[Congressional Bills 103th Congress]
[From the U.S. Government Publishing Office]
[H.R. 21 Introduced in House (IH)]

103d CONGRESS
  1st Session
                                 H. R. 21

 To amend title XVIII of the Social Security Act to make miscellaneous 
             and technical changes to the medicare program.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                            January 5, 1993

 Mr. Rostenkowski (for himself and Mr. Stark) introduced the following 
 bill; which was referred jointly to the Committees on Ways and Means 
                        and Energy and Commerce

_______________________________________________________________________

                                 A BILL


 
 To amend title XVIII of the Social Security Act to make miscellaneous 
             and technical changes to the medicare program.

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

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Miscellaneous and Technical Medicare 
Amendments of 1993''.

SEC. 2. 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.
    (c) Table of Contents.--The table of contents of this Act is as 
follows:

Sec. 1. Short title.
Sec. 2. References in Act.
                 TITLE I--PROVISIONS RELATING TO PART A

Sec. 101. Transition for hospital outlier thresholds.
Sec. 102. Essential access community hospital (EACH) amendments.
Sec. 103. Wage index provisions.
Sec. 104. Reauthorization of rural transition grant program.
Sec. 105. Regional referral centers.
Sec. 106. Medicare-dependent, small rural hospitals.
Sec. 107. Hemophilia pass-through.
Sec. 108. State hospital payment programs.
Sec. 109. Psychology services in hospitals.
Sec. 110. Graduate medical education provided in a hospital-owned 
                            community health center.
Sec. 111. Uniformed services treatment facilities.
Sec. 112. Requiring hospitals and nursing facilities to notify 
                            residents of availability of hospice 
                            benefit.
Sec. 113. Skilled nursing facility wage index.
Sec. 114. DRG payment window technical clarification; miscellaneous and 
                            technical corrections.
Sec. 115. Extension of rural hospital demonstration.
                TITLE II--PROVISIONS RELATING TO PART B

                    Subtitle A--Physicians' Services

Sec. 201. Separate payment for interpretation of electrocardiograms.
Sec. 202. Payments for new physicians and practitioners.
Sec. 203. Basing payments for anesthesia services on actual time.
Sec. 204. Geographic adjustment factors for medicare physicians' 
                            services.
Sec. 205. Extra-billing limits.
Sec. 206. Relative values for pediatric services.
Sec. 207. Antigens under physician fee schedule.
Sec. 208. Administration of claims relating to physicians' services.
Sec. 209. Miscellaneous and technical corrections.
                Subtitle B--Ambulatory Surgical Services

Sec. 211. Eye or eye and ear hospitals.
Sec. 212. Extension of cap on payments for intraocular lenses.
Sec. 213. Miscellaneous and technical corrections.
                 Subtitle C--Durable Medical Equipment

Sec. 221. Certification of suppliers.
Sec. 222. Prohibition against carrier forum shopping.
Sec. 223. Restrictions on certain marketing and sales activities.
Sec. 224. Kickback clarification.
Sec. 225. Beneficiary liability for noncovered services.
Sec. 226. Adjustments for inherent reasonableness.
Sec. 227. Payment for parenteral and enteral nutrients, supplies, and 
                            equipment during 1993.
Sec. 228. Treatment of nebulizers and aspirators.
Sec. 229. Payment for ostomy supplies, tracheostomy supplies, 
                            urologicals, and surgical dressings.
Sec. 230. Payments for TENS devices.
Sec. 231. Miscellaneous and technical corrections.
                      Subtitle D--Other Provisions

Sec. 241. Payment for medically directed certified registered nurse 
                            anesthetist services.
Sec. 242. Extension of Alzheimer's disease demonstration.
Sec. 243. Part B late enrollment penalty.
Sec. 244. Oral cancer drugs.
Sec. 245. Speech-language pathologists and audiologists.
Sec. 246. Extension of municipal health service demonstration projects.
Sec. 247. Treatment of certain Indian health programs and facilities as 
                            Federally-qualified health centers.
Sec. 248. Extension of influenza vaccination demonstration.
Sec. 249. Miscellaneous and technical corrections.
            TITLE III--PROVISIONS RELATING TO PARTS A AND B

Sec. 301. Provisions relating to physician ownership and referral.
Sec. 302. Direct graduate medical education.
Sec. 303. End stage renal disease.
Sec. 304. Medicare secondary payer.
Sec. 305. Improved outreach for qualified medicare beneficiaries.
Sec. 306. Social health maintenance organizations.
Sec. 307. Peer review organizations.
Sec. 308. Hospice information to home health beneficiaries.
Sec. 309. Interest payments.
Sec. 310. Clarification of judicial review rights.
Sec. 311. Adjustments to discretionary spending limits.
Sec. 312. Health maintenance organizations.
Sec. 313. Treatment of certain State health care programs.
Sec. 314. Miscellaneous and technical corrections.
   TITLE IV--PROVISIONS RELATING TO MEDICARE SUPPLEMENTAL INSURANCE 
                                POLICIES

Sec. 401. Standards for medicare supplemental insurance policies.

                 TITLE I--PROVISIONS RELATING TO PART A

SEC. 101. TRANSITION FOR HOSPITAL OUTLIER THRESHOLDS.

    The Secretary of Health and Human Services, under section 1886 of 
the Social Security Act, shall use the day outlier methodology in 
effect for fiscal year 1992 for payment for discharges occurring on or 
after April 1, 1993, and before September 30, 1993. For payment for 
discharges occurring during fiscal year 1994, the Secretary shall use 
the day outlier methodology in effect for the first 6 months of fiscal 
year 1993.

SEC. 102. ESSENTIAL ACCESS COMMUNITY HOSPITAL (EACH) AMENDMENTS.

    (a) Increasing Number of Participating States.--Section 1820(a)(1) 
(42 U.S.C. 1395i4(a)(1)) is amended by striking ``7'' and inserting 
``9''.
    (b) Treatment of Inpatient Hospital Services Provided in Rural 
Primary Care Hospitals.--
            (1) In general.--Section 1820(f)(1)(F) (42 U.S.C. 
        1395i4(f)(1)(F)) is amended to read as follows:
                    ``(F) subject to paragraph (4), provides not more 
                than 6 inpatient beds (meeting such conditions as the 
                Secretary may establish) for providing inpatient care 
                to patients requiring stabilization before discharge or 
                transfer to a hospital, except that the facility may 
                not provide any inpatient hospital services--
                            ``(i) to any patient whose attending 
                        physician does not certify that the patient may 
                        reasonably be expected to be discharged or 
                        transferred to a hospital within 72 hours of 
                        admission to the facility; or
                            ``(ii) consisting of surgery or any other 
                        service requiring the use of general anesthesia 
                        (other than surgical procedures specified by 
                        the Secretary under section 1833(i)(1)(A)), 
                        unless the attending physician certifies that 
                        the risk associated with transferring the 
                        patient to a hospital for such services 
                        outweighs the benefits of transferring the 
                        patient to a hospital for such services.''.
            (2) Limitation on average length of stay.--Section 1820(f) 
        (42 U.S.C. 1395i4(f)) is amended by adding at the end the 
        following new paragraph:
            ``(4) Limitation on average length of inpatient stays.--The 
        Secretary may terminate a designation of a rural primary care 
        hospital under paragraph (1) if the Secretary finds that the 
        average length of stay for inpatients at the facility during 
        the previous year in which the designation was in effect 
        exceeded 72 hours. In determining the compliance of a facility 
        with the requirement of the previous sentence, there shall not 
        be taken into account periods of stay of inpatients in excess 
        of 72 hours to the extent such periods exceed 72 hours because 
        transfer to a hospital is precluded because of inclement 
        weather or other emergency conditions.''.
            (3) Conforming amendment.--Section 1814(a)(8) (42 U.S.C. 
        1395f(a)(8)) is amended by striking ``such services'' and all 
        that follows and inserting ``the individual may reasonably be 
        expected to be discharged or transferred to a hospital within 
        72 hours after admission to the rural primary care hospital.''.
            (4) GAO reports.--Not later than 2 years after the date of 
        the enactment of this Act, the Comptroller General shall submit 
        reports to Congress on--
                    (A) the application of the requirements under 
                section 1820(f) of the Social Security Act (as amended 
                by this subsection) that rural primary care hospitals 
                provide inpatient care only to those individuals whose 
                attending physicians certify may reasonably be expected 
                to be discharged within 72 hours after admission and 
                maintain an average length of inpatient stay during a 
                year that does not exceed 72 hours; and
                    (B) the extent to which such requirements have 
                resulted in such hospitals providing inpatient care 
                beyond their capabilities or have limited the ability 
                of such hospitals to provide needed services.
    (c) Designation of Hospitals.--
            (1) Permitting designation of hospitals located in urban 
        areas.--
                    (A) In general.--Section 1820 (42 U.S.C. 1395i4) is 
                amended--
                            (i) by striking paragraph (1) of subsection 
                        (e) and redesignating paragraphs (2) through 
                        (6) as paragraphs (1) through (5); and
                            (ii) in subsection (e)(1)(A) (as 
                        redesignated by subparagraph (A))--
                                    (I) by striking ``is located'' and 
                                inserting ``except in the case of a 
                                hospital located in an urban area, is 
                                located'',
                                    (II) by striking ``, (ii)'' and 
                                inserting ``or (ii)'',
                                    (III) by striking ``or (iii)'' and 
                                all that follows through ``section,'', 
                                and
                                    (IV) in subsection (i)(1)(B), by 
                                striking ``paragraph (3)'' and 
                                inserting ``paragraph (2)''.
                    (B) No change in medicare prospective payment.--
                Section 1886(d)(5)(D) (42 U.S.C. 1395ww(d)(5)(D)) is 
                amended--
                            (i) in clause (iii)(III), by inserting 
                        ``located in a rural area and'' after ``that 
                        is'', and
                            (ii) in clause (v), by inserting ``located 
                        in a rural area and'' after ``in the case of a 
                        hospital''.
            (2) Permitting hospitals located in adjoining states to 
        participate in state program.--
                    (A) In general.--Section 1820 (42 U.S.C. 1395i4) is 
                amended--
                            (i) by redesignating subsection (k) as 
                        subsection (l); and
                            (ii) by inserting after subsection (j) the 
                        following new subsection:
    ``(k) Eligibility of Hospitals Not Located in Participating 
States.--Notwithstanding any other provision of this section--
            ``(1) for purposes of including a hospital or facility as a 
        member institution of a rural health network, a State may 
        designate a hospital or facility that is not located in the 
        State as an essential access community hospital or a rural 
        primary care hospital if the hospital or facility is located in 
        an adjoining State and is otherwise eligible for designation as 
        such a hospital;
            ``(2) the Secretary may designate a hospital or facility 
        that is not located in a State receiving a grant under 
        subsection (a)(1) as an essential access community hospital or 
        a rural primary care hospital if the hospital or facility is a 
        member institution of a rural health network of a State 
        receiving a grant under such subsection; and
            ``(3) a hospital or facility designated pursuant to this 
        subsection shall be eligible to receive a grant under 
        subsection (a)(2).''.
                    (B) Conforming amendments.--(i) Section 1820(c)(1) 
                (42 U.S.C. 1395i4(c)(1)) is amended by striking 
                ``paragraph (3)'' and inserting ``paragraph (3) or 
                subsection (k)''.
                    (ii) Paragraphs (1)(A) and (2)(A) of section 
                1820(i) (42 U.S.C. 1395i4(i)) are each amended--
                            (I) in clause (i), by striking ``(a)(1)'' 
                        and inserting ``(a)(1) (except as provided in 
                        subsection (k))'', and
                            (II) in clause (ii), by striking 
                        ``subparagraph (B)'' and inserting 
                        ``subparagraph (B) or subsection (k)''.
    (d) Skilled Nursing Services in Rural Primary Care Hospitals.--
Section 1820(f)(3) (42 U.S.C. 1395i4(f)(3)) is amended by striking 
``because the facility'' and all that follows and inserting the 
following: ``because, at the time the facility applies to the State for 
designation as a rural primary care hospital, there is in effect an 
agreement between the facility and the Secretary under section 1883 
under which the facility's inpatient hospital facilities are used for 
the furnishing of extended care services, except that the number of 
beds used for the furnishing of such services may not exceed the total 
number of licensed inpatient beds at the time the facility applies to 
the State for such designation (minus the number of inpatient beds used 
for providing inpatient care pursuant to paragraph (1)(F)). For 
purposes of the previous sentence, the number of beds of the facility 
used for the furnishing of extended care services shall not include any 
beds of a unit of the facility that is licensed as a distinct-part 
skilled nursing facility at the time the facility applies to the State 
for designation as a rural primary care hospital.''.
    (e) Payment for Outpatient Rural Primary Care Hospital Services.--
Section 1834(g)(1) (42 U.S.C. 1395m(g)(1)) is amended by adding at the 
end the following:
        ``The amount of payment shall be determined under either method 
        without regard to the amount of the customary or other 
        charge.''.
    (f) Clarification of Physician Staffing Requirement for Rural 
Primary Care Hospitals.--Section 1820(f)(1)(H) (42 U.S.C. 
1395i4(f)(1)(H)) is amended by striking the period and inserting the 
following: ``, except that in determining whether a facility meets the 
requirements of this subparagraph, subparagraphs (E) and (F) of that 
paragraph shall be applied as if any reference to a `physician' is a 
reference to a physician as defined in section 1861(r)(1).''.
    (g) Technical Amendments Relating to Part A Deductible, 
Coinsurance, and Spell of Illness.--(1) Section 1812(a)(1) (42 U.S.C. 
1395d(a)(1)) is amended--
            (A) by striking ``inpatient hospital services'' the first 
        place it appears and inserting ``inpatient hospital services or 
        inpatient rural primary care hospital services'';
            (B) by striking ``inpatient hospital services'' the second 
        place it appears and inserting ``such services''; and
            (C) by striking ``and inpatient rural primary care hospital 
        services''.
    (2) Sections 1813(a) and 1813(b)(3)(A) (42 U.S.C. 1395e(a), 
1395e(b)(3)(A)) are each amended by striking ``inpatient hospital 
services'' each place it appears and inserting ``inpatient hospital 
services or inpatient rural primary care hospital services''.
    (3) Section 1813(b)(3)(B) (42 U.S.C. 1395e(b)(3)(B)) is amended by 
striking ``inpatient hospital services'' and inserting ``inpatient 
hospital services, inpatient rural primary care hospital services''.
    (4) Section 1861(a) (42 U.S.C. 1395x(a)) is amended--
            (A) in paragraph (1), by striking ``inpatient hospital 
        services'' and inserting ``inpatient hospital services, 
        inpatient rural primary care hospital services''; and
            (B) in paragraph (2), by striking ``hospital'' and 
        inserting ``hospital or rural primary care hospital''.
    (h) Authorization of Appropriations.--Section 1820(k) (42 U.S.C. 
1395i4(k)) is amended by striking ``1990, 1991, and 1992'' and 
inserting ``1990 through 1995''.
    (i) Effective Date.--The amendments made by this section shall take 
effect on the date of the enactment of this Act.

SEC. 103. WAGE INDEX PROVISIONS.

    (a) Wage Index Hold Harmless Protection.--
            (1) In general.--Section 1886(d)(8)(C)(iii) (42 U.S.C. 
        1395ww(d)(8)(C)(iii)) is amended by adding at the end the 
        following new sentence: ``In the case of an urban area that has 
        a wage index below the wage index for rural areas in the State 
        in which it is located, or that is located in a State that is 
        composed of a single urban area, such an application or 
        decision may not result in a reduction of that urban area's 
        wage index.''.
            (2) No standardized amount adjustment.--The Secretary of 
        Health and Human Services shall not revise the fiscal year 1993 
        standardized amounts pursuant to subsections (d)(3)(B) and 
        (d)(8)(D) of section 1886 of the Social Security Act to account 
        for the amendment made by paragraph (1).
            (3) Effective date.--The amendment made by paragraph (1) 
        shall apply to discharges occurring on or after the expiration 
        of the 30-day period that begins on the date of the enactment 
        of this Act.
    (b) Updating Standards for Treating Rural Counties as Urban 
Counties Based on Rates of Commutation.--
            (1) In general.--Section 1886(d)(8)(B) (42 U.S.C. 
        1395ww(d)(8)(B)) is amended--
                    (A) by striking ``standards'' each place it appears 
                and inserting ``standards most recently used'', and
                    (B) by striking ``published in the Federal Register 
                on January 3, 1980''.
            (2) Hold harmless for counties currently treated as 
        urban.--Any hospital that is treated as being located in an 
        urban metropolitan statistical area pursuant to section 
        1886(d)(8)(B) of the Social Security Act as of the date of the 
        enactment of this Act shall continue to be so treated 
        notwithstanding the amendments made by paragraph (1).
            (3) Effective date.--The amendments made by paragraph (1) 
        shall be effective on October 1, 1993.
    (c) Use of Occupational Mix in Guidelines.--
            (1) In general.--Section 1886(d)(10)(D)(i)(I) (42 U.S.C. 
        1395ww(d)(10)(D)(i)(I)) is amended by inserting ``(to the 
        extent the Secretary determines appropriate)'' after ``taking 
        into account''.
            (2) Effective date.--The amendment made by paragraph (1) 
        shall take effect as if included in the enactment of OBRA-1989.

SEC. 104. REAUTHORIZATION OF RURAL TRANSITION GRANT PROGRAM.

    Section 4005(e)(9) of OBRA-1987 is amended--
            (1) by striking ``1989 and'' and inserting ``1989,''; and
            (2) by striking ``1992'' and inserting ``1992 and 
        $30,000,000 for each of fiscal years 1993 through 1997''.

SEC. 105. REGIONAL REFERRAL CENTERS.

    (a) Extension Through Fiscal Year 1994.--Section 6003(d) of OBRA-
1989 (42 U.S.C. 1395ww note) is amended by striking ``October 1, 1992'' 
and inserting ``October 1, 1994''.
    (b) Permitting Hospitals to Decline Reclassification.--If any 
hospital fails to qualify as a rural referral center under section 
1886(d)(5)(C) of the Social Security Act as a result of a decision by 
the Medicare Geographic Classification Review Board under section 
1886(d)(10) of such Act to reclassify the hospital as being located in 
an urban area for fiscal year 1994, the Secretary of Health and Human 
Services shall--
            (1) notify such hospital of such failure to qualify,
            (2) provide an opportunity for such hospital to decline 
        such reclassification, and
            (3) if the hospital declines such reclassification, 
        administer the Social Security Act (other than section 
        1886(d)(8)(D)) for fiscal year 1994 as if the decision by the 
        Review Board had not occurred.

SEC. 106. MEDICARE-DEPENDENT, SMALL RURAL HOSPITALS.

    (a) In General.--Section 1886(d)(5)(G) (42 U.S.C. 1395ww(d)(5)(G)) 
is amended--
            (1) by amending clause (i) to read as follows:
    ``(i) In the case of a subsection (d) hospital which is a medicare-
dependent, small rural hospital, payment under paragraph (1)(A) for 
discharges occurring before October 1, 1994, shall be equal to the sum 
of the amount determined under clause (ii) and the amount determined 
under paragraph (1)(A)(iii).'';
            (2) by redesignating clauses (ii) and (iii) as clauses 
        (iii) and (iv); and
            (3) by inserting after clause (i) the following new clause:
    ``(ii) The amount determined under this clause is
            ``(I) for discharges occurring during the first 3 12-month 
        cost reporting periods that begin on or after April 1, 1990, 
        the amount by which the hospital's target amount for the cost 
        reporting period (as defined in subsection (b)(3)(D)) exceeds 
        the amount determined under paragraph (1)(A)(iii); and
            ``(II) for discharges occurring during any subsequent cost 
        reporting period (or portion thereof), 50 percent of the amount 
        by which the hospital's target amount for the cost reporting 
        period (as defined in subsection (b)(3)(D)) exceeds the amount 
        determined under paragraph (1)(A)(iii).''.
    (b) Permitting Hospitals to Decline Reclassification.--If any 
hospital fails to qualify as a medicare-dependent, small rural hospital 
under section 1886(d)(5)(G)(i) of the Social Security Act as a result 
of a decision by the Medicare Geographic Classification Review Board 
under section 1886(d)(10) of such Act to reclassify the hospital as 
being located in an urban area for fiscal year 1994, the Secretary of 
Health and Human Services shall--
            (1) notify such hospital of such failure to qualify,
            (2) provide an opportunity for such hospital to decline 
        such reclassification, and
            (3) if the hospital declines such reclassification, 
        administer the Social Security Act (other than section 
        1886(d)(8)(D)) for fiscal year 1994 as if the decision by the 
        Review Board had not occurred.

SEC. 107. HEMOPHILIA PASS-THROUGH.

    (a) In General.--Section 6011(d) of OBRA-1989 is amended by 
striking ``2 years after the date of enactment of this Act'' and 
inserting ``September 30, 1994''.
    (b) Effective Date.--The amendment made by subsection (a) shall 
take effect as if included in the enactment of OBRA-1989.

SEC. 108. STATE HOSPITAL PAYMENT PROGRAMS.

    (a) Recoupment From New Jersey Hospitals.--
            (1) Moratorium on recoupment.--Prior to April 1, 1993, the 
        Secretary of Health and Human Services (in this section 
        referred to as the ``Secretary'') may not recoup from or 
        otherwise reduce payments to hospitals in the State of New 
        Jersey because of alleged overpayments to such hospitals under 
        title XVIII of the Social Security Act which occurred during 
        the period of the statewide hospital reimbursement 
        demonstration project conducted in that State between January 
        1, 1985, and December 31, 1988, under a waiver granted under 
        section 1886(c) of the Social Security Act.
            (2) Provision of payment data.--The Secretary may not 
        recoup from or otherwise reduce payments to hospitals in the 
        State of New Jersey because of alleged overpayments described 
        in paragraph (1) until the Secretary provides the State and 
        hospitals located in the State with all relevant data used by 
        the Secretary to determine the amount of such alleged 
        overpayments, including (but not limited to) the cost reports 
        submitted by the hospitals to the Secretary during the period 
        of the statewide hospital reimbursement demonstration project 
        described in such paragraph and the methodology used by the 
        Secretary to determine payments to such hospitals under title 
        XVIII of the Social Security Act during such period.
    (b) Clarification of Payments under a Medicare-Approved State 
Hospital Reimbursement System.--In the case of a State hospital 
reimbursement system that meets the requirements of section 1814(b)(3) 
of the Social Security Act, no other provision in title XVIII of such 
Act, no provision of title XIX of such Act, no provision of the 
Employee Retirement Income Security Act of 1974, and no provision of 
chapter 81 or 89 of title 5, United States Code, shall be construed as 
preventing the system from providing that payment for services covered 
under the system be made on the basis of rates provided for under the 
system.

SEC. 109. PSYCHOLOGY SERVICES IN HOSPITALS.

    Section 1861(e)(4) (42 U.S.C. 1395x(e)(4)) is amended by striking 
``physician;'' and inserting ``physician, except that a patient 
receiving qualified psychologist services (as defined in subsection 
(ii)) may be under the care of a clinical psychologist with respect to 
such services to the extent permitted under State law;''.

SEC. 110. GRADUATE MEDICAL EDUCATION PROVIDED IN A HOSPITAL-OWNED 
              COMMUNITY HEALTH CENTER.

    Section 1886(d)(5)(B)(iv) (42 U.S.C. 1395ww(d)(5)(B)(iv)) is 
amended by inserting after ``the hospital'' the following: ``or 
providing services at any entity receiving a grant under section 330 of 
the Public Health Service Act that is under the ownership or control of 
the hospital (if the hospital incurs all, or substantially all, of the 
costs of the services furnished to the hospital by such interns and 
residents)''.

SEC. 111. UNIFORMED SERVICES TREATMENT FACILITIES.

    (a) Coverage of Services Provided in Certain Uniformed Services 
Treatment Facilities.--
            (1) In general.--Subject to paragraph (2), the Secretary of 
        Health and Human Services may not take any action to recover 
        amounts that were paid by the United States under title XVIII 
        of the Social Security Act to the facilities described in 
        paragraph (3) (or to other individuals or entities with whom 
        such facilities had entered into agreements to provide services 
        under such title) for services provided during the period 
        beginning October 1, 1986, and ending December 31, 1989.
            (2) Exception.--The Secretary may take a recoupment action 
        for the sole purpose of securing obligation of the funds 
        provided to the Uniformed Services Treatment Facilities program 
        pursuant to the Department of Defense Appropriations Act, 1993 
        to fulfill such an action.
            (3) Facilities described.--The facilities referred to in 
        paragraph (1) are the hospitals described in section 248c of 
        title 42, United States Code, that are located in Boston, 
        Massachusetts; Baltimore, Maryland; and Seattle, Washington.
    (b) Study of Joint Medical Facilities.--
            (1) Study.--The Secretary of Health and Human Services, in 
        consultation with the Secretary of Defense and the Secretary of 
        Veterans Affairs, shall conduct a study of the feasibility and 
        desirability of establishing joint medical facilities among the 
        Department of Defense, the Department of Veterans Affairs, and 
        other public and private entities, and shall include in such 
        study an analysis of the need to make changes in the medicare 
        and medicaid programs (including facility certification 
        standards under such programs) in order to facilitate the 
        establishment of such joint medical facilities.
            (2) Report.--Not later than October 1, 1993, the Secretary 
        of Health and Human Services shall submit a report to Congress 
        on the study conducted under paragraph (1).

SEC. 112. REQUIRING HOSPITALS AND NURSING FACILITIES TO NOTIFY 
              RESIDENTS OF AVAILABILITY OF HOSPICE BENEFIT.

    (a) Hospitals.--Section 1861(ee)(2)(D) (42 U.S.C. 1395x(ee)(2)(D)) 
is amended by inserting ``, including hospice services,'' after ``post-
hospital services''.
    (b) Nursing Facilities.--Section 1819(c)(1)(B) (42 U.S.C. 
1395i3(c)(1)(B)) is amended--
            (1) by striking ``and'' at the end of clause (ii);
            (2) by striking the period at the end of clause (iii) and 
        inserting ``; and''; and
            (3) by inserting after clause (iii) the following new 
        clause:
                            ``(iv) inform each resident who is entitled 
                        to benefits under this title, orally and in 
                        writing at the time of admission to the 
                        facility, 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 facility to refer patients to hospice 
                        programs located outside such geographic 
                        area).''.
    (c) Effective Date.--The amendments 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. 113. SKILLED NURSING FACILITY WAGE INDEX.

    (a) In General.--Within 2 years of the date of the enactment of 
this Act, the Secretary of Health and Human Services shall begin to 
collect data on employee compensation and paid hours of employment in 
skilled nursing facilities for the purpose of constructing a skilled 
nursing facility wage index adjustment to the routine service cost 
limits required under section 1888(a)(4) of the Social Security Act.
    (b) ProPAC Report.--The Prospective Payment Assessment Commission 
shall, by March 1, 1994, study and report to the Congress on the impact 
of applying routine cost limits for skilled nursing facilities on a 
regional basis.

SEC. 114. DRG PAYMENT WINDOW TECHNICAL CLARIFICATION; MISCELLANEOUS AND 
              TECHNICAL CORRECTIONS.

    (a) Clarification of DRG Payment Window Expansion.--The first 
sentence of section 1886(a)(4) (42 U.S.C. 1395ww(a)(4)) is further 
amended by striking ``and includes'' and inserting ``and (in the case 
of a subsection (d) hospital) includes''.
    (b) Technical Correction Relating to Resident Assessment in Nursing 
Homes.--Section 1819(b)(3)(C)(i)(I) (42 U.S.C. 1395i-3(b)(3)(C)(i)(I)) 
is amended by striking ``not later than'' before ``14 days''.
    (c) Clerical Corrections.--(1) Section 1814(i)(1)(C)(i) (42 U.S.C. 
1395f(i)(1)(C)(i)) is amended by striking ``1990,,'' and inserting 
``1990,''.
    (2) Section 1816(f)(2)(A)(ii) (42 U.S.C. 1396h(f)(2)(A)(ii)) is 
amended by striking ``such agency'' and inserting ``such agency's''.
    (3) Section 1886(d)(1)(A)(iii) (42 U.S.C. 1395ww(d)(1)(A)(iii)) is 
amended by striking ``, the sum of'' and inserting ``is equal to the 
sum of''.

SEC. 115. EXTENSION OF RURAL HOSPITAL DEMONSTRATION.

    Section 4008(i)(1) of OBRA-1990 is amended by adding at the end the 
following new sentence: ``The Secretary shall continue any such 
demonstration project until at least December 31, 1995.''.

                TITLE II--PROVISIONS RELATING TO PART B

                    Subtitle A--Physicians' Services

SEC. 201. 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 201(a) 
                        of the Miscellaneous and Technical Medicare 
                        Amendments 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)(i)(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 201(a) of the 
                        Miscellaneous and Technical Medicare Amendments 
                        of 1993 would not result in expenditures under 
                        this section in 1993 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)(i)(I), by inserting ``and as 
        adjusted under subsection (c)(2)(E)(ii)'' after ``for 1993'';
            (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 first day of the fourth month 
beginning after the date of the enactment of this Act.

SEC. 202. PAYMENTS FOR NEW PHYSICIANS AND PRACTITIONERS.

    (a) Equal Treatment of New Physicians and Practitioners.--(1) 
Section 1848(a) (42 U.S.C. 1395w4(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 1993 (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 1993 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)(i)(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 201(c), is amended--
            (1) in subsection (a)(2)(B)(i)(I), by inserting ``and 
        section 202(b) of the Miscellaneous and Technical Medicare 
        Amendments of 1993'' after ``(c)(2)(E)(ii)'' after ``for 
        1993'';
            (2) in subsection (c)(2)(A)(i), by inserting ``and section 
        202(b) of the Miscellaneous and Technical Medicare Amendments 
        of 1993'' after ``under subparagraph (E)(i)''; and
            (3) in subsection (i)(1)(B), by inserting ``and section 
        202(b) of the Miscellaneous and Technical Medicare Amendments 
        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 the first day of the fourth 
month beginning after the date of the enactment of this Act.

SEC. 203. 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, 1993, the 
Secretary may not modify the methodology in effect as of January 1, 
1992, 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, 1993, the Secretary may not modify the methodology in effect 
as of January 1, 1992, for determining the amount of time that may be 
billed for such services under this section.''.

SEC. 204. 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. 1395w4(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. 205. 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,
                            ``(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), by inserting ``and 
                suppliers'' after ``physicians'', and by inserting ``or 
                a nonparticipating supplier or other person'' after 
                ``nonparticipating physician'' and 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) of subsection (l)(5) 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'' and by striking the period at the end and 
                inserting ``, and'', and
                    (C) 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)(D)).''.
            (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 249(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 the 
        first day of the fourth month beginning after the date of the 
        enactment of this Act.
            (2) Practitioners.--The amendments made by subsection (b) 
        shall apply to services furnished on or after the first day of 
        the fourth month beginning after the date of the enactment of 
        this Act.
            (3) EOMBs.--The amendments made by subsection (c)(1) shall 
        apply to explanations of benefits provided on or after the 
        first day of the fourth month beginning after the date of the 
        enactment of this Act.
            (4) Carrier determinations.--The amendments made by 
        subsection (c)(2) shall apply to contracts as of the first day 
        of the fourth month beginning after the date of the enactment 
        of this Act.
            (5) Report.--The amendment made by subsection (d) shall 
        apply to reports for years beginning with 1994.

SEC. 206. 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.
            (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. 207. ANTIGENS UNDER PHYSICIAN FEE SCHEDULE.

    (a) In General.--Section 1848(j)(3) (42 U.S.C. 1395w4(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. 208. 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. 209. 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) Effective Date.--The amendments made by this section and the 
provisions of this section shall take effect as if included in the 
enactment of OBRA-1990.

                Subtitle B--Ambulatory Surgical Services

SEC. 211. EYE OR EYE AND EAR HOSPITALS.

    (a) In General.--Section 1833(i) (42 U.S.C. 1395l(i)) is amended--
            (1) in subparagraph (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 (2)(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. 212. 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. 213. 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, 1994, 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 1995), such amounts shall be increased by the percentage increase 
in the consumer price index for all urban consumers (U.S. city average) 
for the 12-month period ending with March of the preceding fiscal 
year.''.
    (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.

                 Subtitle C--Durable Medical Equipment

SEC. 221. 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, 1993, 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, 1993, and on 
                        or before December 31, 1994, the supplier meets 
                        standards prescribed by the Secretary; and
                            ``(ii) for medical equipment and supplies 
                        furnished on or after January 1, 1995, 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, 1993, 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, 1993.
                            ``(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, 1995, 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, 1993, 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, 1995, 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 May 1, 1994, 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 July 1, 1994, 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. 222. 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. 223. 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. 224. 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 ``(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. 225. BENEFICIARY LIABILITY FOR NONCOVERED SERVICES.

    (a) In General.--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);
            ``(2) furnishes an item or service to a beneficiary for 
        which payment is denied in advance under section 1834(a)(15); 
        or
            ``(3) 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 on an unassigned 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.''.
    (b) Effective Date.--The amendment made by subsection (a) shall 
apply to items or services furnished on or after October 1, 1993.

SEC. 226. 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. 227. PAYMENT FOR PARENTERAL AND ENTERAL NUTRIENTS, SUPPLIES, AND 
              EQUIPMENT DURING 1993.

    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. 228. 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) (42 U.S.C. 1395m(a)), as amended by 
section 221(a)(2), is amended by inserting after paragraph (15) the 
following new paragraph:
            ``(16) Payment for accessories relating to nebulizers and 
        aspirators.--In the case of accessories to be used in 
        conjunction with a nebulizer or aspirator for which payment is 
        made under this subsection, payment shall be made in accordance 
        with paragraph (2) of this subsection.''.
    (c) Effective Date.--The amendments made by this section shall 
apply to items furnished on or after January 1, 1994.

SEC. 229. PAYMENT FOR OSTOMY SUPPLIES, TRACHEOSTOMY SUPPLIES, 
              UROLOGICALS, AND SURGICAL DRESSINGS.

    (a) Ostomy Supplies, Tracheostomy Supplies, and Urologicals.--
            (1) In general.--Section 1834(h)(1) (42 U.S.C. 1395m(h)(1)) 
        is amended by adding at the end the following new subparagraph:
                    ``(E) 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).''.
            (2) Conforming amendment.--Section 1834(h)(1)(B) (42 U.S.C. 
        1395m(h)(1)(B)) is amended by striking ``subparagraph (C),'' 
        and inserting ``subparagraphs (C) and (E),''.
            (3) Effective date.--The amendments made by this subsection 
        shall apply to items furnished on or after January 1, 1994.
    (b) Surgical Dressings.--
            (1) In general.--Section 1834 (42 U.S.C. 1395m), as amended 
        by section 221(a), 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.''.
            (2) Conforming amendment.--Section 1833(a)(1) (42 U.S.C. 
        1395l(a)(1)), as amended by sections 249(e)(2) and 205(e)(1), 
        is amended--
                    (A) by striking ``and'' before ``(P)'', and
                    (B) 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);''.
            (3) Effective date.--The amendments made by this subsection 
        shall apply to items furnished on or after January 1, 1994.

SEC. 230. 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. 231. 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 208(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 
        Administration 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.

                      Subtitle D--Other Provisions

SEC. 241. PAYMENT FOR MEDICALLY DIRECTED CERTIFIED REGISTERED NURSE 
              ANESTHETIST SERVICES.

    (a) In General.--Section 1833(l)(4)(B) (42 U.S.C. 1395l(l)(4)(B)) 
is amended to read as follows:
    ``(B) Except as provided in subparagraph (D), the conversion factor 
used to determine the amount paid under the fee schedule under this 
subsection for services furnished by a certified registered nurse 
anesthetist who is medically directed--
            ``(i) in a year after 1993 and before 1997, shall be 
        $10.75, or
            ``(ii) in a subsequent calendar year, shall be the previous 
        year's conversion factor increased by the update determined 
        under section 1848(d)(3) for physician anesthesia services for 
        that year.''.
    (b) Effective Date.--The amendment made by subsection (a) shall 
apply to services furnished on or after January 1, 1994.

SEC. 242. 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 
                ``$58,000,000'', and
                    (B) by striking ``$3,000,000'' and inserting 
                ``$5,000,000''.

SEC. 243. PART B LATE ENROLLMENT PENALTY.

    (a) Limitation on Medicare Part B Late Enrollment Penalty.--
            (1) In general.--Section 1839 (42 U.S.C. 1395r) is amended 
        by adding at the end the following new subsection:
    ``(g) The percent increase in premiums under subsection (b) due to 
late enrollment under this part shall not exceed 25 percent in the case 
of an individual who is annuitant described in subparagraph (A) or (B) 
of section 8901(3) of title 5, United States Code, for a month if--
            ``(1) during the individual's initial enrollment period 
        under section 1837(d)--
                    ``(A) the individual was enrolled in a group health 
                plan (as defined in section 1862(b)(1)(A)(v)) that 
                provided coverage of items and services for which 
                payment may be made under this part, and
                    ``(B) the individual elected not to enroll (or to 
                be deemed enrolled) under this section, and
            ``(2) due to a change of coverage under such plan, there is 
        no coverage during the month under such plan with respect to 
        items and services for which payment may be made under this 
        part unless the individual is enrolled under this part.''.
            (2) Effective date.--The amendment made by paragraph (1) 
        shall apply to premiums for months beginning with January 1992.
    (b) Payment of Part B Premium Late Enrollment Penalties by 
States.--Section 1839 (42 U.S.C. 1395r), as amended by subsection (a), 
is further amended by adding at the end the following new subsection:
    ``(h)(1) Upon the request of a State, the Secretary may enter into 
an agreement with the State under which the State agrees to pay on a 
quarterly or other periodic basis to the Secretary (to be deposited in 
the Treasury to the credit of the Federal Supplementary Medical 
Insurance Trust Fund) an amount equal to the amount of the part B late 
enrollment premium increases with respect to the premiums for eligible 
individuals (as defined in paragraph (3)(A)).
    ``(2) No part B late enrollment premium increase shall apply to an 
eligible individual for premiums for months for which the amount of 
such an increase is payable under an agreement under paragraph (1).
    ``(3) In this subsection:
            ``(A) The term `eligible individual' means an individual 
        who is enrolled under this part B and who is within a class of 
        individuals specified in the agreement under paragraph (1).
            ``(B) The term `part B late enrollment premium increase' 
        means any increase in a premium as a result of the application 
        of subsection (b).''.

SEC. 244. 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 
249(f)(8)(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. 245. SPEECH-LANGUAGE PATHOLOGISTS AND AUDIOLOGISTS.

    (a) Services Defined.--Section 1861 (42 U.S.C. 1395x), as amended 
by section 249(f)(8)(E), is amended by inserting after subsection (kk) 
the following new subsection:

        ``Speech-Language Pathology Services; Audiology Services

    ``(ll)(1) The term `speech-language pathology services' means such 
speech, language, and related function assessment and rehabilitation 
services furnished by a qualified speech-language pathologist as the 
speech-language pathologist is legally authorized to perform under 
State law (or the State regulatory mechanism provided by State law) as 
would otherwise be covered if furnished by a physician.
    ``(2) The term `audiology services' means such hearing and balance 
assessment services furnished by a qualified audiologist as the 
audiologist is legally authorized to perform under State law (or the 
State regulatory mechanism provided by State law).
    ``(3) In this subsection:
            ``(A) The term `qualified speech-language pathologist' 
        means an individual with a master's or doctoral degree in 
        speech-language pathology who has performed not less than 9 
        months of supervised full-time speech-language pathology 
        services after obtaining such degree and who--
                    ``(i) is licensed (or is otherwise certified) as a 
                speech-language pathologist by the State in which the 
                individual furnishes such services, or
                    ``(ii) in the case of an individual who furnishes 
                services in a State which does not provide for the 
                licensing (or other form of certification) of speech-
                language pathologists, has successfully completed a 
                national clinical competency examination in speech-
                language pathology approved by the Secretary.
            ``(B) The term `qualified audiologist' means an individual 
        with a master's or doctoral degree in audiology who has 
        performed not less than 9 months of supervised full-time 
        audiology services after obtaining such degree and who--
                    ``(i) is licensed (or is otherwise certified) as an 
                audiologist by the State in which the individual 
                furnishes such services, or
                    ``(ii) in the case of an individual who furnishes 
                services in a State which does not provide for the 
                licensing (or other form of certification) of 
                audiologists, has successfully completed a national 
                clinical competency examination in audiology approved 
                by the Secretary.''.
    (b) Conforming Amendments Relating to Medicare Treatment of Speech 
and Language Services.--
            (1) Extended care services.--Section 1861(h)(3) (42 U.S.C. 
        1395x(h)(3)) is amended by striking ``, occupational, or speech 
        therapy'' and inserting ``or occupational therapy or speech-
        language pathology services''.
            (2) Home health services.--Section 1861(m)(2) (42 U.S.C. 
        1395x(m)(2)) is amended by striking ``, occupational, or speech 
        therapy'' and inserting ``or occupational therapy or speech-
        language pathology services''.
            (3) Outpatient physical therapy services.--The fourth 
        sentence of section 1861(p) (42 U.S.C. 1395x(p)) is amended by 
        striking ``speech pathology services'' and inserting ``speech-
        language pathology services''.
            (4) Comprehensive outpatient rehabilitation facility 
        services.--Section 1861(cc)(1)(B) (42 U.S.C. 1395x(cc)(1)(B)) 
        is amended by striking ``speech pathology services'' and 
        inserting ``speech-language pathology services''.
            (5) Hospice care.--Section 1861(dd)(1)(B) (42 U.S.C. 
        1395x(dd)(1)(B)) is amended by striking ``therapy or speech-
        language pathology'' and inserting ``therapy, or speech-
        language pathology services''.
    (c) Effective Date.--The amendments made by this section shall 
apply to services furnished on or after January 1, 1994.

SEC. 246. 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. 247. 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. 248. EXTENSION OF INFLUENZA VACCINATION DEMONSTRATION.

    (a) In General.--Section 4071(b)(1) of OBRA-1987 is amended by 
striking the period at the end and inserting the following: ``, except 
that the reference in clause (ii) of paragraph (2)(B) of such 
subsection to `24 months' shall be deemed to be a reference to `30 
months'.''.
    (b) Limitation on Use of Amounts.--The second sentence of section 
4071(b)(2) of OBRA-1987 is amended by striking ``and evaluate'' and 
inserting ``and (during fiscal years other than fiscal year 1993) 
evaluate''.

SEC. 249. 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) Certified registered nurse anesthetists (section 4160 
        of obra-1990).--Section 1833(l)(4)(B)(ii)(VII) (42 U.S.C. 
        1395l(l)(4)(B)(ii)(VII)) is amended by striking ``1997'' and 
        inserting ``1996''.
            (6) 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''.
            (7) 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.''.
            (8) 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''.
            (9) 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.

            TITLE III--PROVISIONS RELATING TO PARTS A AND B

SEC. 301. PROVISIONS RELATING TO PHYSICIAN OWNERSHIP AND REFERRAL.

    (a) 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''.
    (b) 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,
                            ``(iii) the lease provides for a term of 
                        rental or lease for at least one year,
                            ``(iv) in the case of a lease that is 
                        intended to provide the lessee with access to 
                        the premises for periodic intervals of time, 
                        rather than on a full-time basis, the lease 
                        specifies exactly the schedule of such 
                        intervals, their length, and the rent for such 
                        intervals,
                            ``(v) 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,
                            ``(vi) the lease would be commercially 
                        reasonable even if no referrals were made 
                        between the parties, 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,
                            ``(iii) the lease provides for a term of 
                        rental or lease of at least one year,
                            ``(iv) in the case of a lease that is 
                        intended to provide the lessee with use of the 
                        equipment for periodic intervals of time, 
                        rather than on a full-time basis, the lease 
                        specifies exactly the schedule of such 
                        intervals, their length, and the rent for such 
                        intervals,
                            ``(v) 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,
                            ``(vi) the lease would be commercially 
                        reasonable even if no referrals were made 
                        between the parties, 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.--Paragraph (2) of 
        such section is amended--
                    (A) by striking ``with hospitals'',
                    (B) by striking ``An arrangement'' and all that 
                follows through ``if'' and inserting ``Any amount paid 
                by an employer to an employee who has a bona fide 
                employment relationship with the employer for 
                employment, or paid by a hospital pursuant to an 
                arrangement with a physician (or immediate family 
                member) for the provision of administrative services, 
                if'',
                    (C) in subparagraphs (A), (B), and (D), by striking 
                ``arrangement'' and inserting ``employment relationship 
                or arrangement'', and
                    (D) in subparagraph (C), by striking ``to the 
                hospital''.
            (3) Additional exceptions.--Such subsection is further 
        amended by adding at the end the following new paragraphs:
            ``(7) Payments to a physician for other items or 
        services.--
                    ``(A) In general.--Payments made by an entity to a 
                physician (or family member) who is not employed by the 
                entity as compensation for services specified in 
                subparagraph (B), if--
                            ``(i) the compensation agreement is set out 
                        in writing and specifies the services to be 
                        provided by the parties, the compensation for 
                        each unit of service provided under the 
                        agreement, and the schedule for the provision 
                        of such services,
                            ``(ii) 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,
                            ``(iii) the compensation is provided 
                        pursuant to an agreement which would be 
                        commercially reasonable even if no referrals 
                        were made to the entity, and
                            ``(iv) the compensation arrangement meets 
                        such other requirements as the Secretary may 
                        impose by regulation as needed to protect 
                        against program or patient abuse.
                    ``(B) Specified services.--For purposes of 
                subparagraph (A), the services specified in this 
                subparagraph are any of the following:
                            ``(i) Consultative services that--
                                    ``(I) relate to test results that 
                                have been obtained that are outside 
                                established parameters, or are 
                                specifically requested by the referring 
                                physician on a specified patient,
                                    ``(II) are furnished by a physician 
                                other than the referring physician (or 
                                by another physician who is a member of 
                                the same group practice), and
                                    ``(III) for which the physician 
                                furnishes a written report for that 
                                patient.
                            ``(ii) Interpretation of tissue pathology 
                        or Pap smear slides or the provision of other 
                        cytology services.
                            ``(iii) Phlebotomy services for paternity 
                        or toxicology testing where the services are 
                        furnished by a physician other than the 
                        physician referring the individual for such 
                        testing (or by another physician who is a 
                        member of the same group practice).
                            ``(iv) Employment-related health care 
                        services, including a payment by a self-insured 
                        employer for services rendered to employee 
                        applicants, employees, or their families under 
                        the terms of a health benefit plan.
                            ``(v) Services as a clinical consultant to 
                        the entity as required for certification of the 
                        provider under section 353 of the Public Health 
                        Service Act.
                            ``(vi) Services required by local, State, 
                        or Federal licensure, accreditation, or other 
                        health and safety provisions.
                            ``(vii) Services billed in the name of a 
                        group practice provided by a physician under 
                        contract to the group practice for services not 
                        otherwise available directly through a 
                        physician who is a member of the group.
            ``(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 and are 
                generally available to referrors and non-referrors 
                alike on similar terms and conditions.
            ``(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.''.
    (c) Treatment of Group Practice Laboratories.--
            (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) 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 clinical laboratory 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 clinical laboratory services provided by 
        the laboratory of a 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 laboratory provides substantially all 
                of the clinical laboratory 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) is 
                amended by inserting ``(or by a hospital for which such 
                a group practice provides clinical laboratory 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), as redesignated by paragraph 
        (1)(A), is amended by inserting ``, institution of higher 
        education, or medical school'' after ``hospital''.
    (d) Expanding Rural Provider Exception To Cover Compensation 
Arrangements.--
            (1) In general.--Section 1877(b) is further 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 clinical laboratory 
        services if--
                    ``(A) the laboratory 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 laboratory 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) is amended--
                    (A) by striking paragraph (2), and
                    (B) by redesignating paragraph (3) as paragraph 
                (2).
    (e) Exception for Shared Facility Services.--
            (1) In general.--Section 1877 is amended--
                    (A) in subsection (b), as amended by subsection 
                (d)(1), by inserting after paragraph (5) the following 
                new paragraph:
            ``(6) Shared facility services.--
                    ``(A) In general.--In the case of shared facility 
                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 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 services.--The term `shared 
                facility 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 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 services in a 
                building, a financial arrangement--
                            ``(i) which is only between physicians who 
                        are providing services (unrelated to shared 
                        facility 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, 1994, 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.
    (f) 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, mistakenly performed tests, or the 
                correction of minor billing errors.
                    ``(ii) The provision of items, devices, or supplies 
                of minor value that are used to--
                            ``(I) collect, transport, process, or store 
                        specimens for the entity providing the item, 
                        device, or supply, or
                            ``(II) communicate the results of tests for 
                        such entity.
                    ``(iii) The furnishing by an entity of laboratory 
                services to a group practice affiliated with the 
                entity, if the entity provides all or substantially all 
                of the clinical laboratory services of the group 
                practice.''.
    (g) Miscellaneous and Technical Corrections.--Section 1877 (42 
U.S.C. 1395nn) is amended--
            (1) in the fourth sentence of subsection (f)--
                    (A) by striking ``provided'' and inserting 
                ``furnished'', and
                    (B) by striking ``provides'' and inserting 
                ``furnish'';
            (2) 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
            (3) in subsection (a)(2)(B), by striking ``subsection 
        (h)(1)(A)'' and inserting ``subsection (h)(1)''.
    (h) Effective Date.--The amendments made by this section shall 
apply to referrals made on or after January 1, 1992.

SEC. 302. DIRECT GRADUATE MEDICAL EDUCATION.

    (a) Adjustment in GME Base-year Costs of Federal Insurance 
Contributions Act.--
            (1) In general.--In determining the amount of payment to be 
        made under section 1886(h) of the Social Security Act in the 
        case of a hospital described in subsection (b) for cost 
        reporting periods beginning on or after October 1, 1992, the 
        Secretary of Health and Human Services shall redetermine the 
        approved FTE resident amount to reflect the amount that would 
        have been paid the hospital if, during the hospital's base cost 
        reporting period, the hospital had been liable for FICA taxes 
        or for contributions to the retirement system of a State, a 
        political subdivision of a State, or an instrumentality of such 
        a State or political subdivision with respect to interns and 
        residents in its medical residency training program.
            (2) Hospitals affected.--A hospital described in this 
        subsection is a hospital that did not pay FICA taxes with 
        respect to interns and residents in its medical residency 
        training program during the hospital's base cost reporting 
        period, but is required to pay FICA taxes or make contributions 
        to a retirement system described in paragraph (1) with respect 
        to such interns and residents because of the amendments made by 
        section 11332(b) of OBRA-1990.
            (3) Definitions.--In this subsection:
                    (A) the ``base cost reporting period'' for a 
                hospital is the hospital's cost reporting period that 
                began during fiscal year 1984.
                    (B) The term ``FICA taxes'' means, with respect to 
                a hospital, the taxes under section 3111 of the 
                Internal Revenue Code of 1986.
    (b) Publicly-Funded Family Practice Residency Programs.--
            (1) In general.--Section 1886(h)(5) (42 U.S.C. 
        1395ww(h)(5)) is amended by adding at the end the following new 
        subparagraph:
                    ``(H) Adjustments for certain family practice 
                residency programs.--
                            ``(i) In general.--In the case of an 
                        approved medical residency training program 
                        (meeting the requirements of clause (ii)) of a 
                        hospital which received payments from the 
                        United States, a State, or a political 
                        subdivision of a State or an instrumentality of 
                        such a State or political subdivision (other 
                        than payments under this title or a State plan 
                        under title XIX) for the program during the 
                        cost reporting period that began during fiscal 
                        year 1984, the Secretary shall--
                                    ``(I) provide for an average amount 
                                under paragraph (2)(A) that takes into 
                                account the Secretary's estimate of the 
                                amount that would have been recognized 
                                as reasonable under this title if the 
                                hospital had not received such 
                                payments, and
                                    ``(II) reduce the payment amount 
                                otherwise provided under this 
                                subsection in an amount equal to the 
                                proportion of such program payments 
                                during the cost reporting period 
                                involved that is allocable to this 
                                title.
                            ``(ii) Additional requirements.--A 
                        hospital's approved medical residency program 
                        meets the requirements of this clause if--
                                    ``(I) the program is limited to 
                                training for family and community 
                                medicine;
                                    ``(II) the program is the only 
                                approved medical residency program of 
                                the hospital; and
                                    ``(III) the average amount 
                                determined under paragraph (2)(A) for 
                                the hospital (as determined without 
                                regard to the increase in such amount 
                                described in clause (i)(I)) does not 
                                exceed $10,000.''.
            (2) Effective date.--The amendment made by paragraph (1) 
        shall apply to payments under section 1886(h) of the Social 
        Security Act for cost reporting periods beginning on or after 
        October 1, 1990.
    (c) Preventive Care Services as Part of Initial Residency Period.--
            (1) Eligibility of preventive care residency programs for 
        expanded initial residency periods.--Section 1886(h)(5)(F)(ii) 
        (42 U.S.C. 1395ww(h)(5)(F)(ii)) is amended by inserting after 
        ``fellowship program'' the following: ``or a preventive care 
        residency or fellowship program''.
            (2) Effective date.--The amendment made by paragraph (1) 
        shall apply to cost reporting periods beginning on or after 
        October 1, 1993.

SEC. 303. END STAGE RENAL DISEASE.

    (a) Coverage of Immunosuppressive Drugs.--
            (1) In general.--Section 1861(s)(2)(J) (42 U.S.C. 
        1395x(s)(2)(J)) is amended by striking ``title, within'' and 
        all that follows and inserting the following: ``title, but only 
        in the case of drugs furnished--
                    ``(i) before 1994, within 12 months after the date 
                of the transplant procedure,
                    ``(ii) during 1994, within 18 months after the date 
                of the transplant procedure,
                    ``(iii) during 1995, within 24 months after the 
                date of the transplant procedure,
                    ``(iv) during 1996, within 30 months after the date 
                of the transplant procedure, and
                    ``(v) during any year after 1997, within 36 months 
                after the date of the transplant procedure;''.
            (2) Effective date.--The amendment made by paragraph (1) 
        shall take effect on the date of the enactment of this section.
    (b) Payment for Erythropoietin.--
            (1) In general.--Section 1881(b)(11)(B)(ii)(I) (42 U.S.C. 
        1395rr(b)(11)(B)(ii)(I)) is amended--
                    (A) by striking ``1991'' and inserting ``1994''; 
                and
                    (B) by striking ``$11'' and inserting ``$10''.
            (2) Effective date.--The amendments made by paragraph (1) 
        shall apply to erythropoietin furnished on or after January 1, 
        1994.
    (c) Home Dialysis Demonstration Technical Correction.--
            (1) In general.--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)''.
            (2) Effective date.--The amendments made by paragraph (1) 
        shall take effect as if included in the enactment of OBRA-1990.

SEC. 304. MEDICARE SECONDARY PAYER.

    (a) 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.''.
    (b) 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 
                November 1, 1993, 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 July 1, 1993.
    (c) Improvements in Recovery of Payments From Primary Payers.--
            (1) Submission of reports on efforts to recover erroneous 
        payments.--
                    (A) Fiscal intermediaries under part a.--Section 
                1816 (42 U.S.C. 1396h) is amended by adding at the end 
                the following new subsection:
    ``(k) An agreement with an agency or organization under this 
section shall require that such agency or organization submit an annual 
report to the Secretary describing the steps taken to recover payments 
made 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)).''.
                    (B) Carriers under part b.--Section 1842(b)(3) (42 
                U.S.C. 1395u(b)(3)) is amended--
                            (i) by striking ``and'' at the end of 
                        subparagraphs (G) and (H); and
                            (ii) 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.--
                    (A) Fiscal intermediaries under part a.--Section 
                1816(f)(1)(A) (42 U.S.C. 1396h(f)(1)(A)) is amended by 
                striking ``processing'' and inserting ``processing 
                (including the agency's or organization's success in 
                recovering payments made under this title for services 
                for which payment has been or could be made under a 
                primary plan (as defined in section 1862(b)(2)(A)))''.
                    (B) Carriers under part b.--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 1993.
    (d) 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--
                    (A) by striking ``on or before January 1, 1996,'' 
                and inserting ``before January 1, 1996''; and
                    (B) 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 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.''.
            (4) Section 4203(d) of OBRA-1990 is amended by striking 
        ``this subsection'' and inserting ``this section''.
            (5) Except as provided in paragraph (2), the amendments 
        made by this subsection shall be effective as if included in 
        the enactment of OBRA-1990.

SEC. 305. 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. 306. SOCIAL HEALTH MAINTENANCE ORGANIZATIONS.

    (a) Extension of Current Waivers.--Section 4018(b) of OBRA-1987, as 
amended by 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 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. 307. 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 ``basis,'' and 
                                inserting ``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)--
                                    (I) by striking ``(3)'' and 
                                inserting ``and (3)'', and
                                    (II) by striking ``, and (4)'' and 
                                all that follows up to the period at 
                                the end.
                    (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) Section 1154(a)(9)(B) (42 U.S.C. 1320c-3(a)(9)(B)) is amended 
by striking ``this subsection'' and inserting ``section 1156(a)''.
    (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 amendment made by paragraph (2) (relating to the 
requirement on reporting of information to State licensing boards) 
shall take effect on the date of the enactment of this Act.

SEC. 308. 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. 309. INTEREST PAYMENTS.

    (a) In General.--Sections 1816(c)(2)(B)(ii)(IV) and 
1842(c)(2)(B)(ii)(IV) of the Social Security Act shall be applied with 
respect to claims received in the 12-month period beginning October 1, 
1992, by substituting ``30 calendar days'' for ``24 calendar days'' and 
``17 calendar days''.
    (b) Effective Date.--Subsection (a) shall be in effect during the 
period that begins on the date of the enactment of this Act and ends on 
September 30, 1993.

SEC. 310. CLARIFICATION OF JUDICIAL REVIEW RIGHTS.

    (a) In General.--Section 1869(b) (42 U.S.C. 1395ff(b)) is amended 
by adding at the end the following new paragraph:
    ``(6) Nothing in this subsection (including paragraph (5)) shall be 
construed as requiring a person to file a claim with, or obtain 
findings or a decision of, the Secretary prior to seeking judicial 
review of an issue under this subsection, if the issue involves no 
material issues of fact in dispute and involves a challenge to the 
validity of a regulation or instruction which relates to a method for 
determining the amount of payment under part B.''.
    (b) Effective Date.--The amendment made by subsection (a) shall 
apply as if included in the enactment of section 9313 of OBRA-1986.

SEC. 311. ADJUSTMENTS TO DISCRETIONARY SPENDING LIMITS.

    (a) Adjustments.--Section 251(b)(2) of the Balanced Budget and 
Emergency Deficit Control Act of 1985 is amended by redesignating 
subparagraphs (E) and (F) as subparagraphs (F) and (G), respectively, 
and by inserting after subparagraph (D) the following new subparagraph:
                    ``(E) Medicare administrative costs.--To the extent 
                that appropriations are enacted that provide additional 
                new budget authority (as compared with a base level of 
                $1,526,000,000 for new budget authority) for the 
                administration of the Medicare program by fiscal 
                intermediaries and carriers pursuant to sections 1816 
                and 1842(a) of title XVIII of the Social Security Act, 
                the adjustment for that year shall be that amount, but 
                shall not exceed--
                            ``(i) for fiscal year 1994, $198,000,000 in 
                        new budget authority and $198,000,000 in 
                        outlays; and
                            ``(ii) for fiscal year 1995, $220,000,000 
                        in new budget authority and $220,000,000 in 
                        outlays; and
        the prior-year outlays resulting from these appropriations of 
        budget authority and additional adjustments equal to the sum of 
        the maximum adjustments that could have been made in preceding 
        fiscal years under this subparagraph.''.
    (b) Conforming Amendments.--
            (1) Section 603(a) of the Congressional Budget Act of 1974 
        is amended by striking ``section 251(b)(2)(E)(i)'' and 
        inserting ``section 251(b)(2)(F)(i)''.
            (2) Section 606(d) of the Congressional Budget Act of 1974 
        is amended--
                    (A) in paragraph (1)(A) by striking ``section 
                251(b)(2)(E)(i)'' and inserting ``section 
                251(b)(2)(F)(i)''; and
                    (B) in paragraph (2), by inserting 
                ``251(b)(2)(E),'' after ``251(b)(2)(D),''.

SEC. 312. 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 July 1, 1993, 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 1995 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 October 1, 1993, the Comptroller General shall 
review the proposal made pursuant to paragraph (1), 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. 313. TREATMENT OF CERTAIN STATE HEALTH CARE PROGRAMS.

    Section 514(b)(5) of the Employee Retirement Income Security Act of 
1974 (29 U.S.C. 1144(b)(5)) is amended to read as follows:
            ``(5)(A) Except as provided in subparagraphs (B) and (C), 
        subsection (a) shall not apply to the Hawaii Prepaid Health 
        Care Act (Haw. Rev. Stat. Sec. Sec. 393-1 through 393-51).
            ``(B) Nothing in subparagraph (A) shall be construed to 
        exempt from subsection (a) any State tax law relating to 
        employee benefits plans.
            ``(C) If the Secretary of Labor notifies the Governor of 
        the State of Hawaii that as the result of an amendment to the 
        Hawaii Prepaid Health Care Act enacted after October 5, 1992--
                    ``(i) the proportion of the population with health 
                care coverage under such Act is less than such 
                proportion on such date, or
                    ``(ii) the level of benefit coverage provided under 
                such Act is less than the actuarial equivalent of such 
                level of coverage on such date,
        subparagraph (A) shall not apply with respect to the 
        application of such amendment to such Act after the date of 
        such notification.''.

SEC. 314. 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 10149(f)(8)(B)(iii)(II) of 
this title, 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)''.
    (c) Effective Date.--The amendments made by this section shall take 
effect as if included in the enactment of OBRA-1990.

   TITLE IV--PROVISIONS RELATING TO MEDICARE SUPPLEMENTAL INSURANCE 
                                POLICIES

SEC. 401. 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 of 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) 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 401(m)(4) of the 
                Miscellaneous and Technical Medicare Amendments 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 401(m)(4) of 
                the Miscellaneous and Technical Medicare Amendments 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, 1993, 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 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 July 1, 1993, 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 July 1, 1993, and who were not 
        covered under such section before July 1, 1993, the 6-month 
        period specified in that section shall begin July 1, 1993).
    (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.

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