 1919(f)(2)(B)(iii)(I)(b) (42 
        U.S.C. 1396r(f)(2)(B)(iii)(I)(b)) is amended by striking the 
        semicolon and inserting the following: ``, unless the survey 
        shows that the facility is in compliance with the requirements 
        of subsections (b), (c), and (d) of this section;''.
            (2) Effective date.--The amendment made by paragraph (1) 
        shall take effect as included in the enactment of OBRA-1990.
    (b) Requirements for Consultants Conducting Reviews on Use of 
Drugs.--
            (1) In general.--Section 1919(c)(1)(D) (42 U.S.C. 
        1396r(c)(1)(D)) is amended by adding at the end the following 
        sentence: ``In determining whether such a consultant is 
        qualified to conduct reviews under the previous sentence, the 
        Secretary shall take into account the needs of nursing 
        facilities under this title to have access to the services of 
        such a consultant on a timely basis.''.
            (2) Effective date.--The amendment made by paragraph (1) 
        shall take effect as included in the enactment of OBRA-1987.
    (c) Increase in Minimum Amount Required for Separate Deposit of 
Personal Funds.--
            (1) In general.--Section 1919(c)(6)(B)(i) (42 U.S.C. 
        1396r(c)(6)(B)(i)) is amended by striking ``$50'' and inserting 
        ``$100''.
            (2) Effective date.--The amendment made by paragraph (1) 
        shall take effect October 1, 1993.
    (d) Due Process Protections for Nurses Aides.--
            (1) Prohibiting state from including undocumented 
        allegations in nurses aide registry.--Section 1919(e)(2)(B) (42 
        U.S.C. 1396r(e)(2)(B)) is amended by striking the period at the 
        end of the first sentence and inserting the following: ``, but 
        shall not include any allegations of resident abuse or neglect 
        or misappropriation of resident property that are not 
        specifically documented by the State under such subsection.''.
            (2) Due process requirements for rebutting allegations.--
        Section 1919(g)(1)(C) (42 U.S.C. 1396r(g)(1)(C)) is amended by 
        striking the second sentence and inserting the following: ``The 
        State shall, after providing the individual involved with a 
        written notice of the allegations (including a statement of the 
        availability of a hearing for the individual to rebut the 
        allegations) and the opportunity for a hearing on the record, 
        make a written finding as to the accuracy of the 
        allegations.''.
            (3) Effective date.--The amendments made by this subsection 
        shall take effect October 1, 1993.

Subchapter C--Miscellaneous and Technical Corrections Relating to OBRA-
                                  1990

SEC. 5151. EFFECTIVE DATE.

    Except as otherwise provided, the amendments made by this 
subchapter shall take effect as if included in the enactment of OBRA-
1990.

SEC. 5152. CORRECTIONS RELATING TO SECTION 4402 (ENROLLMENT UNDER GROUP 
              HEALTH PLANS).

    Section 4402(b) of OBRA-1990 is amended by striking 
``1903(u)(1)(C)(iv) (42 U.S.C. 1395b(u)(1)(C)(iv))'' and inserting 
``1903(u)(1)(D)(iv) (42 U.S.C. 1395b(u)(1)(D)(iv))''.

SEC. 5153. CORRECTIONS RELATING TO SECTION 4501 (LOW-INCOME MEDICARE 
              BENEFICIARIES).

    (a) Section 1902(a)(10)(E)(iii), as added by section 4501(b)(3) of 
OBRA-1990, is amended by striking ``cost sharing'' and inserting 
``cost-sharing''.
    (b) Section 1905(p)(4)(B), as amended by section 4501(c)(1) of 
OBRA-1990, is amended by striking ``1902(a)(10)(E)(iii)'' and inserting 
``section 1902(a)(10)(E)(iii)''.

SEC. 5154. CORRECTIONS RELATING TO SECTION 4601 (CHILD HEALTH).

    (a) Section 1902(a)(10)(A)(i)(VII), as added by section 
4601(a)(10)(A)(iii) of OBRA-1990, is amended by striking ``family;'' 
and inserting ``family; and''.
    (b) Section 1902(l), as amended by section 4601(a)(1)(C) of OBRA-
1990, is amended--
            (1) in paragraph (1)(C), by striking ``children'' after 
        ``(C)'';
            (2) in paragraph (3), by striking ``(a)(10)(A)(i)(VII),,'' 
        and inserting ``(a)(10)(A)(i)(VII),''; and
            (3) in paragraph (4)(B), by inserting a comma before 
        ``(a)(10)(A)(i)(VI),''.
    (c) Subsections (a)(3)(C) and (b)(3)(C)(i) of section 1925, as 
amended by section 4601(a) of OBRA-1990, are each amended by striking 
``(i)(VI)'' and inserting ``(i)(VI),''.

SEC. 5155. CORRECTIONS RELATING TO SECTION 4602 (OUTREACH LOCATIONS).

    (a) Section 1902(a)(55), as added by section 4602(a)(3) of OBRA-
1990, is amended--
            (1) in the matter preceding subparagraph (A)--
                    (A) by striking ``subsection'' and inserting 
                ``paragraph'', and
                    (B) by striking ``(a)'' each place it appears; and
            (2) in subparagraph (A), by striking ``1905(1)(2)(B)'' and 
        inserting ``1905(l)(2)(B)''.
    (b) Section 1902(l)(1) is amended by striking ``who are not 
described in any of subclauses (I) through (III) of subsection 
(a)(10)(A)(i) and''.

SEC. 5156. CORRECTIONS RELATING TO SECTION 4604 (PAYMENT FOR HOSPITAL 
              SERVICES FOR CHILDREN UNDER 6 YEARS OF AGE).

    (a) Section 1902(a)(10) is amended in clause (X) in the matter 
following subparagraph (F) by striking ``under one year of age'' and 
inserting ``under 6 years of age''.
    (b) Section 1902(s), as added by section 4604(a) of OBRA-1990, is 
amended to read as follows:
    ``(s) In order to meet the requirements of subsection (a)(56), the 
State plan must provide that payments to hospitals under the plan for 
inpatient services furnished to infants who have not attained the age 
of 1 year (or, in the case of such an individual who is an inpatient on 
his first birthday, until such individual is discharged) shall--
            ``(1) if made on a prospective basis (whether per diem, per 
        case, or otherwise) provide for an outlier adjustment in 
        payment amounts for medically necessary inpatient hospital 
        services involving exceptionally high costs or exceptionally 
        long lengths of stay;
            ``(2) not be limited by the imposition of day limits; and
            ``(3) not be limited by the imposition of dollar limits 
        (other than dollar limits resulting from prospective payments 
        as adjusted pursuant to paragraph (1)).''.
    (c) Section 1923(a)(2)(C) is amended by striking ``provided on or 
after July 1, 1989,'' and all that follows and inserting the following: 
``involving exceptionally high costs or exceptionally long lengths of 
stay--
            ``(i) for individuals under 1 year of age, in the case of 
        services provided on or after July 1, 1989, and on or before 
        June 30, 1991; and
            ``(ii) for individuals under 6 years of age, in the case of 
        services provided on or after July 1, 1991.''.

SEC. 5157. CORRECTIONS RELATING TO SECTION 4703 (PAYMENT ADJUSTMENTS 
              FOR DISPROPORTIONATE SHARE HOSPITALS).

    (a) Section 1923(c) is amended--
            (1) in paragraph (2), by striking ``paragraph (b)(3)'' and 
        inserting ``subsection (b)(3)'';
            (2) by striking the period at the end of paragraph (3)(B) 
        and inserting a comma; and
            (3) in the third sentence, by striking ``the payment 
        adjustment described in paragraph (2)'' and inserting ``a 
        payment adjustment described in paragraph (2) or (3)''.
    (b) Effective December 22, 1987, section 1923(d)(2)(A)(ii) is 
amended by striking ``the date of the enactment of this Act'' and 
inserting ``December 22, 1987''.
    (c) Section 4703(d) of OBRA-1990 is amended by striking 
``412(a)(2)'' and inserting ``4112(a)(2)''.

SEC. 5158. CORRECTIONS RELATING TO SECTION 4704 (FEDERALLY-QUALIFIED 
              HEALTH CENTERS).

    (a) Clause (ix) of section 1903(m)(2)(A), as added by section 
4704(b)(1)(C) of OBRA-1990, is amended--
            (1) by striking ``of such center'' the first place it 
        appears;
            (2) by striking ``federally qualified'' and inserting 
        ``Federally-qualified'';
            (3) by inserting ``section'' before ``1905(a)(2)(C)''; and
            (4) by moving such clause 2 ems to the left.
    (b) Section 1903(m)(2)(B), as amended by section 4704(b)(2) of 
OBRA-1990, is amended by striking ``except with respect to clause (ix) 
of subparagraph (A),'' and inserting ``(except with respect to clause 
(ix) of such subparagraph)''.
    (c) Section 1905(l)(2), as amended by section 4704(c) of OBRA-1990, 
is amended--
            (1) in subparagraph (A)--
                    (A) by striking ``Federally-qualififed'' and 
                inserting ``Federally-qualified'', and
                    (B) by striking ``an patient'' and inserting ``a 
                patient''; and
            (2) in subparagraph (B)--
                    (A) in the matter preceding clause (i), by striking 
                ``a entity'' and inserting ``an entity'',
                    (B) by striking ``or'' at the end of clause (i),
                    (C) by striking the semicolon at the end of clause 
                (ii)(II) and inserting ``, or'',
                    (D) by moving clause (ii) 4 ems to the left, and
                    (E) in the last sentence, by striking ``clause 
                (ii)'' and inserting ``clause (iii)''.

SEC. 5159. CORRECTIONS RELATING TO SECTION 4708 (SUBSTITUTE 
              PHYSICIANS).

    Section 1902(a)(32)(C), as added by section 4708(a)(3) of OBRA-
1990, is amended to read as follows:
                    ``(C) payment may be made to a physician for 
                physicians' services (and services furnished incident 
                to such services) furnished by a second physician to 
                patients of the first physician if (i) the first 
                physician is unavailable to provide the services; (ii) 
                the services are furnished pursuant to an arrangement 
                between the two physicians that (I) is informal and 
                reciprocal, or (II) involves per diem or other fee-for-
                time compensation for such services; (iii) the services 
                are not provided by the second physician over a 
                continuous period of more than 60 days; and (iv) the 
                claim form submitted to the carrier for such services 
                includes the second physician's unique identifier 
                (provided under the system established under subsection 
                (x)) and indicates that the claim meets the 
                requirements of this clause for payment to the first 
                physician;''.

SEC. 5160. CORRECTIONS RELATING TO SECTION 4711 (HOME AND COMMUNITY 
              CARE FOR FRAIL ELDERLY).

    (a) Section 1929, as added by section 4711(b) of OBRA-1990, is 
amended--
            (1) in subsection (c)(2)(F), by moving the second sentence 
        2 ems to the right;
            (2) in subsection (d)(2)(F)(ii), by striking ``they 
        manage'' and inserting ``it manages'';
            (3) in subsection (d)(2)(F)(iii), by inserting ``the agency 
        or organization'' after ``(iii)'';
            (4) in subsection (e)(2)(B), by striking ``fiscal year 
        1989'' and inserting ``fiscal year 1990'';
            (5) in subsection (f)(1), by striking ``Community care'' 
        and inserting ``community care'';
            (6) in subsection (g)(1)--
                    (A) by striking ``settings'' and inserting 
                ``setting'', and
                    (B) in subparagraph (B), by striking ``setting.'' 
                and inserting ``setting in which home and community 
                care under this section is provided.'';
            (7) in subsection (g)(2), by striking ``community care'' 
        the second, third, and fourth places it appears and inserting 
        ``home and community care'';
            (8) in subsection (h)(1)--
                    (A) by striking ``more than 8'' each place it 
                appears and inserting ``8 or more'', and
                    (B) in subparagraph (B), by inserting ``(other than 
                merely board)'' after ``personal services'';
            (9) in subsection (h)(2), by striking ``community care'' 
        the second and third places it appears and inserting ``home and 
        community care'';
            (10) in subsection (j)(1)--
                    (A) in subparagraph (B)(ii), by striking ``1990'' 
                and inserting ``1991'', and
                    (B) by adding at the end the following new 
                subparagraph:
                    ``(C) Applicability to community care settings.--
                Subparagraphs (A) and (B) shall apply to community care 
                settings in the same manner as such subparagraphs apply 
                to providers of home or community care.'';
            (11) in subsection (j)(2), by adding at the end the 
        following new subparagraph:
                    ``(D) Applicability to community care settings.--
                Subparagraphs (A), (B), and (C) shall apply to 
                community care settings in the same manner as such 
                subparagraphs apply to providers of home or community 
                care.'';
            (12) in subsection (k)(1)(A)(i)--
                    (A) by striking ``(d)(2)(E)'' and inserting 
                ``(d)(2)'', and
                    (B) by striking ``settings,'' and inserting 
                ``settings),'';
            (13) in subsection (l), by striking ``State wideness'' and 
        inserting ``Statewideness'';
            (14) in subsection (m)--
                    (A) in paragraph (2), by striking ``Individual 
                Community Care Plan'' and inserting ``individual 
                community care plan'',
                    (B) in paragraph (3), by striking ``and need for 
                services'' and inserting ``need for services, and 
                income'',
                    (C) in the second sentence in paragraph (4), by 
                striking ``elderly individuals'' and all that follows 
                and inserting ``individuals receiving home and 
                community care under this section who reside in such 
                State in relation to the total number of individuals 
                receiving home and community care under this 
                section.'', and
                    (D) by adding at the end the following new 
                paragraph:
            ``(5) Notice to states of amounts available for 
        assistance.--
                    ``(A) Notice to secretary.--In order to receive 
                Federal medical assistance for expenditures for home 
                and community care under this section for a fiscal year 
                (beginning with fiscal year 1994), a State shall submit 
                a notice to the Secretary of its intention to provide 
                such care under this section not later than 3 months 
                before the beginning of the fiscal year.
                    ``(B) Notice to states.--Not later than 2 months 
                before the beginning of each fiscal year (beginning 
                with fiscal year 1994), the Secretary shall notify each 
                State that has submitted a notice to the Secretary 
                under subparagraph (A) for the fiscal year of the 
                amount of Federal medical assistance that will be 
                available to the State for the fiscal year (as 
                established under paragraph (4)).''; and
            (15) by adding at the end the following new subsection:
    ``(n) Community Care Setting Defined.--In this section, the term 
`community care setting' means a small community care setting (as 
defined in subsection (g)(1)) or a large community care setting (as 
defined in subsection (h)(1)).''.
    (b) Section 1905(r)(5) is amended by striking ``1905(a)'' and 
inserting ``subsection (a) (other than services described in paragraph 
(22) or (23) of such subsection)''.
    (c) Section 4711(f) of OBRA-1990 is amended by striking ``Act'' 
each place it appears and inserting ``section''.

SEC. 5161. CORRECTIONS RELATING TO SECTION 4712 (COMMUNITY SUPPORTED 
              LIVING ARRANGEMENTS SERVICES).

    (a) Section 1930, as added by section 4712(b)(2) of OBRA-1990, is 
amended--
            (1) in subsection (b)--
                    (A) by striking ``title the term,'' and inserting 
                ``title, the term'',
                    (B) by striking ``guardian'' and inserting 
                ``guardian or'', and
                    (C) by striking ``3 other'' and inserting ``3'';
            (2) in subsection (d)--
                    (A) in the matter preceding paragraph (1), by 
                striking ``program,'' and inserting ``program'', and
                    (B) in the second sentence, by striking ``plan'' 
                each place it appears and inserting ``program''; and
            (3) in subsection (i), by striking ``funds'' and inserting 
        ``Funds''.
    (b) Section 4712(c) of OBRA-1990 is amended--
            (1) in paragraph (1), by inserting ``of section 1930 of the 
        Social Security'' after ``subsection (h)''; and
            (2) in paragraph (2), by striking ``this section'' and 
        inserting ``such section''.

SEC. 5162. CORRECTION RELATING TO SECTION 4713 (COBRA CONTINUATION 
              COVERAGE).

    (a) Section 1902(a)(10) is amended in the matter following 
subparagraph (F)--
            (1) by striking ``; and (XI)'' and inserting ``, (XI)'';
            (2) by striking ``individuals, and (XI)'' and inserting 
        ``individuals, and (XII); and
            (3) by striking ``COBRA continuation premiums'' and 
        inserting ``COBRA premiums''.
    (b) Section 1902(u)(3), as added by section 4713(a)(2) of OBRA-
1990, is amended by striking ``title VI'' and inserting ``part 6 of 
subtitle B of title I''.

SEC. 5163. CORRECTION RELATING TO SECTION 4716 (MEDICAID TRANSITION FOR 
              FAMILY ASSISTANCE).

    Section 4716(a) of OBRA-1990 is amended by striking ``Amendments.--
Subsection (f) of section'' and inserting ``In General.--Section''.

SEC. 5164. CORRECTIONS RELATING TO SECTION 4723 (MEDICAID SPENDDOWN 
              OPTION).

    Section 1903(f)(2), as amended by section 4723(a) of OBRA-1990, is 
amended--
            (1) by striking ``(A)'' after ``(2)'';
            (2) by striking ``or, (B)'' and inserting ``. There shall 
        also be excluded,'';
            (3) by striking ``to the State, provided that'' and 
        inserting ``to the State if''; and
            (4) by striking ``pursuant to this subparagraph.'' and 
        inserting ``pursuant to the previous sentence''.

SEC. 5165. CORRECTIONS RELATING TO SECTION 4724 (OPTIONAL STATE 
              DISABILITY DETERMINATIONS).

    Section 1902(v), as added by section 4724 of OBRA-1990, is 
amended--
            (1) by striking ``(v)(1)'' and inserting ``(v)''; and
            (2) by striking ``of the Social Security Act''.

SEC. 5166. CORRECTION RELATING TO SECTION 4732 (SPECIAL RULES FOR 
              HEALTH MAINTENANCE ORGANIZATIONS).

    Section 1903(m)(2)(F)(i), as amended by section 4732(b)(2)(B) of 
OBRA-1990, is amended by striking ``or'' before ``with an eligible 
organization''.

SEC. 5167. CORRECTIONS RELATING TO SECTION 4741 (HOME AND COMMUNITY-
              BASED WAIVERS).

    The first sentence of section 1915(d)(3) is amended by striking the 
period at the end and inserting the following: ``, and a waiver of the 
requirements of section 1902(a)(23) (relating to choice of providers) 
insofar as such requirements relate to the provision of case management 
services and the State provides assurances satisfactory to the 
Secretary that a waiver of such requirements will not substantially 
limit access to such services).''

SEC. 5168. CORRECTIONS RELATING TO SECTION 4744 (FRAIL ELDERLY 
              WAIVERS).

    (a) Section 1924(a)(5), as added by section 4744(b)(1) of OBRA-
1990, is amended by striking ``1986.'' and inserting ``1986 or a waiver 
under section 603(c) of the Social Security Amendments of 1983.''.
    (b) Section 603(c) of the Social Security Amendments of 1983 is 
amended--
            (1) by striking ``(c)'' and inserting ``(c)(1)'';
            (2) by redesignating paragraphs (1) and (2) as 
        subparagraphs (A) and (B); and
            (3) by adding at the end the following new paragraph:
    ``(2) Section 1924 of the Social Security Act shall apply to any 
individual receiving services from an organization receiving a waiver 
under this subsection.''.

SEC. 5169. CORRECTIONS RELATING TO SECTION 4747 (COVERAGE OF HIV-
              POSITIVE INDIVIDUALS).

    Section 4747 of OBRA-1990 is amended--
            (1) in subsection (a), by striking ``subsection (c)'' and 
        inserting ``subsection (b)'';
            (2) in subsection (b)(2)--
                    (A) by striking ``preventative'' each place it 
                appears and inserting ``preventive'', and
                    (B) by adding a period at the end of subparagraph 
                (J);
            (3) in subsection (c)(1)--
                    (A) by striking ``subsection (c)'' and inserting 
                ``subsection (b)'', and
                    (B) by striking ``paragraphs (1) and (2) of''; and
            (4) in subsection (d)--
                    (A) by striking ``paragraph (3)'' and inserting 
                ``subsection (b)'', and
                    (B) by striking ``paragraph (1)'' and inserting 
                ``subsection (a)''.

SEC. 5170. CORRECTION RELATING TO SECTION 4751 (ADVANCE DIRECTIVES).

    Section 1903(m)(1)(A), as amended by section 4751(b)(1) of OBRA-
1990, is amended--
            (1) by striking ``1902(w)'' and inserting ``1902(w) and''; 
        and
            (2) by striking ``1902(a)'' and inserting ``1902(w)''.

SEC. 5171. CORRECTIONS RELATING TO SECTION 4752 (PHYSICIANS' SERVICES).

    (a) The paragraph (58) of section 1902(a) added by section 
4752(c)(1)(C) of OBRA-1990 is amended by striking ``subsection (v)'' 
and inserting ``subsection (x)''.
    (b) Subparagraphs (A) and (B) of the paragraph (14) of section 
1903(i) added by section 4752(e)(2) of OBRA-1990 are each amended--
            (1) by striking ``or'' at the end of clause (v);
            (2) by redesignating clause (vi) as clause (vii); and
            (3) by inserting after clause (v) the following new clause:
                            ``(vi) delivers such services in the 
                        emergency department of a hospital 
                        participating in the state plan approved under 
                        this title, or''.

SEC. 5172. CORRECTIONS RELATING TO SECTION 4801 (NURSING HOME REFORM).

    (a) Section 1919(b)(3)(C)(i)(I), as amended by section 4801(e)(3) 
of OBRA-1990, is amended by striking ``no later than'' before ``not to 
exceed 14 days''.
    (b) Section 1919(b)(5)(D), as amended by section 4801(a)(4) of 
OBRA-1990, is amended by striking the comma before ``or a new 
competency evaluation program.''.
    (c) Section 1919(b)(5)(G) is amended by striking ``or licensed or 
certified social worker'' and inserting ``licensed or certified social 
worker, registered respiratory therapist, or certified respiratory 
therapy technician''.
    (d) Section 1919(f)(2)(B)(i) is amended by striking ``facilities,'' 
and inserting ``facilities (subject to clause (iii)),''.
    (e) Section 1919(f)(2)(B)(iii)(I)(c) is amended by striking 
``clauses'' each place it appears and inserting ``clause''.
    (f) Section 1919(g)(5)(B) is amended by striking ``paragraphs'' and 
inserting ``paragraph''.
    (g) Section 4801(a)(6)(B) of OBRA-1990 is amended--
            (1) by striking ``The amendments'' and inserting ``(i) The 
        amendments'';
            (2) by redesignating clauses (i) through (v) as subclauses 
        (I) through (V); and
            (3) by adding at the end the following new clause:
                    ``(ii) Notwithstanding clause (i) and subject to 
                section 1919(f)(2)(B)(iii) of the Social Security Act 
                (as amended by subparagraph (A)), a State may approve a 
                training and competency evaluation program or a 
                competency evaluation program offered by or in a 
                nursing facility described in clause (i) if, during the 
                previous 2 years, none of the subclauses of clause (i) 
                applied to the facility.''.

SEC. 5173. OTHER TECHNICAL CORRECTIONS.

    (a) Section 1905(o)(1)(A) is amended--
            (1) in the first sentence, by striking ``intermediate care 
        facility services'' and inserting ``for nursing facility 
        services or intermediate care facility services for the 
        mentally retarded''; and
            (2) in the second sentence, by striking ``or intermediate 
        care facility'' and inserting ``(for purposes of title XVIII), 
        a nursing facility, or an intermediate care facility for the 
        mentally retarded''.
    (b) Section 1915(d) is amended--
            (1) by striking ``skilled nursing facility or intermediate 
        care facility'' each place it appears in paragraphs (1), 
        (2)(B), and (2)(C) and inserting ``nursing facility'';
            (2) in paragraph (2)(B)(i), by striking ``skilled nursing 
        or intermediate care facility'' and inserting ``nursing 
        facility'';
            (3) in paragraph (5)(A), by striking ``under'' the second 
        place it appears and inserting ``(or, in the case of waiver 
        years beginning on or after October 1, 1990, with respect to 
        nursing facility services and home and community-based 
        services) under''; and
            (4) in paragraph (5)(B)--
                    (A) in clause (i), by striking ``furnished'' and 
                inserting ``(or, with respect to waiver years beginning 
                on or after October 1, 1990, for nursing facility 
                services) furnished''; and
                    (B) in clause (iii)(I), by striking ``(regardless'' 
                and inserting ``(or, with respect to waiver years 
                beginning on or after October 1, 1990, which comprise 
                nursing facility services) (regardless''.

SEC. 5174. CORRECTIONS TO DESIGNATIONS OF NEW PROVISIONS.

    (a) Paragraphs Added to Section 1902(a).--Section 1902(a) is 
amended--
            (1) by striking ``and'' at the end of paragraph (54);
            (2) in the paragraph (55) inserted by section 4602(a)(3) of 
        OBRA-1990, by striking the period at the end and inserting a 
        semicolon;
            (3) by redesignating the paragraph (55) inserted by section 
        4604(b)(3) of OBRA-1990 as paragraph (56), by transferring and 
        inserting it after the paragraph (55) inserted by section 
        4602(a)(3) of such Act, and by striking the period at the end 
        and inserting a semicolon;
            (4) by placing paragraphs (57) and (58), inserted by 
        section 4751(a)(1)(C) of OBRA-1990, immediately after paragraph 
        (56), as redesignated by paragraph (3);
            (5) in the paragraph (58) inserted by section 4751(a)(1)(C) 
        of OBRA-1990, by striking the period at the end and inserting 
        ``; and''; and
            (6) by redesignating the paragraph (58) inserted by section 
        4752(c)(1)(C) of OBRA-1990 as paragraph (59) and by 
        transferring and inserting it after the paragraph (58) inserted 
        by section 4751(a)(1)(C) of such Act.
    (b) Paragraphs Added to Section 1903(i).--Section 1903(i), as 
amended by section 2(b)(2) of the Medicaid Voluntary Contribution and 
Provider-Specific Tax Amendments of 1991, is amended--
            (1) in the paragraph (10) inserted by section 4401(a)(1)(B) 
        of OBRA-1990, by striking all that follows ``1927(g)'' and 
        inserting a semicolon;
            (2) by redesignating the paragraph (12) inserted by section 
        4752(a)(2) of OBRA-1990 as paragraph (11), by transferring and 
        inserting it after the paragraph (10) inserted by section 
        4401(a)(1)(B) of OBRA-1990, and by striking the period at the 
        end and inserting a semicolon;
            (3) by redesignating the paragraph (14) inserted by section 
        4752(e) of OBRA-1990 as paragraph (12), by transferring and 
        inserting it after paragraph (11), as redesignated by paragraph 
        (2), and by striking the period at the end and inserting ``; 
        or''; and
            (4) by redesignating the paragraph (11) inserted by section 
        4801(e)(16)(A) of OBRA-1990 as paragraph (13) and by 
        transferring and inserting it after paragraph (12), as 
        redesignated by paragraph (3).
    (c) Paragraphs Added to Section 1905(a).--
            (1) In general.--Section 1905(a) is amended--
                    (A) by striking ``and'' at the end of paragraph 
                (21);
                    (B) in paragraph (24), by striking the comma at the 
                end and inserting ``; and''; and
                    (C) by redesignating paragraphs (22), (23), and 
                (24) as paragraphs (24), (22), and (23), respectively, 
                and by transferring and inserting paragraph (24) after 
                paragraph (23), as so redesignated.
            (2) Conforming amendments.--(A) Effective July 1, 1991, 
        section 1902(a)(10)(C)(iv), as amended by section 4755(c)(1)(A) 
        of OBRA-1990, is amended by striking ``through (21)'' and 
        inserting ``through (23)''.
            (B) Effective July 1, 1991, section 1902(j), as amended by 
        section 4711(d)(1) of OBRA-1990, is amended by striking 
        ``through (22)'' and inserting ``through (24)''.
    (d) Final Sections.--Section 1928, as redesignated by section 
4401(a)(3) of OBRA-1990, is amended--
            (1) by transferring such section to the end of title XIX of 
        the Social Security Act; and
            (2) by redesignating such section as section 1931.

         CHAPTER 2--UNIVERSAL ACCESS TO CHILDHOOD IMMUNIZATIONS

SEC. 5181. ESTABLISHMENT OF ENTITLEMENT AND MONITORING PROGRAMS WITH 
              RESPECT TO CHILDHOOD IMMUNIZATIONS.

    (a) In General.--Title XXI of the Public Health Service Act (42 
U.S.C. 300aa-1 et seq.) is amended by adding at the end the following 
subtitle:

   ``Subtitle 3--Entitlement and Monitoring Programs With Respect to 
                        Childhood Immunizations

                     ``Part A--Entitlement Program

``SEC. 2151. DELIVERY TO STATES OF SUFFICIENT QUANTITIES OF PEDIATRIC 
              VACCINES.

    ``(a) In General.--In the case of any State that submits to the 
Secretary an application in accordance with section 2157, the 
Secretary, acting through the Director of the Centers for Disease 
Control and Prevention, shall provide for the purchase and delivery on 
behalf of the State of such quantities of pediatric vaccines as may be 
necessary for the immunization of each eligible child in the State. The 
preceding sentence is subject to sections 2152(d) and 2159(a).
    ``(b) Eligible Children.--For purposes of this part, the term 
`eligible child' means an individual 18 years of age or younger who--
            ``(1) with respect to the State involved, is entitled to 
        medical assistance under the plan approved for the State under 
        title XIX of the Social Security Act (including a State 
        operating under a statewide waiver under section 1115 of such 
        Act);
            ``(2)(A) is uninsured with respect to health insurance 
        policies or plans (including group health plans or prepaid 
        health plans and including employee welfare benefit plans under 
        the Employee Retirement Income Security Act of 1974); or
            ``(B) is covered under such a policy or plan, but under the 
        policy or plan benefits are not available with respect to 
        immunizations; or
            ``(3) is an Indian.

``SEC. 2152. ENTITLEMENTS.

    ``(a) Entitlement of States.--Subject to subsection (d), in the 
case of any State that submits to the Secretary an application in 
accordance with section 2157, the State is entitled to have the 
Secretary provide for the purchase and delivery on behalf of the State 
of pediatric vaccines under section 2151. The preceding sentence 
constitutes budget authority in advance of appropriations Acts, and 
represents the obligation of the Federal Government to provide for the 
purchase and delivery to the State of the vaccines.
    ``(b) Entitlements of Children and Health Care Providers.--Subject 
to subsection (d), the Secretary may provide for the purchase and 
delivery of pediatric vaccines under section 2151 on behalf of a State 
only if the State agrees as follows:
            ``(1) Each eligible child in the State, in receiving an 
        immunization with a pediatric vaccine from a program-registered 
        provider (as defined in section 2153(a)), is entitled to 
        receive the immunization without charge for the cost of such 
        vaccine.
            ``(2) Each program-registered provider in the State who 
        administers a pediatric vaccine to an eligible child in the 
        State is entitled to receive such vaccine from the State 
        without charge.
            ``(3) The State will carry out a program to administer the 
        entitlements established pursuant to paragraphs (1) and (2).
    ``(c) Enforcement of Provider Rights by Eligible Children.--With 
respect to the obligation of a State under the entitlement established 
in subsection (b)(2), an eligible child (or representative of the 
child) may enforce the rights of the provider under such paragraph if--
            ``(1) the provider administered a pediatric vaccine to the 
        child notwithstanding the failure of the State to carry out 
        such obligation with respect to the vaccine; or
            ``(2) an immunization with the vaccine was sought for the 
        child by a parent of the child, but the provider, on the basis 
        of such failure of the State, did not administer the vaccine to 
        the child.
    ``(d) Certain Conditions.--
            ``(1) In general.--This part does not apply with respect to 
        any vaccine administered before October 1, 1994.
            ``(2) Relationship to purchase contracts with 
        manufacturers.--With respect to a pediatric vaccine, the 
        obligation of the Federal Government pursuant to subsection 
        (a), and the obligations of the State pursuant to subsection 
        (b), are effective only to the extent that there is in effect a 
        contract under section 2158 for the purchase and delivery of 
        the vaccine.
            ``(3) Submission of application.--
                    ``(A) Subject to subparagraph (C), the entitlements 
                established pursuant to subsections (a) and (b) are 
                established with respect to a State upon the State 
                submitting to the Secretary an application in 
                accordance with section 2157.
                    ``(B) An application submitted to the Secretary 
                under section 2157 is deemed to have been submitted in 
                accordance with such section unless the Secretary, not 
                later than 30 days after the date on which the 
                application is submitted, notifies the State that the 
                application is not in accordance with such section.
                    ``(C) In the case of a State whose application 
                submitted under section 2157 is not submitted in 
                accordance with such section, the Secretary may, upon 
                the submission by the State of an application that is 
                in accordance with such section, provide that the 
                entitlements established pursuant to such submission 
                are deemed to have been established on the date on 
                which the State first submitted the application.

``SEC. 2153. VOLUNTARY PARTICIPATION OF HEALTH CARE PROVIDERS.

    ``(a) In General.--
            ``(1) Request for participation; required approval.--The 
        Secretary may provide for the purchase and delivery of 
        pediatric vaccines under section 2151 on behalf of a State only 
        if the State agrees that federally-supplied pediatric vaccines 
        will not be distributed to a health care provider unless--
                    ``(A) the provider submits to the State a written 
                request to participate in the program established by 
                the State pursuant to section 2152(b)(3);
                    ``(B) the request is in such form and is made in 
                such manner as the Secretary may require; and
                    ``(C) the provider makes the agreements described 
                in this section.
            ``(2) Program-registered providers.--For purposes of this 
        part, the term `program-registered provider' means a health 
        care provider that meets the conditions specified in 
        subparagraphs (A) through (C) of paragraph (1).
    ``(b) Eligibility of Children.--
            ``(1) In general.--An agreement for a health care provider 
        under subsection (a) is that the provider--
                    ``(A) before administering a pediatric vaccine to a 
                child, will ask a parent of the child such questions as 
                are necessary to determine whether the child is an 
                eligible child;
                    ``(B) will, for a period of time specified by the 
                Secretary, maintain records of responses made to the 
                questions; and
                    ``(C) will, upon request, make such records 
                available to the State involved and to the Secretary, 
                subject to paragraph (2).
            ``(2) Restriction on use of information.--Records provided 
        to a State or to the Secretary under paragraph (1)(C) may be 
        used only for purposes of audit of the program carried out 
        under section 2152(b)(3) by the State.
    ``(c) Charges for Vaccines.--
            ``(1) Vaccines per se.--An agreement for a health care 
        provider under subsection (a) is that, in administering a 
        federally-supplied pediatric vaccine to an eligible child, the 
        provider will not impose a charge for the cost of the vaccine.
            ``(2) Administration of vaccines.--With respect to 
        compliance with an agreement under paragraph (1), a program-
        registered provider may impose a charge for the administration 
        of a federally-supplied pediatric vaccine, subject to an 
        agreement by the provider that the provider will not impose 
        such charge with respect to a child if a parent of the child 
        certifies to the provider that the parent is unable to pay the 
        charge.
    ``(d) Rules of Construction.--
            ``(1) Extent of participation.--This section may not be 
        construed as requiring that a program-registered provider 
        administer a federally-supplied pediatric vaccine to each 
        eligible child for whom an immunization with the vaccine is 
        sought from the provider.
            ``(2) Verification of information.--With respect to 
        compliance with agreements under subsections (b) and (c), such 
        agreements may not be construed as requiring a program-
        registered provider to verify independently the information 
        provided to the provider by a parent pursuant to such 
        subsections.

``SEC. 2154. INTRASTATE DISTRIBUTION OF PEDIATRIC VACCINES.

    ``(a) In General.--Not later than 180 days after the date of the 
enactment of the Omnibus Budget Reconciliation Act of 1993, the 
Secretary shall, through publication in the Federal Register, establish 
criteria for the delivery on behalf of the States of federally-supplied 
pediatric vaccines to program-registered providers in the State.
    ``(b) Involvement of Certain Providers.--
            ``(1) In general.--In establishing criteria under 
        subsection (a), the Secretary shall establish criteria with 
        respect to encouraging the entities described in paragraph (2) 
        to become program-registered providers.
            ``(2) Relevant providers.--The entities referred to in 
        paragraph (1) are--
                    ``(A) private health care providers; and
                    ``(B)(i) health care providers that receive funds 
                under title V of the Indian Health Care Improvement 
                Act;
                    ``(ii) the Indian Health Service; and
                    ``(iii) health programs or facilities operated by 
                Indian tribes or tribal organizations.
    ``(c) Cultural Context of Services.--In establishing criteria under 
subsection (a), the Secretary shall require that, in providing a 
federally-supplied pediatric vaccine to any population of eligible 
children a substantial portion of whose parents have a limited ability 
to speak the English language, a State have in effect a reasonable plan 
to administer the vaccines through program-registered providers who are 
able to communicate with the population involved in the language and 
cultural context that is most appropriate.
    ``(d) Compliance by States.--The Secretary may provide for the 
purchase and delivery of pediatric vaccines under section 2151 on 
behalf of a State only if the State agrees to maintain compliance with 
the criteria established under subsection (a).

``SEC. 2155. GENERAL PROVISIONS.

    ``(a) Federal Standards on Accountability.--
            ``(1) Establishment of standards.--Not later than 180 days 
        after the date of the enactment of the Omnibus Budget 
        Reconciliation Act of 1993, the Secretary shall, through 
        publication in the Federal Register, establish standards with 
        respect to determining the extent to which States and program-
        registered providers are in compliance with the agreements made 
        under this part.
            ``(2) Compliance by states.-- The Secretary may provide for 
        the purchase and delivery of pediatric vaccines under section 
        2151 on behalf of a State only if the State agrees to maintain 
        compliance with the standards established under subsection (a).
    ``(b) State Maintenance of Immunization Laws.--The Secretary may 
provide for the purchase and delivery of vaccines under section 2151 on 
behalf of a State only if the State certifies to the Secretary that, if 
it had in effect as of May 1, 1993, a law that requires some or all 
health insurance policies or plans to provide some coverage with 
respect to a pediatric vaccine, the State has not modified or repealed 
such law in a manner that reduces the amount of coverage so required.
    ``(c) Participation in National Monitoring System.--On and after 
January 1, 1998, the Secretary may provide for the purchase and 
delivery of vaccines under section 2151 on behalf of a State only if 
the State certifies to the Secretary that the State is operating a 
registry in accordance with part B.

``SEC. 2156. STATE OPTION REGARDING IMMUNIZATION OF ADDITIONAL 
              CATEGORIES OF CHILDREN.

    ``(a) State Purchases.--Subject to subsections (b) and (c), for the 
purpose of administering a pediatric vaccine to children in addition to 
eligible children, any participating State under section 2151 may, 
pursuant to section 2158(a)(2), purchase the vaccine from a 
manufacturer of the vaccine at the price in effect under section 2158.
    ``(b) Requirements.--A State may purchase pediatric vaccines 
pursuant to subsection (a) only if the following conditions are met:
            ``(1) The State agrees that the vaccines will be used to 
        provide immunizations for children who are not eligible 
        children.
            ``(2) The State designates the particular categories of 
        children who are to receive the immunizations, and submits to 
        the Secretary a description of the categories so designated.
            ``(3) The State provides to the Secretary such information 
        as the Secretary determines to be necessary to provide for 
        quantities of pediatric vaccines for the State to purchase 
        pursuant to section 2158(a)(2).
            ``(4) The State agrees, subject to subsection (c), that the 
        program established by the State pursuant to section 2152(b)(3) 
        applies to children designated under paragraph (2) to the same 
        extent and in the same manner as the program applies to 
        eligible children (except for the State being the purchaser of 
        the pediatric vaccines involved).
    ``(c) Certain Limitations.--A State may purchase pediatric vaccines 
pursuant to subsection (a) only if the State agrees as follows:
            ``(1) The authorization established in such subsection with 
        respect to a pediatric vaccine is subject to the quantity of 
        the vaccine that, on behalf of the State, the Secretary 
        provides for under section 2158(a)(2).
            ``(2) In any case in which multiple contracts are in effect 
        under section 2158 with respect to such a vaccine and the State 
        elects to purchase the vaccine pursuant to subsection (a), the 
        Secretary will determine which of such contracts will be 
        applicable to the purchase.

``SEC. 2157. STATE APPLICATION FOR VACCINES.

    ``(a) In General.--An application by a State for pediatric vaccines 
under section 2151(a) is in accordance with this section if the 
application--
            ``(1) is submitted not later than the date specified by the 
        Secretary;
            ``(2) contains each agreement required in this part 
        (including the agreements required in section 2156, if the 
        State is electing to purchase pediatric vaccines pursuant to 
        such section);
            ``(3) contains any information required in this part to be 
        submitted to the Secretary (including the information required 
        in section 2156, if the State is electing to purchase pediatric 
        vaccines pursuant to such section);
            ``(4) contains the certification required in subsection (b) 
        of section 2155 and, as applicable, the certification required 
        in subsection (c) of such section; and
            ``(5) is in such form, is made in such manner, and contains 
        such agreements, assurances, and information as the Secretary 
        determines to be necessary to carry out this part.
    ``(b) Failure to Apply.--
            ``(1) In general.--If, as of January 1, 1998, a State is 
        not receiving pediatric vaccines under section 2151 and 
        carrying out a program pursuant to section 2152(b)(3), the 
        Secretary shall, subject to paragraph (2), terminate payments 
        to the State under part A of title XIX.
            ``(2) Exceptions.--Paragraph (1) does not apply in the case 
        of a State described in such paragraph that--
                    ``(A) is, through all willing health care 
                providers, providing for the immunization of eligible 
                children with pediatric vaccines, and is not imposing a 
                charge on such providers or children for the costs of 
                the vaccines; or
                    ``(B) meets or exceeds the objectives established 
                by the Secretary for the year 2000 for the immunization 
                status of children in the United States who are 2 years 
                of age.

``SEC. 2158. CONTRACTS WITH MANUFACTURERS OF PEDIATRIC VACCINES.

    ``(a) In General.--Subject to the provisions of this section, the 
Secretary shall periodically enter into negotiations with manufacturers 
of pediatric vaccines for the purpose of maintaining contracts under 
which--
            ``(1) the Secretary provides for the purchase of quantities 
        of pediatric vaccines necessary for carrying out section 2151, 
        and provides for the delivery of the vaccines to participating 
        States under such section; and
            ``(2) each participating State, at the option of the State 
        under section 2156, is permitted to obtain additional 
        quantities of pediatric vaccines (subject to limits in such 
        contracts regarding quantities) through purchasing the vaccines 
        from the manufacturers at the price negotiated by the Secretary 
        for the quantities specified in paragraph (1).
The Secretary shall enter into the initial negotiations under the 
preceding sentence not later than 180 days after the date of the 
enactment of the Omnibus Budget Reconciliation Act of 1993.
    ``(b) Negotiation of Purchase Price.--
            ``(1) In general.--In negotiating the prices at which 
        pediatric vaccines will be purchased from a manufacturer under 
        subsection (a), the Secretary shall negotiate a price that 
        provides a reasonable profit for the manufacturer.
            ``(2) Certain factors.--
                    ``(A) In determining a reasonable profit for a 
                manufacturer under paragraph (1), the Secretary shall 
                consider the following factors:
                            ``(i) The costs of the manufacturer in 
                        researching, developing, and producing the 
                        pediatric vaccine involved.
                            ``(ii) The costs of the manufacturer in 
                        researching and developing new or improved 
                        vaccines (pediatric or otherwise).
                            ``(iii) The costs of shipping and handling 
                        pediatric vaccines in compliance with the 
                        agreement under subsection (c).
                            ``(iv) Such other factors as the Secretary 
                        determines to be appropriate.
                    ``(B) With respect to factors considered under 
                subparagraph (A), the Secretary may enter into a 
                contract under subsection (a) only if the manufacturer 
                involved provides to the Secretary such information 
                regarding the factors as the Secretary determines to be 
                appropriate.
            ``(3) Confidentiality.--With respect to information 
        provided to the Secretary by a manufacturer under paragraph 
        (2), the following applies:
                    ``(A) The Secretary shall maintain the 
                confidentiality of the information, with provision for 
                reasonable disclosures.
                    ``(B) For purposes of section 552(b)(4) of title 5, 
                United States Code, the information shall be considered 
                to be trade secrets and commercial or financial 
                information obtained from a person and privileged or 
                confidential.
                    ``(C) Section 1905 of title 18, United States Code, 
                applies to information maintained confidentially under 
                subparagraph (A).
    ``(c) Charges for Shipping and Handling.--The Secretary may enter 
into a contract under subsection (a) only if the manufacturer involved 
agrees that the manufacturer will provide for delivering the vaccines 
on behalf of the States in accordance with the programs established by 
the States pursuant to section 2152(b)(3), and will not impose any 
charges for the costs of such delivery (except to the extent such costs 
are provided for in the price negotiated under subsection (b)).
    ``(d) Quantity of Vaccines.--For the purpose of ensuring that the 
Federal Government has the ability to carry out section 2151, the 
Secretary, in negotiations under subsection (a), shall negotiate for 
maintaining a supply of pediatric vaccines to meet unanticipated needs 
for the vaccines. For purposes of the preceding sentence, the Secretary 
shall negotiate for a 6-month supply of vaccines in addition to the 
quantity that the Secretary otherwise would provide for in such 
negotiations. In carrying out this paragraph, the Secretary shall 
consider the potential for outbreaks of the diseases with respect to 
which the vaccines have been developed.
    ``(e) Negotiating Authority of Secretary.--In carrying out 
subsection (a), the Secretary, to the extent determined by the 
Secretary to be appropriate, may enter into contracts described in such 
subsection, may decline to enter into such contracts, and with the 
consent of the manufacturers involved, may modify such agreements and 
may extend such agreements.
    ``(f) Certain Contract Provisions.--
            ``(1) Duration.--A contract entered into by the Secretary 
        under subsection (a) is effective for such period as the 
        Secretary and the manufacturer involved may agree in the 
        contract.
            ``(2) Advance funding.--The Secretary may, pursuant to 
        section 2152(a), enter into contracts under subsection (a) 
        under which the Federal Government is obligated to make 
        outlays, the budget authority for which is not provided for in 
        advance in appropriations Acts.
    ``(g) Reports to Secretary.--The Secretary may enter into a 
contract under subsection (a) only if the manufacturer involved agrees 
to submit to the Secretary such reports as the Secretary determines to 
be appropriate with respect to compliance with the contract. For 
purposes of paragraph (3) of subsection (b), such reports shall be 
considered to be information provided by the manufacturer to the 
Secretary under paragraph (2) of such subsection.
    ``(h) Multiple Suppliers.--
            ``(1) In general.--In the case of the pediatric vaccine 
        involved, the Secretary shall, as appropriate, enter into a 
        contract under subsection (a) with each manufacturer of the 
        vaccine that meets the terms and conditions of the Secretary 
        for an award of such a contract (including terms and conditions 
        regarding safety, quality, and price).
            ``(2) Rule of construction.--With respect to multiple 
        contracts entered into pursuant to paragraph (1), such 
        paragraph may not be construed as prohibiting the Secretary 
        from having in effect different prices under each of such 
        contracts.

``SEC. 2159. CERTAIN ADMINISTRATIVE VARIATIONS.

    ``(a) Tribes and Tribal Organizations.--
            ``(1) In general.--Subject to paragraph (2), the Secretary 
        shall provide for the purchase and delivery on behalf of each 
        Indian tribe and each tribal organization of such quantities of 
        pediatric vaccines as may be necessary for the immunization of 
        each Indian child in the State in which the tribe or 
        organization (as the case may be) is located.
            ``(2) Entitlements; administering program.--The Secretary 
        may provide for the purchase and delivery of pediatric vaccines 
        under paragraph (1) on behalf of an Indian tribe or tribal 
        organization only if the tribe or organization (as the case may 
        be) agrees that this part applies to the tribe or organization 
        (in relation to Indian children) to the same extent and in the 
        manner as such part applies to States (in relation to eligible 
        children).
    ``(b) State as Manufacturer.--
            ``(1) Payments in lieu of vaccines.--In the case of a 
        participating State under section 2151 that manufactures a 
        pediatric vaccine and is not receiving the vaccine under such 
        section, if the Secretary determines that the program of the 
        State under 2152(b)(3) is carried out with respect to the 
        vaccine, the Secretary shall provide to the State an amount 
        equal to the value of the quantity of such vaccine that 
        otherwise would have been delivered to the State under section 
        2151, subject to the provisions of this subsection.
            ``(2) Determination of value.--In determining the amount to 
        pay a State under paragraph (1) with respect to a pediatric 
        vaccine, the value of the quantity of vaccine shall be 
        determined on the basis of the price in effect for the vaccine 
        under contracts under section 2158. If more than 1 such 
        contract is in effect, the Secretary shall determine such value 
        on the basis of the average of the prices under the contracts, 
        after weighting each such price in relation to the quantity of 
        vaccine under the contract involved.
            ``(3) Use of payments.--A State may expend payments 
        received under paragraph (1) only for purposes relating to 
        pediatric vaccines.

``SEC. 2160. LIST OF PEDIATRIC VACCINES; SCHEDULE FOR ADMINISTRATION.

    ``(a) Recommended Pediatric Vaccines.--
            ``(1) In general.--The Secretary shall establish a list of 
        the vaccines that the Secretary recommends for administration 
        to all children for the purpose of immunizing the children, 
        subject to such contraindications for particular medical 
        categories of children as the Secretary may establish under 
        subsection (b)(1)(D). The Secretary shall periodically review 
        the list, and shall revise the list as appropriate.
            ``(2) Rule of construction.--
                    ``(A) The list of vaccines specified in 
                subparagraph (B) is deemed to be the list of vaccines 
                maintained under paragraph (1).
                    ``(B) The list of vaccines specified in this 
                subparagraph is the list of vaccines that, for purposes 
                of paragraph (1), is established (and periodically 
                reviewed and as appropriate revised) by the Advisory 
                Committee on Immunization Practices, an advisory 
                committee established by the Secretary, acting through 
                the Director of the Centers for Disease Control and 
                Prevention.
    ``(b) Recommended Schedule for Administration.--
            ``(1) In general.--Subject to paragraph (2), in the case of 
        a pediatric vaccine, the Secretary shall establish (and 
        periodically review and as appropriate revise) a schedule of 
        nonbinding recommendations for the following:
                    ``(A) The number of immunizations with the vaccine 
                that children should receive.
                    ``(B) The ages at which children should receive the 
                immunizations.
                    ``(C) The dosage of vaccine that should be 
                administered in the immunizations.
                    ``(D) Any contraindications regarding 
                administration of the vaccine to particular medical 
                categories of children.
                    ``(E) Such other guidelines as the Secretary 
                determines to be appropriate with respect to 
                administering the vaccine to children.
            ``(2) Variations in medical practice.--In establishing and 
        revising a schedule under paragraph (1), the Secretary shall 
        ensure that, in the case of the pediatric vaccine involved, the 
        schedule provides for the full range of variations in medical 
        judgment regarding the administration of the vaccine, subject 
        to remaining within medical norms.
            ``(3) Rule of construction.--
                    ``(A) The schedule specified in subparagraph (B) is 
                deemed to be the schedule maintained under paragraph 
                (1).
                    ``(B) The schedule specified in this subparagraph 
                is the schedule that, for purposes of paragraph (1), is 
                established (and periodically reviewed and as 
                appropriate revised) by the advisory committee 
                specified in subsection (a)(2)(B).
    ``(c) Generally Applicable Rules of Construction.--
            ``(1) In general.--The list established under subsection 
        (a) and the schedules established under subsection (b) do not 
        constitute guidelines, standards, performance measures, or 
        review criteria for purposes of the program carried out by the 
        Administrator for Health Care Policy and Research under part B 
        of title IX or under section 1142 of the Social Security Act.
            ``(2) State laws.--This section does not supersede any 
        State law on requirements with respect to receiving 
        immunizations (including any such law relating to religious 
        exemptions or medical exemptions).
    ``(d) Issuance of List and Schedules.--Not later than 180 days 
after the date of the enactment of the Omnibus Budget Reconciliation 
Act of 1993, the Secretary shall establish the initial list required in 
subsection (a) and the schedule required in subsection (b).

``SEC. 2161. CHILDHOOD IMMUNIZATION TRUST FUND.

    ``(a) Establishment of Fund.--There is established in the Treasury 
of the United States a fund to be known as the National Childhood 
Immunization Trust Fund (in this section referred to as the `Fund'). 
The Fund shall consist of such amounts as may be appropriated to the 
Fund in appropriations Acts, in the Internal Revenue Code of 1986, or 
in subsection (c)(3). Amounts appropriated to the Fund shall remain 
available until expended.
    ``(b) Expenditures From Fund.--Amounts in the Fund are available to 
the Secretary for the purpose of carrying out this part. Payments under 
the program under this part, and the costs of carrying out such 
program, shall be exempt from reduction under any order issued under 
part C of the Balanced Budget and Emergency Deficit Control Act of 
1985.
    ``(c) Investment.--
            ``(1) In general.--The Secretary of the Treasury shall 
        invest such amounts of the Fund as such Secretary determines 
        are not required to meet current withdrawals from the Fund. 
        Such investments may be made only in interest-bearing 
        obligations of the United States. For such purpose, such 
        obligations may be acquired on original issue at the issue 
        price, or by purchase of outstanding obligations at the market 
        price.
            ``(2) Sale of obligations.--Any obligation acquired by the 
        Fund may be sold by the Secretary of the Treasury at the market 
        price.
            ``(3) Availability of income.--Any interest derived from 
        obligations acquired by the Fund, and proceeds from any sale or 
        redemption of such obligations, are hereby appropriated to the 
        Fund.

``SEC. 2162. DEFINITIONS.

    ``For purposes of this subtitle:
            ``(1) The term `eligible child' has the meaning given such 
        term in section 2151(b).
            ``(2) The term `federally-supplied', with respect to a 
        pediatric vaccine, means that such vaccine is purchased and 
        delivered on behalf of a State under section 2151(a).
            ``(3) The term `health care provider', with respect to the 
        administration of vaccines to children, means an entity that is 
        licensed or otherwise authorized for such administration under 
        the law of the State in which the entity administers the 
        vaccine, subject to section 333(e).
            ``(4) The term `immunization' means an immunization against 
        a vaccine-preventable disease.
            ``(5) Each of the terms `Indian', `Indian tribe', and 
        `tribal organization' has the meaning given such term in 
        section 4 of the Indian Health Care Improvement Act.
            ``(6) The term `Indian child' means an Indian who is 18 
        years of age or younger.
            ``(7) The term `manufacturer' means any corporation, 
        organization, or institution, whether public or private 
        (including Federal, State, and local departments, agencies, and 
        instrumentalities), which manufactures, imports, processes, or 
        distributes under its label any pediatric vaccine. The term 
        `manufacture' means to manufacture, import, process, or 
        distribute a vaccine.
            ``(8) The term `parent', with respect to a child, means a 
        legal guardian of the child.
            ``(9) The term `participating State under section 2151' 
        means a State that has submitted to the Secretary an 
        application in accordance with section 2157.
            ``(10) The term `pediatric vaccine' means a vaccine 
        included on the list established under section 2160(a).
            ``(11) The term `program-registered provider' has the 
        meaning given such term in 2153(a)(2).

``SEC. 2163. TERMINATION OF PROGRAM.

    This part shall cease to be in effect beginning on such date as may 
be prescribed in Federal law providing for immunization services for 
all children as part of a broad-based reform of the national health 
care system.

    ``Part B--National System for Monitoring Immunization Status of 
                                Children

``SEC. 2171. FORMULA GRANTS FOR STATE REGISTRIES WITH RESPECT TO 
              MONITORING.

    ``(a) In General.--For the purpose described in subsection (b), the 
Secretary, acting through the Director of the Centers for Disease 
Control and Prevention, shall make an allotment each fiscal year for 
each State in an amount determined in accordance with section 2175. The 
Secretary shall make a grant to the State of the allotment made for the 
State for the fiscal year if the State submits to the Secretary an 
application in accordance with section 2174.
    ``(b) Authorized Activities.--The Secretary may make a grant under 
subsection (a) only if the State agrees to expend the grant for the 
purpose of--
            ``(1) collecting the data described in section 2172;
            ``(2) operating registries to maintain the data (and 
        establishing such registries, in the case of a State that is 
        not operating such a registry);
            ``(3) utilizing the data to monitor the extent to which 
        children have received immunizations in accordance with the 
        schedule established under section 2160(b);
            ``(4) notifying parents if children have not received 
        immunizations in accordance with such schedule; and
            ``(5) such other activities as the Secretary may authorize 
        with respect to achieving the objectives established by the 
        Secretary for the year 2000 for the immunization status of 
        children in the United States.
    ``(c) Requirement Regarding State Laws.--
            ``(1) In general.--The Secretary may make a grant under 
        subsection (a) only if the State involved--
                    ``(A) provides assurances satisfactory to the 
                Secretary that, not later than October 1, 1996, the 
                State will be operating a registry in accordance with 
                this part, including having in effect such laws and 
                regulations as may be necessary to so operate such a 
                registry; and
                    ``(B) agrees that, prior to such date, the State 
                will make such efforts to operate a registry in 
                accordance with this part as may be authorized in the 
                law and regulations of the State.
            ``(2) Rules of construction.--
                    ``(A) With respect to the agreements made by a 
                State under this part, other than the agreement under 
                paragraph (1)(B), the Secretary may require compliance 
                with the agreements only to the extent consistent with 
                such paragraph.
                    ``(B) This part does not authorize the Secretary, 
                as a condition of the receipt of a grant under 
                subsection (a) by a State, to prohibit the State from 
                providing any parent, upon the request of the parent, 
                with an exemption from the requirements established by 
                the State pursuant to this part for the collection of 
                data regarding any child of the parent.

``SEC. 2172. REGISTRY DATA.

    ``(a) In General.--For purposes of section 2171(b)(1), the data 
described in this section are the data described in subsection (b) and 
the data described in subsection (c). This section applies to data 
regarding a child without regard to whether the child is an eligible 
child as defined in section 2162.
    ``(b) Data Regarding Birth of Child.--With respect to the birth of 
a child, the data described in this subsection is as follows:
            ``(1) The name of each child born in the State involved on 
        or after October 1, 1993.
            ``(2) Demographic data on the child.
            ``(3) The name of one or both of the parents of the child.
            ``(4) The address, as of the date of the birth of the 
        child, of each parent whose name is received in the registry 
        pursuant to paragraph (3).
    ``(c) Data Regarding Individual Immunizations.--With respect to a 
child to whom a pediatric vaccine is administered in the State 
involved, the data described in this subsection is as follows:
            ``(1) The name, age, and address of the child.
            ``(2) The date on which the vaccine was administered to the 
        child.
            ``(3) The name and business address of the health care 
        provider that administered the vaccine.
            ``(4) The address of the facility at which the vaccine was 
        administered.
            ``(5) The name and address of one or both parents of the 
        child as of the date on which the vaccine was administered, if 
        such information is available to the health care provider.
            ``(6) The type of vaccine.
            ``(7) The number or other information identifying the 
        particular manufacturing batch of the vaccine, if such 
        information appears on the container or packaging for the 
        vaccine or is otherwise readily accessible to the health care 
        provider.
            ``(8) The dosage of vaccine that was administered.
            ``(9) A description of any adverse medical reactions that 
        the child experienced in relation to the vaccine and of which 
        the health care provider is aware.
            ``(10) Any other contraindications noted by the health care 
        provider with respect to administration of the vaccine to the 
        child.
            ``(11) Such other data regarding immunizations for the 
        child, including identifying data, as the Secretary may require 
        consistent with applicable law (including social security 
        account numbers furnished pursuant to section 205(c)(2)(E) of 
        the Social Security Act).
    ``(d) Date Certain for Submission to Registry.--The Secretary may 
make a grant under section 2171 only if the State involved agrees to 
ensure that, with respect to a child--
            ``(1) the data described in subsection (b) are submitted to 
        the registry under such section not later than 6 weeks after 
        the date on which the child is born; and
            ``(2) the data described in subsection (c) with respect to 
        a vaccine are submitted to such registry not later than 6 weeks 
        after the date on which the vaccine is administered to the 
        child.

``SEC. 2173. GENERAL PROVISIONS.

    ``(a) Federal Standards on Confidentiality.--The Secretary shall by 
regulation establish standards providing for maintaining the 
confidentiality of the identity of individuals with respect to whom 
data are maintained in a registries under section 2171. Such standards 
shall, with respect to a State, provide that the State is to have in 
effect laws regarding such confidentiality, including appropriate 
penalties for violation of the laws. The Secretary may make a grant 
under such section only if the State involved agrees to comply with the 
standards.
    ``(b) Use of Social Security Account Numbers.--Any usage or 
disclosure of data in registries under section 2171 that consists of 
social security account numbers and related information which is 
otherwise permitted under this part may be exercised only to the extent 
permitted under section 205(c)(2)(E) of the Social Security Act. For 
purposes of the preceding sentence, the term `related information' has 
the meaning given such term in clause (iv)(II) of such section.
    ``(c) Uniformity in Methodologies.--The Secretary shall establish 
standards regarding the methodologies used in establishing and 
operating registries under section 2171, and may make a grant under 
such section only if the State agrees to comply with the standards. The 
Secretary shall provide for a reasonable degree of uniformity among the 
States in such methodologies for the purpose of ensuring the utility, 
comparability, and exchange of the data maintained in such registries.
    ``(d) Coordination Among States.--The Secretary may make a grant 
under section 2171 to a State only if, with respect to the operation of 
the registry of the State under such section, the State agrees to 
cooperate with the Secretary and with other States in carrying out 
activities with respect to achieving the objectives established by the 
Secretary for the year 2000 for the immunization status of children in 
the United States.
    ``(e) Reports to Secretary.--The Secretary may make a grant under 
section 2171 only if the State involved agrees to submit to the 
Secretary such reports as the Secretary determines to be appropriate 
with respect to the activities of the State under this part.

``SEC. 2174. APPLICATION FOR GRANT.

    ``An application by a State for a grant under section 2171 is in 
accordance with this section if the application--
            ``(1) is submitted not later than the date specified by the 
        Secretary;
            ``(2) contains each agreement required in this part;
            ``(3) contains any information required in this part to be 
        submitted to the Secretary; and
            ``(4) is in such form, is made in such manner, and contains 
        such agreements, assurances, and information as the Secretary 
        determines to be necessary to carry out this part.

``SEC. 2175. DETERMINATION OF AMOUNT OF ALLOTMENT.

    ``The Secretary shall determine the amount of the allotments 
required in section 2171 for States for a fiscal year in accordance 
with a formula established by the Secretary that allots the amounts 
appropriated under section 2177 for the fiscal year on the basis of the 
costs of the States in establishing and operating registries under 
section 2171.

``SEC. 2176. DEFINITIONS.

    ``For purposes of this part, each of the terms `health care 
provider, `pediatric vaccine' and `parent' has the meaning given the 
term in section 2162.

``SEC. 2177. AUTHORIZATION OF APPROPRIATIONS.

    ``For the purpose of carrying out this part, there are authorized 
to be appropriated $50,000,000, for fiscal year 1994, $152,000,000 for 
fiscal year 1995, $125,000,000 for fiscal year 1996, and $35,000,000 
for each of the fiscal years 1997 through 1999.

 ``Part C--Funding for Other Purposes Regarding Childhood Immunizations

``SEC. 2181. GRANTS REGARDING YEAR 2000 HEALTH OBJECTIVES.

    ``(a) In General.--The Secretary, acting through the Director of 
the Centers for Disease Control and Prevention, may make grants to 
States for the purpose of carrying out activities with respect to 
achieving the objectives established by the Secretary for the year 2000 
for the immunization status of children in the United States, other 
than providing for the purchase and delivery on behalf of the State of 
any pediatric vaccine (as defined in section 2162).
    ``(b) Certain Activities.--Subject to subsection (a), the purposes 
for which a grant under such subsection may be expended include the 
following:
            ``(1) Research into the prevention and control of diseases 
        that may be prevented through vaccination.
            ``(2) Demonstration projects for the prevention and control 
        of such diseases.
            ``(3) Public information and education programs for the 
        prevention and control of such diseases.
            ``(4) Education, training, and clinical skills improvement 
        activities in the prevention and control of such diseases for 
        health professionals (including allied health personnel).
            ``(5) Such other activities as the Secretary determines to 
        be appropriate.
    ``(c) Application for Grant.--The Secretary may make a grant under 
subsection (a) only if an application for the grant is submitted to the 
Secretary and the application is in such form, is made in such manner, 
and contains such agreements, assurances, and information as the 
Secretary determines to be necessary to carry out this section.
    ``(d) Supplies and Services in Lieu of Grant Funds.-- The 
Secretary, at the request of a recipient of a grant under subsection 
(a), may reduce the amount of such grant by--
            ``(1) the fair market value of any supplies or equipment 
        furnished the grant recipient, and
            ``(2) the amount of the pay, allowances, and travel 
        expenses of any officer or employee of the Federal Government 
        when detailed to the grant recipient and the amount of any 
        other costs incurred in connection with the detail of such 
        officer or employee.
When the furnishing of such supplies or equipment or the detail of such 
an officer or employee is for the convenience of and at the request of 
such grant recipient and for the purpose of carrying out a program with 
respect to which the grant under subsection (a) is made. The amount by 
which any such grant is so reduced shall be available for payment by 
the Secretary of the costs incurred in furnishing the supplies or 
equipment, or in detailing the personnel, on which the reduction of 
such grant is based, and such amount shall be deemed as part of the 
grant and shall be deemed to have been paid to the grant recipient.
    ``(e) Authorization of Appropriations.--For the purpose of carrying 
out this part, there are authorized to be appropriated $580,000,000 for 
fiscal year 1993, $680,000,000 for fiscal year 1994, and such sums as 
may be necessary for each of the fiscal years 1995 through 1999.''.
    (b) Authority To Use Social Security Account Numbers.--Section 
205(c)(2) of the Social Security Act (42 U.S.C. 405(c)(2)) is amended--
            (1) by redesignating subparagraphs (E) and (F) as 
        subparagraphs (F) and (G), respectively; and
            (2) by inserting after subparagraph (D) the following new 
        subparagraph:
    ``(E)(i) The Secretary and each State receiving grants under 
section 2171(a) of the Public Health Service Act may utilize social 
security account numbers issued by the Secretary under this subsection 
for purposes of--
            ``(I) operating registries under such section to maintain 
        information including such numbers (and establishing such 
        registries, in the case of a State that is not operating such a 
        registry),
            ``(II) utilizing such numbers to monitor the extent to 
        which children have received immunizations in accordance with 
        the schedule established under section 2160(b) of the Public 
        Health Service Act, and
            ``(III) notifying parents if children have not received 
        immunizations in accordance with such schedule.
    ``(ii) Disclosure by individuals of social security account numbers 
may be required by a State for purposes of identification of children 
in a registry operated pursuant to a grant referred to in clause (i), 
except that such disclosure may be required to be made only to persons 
specifically authorized in regulations of the Secretary prescribed 
under part B of subtitle 3 of title XXI of the Public Health Service 
Act. The Secretary shall take such actions as are necessary to restrict 
access to information consisting of such numbers and related 
information only to such authorized persons whose duties or 
responsibilities require access for the purposes described in clause 
(i). The Secretary shall issue regulations governing the use, 
maintenance, and disclosure by any holder of such information, 
including appropriate administrative, technical, and physical 
safeguards, to ensure that only such authorized persons have access to 
such information. Any use or disclosure of such information in 
violation of such regulations shall be deemed a disclosure in violation 
of subparagraph (C)(vii).
    ``(iii) The Secretary shall submit a report to the Committee on 
Ways and Means of the House of Representatives and the Committee on 
Finance of the Senate not later than January 1, 1996, and biennially 
thereafter, on the operation of this subparagraph.
    ``(iv) For purposes of this subparagraph--
            ``(I) the term `State' has the meaning provided such term 
        under section 2(f) of the Public Health Service Act, and
            ``(II) the term `related information' means any record, 
        list, or compilation which indicates, directly or indirectly, 
        the identity of any individual with respect to whom a social 
        security account number is maintained pursuant to this 
        subparagraph and part B of subtitle 3 of title XXI of the 
        Public Health Service Act.''.
    (c) Relationship of New Program of Immunization Grants to Current 
Program.--
            (1) Striking of current program.--Section 317 of the Public 
        Health Service Act (42 U.S.C. 247b) is amended--
                    (A) in subsection (j)--
                            (i) by striking paragraph (1); and
                            (ii) by striking the remaining paragraph 
                        designation; and
                    (B) in subsection (k)--
                            (i) by striking paragraph (1); and
                            (ii) by redesignating paragraphs (2) and 
                        (3) as paragraphs (1) and (2), respectively.
            (2) Transitional authority under new program.--With respect 
        to activities that the Secretary of Health and Human Services 
        was authorized to carry out pursuant to section 317(j)(1) of 
        the Public Health Service Act (as in effect on the day before 
        the date of the enactment of this Act), the Secretary may, for 
        fiscal year 1994, carry out any such activity under section 
        2181 of the Public Health Service Act (as added by subsection 
        (a) of this section), notwithstanding the provisions of such 
        section 2181. The authority established in the preceding 
        sentence includes the authority to purchase vaccines.
    (d) Continued Coverage of Costs of a Pediatric Vaccine Under Group 
Health Plans.--
            (1) Requirement.--The requirement of this paragraph, with 
        respect to a group health plan for plan years beginning after 
        the date of the enactment of this Act, is that the group health 
        plan not reduce its coverage of the costs of pediatric vaccines 
        (as defined under section 2162 of the Public Health Service 
        Act) below the coverage it provided as of May 1, 1993.
            (2) Enforcement.--
                    (A) For purposes of section 2207 of the Public 
                Health Service Act, the requirement of paragraph (1) is 
                deemed a requirement of title XXII of such Act.
                    (B) For purposes of subsections (a) through (e) of 
                section 4980B of the Internal Revenue Code of 1986, 
                paragraph (1) is deemed a requirement of subsection (f) 
                of such section.
                    (C) For purposes of section 502 of the Employee 
                Retirement Income Security Act of 1974, paragraph (1) 
                is deemed a provision of part 6 of subtitle B of title 
                I of such Act.

SEC. 5182. NATIONAL VACCINE INJURY COMPENSATION PROGRAM AMENDMENTS.

    (a) Use of Vaccine Injury Compensation Trust Fund.--Section 6601(r) 
of the Omnibus Budget Reconciliation Act of 1989 is amended by striking 
``$2,500,000 for each of fiscal years 1991 and 1992'' each place it 
appears and inserting ``$3,000,000 for fiscal year 1994 and each fiscal 
year thereafter'' (in three places).
    (b) Amendment of Vaccine Injury Table.--Section 2116(b) of the 
Public Health Service Act (42 U.S.C. 300aa-16(b)) is amended by 
striking ``such person may file'' and inserting ``or to significantly 
increase the likelihood of obtaining compensation, such person may, 
notwithstanding section 2111(b)(2), file''.
    (c) Extension of Time for Decision.--Section 2112(d)(3)(D) of such 
Act (42 U.S.C. 300aa-12(d)(3)(D)) is amended by striking ``540 days'' 
and inserting ``30 months (but for no more than 6 months at a time)''.
    (d) Simplification of Vaccine Information Materials.--
            (1) Section 2126(b) of such Act (42 U.S.C. 300aa-26(b)) is 
        amended--
                    (A) by striking ``by rule'' in the matter preceding 
                paragraph (1);
                    (B) by striking, in paragraph (1), ``, opportunity 
                for a public hearing, and 90'' and inserting ``and 
                30''; and
                    (C) by striking, in paragraph (2), ``, appropriate 
                health care providers and parent organizations''.
            (2) Section 2126(c) of such Act (42 U.S.C. 300aa-26(c)) is 
        amended--
                    (A) by inserting ``shall be based on available data 
                and information,'' after ``such materials'' in the 
                matter preceding paragraph (1), and
                    (B) by striking paragraphs (1) through (10) and 
                inserting the following:
            ``(1) a concise description of the benefits of the vaccine,
            ``(2) a concise description of the risks associated with 
        the vaccine,
            ``(3) a statement of the availability of the National 
        Vaccine Injury Compensation Program, and
            ``(4) such other relevant information as may be determined 
        by the Secretary.''.
            (3) Subsections (a) and (d) of section 2126 of such Act (42 
        U.S.C. 300aa-26) are each amended by inserting ``or to any 
        other individual'' after ``to the legal representative of any 
        child''.
            (4) Subsection (d) of section 2126 of such Act (42 U.S.C. 
        300aa-26) is amended--
                    (A) by striking all after ``subsection (a),'' the 
                second place it appears in the first sentence and 
                inserting ``supplemented with visual presentations or 
                oral explanations, in appropriate cases.'', and
                    (B) by striking ``or other information'' in the 
                last sentence.

SEC. 5183. MEDICAID IMMUNIZATION PROVISIONS.

    (a) Outreach and Education.--
            (1) Immunization outreach through epsdt program.--Section 
        1902(a)(43)(A) (42 U.S.C. 1396a(a)(43)(A)) is amended by 
        inserting before the comma at the end the following: ``and the 
        need for age-appropriate immunizations against vaccine-
        preventable diseases''.
            (2) Coordination with maternal and child health block grant 
        programs and wic programs.--Section 1902(a)(11) (42 U.S.C. 
        1396a(a)(11)) is amended--
                    (A) in clause (B)--
                            (i) by striking ``effective July 1, 
                        1969,'',
                            (ii) by striking ``and'' before ``(ii)'', 
                        and
                            (iii) by striking ``to him under section 
                        1903'' and inserting ``to the individual under 
                        section 1903, and (iii) providing for 
                        coordination of information and education on 
                        childhood vaccinations and delivery of 
                        immunization services''; and
                    (B) in clause (C), by inserting ``(including the 
                provision of information and education on childhood 
                vaccinations and the delivery of immunization 
                services)'' after ``operations under this title''.
            (3) Coverage of public housing health centers as federally-
        qualified health centers.--Section 1905(l)(2)(B) (42 U.S.C. 
        1396d(l)(2)(B)) is amended by striking ``or 340'' each place it 
        appears and inserting ``340, or 340A''.
            (4) Effective date.--(A) Except as provided in subparagraph 
        (B), the amendments made by this subsection shall apply to 
        calendar quarters beginning on or after October 1, 1993, 
        without regard to whether or not final regulations to carry out 
        such amendments have been promulgated by such date.
            (B) In the case of a State plan for medical assistance 
        under title XIX of the Social Security Act which the Secretary 
        of Health and Human Services determines requires State 
        legislation (other than legislation appropriating funds) in 
        order for the plan to meet the additional requirements imposed 
        by the amendments made by this subsection, the State plan shall 
        not be regarded as failing to comply with the requirements of 
        such title solely on the basis of its failure to meet these 
        additional requirements before the first day of the first 
        calendar quarter beginning after the close of the first regular 
        session of the State legislature that begins after the date of 
        the enactment of this Act. For purposes of the previous 
        sentence, in the case of a State that has a 2-year legislative 
        session, each year of such session shall be deemed to be a 
        separate regular session of the State legislature.
    (b) Schedule of Immunizations Under EPSDT.--
            (1) In general.--Section 1905(r)(1) (42 U.S.C. 1396d(r)(1)) 
        is amended--
                    (A) in subparagraph (A)(i), by inserting ``and, 
                with respect to immunizations under subparagraph 
                (B)(iii), in accordance with the schedule recommended 
                by the Secretary under section 2160 of the Public 
                Health Service Act'' after ``child health care''; and
                    (B) in subparagraph (B)(iii), by inserting 
                ``(according to the schedule recommended by the 
                Secretary under section 2160 of the Public Health 
                Service Act)'' after ``appropriate immunizations''.
            (2) Effective date.--The amendments made by subparagraphs 
        (A) and (B) of paragraph (1) shall first apply 90 days after 
        the date the Secretary of Health and Human Services first 
        issues the recommended schedule referred to in subparagraphs 
        (A)(i) and subparagraph (B)(iii) of section 1905(r)(1) of the 
        Social Security Act (as amended by such respective 
        subparagraphs).
    (c) Assuring Adequate Payment Rates for Administration of Vaccines 
to Children.--
            (1) Payment rates.--Section 1926(a)(4)(B) (42 U.S.C. 1396r-
        7(a)(4)(B)) is amended by inserting ``(including the 
        administration of vaccines)'' after ``means services''.
            (2) Effective date.--The amendment made by paragraph (1) 
        shall apply to the plan amendment required to be submitted 
        under section 1926(a)(2) of the Social Security Act by not 
        later than April 1, 1994.
    (d) Denial of Federal Financial Participation for Inappropriate 
Administration of Single-Antigen Vaccine.--
            (1) In general.--Section 1903(i) (42 U.S.C. 1396b(i)), as 
        amended by sections 5174(b) and 5131(a), is amended--
                    (A) in paragraph (13), by striking ``or'' at the 
                end,
                    (B) in paragraph (14), by striking the period at 
                the end and inserting ``; or'', and
                    (C) by inserting after paragraph (14) the following 
                new paragraph:
            ``(15) with respect to any amount expended for a single-
        antigen vaccine and its administration in any case in which the 
        administration of a combined-antigen vaccine was medically 
        appropriate (as determined by the Secretary).''.
            (2) Effective date.--The amendments made by paragraph (1) 
        shall apply to amounts expended for vaccines administered on or 
        after October 1, 1993.
    (e) Requiring Medicaid Managed Care Plans 
T<plus-minus><plus-minus>o Comply with Immunization and Other EPSDT 
Requirements.--
            (1) In general.--Section 1903(m) (42 U.S.C. 1396b(m)) is 
        amended--
                    (A) in paragraph (2)(A), as amended by subsections 
                (a)(1) and (b)(1) of section 5135--
                            (i) by striking ``and'' at the end of 
                        clause (xii),
                            (ii) by striking the period at the end of 
                        clause (xiii) and inserting ``; and'', and
                            (iii) by adding at the end the following 
                        new clause:
            ``(xiv) the entity complies with the requirements of 
        paragraph (7) (relating to EPSDT compliance).''; and
                    (B) by adding at the end the following new 
                paragraph:
    ``(7) The contract between the State and an entity referred to in 
paragraph (2)(A)(iii) shall--
            ``(A) specify which early and periodic screening, 
        diagnostic, and treatment services are to be provided under the 
        contract to individuals under age 21 enrolled with the entity;
            ``(B) in the case of such services which are not to be so 
        provided, specify the steps the entity will take (through 
        referrals or other arrangements) to assure that such 
        individuals will receive such services; and
            ``(C) require the entity to submit such periodic reports as 
        may be necessary to enable the State to prepare and submit 
        timely reports under section 1902(a)(43)(D) and section 
        506(a)(2).''.
            (2) Application of intermediate sanctions for failure to 
        provide immunizations and other epsdt services.--Section 
        1903(m)(5)(A) (42 U.S.C. 1396b(m)(5)(A)) is amended--
                    (A) by striking ``, or'' at the end of clause (iv) 
                and inserting a semicolon,
                    (B) by striking the comma at the end of clause (v) 
                and inserting ``; or'', and
                    (C) by inserting after clause (v) the following new 
                clause:
            ``(vi) fails substantially to provide early and periodic 
        screening, diagnostic, and treatment services to the extent 
        specified in the contract under paragraph (7)(A);''.
            (3) Effective date.--The amendments made by this subsection 
        shall apply to contract years beginning on or after October 1, 
        1993, without regard to whether or not final regulations to 
        carry out such amendments have been promulgated by such date.
    (f) Transition Rule.--
            (1) Medicaid use of cdc contract price.--The Secretary of 
        Health and Human Services shall not, on or after the date of 
        the enactment of this Act, enter into a contract for the 
        purchase by the Centers for Disease Control and Prevention of 
        pediatric vaccines for distribution (as provided for in section 
        317 or section 2181 of the Public Health Service Act) unless 
        such contract provides that the charge for such vaccines, for 
        which medical assistance is provided under a State plan under 
        title XIX of the Social Security Act, will not exceed the price 
        negotiated under the contract. The previous sentence shall not 
        apply, with respect to a vaccine for which medical assistance 
        is provided by a State, on and after such date as the State 
        becomes entitled to have the Secretary provide for the purchase 
        and delivery on behalf of the State of that vaccine under 
        section 2151 of the Public Health Service Act.
            (2) Optional use by states of cdc contract price.--Nothing 
        in paragraph (1) shall be construed as limiting the Federal 
        financial participation available to States, under title XIX of 
        the Social Security Act, for the cost of a pediatric vaccine to 
        the contract price described in such paragraph for the vaccine.

SEC. 5184. AVAILABILITY OF MEDICAID PAYMENTS FOR CHILDHOOD VACCINE 
              REPLACEMENT PROGRAMS.

    (a) In General.--Section 1902(a)(32) (42 U.S.C. 1396a(a)(32)) is 
amended--
            (1) by striking ``and'' at the end of subparagraph (B),
            (2) by striking the period at the end of subparagraph (C) 
        and inserting ``; and'', and
            (3) by adding at the end the following new subparagraph:
                    ``(D) in the case of payment for a childhood 
                vaccine administered to individuals entitled to medical 
                assistance under the State plan, the State plan may 
                make payment directly to the manufacturer of the 
                vaccine under a voluntary replacement program agreed to 
                by the State pursuant to which the manufacturer (i) 
                supplies doses of the vaccine to providers 
                administering the vaccine, (ii) periodically replaces 
                the supply of the vaccine, and (iii) charges the State 
                the manufacturer's bid price to the Centers for Disease 
                Control and Prevention for the vaccine so administered 
                plus a reasonable premium to cover shipping and the 
                handling of returns;''.
    (b) Effective Date.--The amendments made by subsection (a) shall 
take effect on the date of the enactment of this Act.

SEC. 5185. HEALTHY START FOR INFANTS.

    (a) In General.--Part D of title III of the Public Health Service 
Act (42 U.S.C. 254b et seq.) is amended by inserting after section 330 
the following section:

                      ``healthy start for infants

    ``Sec. 330A. (a) Grants for Comprehensive Services.--
            ``(1) In general.--The Secretary may make grants for the 
        operation of not more than 21 demonstration projects to provide 
        the services described in subsection (b) for the purpose of 
        reducing, in the geographic areas in which the projects are 
        carried out--
                    ``(A) the incidence of infant mortality and 
                morbidity;
                    ``(B) the incidence of fetal deaths;
                    ``(C) the incidence of maternal mortality;
                    ``(D) the incidence of fetal alcohol syndrome; and
                    ``(E) the incidence of low-birthweight births.
            ``(2) Achievement of year 2000 health status objectives.--
        With respect to the objectives established by the Secretary for 
        the health status of the population of the United States for 
        the year 2000, the Secretary shall, in providing for a 
        demonstration project under paragraph (1) in a geographic area, 
        seek to meet the objectives that are applicable to the purpose 
        described in such paragraph and the populations served by the 
        project.
    ``(b) Authorized Services.--
            ``(1) In general.--Subject to subsection (h), the services 
        referred to in this subsection are comprehensive services 
        (including preventive and primary health services for pregnant 
        women and infants and childhood immunizations in accordance 
        with the schedule recommended by the Secretary under section 
        2160) for carrying out the purpose described in subsection (a), 
        including services other than health services.
            ``(2) Certain providers.--The Secretary may make a grant 
        under subsection (a) only if the applicant involved agrees 
        that, in making any arrangements under which other entities 
        provide authorized services in the demonstration project 
        involved, the applicant will include among the entities with 
        which the arrangements are made grantees under any of sections 
        329, 330, 340, and 340A, if such grantees are providing 
        services in the service area of such project and the grantees 
        are willing to make such arrangements with the applicant.
    ``(c) Eligible Geographic Areas.--The Secretary may make a grant 
under subsection (a) only if--
            ``(1) the applicant for the grant specifies the geographic 
        area in which the demonstration project under such subsection 
        is to be carried out and agrees that the project will not be 
        carried out in other areas; and
            ``(2) the rate of infant mortality in the geographic area 
        equals or exceeds 150 percent of the national average in the 
        United States of such rates.
    ``(d) Minimum Qualifications of Grantees.--
            ``(1) Public or nonprofit private entities.--The Secretary 
        may make a grant under subsection (a) only if the applicant for 
        the grant is a State or local department of health, or other 
        public or nonprofit private entity, or a consortium of public 
        or nonprofit private entities.
            ``(2) Approval of political subdivisions.--With respect to 
        a proposed demonstration project under subsection (a), the 
        Secretary may make a grant under such subsection only if--
                    ``(A) the chief executive officer of each political 
                subdivision in the service area of such project 
                approves the applicant for the grant as being qualified 
                to carry out the project; and
                    ``(B) the leadership of any Indian tribe or tribal 
                organization with jurisdiction over any portion of such 
                area so approves the applicant.
            ``(3) Status as medicaid provider.--
                    ``(A) In the case of any service described in 
                subsection (b) that is available pursuant to the State 
                plan approved under title XIX of the Social Security 
                Act for a State in which a demonstration project under 
                subsection (a) is carried out, the Secretary may make a 
                grant under such subsection for the project only if, 
                subject to subparagraph (B)--
                            ``(i) the applicant for the grant will 
                        provide the service directly, and the applicant 
                        has entered into a participation agreement 
                        under the State plan and is qualified to 
                        receive payments under such plan; or
                            ``(ii) the applicant will enter into an 
                        agreement with a public or private entity under 
                        which the entity will provide the service, and 
                        the entity has entered into such a 
                        participation agreement under the State plan 
                        and is qualified to receive such payments.
                    ``(B)(i) In the case of an entity making an 
                agreement pursuant to subparagraph (A)(ii) regarding 
                the provision of services, the requirement established 
                in such subparagraph regarding a participation 
                agreement shall be waived by the Secretary if the 
                entity does not, in providing health care services, 
                impose a charge or accept reimbursement available from 
                any third-party payor, including reimbursement under 
                any insurance policy or under any Federal or State 
                health benefits plan.
                    ``(ii) A determination by the Secretary of whether 
                an entity referred to in clause (i) meets the criteria 
                for a waiver under such clause shall be made without 
                regard to whether the entity accepts voluntary 
                donations regarding the provision of services to the 
                public.
    ``(e) State Approval of Project.--With respect to a proposed 
demonstration project under subsection (a), the Secretary may make a 
grant under such subsection to the applicant involved only if--
            ``(1) the chief executive officer of the State in which the 
        project is to be carried out approves the proposal of the 
        applicant for carrying out the project; and
            ``(2) the leadership of any Indian tribe or tribal 
        organization with jurisdiction over any portion of the service 
        area of the project so approves the proposal.
    ``(f) Eligibility for Services Provided With Grant Funds.--
            ``(1) In general.--With respect to any authorized service 
        under subsection (b), if the service is a service that States 
        are required or authorized to provide under title XIX of the 
        Social Security Act, the Secretary may make a grant under 
        subsection (a) only if the applicant involved agrees that the 
        grant will not be expended to provide the service to any 
        individual to whom States are required or authorized under such 
        title to provide the service. The Secretary may not make a 
        grant under subsection (a) unless the State involved agrees 
        that the grant will not be expended to make payment for any 
        item or service to the extent that payment has been made, or 
        can reasonably be expected to be made, with respect to such 
        item or service--
                    ``(A) under a health insurance policy or plan 
                (including a group health plan or a prepaid health 
                plan),
                    ``(B) under any Federal or State health benefits 
                program, including any program under title V, XVIII, or 
                XIX of the Social Security Act, or
                    ``(C) under subpart 2 of part B of title XIX of 
                this Act.
            ``(2) Rules of construction.--For purposes of paragraph 
        (1):
                    ``(A) Individuals to whom States are authorized to 
                provide services under title XIX of the Social Security 
                Act include, pursuant to section 1902(l) of such title, 
                pregnant women, infants, and children with an income 
                level not less than 133 percent, and not more than 185 
                percent, of the official poverty line.
                    ``(B) Authorized services under subsection (b) that 
                are authorized to be provided under title XIX of such 
                Act include, pursuant to section 1920 of such title, 
                ambulatory prenatal services during a period of 
                presumptive eligibility.
                    ``(C) Authorized services under subsection (b) that 
                are required to be provided under title XIX of such Act 
                include, pursuant to section 1905(a)(4)(B) of such 
                title, early and periodic screening, diagnostic, and 
                treatment services for children under the age of 21.
                    ``(D) Authorized services under subsection (b) that 
                are authorized to be provided under title XIX of such 
                Act include, pursuant to section 1905(a)(19) of such 
                title, case-management services.
    ``(g) Maintenance of Effort.--
            ``(1) Grantee.--With respect to authorized services under 
        subsection (b), the Secretary may make a grant under subsection 
        (a) only if the applicant involved agrees to maintain 
        expenditures of non-Federal amounts for such services at a 
        level that is not less than the level of such expenditures 
        maintained by the applicant for fiscal year 1991.
            ``(2) Relevant political subdivisions.--With respect to 
        authorized services under subsection (b), the Secretary may 
        make a grant under subsection (a) only if each political 
        subdivision in the service area of the demonstration project 
        involved agrees to maintain expenditures of non-Federal amounts 
        for such services at a level that is not less than the level of 
        such expenditures maintained by the political subdivision for 
        fiscal year 1991.
    ``(h) Restrictions on Expenditure of Grant.--
            ``(1) In general.--Except as provided in paragraph (3), the 
        Secretary may make a grant under subsection (a) only if the 
        applicant involved agrees that the grant will not be expended--
                    ``(A) to provide inpatient services, except with 
                respect to residential treatment for substance abuse 
                provided in settings other than hospitals;
                    ``(B) to make cash payments to intended recipients 
                of health services or mental health services; or
                    ``(C) to purchase or improve real property (other 
                than minor remodeling of existing improvements to real 
                property) or to purchase major medical equipment (other 
                than mobile medical units for providing ambulatory 
                prenatal services).
            ``(2) Administrative expenses; data collection.--The 
        Secretary may make a grant under subsection (a) only if the 
        applicant involved agrees that not more than an aggregate 10 
        percent of the grant will be expended for administering the 
        grant and the collection and analysis of data.
            ``(3) Waiver.--If the Secretary finds that the purpose 
        described in subsection (a) cannot otherwise be carried out, 
        the Secretary may, with respect to an otherwise qualified 
        applicant, waive the restriction established in paragraph 
        (1)(C).
    ``(i) Determination of Cause of Infant Deaths.--The Secretary may 
make a grant under subsection (a) only if the applicant involved--
            ``(1) agrees to provide for a determination of the cause of 
        each infant death in the service area of the demonstration 
        project involved; and
            ``(2) the applicant has made such arrangements with public 
        entities as may be necessary to carry out paragraph (1).
    ``(j) Annual Reports to Secretary.--The Secretary may make a grant 
under subsection (a) only if the applicant involved agrees that, for 
each fiscal year for which the applicant operates a demonstration 
project under such subsection the applicant will, not later than April 
1 of the subsequent fiscal year, submit to the Secretary a report 
providing the following information with respect to the project:
            ``(1) The number of individuals that received authorized 
        services, and the demographic characteristics of the population 
        of such individuals.
            ``(2) The types of authorized services provided, including 
        the types of ambulatory prenatal services provided and the 
        trimester of the pregnancy in which the services were provided.
            ``(3) The sources of payment for the authorized services 
        provided.
            ``(4) The extent to which children under age 2 receiving 
        authorized services have received the appropriate number and 
        variety of immunizations against vaccine-preventable diseases.
            ``(5) An analysis of the causes of death determined under 
        subsection (i).
            ``(6) The extent of progress being made toward meeting the 
        health status objectives specified in subsection (a)(2).
            ``(7) The extent to which, in the service area involved, 
        progress is being made toward meeting the participation goals 
        established for the State by the Secretary under section 
        1905(r) of the Social Security Act (relating to early periodic 
        screening, diagnostic, and treatment services for children 
        under the age of 21).
    ``(k) Community Participation.--The Secretary may make a grant 
under subsection (a) only if the applicant involved agrees that, in 
preparing the proposal of the applicant for the demonstration project 
involved, and in the operation of the project, the applicant will 
consult with the residents of the service area for the project and with 
public and nonprofit private entities that provide authorized services 
to such residents.
    ``(l) Application for Grant.--The Secretary may make a grant under 
subsection (a) only if an application for the grant is submitted to the 
Secretary and the application is in such form, is made in such manner, 
and contains such agreements, assurances, and information as the 
Secretary determines to be necessary to carry out this subsection.
    ``(m) Report to Congress.--Not later than February 1, 1998, the 
Secretary shall submit to the Committee on Energy and Commerce of the 
House of Representatives, and the Committee on Labor and Human 
Resources of the Senate, a report--
            ``(1) summarizing the reports received by the Secretary 
        under subsection (j);
            ``(2) describing the extent to which demonstration projects 
        under subsection (a) have been cost effective; and
            ``(3) describing the extent to which the Secretary has, in 
        the service areas of such projects, been successful in meeting 
        the health status objectives specified in subsection (a)(2).
    ``(n) Limitation on Certain Expenses of Secretary.--Of the amounts 
appropriated under subsection (o) for a fiscal year, the Secretary may 
not obligate more than an aggregate 5 percent for the administrative 
costs of the Secretary in carrying out this section, for the provision 
of technical assistance regarding demonstration projects under 
subsection (a), and for evaluations of such projects.
    ``(o) Definitions.--For purposes of this section:
            ``(1) The term `authorized services' means the services 
        specified in subsection (b).
            ``(2) The terms `Indian tribe' and `tribal organization' 
        have the meaning given such terms in section 4(b) and section 
        4(c) of the Indian Self-Determination and Education Assistance 
        Act.
            ``(3) The term `service area', with respect to a 
        demonstration project under subsection (a), means the 
        geographic area specified in subsection (c).
    ``(p) Authorization of Appropriations.--For the purpose of carrying 
out this section, there are authorized to be appropriated for each of 
the fiscal years 1994 through 1997 such sums as may be necessary.
    ``(q) Sunset.--Effective October 1, 1997, this section is 
repealed.''.
    (b) Report for Fiscal Year 1993.--With respect to grants under 
section 330A of the Public Health Service Act, as added by subsection 
(a) of this section, the Secretary of Health and Human Services may 
make a grant under such section for fiscal year 1994 only if the 
applicant for the grant agrees to submit to the Secretary, not later 
than April 1 of such year, a report on any federally-supported project 
of the applicant that is substantially similar to the demonstration 
projects authorized in such section 330A, which report provides, to the 
extent practicable, the information described in subsection (j) of such 
section.
    (c) Savings Provision.--With respect to grants under section 330A 
of the Public Health Service Act, as added by subsection (a) of this 
section and in effect for the fiscal years 1994 through 1997, such 
grants remain available for obligation and expenditure in accordance 
with the terms upon which the grants were made, notwithstanding the 
repeal of such section 330A pursuant to subsection (q) of such section.
    (d) Use of General Authority Under Public Health Service Act.--With 
respect to the program established in section 330A of the Public Health 
Service Act, as added by subsection (a) of this section, section 301 of 
the Public Health Service Act may not be construed as providing to the 
Secretary of Health and Human Services any authority to carry out, 
during any fiscal year in which such program is in operation, any 
demonstration project to provide any of the services specified in 
subsection (b) of such section 330A.

SEC. 5186. INCREASE IN AUTHORIZATION OF APPROPRIATIONS FOR THE MATERNAL 
              AND CHILD HEALTH SERVICES BLOCK GRANT PROGRAM.

    Section 501(a) (42 U.S.C. 701(a)) is amended by striking 
``$686,000,000 for fiscal year 1990'' and inserting ``$705,000,000 for 
fiscal year 1994''.

SEC. 5187. MISCELLANEOUS TECHNICAL CORRECTIONS TO PUBLIC HEALTH SERVICE 
              ACT PROVISIONS.

    (a) Compensation for Members of National Advisory Council on 
National Health Service Corps.--
            (1) In general.--Section 337(b)(2) of the Public Health 
        Service Act (42 U.S.C. 254j(b)(2)) is amended--
                    (A) by inserting after ``so serving'' the 
                following: ``compensation at a rate fixed by the 
                Secretary (but not to exceed'', and
                    (B) by striking ``Schedule;'' and inserting 
                ``Schedule);''.
            (2) Effective date.--The amendments made by paragraph (1) 
        shall take effect on the date of the enactment of this Act.
    (b) Liability Protections for Individuals Providing Services at 
Certain Clinics.--
            (1) Clarification of voluntary participation by certain 
        entities.--(A) Section 224(g) of the Public Health Service Act 
        (42 U.S.C. 133(g)(1)), as added by section 2(a) of the 
        Federally Supported Health Centers Assistance Act of 1992, is 
        amended--
                    (i) in paragraph (4), by striking ``An entity'' and 
                inserting ``Except as provided in paragraph (6), an 
                entity'', and
                    (ii) by adding at the end the following new 
                paragraph:
    ``(6) An entity may elect not to be treated as being described in 
paragraph (4) if the entity establishes that on a continuous basis 
since October 24, 1992, the entity has been a participant in, and 
partial owner of, a nonprofit risk retention group which offers 
malpractice and other liability coverage to the entity.''.
            (B) Section 224(k)(2) of such Act (42 U.S.C. 233(k)(2)), as 
        added by section 4 of the Federally Supported Health Centers 
        Assistance Act of 1992, is amended by striking ``entities 
        receiving funds'' and all that follows through ``subsection 
        (g)'' and inserting the following: ``entities described in 
        subsection (g)(4) and receiving funds under each of the grant 
        programs described in such subsection''.
            (2) Clarification of coverage of officers and employees of 
        clinics.--The first sentence of section 224(g)(1) of the Public 
        Health Service Act (42 U.S.C. 233(g)(1)) is amended by striking 
        ``officer, employee, or contractor'' and inserting the 
        following: ``officer or employee of such an entity, and any 
        contractor''.
            (3) Coverage for services furnished to individuals other 
        than patients of clinic.--Section 224(g) of such Act (42 U.S.C. 
        233(g)(1)), as amended by paragraph (1), is amended--
                    (A) in the first sentence of paragraph (1), by 
                inserting after ``Service'' the following: ``with 
                respect to services provided to patients of the entity 
                and (subject to paragraph (7)) to certain other 
                individuals''; and
                    (B) by adding at the end the following new 
                paragraph:
    ``(7) For purposes of paragraph (1), an officer, employee, or 
contractor described in such paragraph may be deemed to be an employee 
of the Public Health Service with respect to services provided to 
individuals who are not patients of an entity described in paragraph 
(4) only if the Secretary determines--
            ``(A) that the provision of the services to such 
        individuals is necessary to assure the treatment of patients of 
        such an entity; or
            ``(B) that such services are otherwise required to be 
        provided to such individuals under an employment contract (or 
        other similar arrangement) between the individual and the 
        entity.''.
            (4) Determining compliance of entity with requirements for 
        coverage.--Section 224(h) of such Act (42 U.S.C. 233(h)), as 
        added by section 2(b) of the Federally Supported Health Centers 
        Assistance Act of 1992, is amended by striking ``the entity--'' 
        and inserting the following: ``the Secretary, after receiving 
        such assurances and conducting such investigation as the 
        Secretary considers necessary, finds that the entity--''.
            (5) Effective date.--The amendments made by this subsection 
        shall take effect as if included in the enactment of the 
        Federally Supported Health Centers Assistance Act of 1992.
    (c) Elimination of Duplicate Waiver Authority for Participants in 
National Health Service Corps.--Section 338E(c) of the Public Health 
Service Act (42 U.S.C. 254o(c)) is amended by striking paragraph (3) 
and redesignating paragraph (4) as paragraph (3).
    (d) Clarification of Prohibition Against Resale of Drugs Under Drug 
Rebate Agreements.--Section 340B(a)(5)(B) of the Public Health Service 
Act (42 U.S.C. 256b(a)(5)(B)), as added by section 602(a) of the 
Veterans Health Care of 1992, is amended by striking ``entity.'' and 
inserting ``covered entity.''.

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