[Congressional Bills 103th Congress]
[From the U.S. Government Publishing Office]
[S. 1668 Placed on Calendar Senate (PCS)]

                                                       Calendar No. 295

103d CONGRESS

  1st Session

                                S. 1668

_______________________________________________________________________

                                 A BILL

To amend the Social Security Act and related Acts to make miscellaneous 
           and technical amendments, and for other purposes.

_______________________________________________________________________

            November 17 (legislative day, November 2), 1993

                         Placed on the calendar





                                                       Calendar No. 295
103d CONGRESS
  1st Session
                                S. 1668

To amend the Social Security Act and related Acts to make miscellaneous 
           and technical amendments, and for other purposes.


_______________________________________________________________________


                   IN THE SENATE OF THE UNITED STATES

            November 17 (legislative day, November 2), 1993

  Mr. Moynihan, from the Committee on Finance, reported the following 
     original bill; which was read twice and placed on the calendar

_______________________________________________________________________

                                 A BILL


 
To amend the Social Security Act and related Acts to make miscellaneous 
           and technical amendments, and for other purposes.

    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 ``Social Security Act Amendments of 
1993''.

SEC. 2. REFERENCES IN ACT; TABLE OF CONTENTS.

    (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'', ``OBRA-1990'', and ``OBRA-1993'' 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), the 
Omnibus Budget Reconciliation Act of 1990 (Public Law 101-508), and the 
Omnibus Budget Reconciliation Act of 1993 (Public Law 103-66), 
respectively.
    (c) Table of Contents.--The table of contents is as follows:

Sec. 1. Short title.
Sec. 2. References in Act; table of contents.
                      TITLE I--MEDICARE PROVISIONS

               Subtitle A--Provisions Relating to Part A

Sec. 101. Provisions relating to adjustments to standardized amounts 
                            for wages and wage-related costs.
Sec. 102. Essential access community hospital (EACH) amendments.
Sec. 103. Provisions relating to rural health transition grant program.
Sec. 104. Psychology services in hospitals.
Sec. 105. Medicare-dependent, small rural hospitals and sole community 
                            hospitals.
Sec. 106. Skilled nursing facilities.
Sec. 107. Notification of availability of hospice benefit.
Sec. 108. Clarifying expertise of individuals to serve on the 
                            Prospective Payment Assessment Commission.
Sec. 109. Authority for budget neutral adjustments for changes in 
                            payment amounts for transfer cases.
Sec. 110. Clarification of DRG payment window expansion; miscellaneous 
                            and technical corrections.
               Subtitle B--Provisions Relating to Part B

                      Part I--Physicians' Services

Sec. 121. Development and implementation of resource-based methodology 
                            for practice expenses.
Sec. 122. Geographic cost of practice index refinements.
Sec. 123. Extra-billing limits.
Sec. 124. Relative values for pediatric services.
Sec. 125. Administration of claims relating to physicians' services.
Sec. 126. Miscellaneous and technical corrections.
                   Part II--Durable Medical Equipment

Sec. 131. Certification of suppliers.
Sec. 132. Prohibition against carrier forum shopping.
Sec. 133. Restrictions on certain marketing and sales activities.
Sec. 134. Kickback clarification.
Sec. 135. Beneficiary liability for noncovered services.
Sec. 136. Adjustments for inherent reasonableness.
Sec. 137. Miscellaneous and technical corrections.
                   Part III--Other Items and Services

Sec. 141. Ambulatory surgical center services.
Sec. 142. Study of medicare coverage of patient care costs associated 
                            with clinical trials of new cancer 
                            therapies.
Sec. 143. Study of annual cap on amount of medicare payment for 
                            outpatient physical therapy and 
                            occupational therapy services.
Sec. 144. Payment of part B premium late enrollment penalties by 
                            States.
Sec. 145. Treatment of inpatients and provision of diagnostic x-ray 
                            services by rural health clinics and 
                            federally qualified health centers.
Sec. 146. Application of mammography certification requirements.
Sec. 147. Coverage of services of speech-language pathologists and 
                            audiologists.
Sec. 148. Miscellaneous and technical corrections.
            Subtitle C--Provisions Relating to Parts A and B

Sec. 151. Medicare secondary payer reforms.
Sec. 152. Physician ownership and referral.
Sec. 153. Definition of FMGEMS examination for payment of direct 
                            graduate medical education.
Sec. 154. Qualified medicare beneficiary outreach.
Sec. 155. Hospital agreements with organ procurement organizations.
Sec. 156. Peer review organizations.
Sec. 157. Health maintenance organizations.
Sec. 158. Home health agencies.
Sec. 159. Permanent extension of authority to contract with fiscal 
                            intermediaries and carriers on other than a 
                            cost basis.
Sec. 160. Miscellaneous and technical corrections.
  Subtitle D--Provisions Relating to Medicare Supplemental Insurance 
                                Policies

Sec. 171. Standards for medicare supplemental insurance policies.
                     TITLE II--MEDICAID PROVISIONS

                   Subtitle A--Substantive Provisions

                    Part I--Managed Care Provisions

Sec. 201. Medicaid managed care antifraud provisions.
Sec. 202. Extension of medicaid waiver for Tennessee Primary Care 
                            Network.
Sec. 203. Waiver of application of medicaid enrollment mix requirement 
                            to District of Columbia Chartered Health 
                            Plan, Inc.
Sec. 204. Waiver of application of medicaid enrollment mix requirement 
                            to Managed Health Services Insurance 
                            Corporation of Milwaukee, Wisconsin.
Sec. 205. Extension of Minnesota prepaid medicaid demonstration 
                            project.
      Part II--Home and Community-Based Services Waiver Provisions

Sec. 211. Elimination of requirement of prior institutionalization with 
                            respect to habilitation services furnished 
                            under a waiver for home or community-based 
                            services.
Sec. 212. Relief from third party liability requirements when cost-
                            effective.
Sec. 213. State expenditures for medical assistance with respect to 
                            home and community-based services provided 
                            under a waiver.
                       Part III--Other Provisions

Sec. 221. Presumptive eligibility for pregnant women.
Sec. 222. Criteria for determining the amount of disallowances.
Sec. 223. Intermediate sanctions for kickback violations.
Sec. 224. Technical amendment related to taxes on certain health care 
                            items and services.
Sec. 225. Application of mammography certification requirements under 
                            the medicaid program.
Sec. 226. Nursing home reform.
Sec. 227. Increase in authorization of appropriations for the maternal 
                            and child health services block grant 
                            program.
 Subtitle B--Miscellaneous and Technical Corrections Relating to OBRA-
                                  1990

Sec. 241. Effective date.
Sec. 242. Corrections relating to section 4401 (drug rebate program).
Sec. 243. Corrections relating to section 4402 (enrollment under group 
                            health plans).
Sec. 244. Corrections relating to section 4501 (low-income medicare 
                            beneficiaries).
Sec. 245. Corrections relating to section 4601 (child health).
Sec. 246. Corrections relating to section 4602 (outreach locations).
Sec. 247. Corrections relating to section 4604 (payment for hospital 
                            services for children under 6 years of 
                            age).
Sec. 248. Corrections relating to section 4703 (payment adjustments for 
                            disproportionate share hospitals).
Sec. 249. Corrections relating to section 4704 (Federally-qualified 
                            health centers).
Sec. 250. Corrections relating to section 4708 (substitute physicians).
Sec. 251. Corrections relating to section 4711 (home and community care 
                            for frail elderly).
Sec. 252. Corrections relating to section 4712 (community supported 
                            living arrangements).
Sec. 253. Correction relating to section 4713 (COBRA continuation 
                            coverage).
Sec. 254. Correction relating to section 4716 (medicaid transition for 
                            family assistance).
Sec. 255. Corrections relating to section 4718 (medically needy income 
                            levels for certain 1-member families).
Sec. 256. Corrections relating to section 4723 (medicaid spend-down 
                            option).
Sec. 257. Corrections relating to section 4724 (optional State 
                            disability determinations).
Sec. 258. Correction relating to section 4732 (special rules for health 
                            maintenance organizations).
Sec. 259. Corrections relating to section 4747 (coverage of HIV-
                            positive individuals).
Sec. 260. Correction relating to section 4751 (advanced directives).
Sec. 261. Corrections relating to section 4752 (physicians' services).
Sec. 262. Corrections relating to section 4801 (nursing home reform).
Sec. 263. Other technical corrections.
 Subtitle C--Miscellaneous and Technical Corrections Relating to OBRA-
                                  1993

Sec. 271. Effective date.
Sec. 272. Corrections relating to section 13601 (personal care 
                            services).
Sec. 273. Corrections relating to section 13604 (emergency services for 
                            aliens).
Sec. 274. Corrections relating to section 13611 (transfers of assets; 
                            treatment of certain trusts).
Sec. 275. Corrections relating to section 13612 (medicaid estate 
                            recoveries).
Sec. 276. Corrections relating to section 13622 (liability of third 
                            parties to pay for care and services).
Sec. 277. Corrections relating to section 13623 (medical child 
                            support).
Sec. 278. Corrections relating to section 13624 (physician referrals).
Sec. 279. Corrections relating to section 13631 (medicaid pediatric 
                            immunization provisions).
Sec. 280. Corrections relating to section 13643 (demonstration 
                            projects).
   TITLE III--INCOME SECURITY, HUMAN RESOURCES, AND RELATED PROGRAMS

            Subtitle A--Child Welfare, Foster Care, Adoption

Sec. 301. Required protections for foster children.
Sec. 302. Conformity reviews.
Sec. 303. States required to report on measures taken to comply with 
                            the Indian Child Welfare Act.
Sec. 304. Child welfare traineeships.
Sec. 305. Dispositional hearing.
Sec. 306. Elimination of foster care ceilings and of authority to 
                            transfer unused foster care funds to child 
                            welfare services programs.
Sec. 307. Demonstration projects.
Sec. 308. Placement accountability.
Sec. 309. Payments of State claims for foster care and adoption 
                            assistance.
Sec. 310. Effect of failure to carry out State plan.
                 Subtitle B--Child Support Enforcement

Sec. 311. Reports to credit bureaus on persons delinquent in child 
                            support payments.
Sec. 312. Technical amendments to provision on State paternity 
                            establishment programs.
Sec. 313. Agreement to assist in locating missing children under the 
                            parent locator service.
                Subtitle C--Supplemental Security Income

Sec. 321. Definition of disability for children under age 18 applied to 
                            all individuals under age 18.
Sec. 322. Commission on Childhood Disability.
Sec. 323. Exemption from pass-along requirements.
          Subtitle D--Aid to Families With Dependent Children

Sec. 331. Simplification of income and eligibility verification system.
Sec. 332. Measurement and reporting of welfare receipt.
Sec. 333. New Hope demonstration project.
Sec. 334. Delay in requirement that outlying areas operate an AFDC-up 
                            program.
Sec. 335. New York State child support demonstration program.
Sec. 336. State option to use retrospective budgeting without monthly 
                            reporting.
                        Subtitle E--JOBS Program

Sec. 341. Expansion of coverage for Indian tribes.
Sec. 342. Report to the Congress with respect to performance standards 
                            in the JOBS program.
                   Subtitle F--Unemployment Insurance

Sec. 351. Extension of reporting date for advisory council.
Sec. 352. Technical amendment to unemployment trust fund.
                      Subtitle G--Other Provisions

Sec. 361. Extension of demonstration to expand job opportunities.
Sec. 362. Early childhood development projects.
Sec. 363. Reallocation of funds under title XX for empowerment and 
                            enterprise grants.
Sec. 364. Corrections related to the income security and human 
                            resources provisions of OBRA-1990.
Sec. 365. Technical corrections related to the human resource and 
                            income security provisions of OBRA-1989.
Sec. 366. Technical correction related to the human resource and income 
                            security provisions of OBRA-1993.
Sec. 367. Elimination of obsolete provisions relating to treatment of 
                            the earned income tax credit.
Sec. 368. Redesignation of certain provisions.

                      TITLE I--MEDICARE PROVISIONS

               Subtitle A--Provisions Relating to Part A

SEC. 101. PROVISIONS RELATING TO ADJUSTMENTS TO STANDARDIZED AMOUNTS 
              FOR WAGES AND WAGE-RELATED COSTS.

    (a) Use of Occupational Mix in Guidelines for Determination of Area 
Wage Index.--
            (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.
    (b) Conforming Amendments Relating to Geographic Area Used to 
Determine Wage Index Applicable to Hospital.--(1) Section 1886(d)(8)(C) 
(42 U.S.C. 1395ww(d)(8)(C)), as amended by section 13501(b)(1) of OBRA-
1993, is amended--
            (A) in clause (iv), by striking ``paragraph (1)'' and 
        inserting ``paragraph (10)''; and
            (B) by adding at the end the following new clause:
    ``(v) This subparagraph shall apply with respect to discharges 
occurring in a fiscal year only if the Secretary uses a method for 
making adjustments to the DRG prospective payment rate for area 
differences in hospital wage levels under paragraph (3)(E) for the 
fiscal year that is based on the use of Metropolitan Statistical Area 
classifications.''.
    (2) Section 1886(d)(10) (42 U.S.C. 1395ww(d)(10)) is amended--
            (A) in subparagraph (C)(i)(II), by striking ``the area wage 
        index applicable'' and inserting ``the factor used to adjust 
        the DRG prospective payment rate for area differences in 
        hospital wage levels that applies''; and
            (B) in subparagraph (D)--
                    (i) by redesignating clause (ii) as clause (iii), 
                and
                    (ii) by inserting after clause (i) the following 
                new clause:
    ``(ii) Notwithstanding clause (i), if the Secretary uses a method 
for making adjustments to the DRG prospective payment rate for area 
differences in hospital wage levels under paragraph (3)(E) that is not 
based on the use of Metropolitan Statistical Area classifications, the 
Secretary may revise the guidelines published under clause (i) to the 
extent such guidelines are used to determine the appropriateness of the 
geographic area in which the hospital is determined to be located for 
purposes of making such adjustments.''.
    (c) Adjustment of Labor and Non-Labor Portions of Standardized 
Amounts.--Section 1886(d)(3)(A)(iii) (42 U.S.C. 1395ww(d)(3)(A)(iii)) 
is amended by adding at the end the following: ``For discharges 
occurring on or after October 1, 1994, the Secretary shall adjust the 
ratio of the labor portion to non-labor portion of each average 
standardized amount to equal such ratio for the national average of all 
standardized amounts.''.

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

    (a) Increasing Number of Participating States.--Section 1820(a)(1) 
(42 U.S.C. 1395i-4(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. 1395i-
        4(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. 1395i-4(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. 1395i-4) 
                is amended--
                            (i) by striking paragraph (1) of subsection 
                        (e) and redesignating paragraphs (2) through 
                        (6) as paragraphs (1) through (5);
                            (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)'', and
                                    (III) by striking ``or (iii)'' and 
                                all that follows through ``section,''; 
                                and
                            (iii) 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. 1395i-4) 
                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. 1395i-4(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. 1395i-4(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. 1395i-4(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) Deadline for Development of Prospective Payment System for 
Inpatient Rural Primary Care Hospital Services.--Section 1814(l)(2) (42 
U.S.C. 1395f(l)(2)) is amended by striking ``January 1, 1993'' and 
inserting ``January 1, 1996''.
    (f) Payment for Outpatient Rural Primary Care Hospital Services.--
            (1) Implementation of prospective payment system.--Section 
        1834(g) (42 U.S.C. 1395m(g)) is amended--
                    (A) in paragraph (1), by striking ``during a year 
                before 1993'' and inserting ``during a year before the 
                prospective payment system described in paragraph (2) 
                is in effect''; and
                    (B) in paragraph (2), by striking ``January 1, 
                1993,'' and inserting ``January 1, 1996,''.
            (2) No use of customary charge in determining payment.--
        Section 1834(g)(1) (42 U.S.C. 1395m(g)(1)) is amended by adding 
        at the end the following new flush sentence:
        ``The amount of payment shall be determined under either method 
        without regard to the amount of the customary or other 
        charge.''.
    (g) Clarification of Physician Staffing Requirement for Rural 
Primary Care Hospitals.--Section 1820(f)(1)(H) (42 U.S.C. 1395i-
4(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).''.
    (h) 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''.
    (i) Authorization of Appropriations.--Section 1820(l) (42 U.S.C. 
1395i-4(l)), as redesignated by subsection (c)(2)(A), is amended by 
striking ``1990, 1991, and 1992'' and inserting ``1990 through 1995''.
    (j) Effective Date.--The amendments made by this section shall take 
effect on the date of the enactment of this Act.

SEC. 103. PROVISIONS RELATING TO RURAL HEALTH TRANSITION GRANT PROGRAM.

    (a) Eligibility of Rural Primary Care Hospitals for Grants.--
            (1) In general.--Section 4005(e)(2) of OBRA-1987 is amended 
        in the matter preceding subparagraph (A) by inserting ``any 
        rural primary care hospital designated by the Secretary under 
        section 1820(i)(2) of the Social Security Act, or'' after 
        ``means''.
            (2) Effective date.--The amendment made by paragraph (1) 
        shall apply to grants made on or after October 1, 1993.
    (b) Extension of Authorization of Appropriations.--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''.
    (c) Frequency of Required Reports.--Section 4008(e)(8)(B) of OBRA-
1987 is amended by striking ``every 6 months'' and inserting ``every 12 
months''.

SEC. 104. 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. 105. MEDICARE-DEPENDENT, SMALL RURAL HOSPITALS AND SOLE COMMUNITY 
              HOSPITALS.

    (a) Medicare Dependent, Small Rural Hospitals.--
            (1) Clarification of additional payment.--Section 
        1886(d)(5)(G)(ii)(I) (42 U.S.C. 1395ww(d)(5)(G)(ii)(I)), as 
        amended by section 13501(e)(1) of OBRA-1993, is amended by 
        striking ``the first 3 12-month cost reporting periods that 
        begin'' and inserting ``the 36-month period beginning with the 
        first day of the cost reporting period that begins''.
            (2) Conforming target amounts to extension of additional 
        payments.--Section 1886(b)(3)(D) (42 U.S.C. 1395ww(b)(3)(D)) is 
        amended in the matter preceding clause (i) by striking ``March 
        31, 1993'' and inserting ``September 30, 1994''.
    (b) Clarification of Updates.--Section 1886(b)(3)(B)(iv)(II) (42 
U.S.C. 1395ww(b)(3)(B)(iv)(II)), as added by section 13501(a)(2) of 
OBRA-1993, is amended by striking ``(taking into account'' and all that 
follows through ``1994)'' and inserting ``(adjusted to exclude any 
portion of a cost reporting period beginning during fiscal year 1993 
for which the applicable percentage increase is determined under 
subparagraph (I))''.

SEC. 106. SKILLED NURSING FACILITIES.

    (a) Construction of Wage Index.--Not later than 1 year after 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) Clarification of Repeal of Utilization Review Requirements.--
            (1) In general.--(A) Section 1814(a)(5) (42 U.S.C. 
        1395f(a)(5)) is amended--
                    (i) by striking ``and with respect'' and all that 
                follows through ``regulations'';
                    (ii) by striking ``or skilled nursing facility, as 
                the case may be''; and
                    (iii) by striking ``or facility''.
            (B) Section 1866(d) (42 U.S.C. 1395cc(d)) is amended--
                    (i) by striking ``or skilled nursing facility'';
                    (ii) by striking ``or facility'' each place it 
                appears;
                    (iii) by striking ``or for post-hospital'' and all 
                that follows through ``the case may be''; and
                    (iv) by striking ``, or (in the case of'' and all 
                that follows through ``transfer agreement,''.
             (2) Effective date.--The amendments made by paragraph (1) 
        shall take effect as if included in the enactment of OBRA-1987.
    (c) Conforming Amendments to Nursing Home Reform.--
            (1) Suspension of decertification of nurses aide training 
        and competency evaluation programs based on extended surveys.--
                    (A) In general.--Section 1819(f)(2)(B)(iii)(I)(b) 
                (42 U.S.C. 1395i-3(f)(2)(B)(iii)(I)(b)) is amended by 
                striking the semicolon and inserting the following: ``, 
                unless the survey shows that the facility is in 
                compliance with the requirements of subsections (b), 
                (c), and (d) of this section;''.
                    (B) Effective date.--The amendment made by 
                subparagraph (A) shall take effect as if included in 
                the enactment of OBRA-1990.
            (2) Requirements for consultants conducting reviews on use 
        of drugs.--
                    (A) In general.--Section 1819(c)(1)(D) (42 U.S.C. 
                1395i-3(c)(1)(D)) is amended by adding at the end the 
                following sentence: ``In determining whether such a 
                consultant is qualified to conduct reviews under the 
                preceding sentence, the Secretary shall take into 
                account the needs of nursing facilities under this 
                title to have access to the services of such a 
                consultant on a timely basis.''.
                    (B) Effective date.--The amendment made by 
                subparagraph (A) shall take effect as if included in 
                the enactment of OBRA-1987.
            (3) Increase in minimum amount required for separate 
        deposit of personal funds.--
                    (A) In general.--Section 1819(c)(6)(B)(i) (42 
                U.S.C. 1395i-3(c)(6)(B)(i)) is amended by striking 
                ``$50'' and inserting ``$100''.
                    (B) Effective date.--The amendment made by 
                subparagraph (A) shall take effect January 1, 1994.
            (4) Due process protections for nurse aides.--
                    (A) Prohibiting state from including undocumented 
                allegations in nurses aide registry.--Section 
                1819(e)(2)(B) (42 U.S.C. 1395i-3(e)(2)(B)) is amended 
                by striking the period at the end of the first sentence 
                and inserting the following: ``, but shall not include 
                any allegations of resident abuse or neglect or 
                misappropriation of resident property that are not 
                specifically documented by the State under such 
                subsection.''.
                    (B) Due process requirements for rebutting 
                allegations.--Section 1819(g)(1)(C) (42 U.S.C. 1395i-
                3(g)(1)(C)) is amended by striking the second sentence 
                and inserting the following: ``The State shall, after 
                providing the individual involved with a written notice 
                of the allegations (including a statement of the 
                availability of a hearing for the individual to rebut 
                the allegations) and the opportunity for a hearing on 
                the record, make a written finding as to the accuracy 
                of the allegations.''.
                    (C) Effective date.--The amendments made by this 
                paragraph shall take effect January 1, 1994.
    (d) Corrections Relating to Section 4008.--
            (1) Section 1819(b)(5)(D) (42 U.S.C. 1395i-3(b)(5)(D)), as 
        amended by section 4008(h)(1)(D) of OBRA-1990, is amended by 
        striking the comma before ``or a new competency evaluation 
        program.''.
            (2) Section 1819(b)(5)(G) (42 U.S.C. 1395i-3(b)(5)(G)) is 
        amended by striking ``or licensed or certified social worker'' 
        and inserting ``licensed or certified social worker, registered 
        respiratory therapist, or certified respiratory therapy 
        technician''.
            (3) Section 1819(f)(2)(B)(i) (42 U.S.C. 1395i-
        3(f)(2)(B)(i)) is amended by striking ``facilities,'' and 
        inserting ``facilities (subject to clause (iii)),''.
            (4) Section 1819(f)(2)(B)(iii)(I)(c) (42 U.S.C. 1395i-
        3(f)(2)(B)(iii)(I)(c)) is amended by striking ``clauses'' each 
        place it appears and inserting ``clause''.
            (5) Section 1819(g)(5)(B) (42 U.S.C. 1395i-3(g)(5)(B)) is 
        amended by striking ``paragraphs'' and inserting ``paragraph''.
            (6) Section 4008(h)(1)(F)(ii) of OBRA-1990 is amended--
                    (A) by striking ``The amendments'' and inserting 
                ``(I) The amendments'';
                    (B) by striking ``nursing facility'' each place it 
                appears and inserting ``skilled nursing facility'';
                    (C) by redesignating subclauses (I) through (V) as 
                items (aa) through (ee); and
                    (D) by adding at the end the following new 
                subclause:
                            ``(II) Notwithstanding subclause (I) and 
                        subject to section 1819(f)(2)(B)(iii)(I) of the 
                        Social Security Act (as amended by clause (i)), 
                        a State may approve a training and competency 
                        evaluation program or a competency evaluation 
                        program offered by or in a skilled nursing 
                        facility described in subclause (I) if, during 
                        the previous 2 years, item (aa), (bb), (cc), 
                        (dd), or (ee) of subclause (I) did not apply to 
                        the facility.''.
            (7) Effective date.--The amendments made by this subsection 
        shall take effect as if included in the enactment of OBRA-1990.

SEC. 107. NOTIFICATION OF AVAILABILITY OF HOSPICE BENEFIT.

    (a) In General.--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) 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. 108. CLARIFYING EXPERTISE OF INDIVIDUALS TO SERVE ON THE 
              PROSPECTIVE PAYMENT ASSESSMENT COMMISSION.

    Section 1886(e)(6)(B) (42 U.S.C. 1395ww(e)(6)(B)) is amended by 
striking ``hospital reimbursement, hospital financial management'' and 
inserting ``health facility management, reimbursement of health 
facilities or other providers of services which reflect the scope of 
the Commission's responsibilities''.

SEC. 109. AUTHORITY FOR BUDGET NEUTRAL ADJUSTMENTS FOR CHANGES IN 
              PAYMENT AMOUNTS FOR TRANSFER CASES.

    Section 1886(d)(5)(I) (42 U.S.C. 1395ww(d)(5)) is amended--
            (1) by inserting ``(i)'' after ``(I)''; and
            (2) by adding at the end the following new clause:
    ``(ii) In making adjustments under clause (i) for transfer cases 
(as defined by the Secretary) in a fiscal year, the Secretary may make 
adjustments to each of the average standardized amounts determined 
under paragraph (3) to assure that the aggregate payments made under 
this subsection for such fiscal year are not greater or lesser than 
those that would have otherwise been made in such fiscal year.''.

SEC. 110. CLARIFICATION OF DRG PAYMENT WINDOW EXPANSION; 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 amended by 
inserting ``(or, in the case of a hospital that is not a subsection (d) 
hospital, during the 1 day)'' after ``3 days''.
    (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) Technical Correction Relating to Applicable Adjustment Factor 
for Indirect Medical Education Adjustment.--Section 1886(d)(5)(B)(ii) 
(42 U.S.C. 1395ww(d)(5)(B)(ii)) is amended by striking ``May 1, 1986,'' 
and inserting ``October 1, 1988,''.
    (d) 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''.

               Subtitle B--Provisions Relating to Part B

                      PART I--PHYSICIANS' SERVICES

SEC. 121. DEVELOPMENT AND IMPLEMENTATION OF RESOURCE-BASED METHODOLOGY 
              FOR PRACTICE EXPENSES.

    (a) Development.--
            (1) In general.--The Secretary of Health and Human Services 
        shall develop a methodology for implementing in 1997 a 
        resource-based system for determining practice expense relative 
        value units for each physicians' service. The methodology 
        utilized shall recognize the staff, equipment, and supplies 
        used in the provision of various medical and surgical services 
        in various settings.
            (2) Report.--The Secretary shall transmit a report by June 
        30, 1995, on the methodology developed under paragraph (1) to 
        the Committees on Ways and Means and Energy and Commerce of the 
        House of Representatives and the Committee on Finance of the 
        Senate. The report shall include a presentation of data 
        utilized in developing the methodology and an explanation of 
        the methodology.
    (b) Implementation.--
            (1) In general.--Section 1848(c)(2)(C)(ii) (42 U.S.C. 
        1395w-4(c)(2)(C)(ii)) is amended--
                    (A) by inserting ``for the service for years before 
                1997'' before ``equal to'',
                    (B) by striking the period at the end of subclause 
                (II) and inserting a comma, and
                    (C) by adding after and below subclause (II) the 
                following:
                        ``and for years beginning with 1997 based on 
                        the relative practice expense resources 
                        involved in furnishing the service.''.
            (2) Conforming amendment.--Section 1848(c)(3)(C)(ii) (42 
        U.S.C. 1395w-4(c)(3)(C)(ii)) is amended by striking ``The 
        practice'' and inserting ``For years before 1997, the 
        practice''.
            (3) Application of certain provisions.--In implementing the 
        amendment made by paragraph (1)(C), the provisions of clauses 
        (ii)(II) and (iii) of section 1848(c)(2)(B) of the Social 
        Security Act shall apply in the same manner as they apply to 
        adjustments under clause (ii)(I) of such section.

SEC. 122. GEOGRAPHIC COST OF PRACTICE INDEX REFINEMENTS.

    (a) Requiring Consultation with Representatives of Physicians in 
Reviewing Geographic Adjustment Factors.--Section 1848(e)(1)(C) (42 
U.S.C. 1395w-4(e)(1)(C)) is amended by striking ``shall review'' and 
inserting ``shall, in consultation with appropriate representatives of 
physicians, review''.
    (b) Use of Most Recent Data In Geographic Adjustment.--Section 
1848(e)(1) (42 U.S.C. 1395w-4(e)(1)) is amended by adding at the end 
the following new subparagraph:
                    ``(D) Use of recent data.--In establishing indices 
                and index values under this paragraph, the Secretary 
                shall use the most recent data available relating to 
                practice expenses, malpractice expenses, and physician 
                work effort in different fee schedule areas.''.
    (c) Deadline for Initial Review and Revision.--The Secretary of 
Health and Human Services shall first review and revise geographic 
adjustment factors under section 1848(e)(1)(C) of the Social Security 
Act by not later than January 1, 1995. Not later than April 1, 1994, 
the Secretary 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 the construction of the 
geographic cost of practice index under section 1848(e)(1)(A)(i) of 
such Act.
    (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. 123. EXTRA-BILLING LIMITS.

    (a) Enforcement of Limits.--Section 1848(g) (42 U.S.C. 1395w-4(g)), 
as amended by section 13517(a) of OBRA-1993, is amended--
            (1) by amending paragraph (1) to read as follows:
            ``(1) Limitation on actual charges.--
                    ``(A) In general.--In the case of a 
                nonparticipating physician or nonparticipating supplier 
                or other person (as defined in section 1842(i)(2)) who 
                does not accept payment on an assignment-related basis 
                for a physician's service furnished with respect to an 
                individual enrolled under this part, the following 
                rules apply:
                            ``(i) Application of limiting charge.--No 
                        person may bill or collect an actual charge for 
                        the service in excess of the limiting charge 
                        described in paragraph (2) for such service.
                            ``(ii) No liability for excess charges.--No 
                        person is liable for payment of any amounts 
                        billed for the service in excess of such 
                        limiting charge.
                            ``(iii) Correction of excess charges.--If 
                        such a physician, supplier, or other person 
                        bills, but does not collect, an actual charge 
                        for a service in violation of clause (i), the 
                        physician, supplier, or other person shall 
                        reduce on a timely basis the actual charge 
                        billed for the service to an amount not to 
                        exceed the limiting charge for the service.
                            ``(iv) Refund of excess collections.--If 
                        such a physician, supplier, or other person 
                        collects an actual charge for a service in 
                        violation of clause (i), the physician, 
                        supplier, or other person shall provide on a 
                        timely basis a refund to the individual charged 
                        in the amount by which the amount collected 
                        exceeded the limiting charge for the service. 
                        The amount of such a refund shall be reduced to 
                        the extent the individual has an outstanding 
                        balance owed by the individual to the 
                        physician.
                    ``(B) Sanctions.--If a physician, supplier, or 
                other person--
                            ``(i) knowingly and willfully bills or 
                        collects for services in violation of 
                        subparagraph (A)(i) on a repeated basis, or
                            ``(ii) fails to comply with clause (iii) or 
                        (iv) of subparagraph (A) on a timely basis,
                the Secretary may apply sanctions against the 
                physician, supplier, or other person in accordance with 
                paragraph (2) of section 1842(j). In applying this 
                subparagraph, paragraph (4) of such section applies in 
                the same manner as such paragraph applies to such 
                section and any reference in such section to a 
                physician is deemed also to include a reference to a 
                supplier or other person under this subparagraph.
                    ``(C) Timely basis.--For purposes of this 
                paragraph, a correction of a bill for an excess charge 
                or refund of an amount with respect to a violation of 
                subparagraph (A)(i) in the case of a service is 
                considered to be provided `on a timely basis', if the 
                reduction or refund is made not later than 30 days 
                after the date the physician, supplier, or other person 
                is notified by the carrier under this part of such 
                violation and of the requirements of subparagraph 
                (A).''; and
            (2) in paragraph (3)(B)--
                    (A) 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
                    (B) in the last sentence, by striking ``previous 
                sentence'' and inserting ``first sentence''.
    (b) Clarification of Mandatory Assignment Rules for Certain 
Practitioners.--
            (1) In general.--Section 1842(b) (42 U.S.C. 1395u(b)), as 
        amended by section 126(e), is amended by adding at the end the 
        following new paragraph:
    ``(18)(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 subsection (j)(2) in the same manner as such section applies with 
respect to a physician. Paragraph (4) of subsection (j) shall apply in 
this subparagraph in the same manner as such paragraph applies to such 
section.
    ``(C) A practitioner described in this subparagraph is any of the 
following:
            ``(i) A physician assistant, nurse practitioner, or 
        clinical nurse specialist (as defined in section 1861(aa)(5)).
            ``(ii) A certified registered nurse anesthetist (as defined 
        in section 1861(bb)(2)).
            ``(iii) A certified nurse-midwife (as defined in section 
        1861(gg)(2)).
            ``(iv) A clinical social worker (as defined in section 
        1861(hh)(1)).
            ``(v) A clinical psychologist (as defined by the Secretary 
        for purposes of section 1861(ii)).
    ``(D) For purposes of this paragraph, a service furnished by a 
practitioner described in subparagraph (C) includes any services and 
supplies furnished as incident to the service as would otherwise be 
covered under this part if furnished by a physician or as incident to a 
physician's service.''.
            (2) Conforming amendments.--
                    (A) Section 1833 (42 U.S.C. 1395l) is amended--
                            (i) in subsection (l)(5), by striking 
                        subparagraph (B) and redesignating subparagraph 
                        (C) as subparagraph (B);
                            (ii) by striking subsection (p); and
                            (iii) in subsection (r), by striking 
                        paragraph (3) and redesignating paragraph (4) 
                        as paragraph (3).
                    (B) Section 1842(b)(12) (42 U.S.C. 1395u(b)(12)) is 
                amended by striking subparagraph (C).
    (c) Information on Extra-Billing Limits.--
            (1) Part of explanation of medicare benefits.--Section 
        1842(h)(7) (42 U.S.C. 1395u(h)(7)) is amended--
                    (A) by striking ``and'' at the end of subparagraph 
                (B),
                    (B) in subparagraph (C), by striking ``shall 
                include'',
                    (C) in subparagraph (C), by striking the period at 
                the end and inserting ``, and'', and
                    (D) by adding at the end the following new 
                subparagraph:
            ``(D) in the case of services for which the billed amount 
        exceeds the limiting charge imposed under section 1848(g), 
        information regarding such applicable limiting charge 
        (including information concerning the right to a refund under 
        section 1848(g)(1)(A)(iv)).''.
            (2) Determinations by carriers.--Subparagraph (G) of 
        section 1842(b)(3) (42 U.S.C. 1395u(b)(3)) is amended to read 
        as follows:
            ``(G) will, for a service that is furnished with respect to 
        an individual enrolled under this part, that is not paid on an 
        assignment-related basis, and that is subject to a limiting 
        charge under section 1848(g)--
                    ``(i) determine, prior to making payment, whether 
                the amount billed for such service exceeds the limiting 
                charge applicable under section 1848(g)(2);
                    ``(ii) notify the physician, supplier, or other 
                person periodically (but not less often than once every 
                30 days) of determinations that amounts billed exceeded 
                such applicable limiting charges; and
                    ``(iii) provide for prompt response to inquiries of 
                physicians, suppliers, and other persons concerning the 
                accuracy of such limiting charges for their 
                services;''.
    (d) Report on Charges in Excess of Limiting Charge.--Section 
1848(g)(6)(B) (42 U.S.C. 1395w-4(g)(6)(B)) is amended by inserting 
``information on the extent to which actual charges exceed limiting 
charges, the number and types of services involved, and the average 
amount of excess charges and information'' after ``report to the 
Congress''.
    (e) Miscellaneous and Technical Amendments.--Section 1833(h)(5)(D) 
(42 U.S.C. 1395l(h)(5)(D)) is amended--
            (1) by striking ``paragraphs (2) and (3)'' and by inserting 
        ``paragraph (2)''; and
            (2) 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; miscellaneous and technical amendments.--
        The amendments made by subsections (a) and (e) shall apply to 
        services furnished on or after the date of the enactment of 
        this Act; except that the amendments made by subsection (a) 
        shall not apply to services of a nonparticipating supplier or 
        other person furnished before January 1, 1994.
            (2) Practitioners.--The amendments made by subsection (b) 
        shall apply to services furnished on or after January 1, 1994.
            (3) EOMBs.--The amendments made by subsection (c)(1) shall 
        apply to explanations of benefits provided on or after July 1, 
        1994.
            (4) Carrier determinations.--The amendments made by 
        subsection (c)(2) shall apply to contracts as of January 1, 
        1994.
            (5) Report.--The amendment made by subsection (d) shall 
        apply to reports for years beginning with 1994.

SEC. 124. RELATIVE VALUES FOR PEDIATRIC SERVICES.

    (a) In General.--The Secretary of Health and Human Services shall 
fully develop, by not later than October 1, 1994, relative values for 
the full range of pediatric physicians' services which are consistent 
with the relative values developed for other physicians' services under 
section 1848(c) of the Social Security Act. In developing such values, 
the Secretary shall conduct such refinements as may be necessary to 
produce appropriate estimates for such relative values.
    (b) Study.--
            (1) In general.--The Secretary shall conduct a study of the 
        relative values for pediatric and other services to determine 
        whether there are significant variations in the resources used 
        in providing similar services to different populations. In 
        conducting such study, the Secretary shall consult with 
        appropriate organizations representing pediatricians and other 
        physicians and physical and occupational therapists.
            (2) Report.--Not later than July 1, 1995, 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. 125. 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 
        subparagraph 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. 126. MISCELLANEOUS AND TECHNICAL CORRECTIONS.

    (a) Overvalued Procedures.--(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.--(1) Section 1834(b)(4) (42 U.S.C. 
1395m(b)(4)) is amended by redesignating the subparagraphs (E) and (F) 
redesignated by section 4102(a)(1) of OBRA-1990 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.--(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.--(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 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 is 
amended--
            (1) in subsection (a)--
                    (A) by striking ``(a) 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 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 4106(c) of OBRA-1990 is amended by inserting ``of the 
Social Security Act'' after ``1848(d)(1)(B)''.
    (4) Section 4114 of OBRA-1990 is amended by striking ``patients'' 
the second place it appears.
    (5) Section 1848(e)(1)(C) (42 U.S.C. 1395w-4(e)(1)(C)) is amended 
by inserting ``date of the'' after ``since the''.
    (6) Section 4118(f)(1)(D) of OBRA-1990 is amended by striking ``is 
amended''.
    (7) Section 4118(f)(1)(N)(ii) of OBRA-1990 is amended by striking 
``subsection (f)(5)(A)'' and inserting ``subsection (f)(5)(A))''.
    (8) 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).
    (9) Section 4118(j)(2) of OBRA-1990 is amended by striking ``In 
section'' and inserting ``Section''.
    (10)(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--
            (i) by striking ``apply to'' and inserting ``would 
        otherwise apply to'', and
            (ii) by inserting before the period at the end ``but for 
        the application of section 1848(i)(3)''.
    (i) Other Corrections.--(1) Effective on the date of the enactment 
of this Act, section 6102(d)(4) of OBRA-1989 is amended by striking all 
that follows the first sentence.
    (2) Effective for payments for fiscal years beginning with fiscal 
year 1994, section 1842(c)(1) (42 U.S.C. 1395u(c)(1)) is amended--
            (A) in subparagraph (A), by striking ``(A) Any contract'' 
        and inserting ``Any contract''; and
            (B) by striking subparagraph (B).
    (j) Effective Date.--Except as provided in subsection (i), the 
amendments made by this section and the provisions of this section 
shall take effect as if included in the enactment of OBRA-1990.

                   PART II--DURABLE MEDICAL EQUIPMENT

SEC. 131. CERTIFICATION OF SUPPLIERS.

    (a) Requirements.--
            (1) In general.--Section 1834 (42 U.S.C. 1395m), as amended 
        by section 13544(b)(1) of OBRA-1993, is amended by adding at 
        the end the following new subsection:
    ``(j) 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 May 
                1, 1994, for items furnished by a supplier of medical 
                equipment and supplies unless such supplier obtains 
                (and renews at such intervals as the Secretary may 
                require) a supplier number.
                    ``(B) Standards for possessing a supplier number.--
                A supplier may not obtain a supplier number unless--
                            ``(i) for medical equipment and supplies 
                        furnished on or after May 1, 1994, and before 
                        January 1, 1996, the supplier meets standards 
                        prescribed by the Secretary in regulations 
                        issued on June 18, 1992; and
                            ``(ii) for medical equipment and supplies 
                        furnished on or after January 1, 1996, the 
                        supplier meets revised standards prescribed by 
                        the Secretary (in consultation with 
                        representatives of suppliers of medical 
                        equipment and supplies, carriers, and 
                        consumers) that shall include requirements that 
                        the supplier--
                                    ``(I) comply with all applicable 
                                State and Federal licensure and 
                                regulatory requirements;
                                    ``(II) maintain a physical facility 
                                on an appropriate site;
                                    ``(III) have proof of appropriate 
                                liability insurance; and
                                    ``(IV) meet such other requirements 
                                as the Secretary may specify.
                    ``(C) Exception for items furnished as incident to 
                a physician's service.--Subparagraph (A) shall not 
                apply with respect to medical equipment and supplies 
                furnished incident to a physician's service.
                    ``(D) Prohibition against multiple supplier 
                numbers.--The Secretary may not issue more than one 
                supplier number to any supplier of medical equipment 
                and supplies unless the issuance of more than one 
                number is appropriate to identify subsidiary or 
                regional entities under the supplier's ownership or 
                control.
                    ``(E) Prohibition against delegation of supplier 
                determinations.--The Secretary may not delegate (other 
                than by contract under section 1842) the responsibility 
                to determine whether suppliers meet the standards 
                necessary to obtain a supplier number.
            ``(2) Certificates of medical necessity.--
                    ``(A) Standardized certificates.--Not later than 
                October 1, 1994, the Secretary shall, in consultation 
                with carriers under this part, develop one or more 
                standardized certificates of medical necessity (as 
                defined in subparagraph (C)) for medical equipment and 
                supplies for which the Secretary determines that such a 
                certificate is necessary.
                    ``(B) Limitation on information provided by 
                suppliers on certificates of medical necessity.--
                            ``(i) In general.--Effective May 1, 1994, a 
                        supplier of medical equipment and supplies may 
                        distribute to physicians, or to individuals 
                        entitled to benefits under this part, a 
                        certificate of medical necessity for commercial 
                        purposes which contains no more than the 
                        following information completed by the 
                        supplier:
                                    ``(I) An identification of the 
                                supplier and the beneficiary to whom 
                                such medical equipment and supplies are 
                                furnished.
                                    ``(II) A description of such 
                                medical equipment and supplies.
                                    ``(III) Any product code 
                                identifying such medical equipment and 
                                supplies.
                                    ``(IV) Any other administrative 
                                information (other than information 
                                relating to the beneficiary's medical 
                                condition) identified by the Secretary.
                            ``(ii) Information on payment amount and 
                        charges.--If a supplier distributes a 
                        certificate of medical necessity containing any 
                        of the information permitted to be supplied 
                        under clause (i), the supplier shall also list 
                        on the certificate of medical necessity 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) or fails 
                        to provide the information required under 
                        clause (ii) 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 carrier to be submitted to show that an item is 
                reasonable and necessary for the diagnosis or treatment 
                of illness or injury or to improve the functioning of a 
                malformed body member.
            ``(3) Coverage and review criteria.--
                    ``(A) Development and establishment.--Not later 
                than January 1, 1996, the Secretary, in consultation 
                with representatives of suppliers of medical equipment 
                and supplies, individuals enrolled under this part, and 
                appropriate medical specialty societies, shall develop 
                and establish coverage and utilization review criteria 
                for 100 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 available to 
                suppliers 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) a wide variation in the coverage or 
                        utilization criteria applied to the item exists 
                        among carriers (as of the date of the enactment 
                        of this subsection).
                    ``(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 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)),
                            ``(ii) immunosuppressive drugs (as 
                        described in section 1861(s)(2)(J)),
                            ``(iii) therapeutic shoes for diabetics (as 
                        described in section 1861(s)(12)),
                            ``(iv) oral drugs prescribed for use as an 
                        anticancer therapeutic agent (as described in 
                        section 1861(s)(2)(Q)), and
                            ``(v) self-administered erythropoetin (as 
                        described in section 1861(s)(2)(P)).''.
            (2) Conforming amendment.--Effective October 1, 1994, 
        paragraph (16) of section 1834(a) (42 U.S.C. 1395m(a)) is 
        repealed.
    (b) Use of Covered Items by Disabled Beneficiaries.--
            (1) In general.--The Secretary of Health and Human 
        Services, in consultation with representatives of suppliers of 
        durable medical equipment under part B of the medicare program 
        and individuals entitled to benefits under such program on the 
        basis of disability, shall conduct a study of the effects of 
        the methodology for determining payments for items of such 
        equipment under such part on the ability of such individuals to 
        obtain items of such equipment, including customized items.
            (2) Report.--Not later than one year after the date of the 
        enactment of this Act, the Secretary shall submit a report to 
        Congress on the study conducted under paragraph (1), and shall 
        include in the report such recommendations as the Secretary 
        considers appropriate to assure that disabled medicare 
        beneficiaries have access to items of durable medical 
        equipment.
    (c) Criteria for Treatment of Items as Prosthetic Devices or 
Orthotics and Prosthetics.--Not later than one year after the date of 
the enactment of this Act, the Secretary of Health and Human Services 
shall submit a report to the Committees on Ways and Means and Energy 
and Commerce of the House of Representatives and the Committee on 
Finance of the Senate describing prosthetic devices or orthotics and 
prosthetics covered under part B of the medicare program that do not 
require individualized or custom fitting and adjustment to be used by a 
patient. Such report shall include recommendations for an appropriate 
methodology for determining the amount of payment for such items under 
such program.

SEC. 132. PROHIBITION AGAINST CARRIER FORUM SHOPPING.

    (a) In General.--
            (1) Prohibition described.--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, 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) 
                Unless permitted by the Secretary, 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.''.
            (2) Clarification of authority to designate carriers for 
        other items and services.--Nothing in the amendment made by 
        paragraph (1) 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.
    (b) Effective Date.--The amendment made by subsection (a) shall 
apply to claims processed on or after May 1, 1994.

SEC. 133. 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 unless 1 
                of the following applies:
                            ``(i) The individual has given written 
                        permission to the supplier to make contact by 
                        telephone regarding the furnishing of a covered 
                        item.
                            ``(ii) The supplier has furnished a covered 
                        item to the individual and the supplier is 
                        contacting the individual only regarding the 
                        furnishing of such covered item.
                            ``(iii) If the contact is regarding the 
                        furnishing of a covered item other than a 
                        covered item already furnished to the 
                        individual, the supplier has furnished at least 
                        1 covered item to the individual during the 15-
                        month period preceding the date on which the 
                        supplier makes such contact.
                    ``(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. 134. KICKBACK CLARIFICATION.

    (a) In General.--Section 1128B(b)(3)(B) (42 U.S.C. 1320a-
7b(b)(3)(B)) is amended by inserting before the semicolon the 
following: ``(except that in the case of a contract supply arrangement 
between any entity and a supplier of medical supplies and equipment (as 
defined in section 1834(j)(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. 135. BENEFICIARY LIABILITY FOR NONCOVERED SERVICES.

    (a) Unassigned Claims.--
            (1) In general.--Section 1834(j) (42 U.S.C. 1395m(i)), as 
        added by section 131(a)(1), is amended--
                    (A) by redesignating paragraph (4) as paragraph 
                (5), and
                    (B) by inserting after paragraph (3) the following 
                new paragraph:
            ``(4) Limitation on patient liability.--If a supplier of 
        medical equipment and supplies (as defined in paragraph (5))--
                    ``(A) furnishes an item or service to a beneficiary 
                for which no payment may be made by reason of paragraph 
                (1);
                    ``(B) furnishes an item or service to a beneficiary 
                for which payment is denied in advance under subsection 
                (a)(15); or
                    ``(C) furnishes an item or service to a beneficiary 
                for which payment is denied under section 1862(a)(1);
        any expenses incurred for items and services furnished to an 
        individual by such a supplier not on an assigned basis shall be 
        the responsibility of such supplier. The individual shall have 
        no financial responsibility for such expenses and the supplier 
        shall refund on a timely basis to the individual (and shall be 
        liable to the individual for) any amounts collected from the 
        individual for such items or services. The provisions of 
        subsection (a)(18) shall apply to refunds required under the 
        previous sentence in the same manner as such provisions apply 
        to refunds under such subsection.''.
            (2) Conforming amendment.--Section 1128B(b)(3)(B) (42 
        U.S.C. 1320a-7b(b)(3)(B)), as amended by section 134(a), is 
        amended by striking ``1834(j)(4)'' and inserting 
        ``1834(j)(5)''.
    (b) Assigned Claims.--Section 1879 (42 U.S.C. 1395pp) is amended by 
adding at the end the following new subsection:
    ``(h) If a supplier of medical equipment and supplies (as defined 
in section 1834(j)(5))--
            ``(1) furnishes an item or service to a beneficiary for 
        which no payment may be made by reason of section 1834(j)(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 no payment may be made by reason of section 
        1834(a)(17)(B),
any expenses incurred for items and services furnished to an individual 
by such a supplier on an assignment-related basis shall be the 
responsibility of such supplier. The individual shall have no financial 
responsibility for such expenses and the supplier shall refund on a 
timely basis to the individual (and shall be liable to the individual 
for) any amounts collected from the individual for such items or 
services. The provisions of section 1834(a)(18) shall apply to refunds 
required under the previous sentence in the same manner as such 
provisions apply to refunds under such section.''.
    (c) Effective Date.--The amendments made by this section shall 
apply to items or services furnished on or after October 1, 1994.

SEC. 136. 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. 137. MISCELLANEOUS AND TECHNICAL CORRECTIONS.

    (a) Updates to Payment Amounts.--(1) 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''.
    (2) The amendment made by paragraph (1) shall be effective on the 
date of the enactment of this Act.
    (b) Advance 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) Advance determinations of coverage for certain 
        items.--
                    ``(A) Development of lists of items by Secretary.--
                The Secretary may develop and periodically update a 
                list of items for which payment may be made under this 
                subsection that the Secretary determines, on the basis 
                of prior payment experience, are frequently subject to 
                unnecessary utilization throughout a carrier's entire 
                service area or a portion of such area.
                    ``(B) Development of lists of suppliers by 
                Secretary.--The Secretary may develop and periodically 
                update a list of suppliers of items for which payment 
                may be made under this subsection with respect to 
                whom--
                            ``(i) the Secretary has found that a 
                        substantial number of claims for payment under 
                        this part for items furnished by the supplier 
                        have been denied on the basis of the 
                        application of section 1862(a)(1); or
                            ``(ii) the Secretary has identified a 
                        pattern of overutilization resulting from the 
                        business practice of the supplier.
                    ``(C) Determinations of coverage in advance.--A 
                carrier shall determine in advance of delivery of an 
                item whether payment for the item may not be made 
                because the item is not covered or because of the 
                application of section 1862(a)(1) if--
                            ``(i) the item is included on the list 
                        developed by the Secretary under subparagraph 
                        (A);
                            ``(ii) the item is furnished by a supplier 
                        included on the list developed by the Secretary 
                        under subparagraph (B); or
                            ``(iii) the item is a customized item 
                        (other than inexpensive items specified by the 
                        Secretary) and the patient to whom the item is 
                        to be furnished or the supplier requests that 
                        such advance determination be made.''.
    (2) 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 125(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)(15)(C).''.
    (3) Effective on the date of the enactment of this Act, section 
1834(h)(3) (42 U.S.C. 1395m(h)(3)), as amended by section 133(b), is 
amended by striking ``(12) and (17)'' and inserting ``(12), (15), and 
(17)''.
    (c) Study of Variations in Durable Medical Equipment Supplier 
Costs.--
            (1) Collection and analysis of supplier cost data.--The 
        Administrator of the Health Care Financing Administration 
        shall, in consultation with appropriate organizations, collect 
        data on supplier costs of durable medical equipment for which 
        payment may be made under part B of the medicare program, and 
        shall analyze such data to determine the proportions of such 
        costs attributable to the service and product components of 
        furnishing such equipment and the extent to which such 
        proportions vary by type of equipment and by the geographic 
        region in which the supplier is located.
            (2) Development of geographic adjustment index; reports.--
        Not later than January 1, 1995--
                    (A) the Administrator shall submit a report to the 
                Committees on Energy and Commerce and Ways and Means of 
                the House of Representatives and the Committee on 
                Finance of the Senate on the data collected and the 
                analysis conducted under paragraph (1), and shall 
                include in such report the Administrator's 
                recommendations for a geographic cost adjustment index 
                for suppliers of durable medical equipment under the 
                medicare program and an analysis of the impact of such 
                proposed index on payments under the medicare program; 
                and
                    (B) the Comptroller General shall submit a report 
                to the Committees on Energy and Commerce and Ways and 
                Means of the House of Representatives and the Committee 
                on Finance of the Senate analyzing on a geographic 
                basis the supplier costs of durable medical equipment 
                under the medicare program.
    (d) Oxygen Retesting.--(1) Section 1834(a)(5)(E) (42 U.S.C. 
1395m(a)(5)(E)) is amended by striking ``55'' and inserting ``56''.
    (2) The amendment made by paragraph (1) shall be effective on the 
date of the enactment of this Act.
    (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.

                   PART III--OTHER ITEMS AND SERVICES

SEC. 141. AMBULATORY SURGICAL CENTER SERVICES.

    (a) Payment Amounts for Services Furnished in Ambulatory Surgical 
Centers.--
            (1) Use of survey to determine incurred costs.--Section 
        1833(i)(2)(A)(i) (42 U.S.C. 1395l(i)(2)(A)(i)) is amended by 
        striking the comma at the end and inserting the following: ``, 
        as determined in accordance with a survey (based upon a 
        representative sample of procedures and facilities) taken not 
        later than January 1, 1995, and every 5 years thereafter, of 
        the actual audited costs incurred by such centers in providing 
        such services,''.
            (2) Automatic application of inflation adjustment.--Section 
        1833(i)(2) (42 U.S.C. 1395l(i)(2)) is amended--
                    (A) 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
                    (B) by adding at the end the following new 
                subparagraph:
    ``(C) Notwithstanding the second sentence of subparagraph (A) or 
the second sentence of subparagraph (B), if the Secretary has not 
updated amounts established under such subparagraphs with respect to 
facility services furnished during a fiscal year (beginning with fiscal 
year 1996), such amounts shall be increased by the percentage increase 
in the consumer price index for all urban consumers (U.S. city average) 
as estimated by the Secretary for the 12-month period ending with the 
midpoint of the year involved.''.
            (3) Consultation requirement.--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.''.
    (b) Adjustments to Payment Amounts for New Technology Intraocular 
Lenses.--
            (1) Establishment of process for review of amounts.--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) Factors considered.--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) Notice and comment.--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 the Secretary's 
        determinations with respect to intraocular lenses listed in the 
        notice within 90 days after the close of the comment period.
            (4) Effective date of adjustment.--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) Technical Correction Relating to 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.
    (d) Technical Correction Related to Cataract Surgery.--Effective as 
if included in the enactment of OBRA-1990, section 4151(c)(3) of such 
Act is amended by striking ``for the insertion of an intraocular lens'' 
and inserting ``for an intraocular lens inserted''.

SEC. 142. STUDY OF MEDICARE COVERAGE OF PATIENT CARE COSTS ASSOCIATED 
              WITH CLINICAL TRIALS OF NEW CANCER THERAPIES.

    (a) Study.--The Secretary of Health and Human Services shall 
conduct a study of the effects of expressly covering under the medicare 
program the patient care costs for beneficiaries enrolled in clinical 
trials of new cancer therapies, where the protocol for the trial has 
been approved by the National Cancer Institute or meets similar 
scientific and ethical standards, including approval by an 
institutional review board. The study shall include--
            (1) an estimate of the cost of such coverage, taking into 
        account the extent to which medicare currently pays for such 
        patient care costs in practice;
            (2) an assessment of the extent to which such clinical 
        trials represent the best available treatment for the patients 
        involved and of the effects of participation in the trials on 
        the health of such patients;
            (3) an assessment of whether progress in developing new 
        anticancer therapies would be assisted by medicare coverage of 
        such patient care costs; and
            (4) an evaluation of whether there should be special 
        criteria for the admission of medicare beneficiaries (on 
        account of their age or physical condition) to clinical trials 
        for which medicare would pay the patient care costs.
    (b) Report.--Not later than 2 years after the date of the enactment 
of this Act, the Secretary of Health and Human Services shall submit a 
report on the study conducted under subsection (a) 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. Such report 
shall include recommendations as to the coverage under the medicare 
program of patient care costs of beneficiaries enrolled in clinical 
trials of new cancer therapies.

SEC. 143. STUDY OF ANNUAL CAP ON AMOUNT OF MEDICARE PAYMENT FOR 
              OUTPATIENT PHYSICAL THERAPY AND OCCUPATIONAL THERAPY 
              SERVICES.

    (a) Study.--The Secretary of Health and Human Services shall 
conduct a study of the appropriateness of continuing an annual 
limitation on the amount of payment for outpatient services of 
independently practicing physical and occupational therapists under the 
medicare program.
    (b) Report.--By not later than January 1, 1995, the Secretary shall 
submit to the Committees on Energy and Commerce and Ways and Means of 
the House of Representatives and the Committee on Finance of the Senate 
a report on the study conducted under subsection (a). Such report shall 
include such recommendations for changes in such annual limitation as 
the Secretary finds appropriate.

SEC. 144. PAYMENT OF PART B PREMIUM LATE ENROLLMENT PENALTIES BY 
              STATES.

    Section 1839 (42 U.S.C. 1395r) is amended by adding at the end the 
following new subsection:
    ``(g)(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. 145. TREATMENT OF INPATIENTS AND PROVISION OF DIAGNOSTIC X-RAY 
              SERVICES BY RURAL HEALTH CLINICS AND FEDERALLY QUALIFIED 
              HEALTH CENTERS.

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

SEC. 146. APPLICATION OF MAMMOGRAPHY CERTIFICATION REQUIREMENTS.

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

SEC. 147. COVERAGE OF SERVICES OF SPEECH-LANGUAGE PATHOLOGISTS AND 
              AUDIOLOGISTS.

    (a) Services Defined.--Section 1861 (42 U.S.C. 1395x), as amended 
by section 148(f)(6)(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), as would otherwise 
be covered if furnished by a physician.
    ``(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--
                    ``(i) is licensed 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 license speech-
                language pathologists, has successfully completed 350 
                clock hours of supervised clinical practicum (or is in 
                the process of accumulating such supervised clinical 
                experience), performed not less than 1 month of 
                supervised full-time speech-language pathology services 
                after obtaining a master's or doctoral degree in 
                speech-language pathology or a related field, and 
                successfully completed a national 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--
                    ``(i) is licensed 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 license speech-
                language pathologists, has successfully completed 350 
                clock hours of supervised clinical practicum (or is in 
                the process of accumulating such supervised clinical 
                experience), performed not less than 1 month of 
                supervised full-time speech-language pathology services 
                after obtaining a master's or doctoral degree in 
                speech-language pathology or a related field, and 
                successfully completed a national examination in 
                speech-language pathology 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 take 
effect on January 1, 1994.

SEC. 148. 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 inserting ``and for services described in subsection 
        (a)(2)(E)(ii) furnished on or after January 1, 1992'' after 
        ``1989''; 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(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''.
    (3) 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)''.
    (4) 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)''.
    (5) Section 1861(aa)(5) (42 U.S.C. 1395x(aa)(5)) is amended by 
striking ``this Act'' and inserting ``this title''.
    (6) 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)''.
    (7) 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) Clinical diagnostic laboratory tests.--Section 
        4154(e)(5) of OBRA-1990 is amended by striking ``(1)(A)'' and 
        inserting ``(1)(A),''.
            (3) Separate payment under part b for certain services.--
        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''.
            (4) Community health centers and rural health clinics.--(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''.
            (5) Screening mammography.--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''.
            (6) 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 a 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 
                        of subparagraph (E) and inserting ``; and''; 
                        and
                            (iv) by adding at the end the following new 
                        subparagraph:
                    ``(F) with respect to a 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 a 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''.
            (7) Other miscellaneous and technical corrections.--
                    (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.

            Subtitle C--Provisions Relating to Parts A and B

SEC. 151. MEDICARE SECONDARY PAYER REFORMS.

    (a) 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 July 1, 
                1994, to distribute the questionnaire described in 
                section 1862(b)(5)(D) of the Social Security Act (as 
                added by subparagraph (A)).
                    (C) No medicare secondary payer denial based on 
                failure to complete questionnaire.--Section 1862(b)(2) 
                (42 U.S.C. 1395y(b)(2)) is amended by adding at the end 
                the following new subparagraph:
                    ``(C) Treatment of questionnaires.--The Secretary 
                may not fail to make payment under subparagraph (A) 
                solely on the ground that an individual failed to 
                complete a questionnaire concerning the existence of a 
                primary plan.''.
            (2) Mandatory screening by providers and suppliers under 
        part b.--
                    (A) In general.--Section 1862(b) (42 U.S.C. 
                1395y(b)) is amended by adding at the end the following 
                new paragraph:
            ``(6) Screening requirements for providers and suppliers.--
                    ``(A) In general.--Notwithstanding any other 
                provision of this title, no payment may be made for any 
                item or service furnished under part B unless the 
                entity furnishing such item or service completes (to 
                the best of its knowledge and on the basis of 
                information obtained from the individual to whom the 
                item or service is furnished) the portion of the claim 
                form relating to the availability of other health 
                benefit plans.
                    ``(B) Penalties.--An entity that knowingly, 
                willfully, and repeatedly fails to complete a claim 
                form in accordance with subparagraph (A) or provides 
                inaccurate information relating to the availability of 
                other health benefit plans on a claim form under such 
                subparagraph shall be subject to a civil money penalty 
                of not to exceed $2,000 for each such incident. The 
                provisions of section 1128A (other than subsections (a) 
                and (b)) shall apply to a civil money penalty under the 
                previous sentence in the same manner as such provisions 
                apply to a penalty or proceeding under section 
                1128A(a).''.
                    (B)  Effective date.--The amendment made by 
                subparagraph (A) shall apply with respect to items and 
                services furnished on or after January 1, 1994.
    (b) 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 
                        subparagraph (G);
                            (ii) by striking ``and'' at the end of 
                        subparagraph (H); and
                            (iii) 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)); and''.
            (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 carrier shall be 
subject to standards and criteria relating to the carrier's success in 
recovering payments made under this part for items or services for 
which payment has been or could be made under a primary plan (as 
defined in section 1862(b)(2)(A)).''.
            (3) Deadline for reimbursement by primary plans.--
                    (A) In general.--Section 1862(b)(2)(B)(i) (42 
                U.S.C. 1395y(b)(2)(B)(i)) is amended by adding at the 
                end the following sentence: ``If reimbursement is not 
                made to the appropriate Trust Fund before the 
                expiration of the 60-day period that begins on the date 
                such notice or other information is received, the 
                Secretary may charge interest (beginning with the date 
                on which the notice or other information is received) 
                on the amount of the reimbursement until reimbursement 
                is made (at a rate determined by the Secretary in 
                accordance with regulations of the Secretary of the 
                Treasury applicable to charges for late payments).''.
                    (B) Conforming amendment.--The heading of clause 
                (i) of section 1862(b)(2)(B) is amended to read as 
                follows: ``Repayment required.--''.
                    (C) Effective date.--The amendments made by this 
                paragraph shall apply to payments for items and 
                services furnished on or after the date of the 
                enactment of this Act.
            (4) Effective date.--The amendments made by paragraphs (1) 
        and (2) shall apply to contracts with fiscal intermediaries and 
        carriers under title XVIII of the Social Security Act for years 
        beginning with 1994.
    (c) Miscellaneous and Technical Corrections.--
            (1) Effective as if included in the enactment of OBRA-1993, 
        section 1862(b)(1)(A) (42 U.S.C. 1395y(b)(1)(A)), as amended by 
        section 13561(e)(1) of OBRA-1993, is amended--
                    (A) in clause (i)(II), by striking ``over (and the 
                individual's spouse age 65 or older) who is covered 
                under the plan by virtue of the individual's current 
                employment status with an employer'' and inserting 
                ``older (and the spouse age 65 or older of any 
                individual) who has current employment status with an 
                employer''; and
                    (B) in clause (ii), by striking ``or employee 
                organization that has 20 or more individuals in current 
                employment status'' and inserting ``that has 20 or more 
                employees''.
            (2) Effective as if included in the enactment of OBRA-1993, 
        section 1837(i) (42 U.S.C. 1395p(i)) is amended--
                    (A) by striking ``as an active individual (as those 
                terms are defined in section 1862(b)(1)(B)(iv))'' each 
                place it appears in the second sentence of paragraph 
                (1), and the second sentence of paragraph (2) and 
                inserting ``(as that term is defined in section 
                1862(b)(1)(B)(iv)) by reason of the individual's 
                current employment status (or the current employment 
                status of a family member of the individual)'';
                    (B) in paragraph (3)(B), by striking ``as an active 
                individual in a large group health plan (as such terms 
                are defined in section 1862(b)(1)(B)(iv))'' and 
                inserting ``in a large group health plan (as that term 
                is defined in section 1862(b)(1)(B)(iv)) by reason of 
                the individual's current employment status (or the 
                current employment status of a family member of the 
                individual)'';
                    (C) in the second sentence of paragraph (2) (as 
                amended by subparagraph (A)), by striking ``as an 
                active individual'' and inserting ``by reason of the 
                individual's current employment status (or the current 
                employment status of a family member of the 
                individual)''; and
                    (D) by inserting ``status'' after ``current 
                employment'' each place it appears in paragraphs 
                (1)(A), (2)(B), (2)(C), and (3)(A).
            (3) Effective as if included in the enactment of OBRA-1993, 
        the second sentence of section 1839(b) (42 U.S.C. 1395r(b)) is 
        amended--
                    (A) by inserting ``status'' after ``current 
                employment'', and
                    (B) by striking ``as an active individual (as those 
                terms are defined in section 1862(b)(1)(B)(iv))'' and 
                inserting ``(as that term is defined in section 
                1862(b)(1)(B)(iv)) by reason of the individual's 
                current employment status (or the current employment 
                status of a family member of the individual)''.
            (4) Effective as if included in the enactment of OBRA-1990, 
        the sentence in section 1862(b)(1)(C) added by section 
        4203(c)(1)(B) of OBRA-1990 is amended by striking ``clauses (i) 
        and (ii)'' and inserting ``this subparagraph''.
            (5) Effective as if included in the enactment of OBRA-1989, 
        section 1862(b)(1)(C) is amended in the matter after clause 
        (ii), by striking ``taking into account that'' and inserting 
        ``paying benefits secondary to this title when''.
            (6) Effective as if included in the enactment of OBRA-1989, 
        section 1862(b)(5)(C)(i) (42 U.S.C. 1395y(b)(5)(C)(i)) is 
        amended by striking ``6103(l)(12)(D)(iii)'' and inserting 
        ``6103(l)(12)(E)(iii)''.
            (7) Effective as if included in the enactment of OBRA-1990, 
        section 4203(c)(2) of such Act 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.''.
            (8) Effective as if included in the enactment of OBRA-1990, 
        section 4203(d) of OBRA-1990 is amended by striking ``this 
        subsection'' and inserting ``this section''.
            (9) Effective as if included in the enactment of OBRA-1993, 
        section 13561(e)(1)(D) of OBRA-1993 is amended--
                    (A) by inserting ``effective as if included in the 
                enactment of OBRA-1989,'' after ``(D)'', and
                    (B) by striking ``of each subparagraph''.
            (10) The amendment made by section 13561(e)(1)(G) of OBRA-
        1993, to the extent it relates to the definition of large group 
        health plan, shall be effective as if included in the enactment 
        of OBRA-1989.

SEC. 152. PHYSICIAN OWNERSHIP AND REFERRAL.

    (a) In General.--Section 1877(f) (42 U.S.C. 1395nn) is amended--
            (1) in the matter before paragraph (1), by inserting ``, 
        investment, and compensation'' after ``ownership'';
            (2) in paragraph (2), by inserting ``, or with a 
        compensation arrangement (as described in subsection 
        (a)(2)(B)),'' after ``investment interest (as described in 
        subsection (a)(2)(A))'';
            (3) in paragraph (2), by inserting ``interest or who have 
        such a compensation relationship with the entity'' before the 
        period at the end;
            (4) in the fourth sentence, by striking ``covered items 
        and'' and inserting ``designated health''; and
            (5) by striking the third and fifth sentences.
    (b) Radiology Services.--Section 1877(h)(6) (42 U.S.C. 
1395nn(h)(6)), as amended by section 13562(a)(2) of OBRA-1993, is 
amended--
            (1) in subparagraph (D), by striking ``or other diagnostic 
        services'' and inserting ``services, including magnetic 
        resonance imaging, computerized axial tomography scans, and 
        ultrasound services''; and
            (2) in subparagraphs (E), (F), and (H), by inserting ``and 
        supplies'' before the period at the end.
    (c) Revision of Effective Date Exception Provision.--Section 
13562(b)(2) of OBRA-1993 is amended by striking subparagraphs (A) and 
(B) and inserting the following:
                    ``(A) the second sentence of subsection (a)(2), and 
                subsections (b)(2)(B) and (d)(2), of section 1877 of 
                the Social Security Act (as in effect on the day before 
                the date of the enactment of this Act) shall apply 
                instead of the corresponding provisions in section 1877 
                (as amended by this Act);
                    ``(B) section 1877(b)(4) of the Social Security Act 
                (as in effect on the day before the date of the 
                enactment of this Act) shall apply;
                    ``(C) the requirements of section 1877(c)(2) of the 
                Social Security Act (as amended by this Act) shall not 
                apply to any securities of a corporation that meets the 
                requirements of section 1877(c)(2) of the Social 
                Security Act (as in effect on the day before the date 
                of the enactment of this Act);
                    ``(D) section 1877(e)(3) of the Social Security Act 
                (as amended by this Act) shall apply, except that it 
                shall not apply to any arrangement that meets the 
                requirements of subsection (e)(2) or subsection (e)(3) 
                of section 1877 of the Social Security Act (as in 
                effect on the day before the date of the enactment of 
                this Act);
                    ``(E) the requirements of clauses (iv) and (v) of 
                section 1877(h)(4)(A), and of clause (i) of section 
                1877(h)(4)(B), of the Social Security Act (as amended 
                by this Act) shall not apply; and
                    ``(F) section 1877(h)(4)(B) of the Social Security 
                Act (as in effect on the day before the date of the 
                enactment of this Act) shall apply instead of section 
                1877(h)(4)(A)(ii) of such Act (as amended by this 
                Act).''.
    (d) Effective Dates.--
            (1) The amendments made by subsections (a) and (b) shall 
        apply to referrals made on or after January 1, 1995.
            (2) The amendment made by subsection (c) shall apply as if 
        included in the enactment of OBRA-1993.

SEC. 153. DEFINITION OF FMGEMS EXAMINATION FOR PAYMENT OF DIRECT 
              GRADUATE MEDICAL EDUCATION.

    (a) In General.--Section 1886(h)(5)(E) (42 U.S.C. 1395ww(h)(5)(E)) 
is amended by inserting ``or any successor examination'' after 
``Medical Sciences''.
    (b) Effective Date.--The amendment made by subsection (a) shall 
apply as if included in the enactment of the Consolidated Omnibus 
Budget Reconciliation Act of 1985 (Public Law 99-272).

SEC. 154. QUALIFIED MEDICARE BENEFICIARY OUTREACH.

    Not later than 1 year after the date of the enactment of this Act, 
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. 155. HOSPITAL AGREEMENTS WITH ORGAN PROCUREMENT ORGANIZATIONS.

    (a) Hospital Agreements.--
            (1) In general.--
                    (A) Identification of organ donors.--Section 
                1138(a)(1)(A)(iii) (42 U.S.C. 1320b-8(a)(1)(A)(iii)) is 
                amended to read as follows:
                    ``(iii) require that such hospital's designated 
                organ procurement agency (as defined in paragraph 
                (3)(B)) is notified of potential organ donors;''.
                    (B) Agreements with designated organ procurement 
                agencies.--Section 1138(a)(1) (42 U.S.C. 1320b-8(a)(1)) 
                is amended--
                            (i) by striking the period at the end of 
                        subparagraph (B) and inserting ``; and''; and
                            (ii) by adding at the end the following new 
                        subparagraph:
            ``(C) the hospital or rural primary care hospital has an 
        agreement (as defined in paragraph (3)(A)) only with such 
        hospital's designated organ procurement agency.''.
                    (C) Waiver of requirements related to agreements.--
                Section 1138(a) (42 U.S.C. 1320b-8(a)) is amended--
                            (i) by redesignating paragraph (2) as 
                        paragraph (3); and
                            (ii) by inserting after paragraph (1) the 
                        following new paragraph:
    ``(2)(A) The Secretary shall grant a waiver of the requirements 
under subparagraphs (A)(iii) and (C) of paragraph (1) to a hospital or 
rural primary care hospital desiring to enter into an agreement with an 
organ procurement agency other than such hospital's designated organ 
procurement agency if the Secretary determines that--
            ``(i) the waiver is expected to increase organ donation; 
        and
            ``(ii) the waiver will assure equitable treatment of 
        patients referred for transplants within the service area 
        served by such hospital's designated organ procurement agency 
        and within the service area served by the organ procurement 
        agency with which the hospital seeks to enter into an agreement 
        under the waiver.
    ``(B) In making a determination under subparagraph (A), the 
Secretary may consider factors that would include, but not be limited 
to--
            ``(i) cost effectiveness;
            ``(ii) improvements in quality;
            ``(iii) whether there has been any change in a hospital's 
        designated organ procurement agency due to a change made on or 
        after December 28, 1992, in the definitions for metropolitan 
        statistical areas (as established by the Office of Management 
        and Budget); and
            ``(iv) the length and continuity of a hospital's 
        relationship with an organ procurement agency other than the 
        hospital's designated organ procurement agency;
except that nothing in this subparagraph shall be construed to permit 
the Secretary to grant a waiver that does not meet the requirements of 
subparagraph (A).
    ``(C) Any hospital or rural primary care hospital seeking a waiver 
under subparagraph (A) shall submit an application to the Secretary 
containing such information as the Secretary determines appropriate.
    ``(D) The Secretary shall--
            ``(i) publish a public notice of any waiver application 
        received from a hospital or rural primary care hospital under 
        this paragraph within 30 days of receiving such application; 
        and
            ``(ii) prior to making a final determination on such 
        application under subparagraph (A), offer interested parties 
        the opportunity to submit written comments to the Secretary 
        during the 60-day period beginning on the date such notice is 
        published.''.
                    (D) Definitions.--Section 1138(a)(3) (42 U.S.C. 
                1320b-8(a)(3)), as redesignated by subparagraph (C), is 
                amended to read as follows:
    ``(3) For purposes of this subsection--
            ``(A) the term `agreement' means an agreement described in 
        section 371(b)(3)(A) of the Public Health Service Act;
            ``(B) the term `designated organ procurement agency' means, 
        with respect to a hospital or rural primary care hospital, the 
        organ procurement agency designated pursuant to subsection (b) 
        for the service area in which such hospital is located; and
            ``(C) the term `organ' means a human kidney, liver, heart, 
        lung, pancreas, and any other human organ or tissue specified 
        by the Secretary for purposes of this subsection.''.
            (2) Existing agreements.--Any hospital or rural primary 
        care hospital which has an agreement (as defined in section 
        1138(a)(3)(A) of the Social Security Act) with an organ 
        procurement agency other than such hospital's designated organ 
        procurement agency (as defined in section 1138(a)(3)(B) of such 
        Act) on the date of the enactment of this section shall, if 
        such hospital desires to continue such agreement on and after 
        the effective date of the amendments made by paragraph (1), 
        submit an application to the Secretary for a waiver under 
        section 1138(a)(2) of such Act not later than January 1, 1995, 
        and such agreement may continue in effect pending the 
        Secretary's determination with respect to such application.
            (3) Effective date.--The amendments made by paragraph (1) 
        shall apply to hospitals and rural primary care hospitals 
        participating in the programs under titles XVIII and XIX of the 
        Social Security Act beginning January 1, 1995.
    (b) Study on Hospital Agreements with Organ Procurement Agencies.--
            (1) In general.--The Office of Technology Assessment 
        (referred to in this section as the ``OTA'') shall, pursuant to 
        the approval of the Technology Assessment Board of the OTA, 
        conduct a study to determine the efficacy and fairness of 
        requiring a hospital to enter into an agreement under section 
        371(b)(3)(A) of the Public Health Service Act with the organ 
        procurement agency designated pursuant to section 1138(b) of 
        the Social Security Act for the service area in which such 
        hospital is located and the impact of such requirement on the 
        efficacy and fairness of organ procurement and distribution.
            (2) Report.--Not later than 2 years after the date of the 
        enactment of this Act, the OTA shall complete the study 
        required under paragraph (1) and prepare and submit to the 
        Committee on Finance and the Committee on Labor and Human 
        Resources of the Senate and the Committee on Ways and Means and 
        the Committee on Energy and Commerce of the House of 
        Representatives a report containing the findings of such study 
        and the implications of such findings with respect to policies 
        affecting organ procurement and distribution.

SEC. 156. 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 
                        subparagraph (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), by striking ``(4)'' and all that follows 
                        through ``and (5)'' and inserting ``and (4)''.
                    (C) Section 1834(g)(1)(B) (42 U.S.C. 
                1395m(g)(1)(B)) is amended by striking ``and for items 
                and services furnished in connection with obtaining a 
                second opinion required under section 1164(c)(2), or a 
                third opinion, if the second opinion was in 
                disagreement with the first opinion''.
                    (D) Section 1862(a) (42 U.S.C. 1395y(a)) is 
                amended--
                            (i) by adding ``or'' at the end of 
                        paragraph (14),
                            (ii) by striking ``; or'' at the end of 
                        paragraph (15) and inserting a period, and
                            (iii) by striking paragraph (16).
                    (E) The third sentence of section 1866(a)(2)(A) (42 
                U.S.C. 1395w(a)(2)(A)) is amended by striking ``, with 
                respect to items and services furnished in connection 
                with obtaining a second opinion required under section 
                1164(c)(2) (or a third opinion, if the second opinion 
                was in disagreement with the first opinion),''.
            (3) Effective date.--The amendments made by this subsection 
        shall apply to services provided on or after the date of the 
        enactment of this Act.
    (b) Miscellaneous and Technical Corrections.--(1) The third 
sentence of section 1156(b)(1) (42 U.S.C. 1320c-5(b)(1)) is amended by 
striking ``whehter'' and inserting ``whether''.
    (2)(A) Section 1154(a)(9)(B) (42 U.S.C. 1320c-3(a)(9)(B)) is 
amended to read as follows:
            ``(B) If the organization finds, after reasonable notice to 
        and opportunity for discussion with the physician or 
        practitioner concerned, that the physician or practitioner has 
        furnished services in violation of section 1156(a) and the 
        organization determines that the physician or practitioner 
        should enter into a corrective action plan under section 
        1156(b)(1), the organization shall notify the State board or 
        boards responsible for the licensing or disciplining of the 
        physician or practitioner of its finding and of any action 
        taken as a result of the finding.''.
    (B) Subparagraph (D) of section 1160(b)(1) (42 U.S.C. 1320c-
9(b)(1)) is amended to read as follows:
                    ``(D) to provide notice in accordance with section 
                1154(a)(9)(B);''.
    (3) Section 4205(d)(2)(B) of OBRA-1990 is amended by striking 
``amendments'' and inserting ``amendment''.
    (4) Section 1160(d) (42 U.S.C. 1320c-9(d)) is amended by striking 
``subpena'' and inserting ``subpoena''.
    (5) Section 4205(e)(2) of OBRA-1990 is amended by striking 
``amendments'' and inserting ``amendment'' and by striking ``all''.
    (6)(A) Except as provided in subparagraph (B), the amendments made 
by this subsection shall take effect as if included in the enactment of 
OBRA-1990.
    (B) The amendments made by paragraph (2) (relating to the 
requirement on reporting of information to State boards) shall take 
effect on the date of the enactment of this Act.

SEC. 157. HEALTH MAINTENANCE ORGANIZATIONS.

    (a) Adjustment in Medicare Capitation Payments to Take Into Account 
Secondary Payer Status.--
            (1) In general.--In defining the classes to be used in 
        determining the annual per capita rate of payment under section 
        1876(a)(1)(B) of the Social Security Act to an eligible 
        organization with a risk-sharing contract under such section 
        (for months beginning after June 1994), the Secretary of Health 
        and Human Services shall treat as a separate class individuals 
        entitled to benefits under title XVIII of such Act with respect 
        to whom there is a group health plan that is a primary plan 
        (within the meaning of section 1862(b)(2)(A) of such Act).
            (2) Deadline for announcement of rates.--Not later than May 
        15, 1994, the Secretary shall announce annual per capita rates 
        of payment for eligible organizations described in paragraph 
        (1) that take into account the separate treatment of 
        individuals with respect to whom there is a group health plan 
        that is a primary plan.
    (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 October 1, 1994, the Secretary of Health and 
Human Services (in this subsection referred to as the `Secretary') 
shall submit a proposal to the Congress that provides for revisions to 
the payment method to be applied in years beginning with 1996 for 
organizations with a risk-sharing contract under section 1876(g) of the 
Social Security Act.
    ``(B) In proposing the revisions required under subparagraph (A), 
the Secretary shall consider--
            ``(i) the difference in costs associated with medicare 
        beneficiaries with differing health status and demographic 
        characteristics; and
            ``(ii) the effects of using alternative geographic 
        classifications on the determinations of costs associated with 
        beneficiaries residing in different areas.
    ``(2) Not later than 3 months after the date of submittal of the 
proposal under paragraph (1), the Comptroller General shall review the 
proposal and shall report to Congress on the appropriateness of the 
proposed modifications.''.
    (c) Miscellaneous and Technical Corrections.--(1) Section 
1876(a)(3) (42 U.S.C. 1395mm(a)(3)) is amended by striking ``subsection 
(c)(7)'' and inserting ``subsections (c)(2)(B)(ii) and (c)(7)''.
    (2) Section 4204(c)(3) of OBRA-1990 is amended by striking ``for 
1991'' and inserting ``for years beginning with 1991''.
    (3) Section 4204(d)(2) of OBRA-1990 is amended by striking 
``amendment'' and inserting ``amendments''.
    (4) Section 1876(a)(1)(E)(ii)(I) (42 U.S.C. 1395mm(a)(1)(E)(ii)(I)) 
is amended by striking the comma after ``contributed to''.
    (5) Section 4204(e)(2) of OBRA-1990 is amended by striking ``(which 
has a risk-sharing contract under section 1876 of the Social Security 
Act)''.
    (6) Section 4204(f)(4) of OBRA-1990 is amended by striking 
``final''.
    (7) Section 1862(b)(3)(C) (42 U.S.C. 1395y(b)(3)(C)) is amended--
            (A) in the heading, by striking ``plan'' and inserting 
        ``plan or a large group health plan'';
            (B) by striking ``group health plan'' and inserting ``group 
        health plan or a large group health plan'';
            (C) by striking ``, unless such incentive is also offered 
        to all individuals who are eligible for coverage under the 
        plan''; and
            (D) by striking ``the first sentence of subsection (a) and 
        other than subsection (b)'' and inserting ``subsections (a) and 
        (b)''.
    (8) The amendments made by this subsection shall take effect as if 
included in the enactment of OBRA-1990.

SEC. 158. HOME HEALTH AGENCIES.

    (a) Use of Most Current Data in Determining Wage Index.--
            (1) In general.--Section 1861(v)(1)(L)(iii) (42 U.S.C. 
        1395x(v)(1)(L)(iii)) is amended by striking ``as of such date 
        to'' and inserting ``and determined using the survey of the 
        most recent available wages and wage-related costs of''.
            (2) Effective date.--The amendment made by paragraph (1) 
        shall apply with respect to cost reporting periods beginning on 
        or after July 1, 1996.
    (b) Clarification of Extension of Waiver of Liability.--
            (1) In general.--The second sentence of section 9205 of the 
        Consolidated Omnibus Budget Reconciliation Act of 1985 is 
        amended by striking ``November 1, 1990'' and inserting 
        ``December 31, 1995''.
            (2) Effective date.--The amendment made by paragraph (1) 
        shall take effect as if included in the enactment of OBRA-1990.

SEC. 159. PERMANENT EXTENSION OF AUTHORITY TO CONTRACT WITH FISCAL 
              INTERMEDIARIES AND CARRIERS ON OTHER THAN A COST BASIS.

    (a) In General.--Section 2326(a) of the Deficit Reduction Act of 
1984, as amended by section 6215 of OBRA-1989, is amended in the third 
sentence by striking ``during such period'' and inserting ``beginning 
with fiscal year 1990 and any subsequent fiscal year''.
    (b) Effective Date.--The amendment made by subsection (a) shall 
apply beginning with fiscal year 1994.

SEC. 160. 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) Home Dialysis Demonstration Technical Corrections.--Section 
4202 of OBRA-1990 is amended--
            (1) in subsection (b)(1)(A), by striking ``home 
        hemodialysis staff assistant'' and inserting ``qualified home 
        hemodialysis staff assistant (as described in subsection 
        (d))'';
            (2) in subsection (b)(2)(B)(ii)(I), by striking ``(as 
        adjusted to reflect differences in area wage levels)'';
            (3) in subsection (c)(1)(A), by striking ``skilled''; and
            (4) in subsection (c)(1)(E), by striking ``(b)(4)'' and 
        inserting ``(b)(2)''.
    (c) Technical Correction to Revisions of Coverage for 
Immunosuppressive Drug Therapy.--Section 1861(s)(2)(J) (42 U.S.C. 
1395x(s)(2)(J)), as amended by section 13565 of OBRA-1993, is amended--
            (1) by redesignating clauses (ii) through (v) as clauses 
        (iii) through (vi); and
            (2) by striking clause (i) and inserting the following:
                    ``(i) before 1994, within 12 months after the date 
                of the transplant procedure,
                    ``(ii) to an individual who receives a transplant 
                during 1994, within 487 days after the date of the 
                transplant procedure,''.
    (d) 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 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.
    (4) 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.
    (5)(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)''.
    (6) 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''.
    (7) Section 4207(b)(4)(B)(iii)(III) of OBRA-1990 is amended by 
striking the period at the end and inserting a semicolon.
    (8) 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)''.
    (9) 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''.
    (10) Section 4207(d) of OBRA-1990 is amended by redesignating the 
second paragraph (3) (relating to effective date) as paragraph (4).
    (11) 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''.
    (12) Section 4207(j) of OBRA-1990 is amended by striking ``title'' 
each place it appears and inserting ``subtitle''.

  Subtitle D--Provisions Relating to Medicare Supplemental Insurance 
                                Policies

SEC. 171. 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 
(aa) a State medicaid plan under such title pays the premiums for the 
policy, (bb) in the case of a qualified medicare beneficiary described 
in section 1905(p)(1), the policy provides for coverage of outpatient 
prescription drugs, or (cc) the only medical assistance to which the 
individual is entitled under the State plan is medicare cost sharing 
described in section 1905(p)(3)(A)(ii).''.
            (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, but not limited to, as separate types of 
        policies, policies paying directly to the beneficiary fixed, 
        cash benefits, and policies that limit benefit payments to 
        specific diseases) which are sold or issued 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, but not limited to, as separate types of policies, 
policies paying directly to the beneficiary fixed, cash benefits, and 
policies that limit benefit payments to specific diseases) which are 
sold or issued to persons entitled to health benefits under this title, 
of the extent to which benefits payable under the policy or plan 
duplicate benefits under this title, and each such statement shall be 
(for purposes of subparagraph (C)) the statement specified under this 
subparagraph for the type of policy involved.''.
            (C) The requirement of a disclosure under section 
        1882(d)(3)(C)(ii) of the Social Security Act shall not apply to 
        an application made for a policy or plan before 60 days after 
        the date the Secretary of Health and Human Services publishes 
        or promulgates all the statements under section 1882(d)(3)(D) 
        of such Act.
            (4) Subparagraphs (A) and (B) of section 1882(q)(5) are 
        amended by striking ``of the Social Security Act''.
    (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 171(m)(4) of the 
                Social Security Act 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 171(m)(4) of 
                the Social Security Act 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 the 
        Social Security Act.''.
    (f) Treatment of HMO's.--
            (1) Section 1882(g)(1) (42 U.S.C. 1395ss(g)(1)) is amended 
        by striking ``a health maintenance organization or other direct 
        service organization'' and all that follows through ``1833'' 
        and inserting ``an eligible organization (as defined in section 
        1876(b)) if the policy or plan provides benefits pursuant to a 
        contract under section 1876 or an approved demonstration 
        project described in section 603(c) of the Social Security 
        Amendments of 1983, section 2355 of the Deficit Reduction Act 
        of 1984, or section 9412(b) of the Omnibus Budget 
        Reconciliation Act of 1986, or, during the period beginning on 
        the date specified in subsection (p)(1)(C) and ending on 
        December 31, 1994, a policy or plan of an organization if the 
        policy or plan provides benefits pursuant to an agreement under 
        section 1833(a)(1)(A)''.
            (2) Section 4356(b) of OBRA-1990 is amended by striking 
        ``on the date of the enactment of this Act'' and inserting ``on 
        the date specified in section 1882(p)(1)(C) of the Social 
        Security Act''.
    (g) Pre-existing Condition Limitations.--Section 1882(s) (42 U.S.C. 
1395ss(s)) is amended--
            (1) in paragraph (2)(A), by striking ``for which an 
        application is submitted'' and inserting ``in the case of an 
        individual for whom an application is submitted prior to or'',
            (2) in paragraph (2)(A), by striking ``in which the 
        individual (who is 65 years of age or older) first is enrolled 
        for benefits under part B'' and inserting ``as of the first day 
        on which the individual is 65 years of age or older and is 
        enrolled for benefits under part B'', and
            (3) in paragraph (2)(B), by striking ``before it'' and 
        inserting ``before the policy''.
    (h) Medicare Select Policies.--
            (1) Section 1882(t) (42 U.S.C. 1395ss(t)) is amended--
                    (A) in paragraph (1), by inserting ``medicare 
                supplemental'' after ``If a'',
                    (B) in paragraph (1), by striking ``NAIC Model 
                Standards'' and inserting ``1991 NAIC Model Regulation 
                or 1991 Federal Regulation'',
                    (C) in paragraph (1)(A), by inserting ``or 
                agreements'' after ``contracts'',
                    (D) in subparagraphs (E)(i) and (F) of paragraph 
                (1), by striking ``NAIC standards'' and inserting 
                ``standards in the 1991 NAIC Model Regulation or 1991 
                Federal Regulation'', and
                    (E) in paragraph (2), by inserting ``the issuer'' 
                before ``is subject to a civil money penalty''.
            (2) Section 1154(a)(4)(B) (42 U.S.C. 1320c-3(a)(4)(B)) is 
        amended--
                    (A) by inserting ``that is'' after ``(or'', and
                    (B) by striking ``1882(t)'' and inserting 
                ``1882(t)(3)''.
    (i) Health Insurance Counseling.--Section 4360 of OBRA-1990 is 
amended--
            (1) in subsection (b)(2)(A)(ii), by striking ``Act'' and 
        inserting ``Act)'';
            (2) in subsection (b)(2)(D), by striking ``services'' and 
        inserting ``counseling'';
            (3) in subsection (b)(2)(I), by striking ``assistance'' and 
        inserting ``referrals'';
            (4) in subsection (c)(1), by striking ``and that such 
        activities will continue to be maintained at such level'';
            (5) in subsection (d)(3), by striking ``to the rural 
        areas'' and inserting ``eligible individuals residing in rural 
        areas'';
            (6) in subsection (e)--
                    (A) by striking ``subsection (c) or (d)'' and 
                inserting ``this section'',
                    (B) by striking ``and annually thereafter, issue an 
                annual report'' and inserting ``and annually thereafter 
                during the period of the grant, issue a report'', and
                    (C) in paragraph (1), by striking ``State-wide'';
            (7) in subsection (f), by striking paragraph (2) and by 
        redesignating paragraphs (3) through (5) as paragraphs (2) 
        through (4), respectively; and
            (8) in the second subsection (f) (relating to authorization 
        of appropriations for grants)--
                    (A) by striking ``and 1993'' and inserting ``1993, 
                1994, 1995, and 1996''; and
                    (B) by redesignating such subsection 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, 1994, and shall apply to individuals who 
        attain 65 years of age or older on or after the effective date 
        of section 1882(s)(2) of the Social Security Act (and, in the 
        case of individuals who attained 65 years of age after such 
        effective date and before July 1, 1994, and who were not 
        covered under such section before July 1, 1994, the 6-month 
        period specified in that section shall begin July 1, 1994).
    (m) Transition Provisions.--
            (1) In general.--If the Secretary of Health and Human 
        Services identifies a State as requiring a change to its 
        statutes or regulations to conform its regulatory program to 
        the changes made by this section, the State regulatory program 
        shall not be considered to be out of compliance with the 
        requirements of section 1882 of the Social Security Act due 
        solely to failure to make such change until the date specified 
        in paragraph (4).
            (2) NAIC standards.--If, within 6 months after the date of 
        the enactment of this Act, the National Association of 
        Insurance Commissioners (in this subsection referred to as the 
        ``NAIC'') modifies its 1991 NAIC Model Regulation (adopted in 
        July 1991) to conform to the amendments made by this section 
        and to delete from section 15C the exception which begins with 
        ``unless'', such revised regulation incorporating the 
        modifications shall be considered to be the 1991 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 revised regulation incorporating the 
        modifications shall be considered to be the 1991 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.

                     TITLE II--MEDICAID PROVISIONS

                   Subtitle A--Substantive Provisions

                    PART I--MANAGED CARE PROVISIONS

SEC. 201. MEDICAID MANAGED CARE ANTIFRAUD PROVISIONS.

    (a) Prohibiting Affiliations With Individuals Debarred by Federal 
Agencies.--
            (1) In general.--Section 1903(m) (42 U.S.C. 1396b(m)) is 
        amended--
                    (A) in paragraph (2)(A)--
                            (i) by striking ``and'' at the end of 
                        clause (x),
                            (ii) by striking the period at the end of 
                        clause (xi) and inserting ``; and'', and
                            (iii) by adding at the end the following 
                        new clause:
            ``(xii) the entity complies with the requirements of 
        paragraph (3) (relating to certain protections against fraud 
        and abuse).'';
                    (B) in paragraph (2)(B), as amended by section 249, 
                by striking ``clause (ix)'' and inserting ``clauses 
                (ix) and (xii)''; and
                    (C) by inserting after paragraph (2) the following 
                new paragraph:
    ``(3)(A)(i) An entity with a contract under this subsection may not 
have a person described in clause (iv) as a director, officer, partner, 
or person with beneficial ownership of more than 5 percent of the 
entity's equity.
    ``(ii) An entity with a contract under this subsection may not have 
an employment, consulting, or other agreement with a person described 
in clause (iv) for the provision of goods and services that are 
significant and material to the entity's obligations under its contract 
with the State described in paragraph (2)(A)(iii).
    ``(iii) If an entity with a contract under this subsection is not 
in compliance with clause (i) or (ii)--
            ``(I) a State may continue an existing agreement with the 
        entity unless the Secretary (in consultation with the Inspector 
        General of the Department of Health and Human Services) directs 
        otherwise; and
            ``(II) a State may not renew or otherwise extend the 
        duration of an existing agreement with the entity unless the 
        State provides a written statement to the Secretary describing 
        compelling reasons that exist for renewing or extending the 
        agreement and the Secretary (in consultation with the Inspector 
        General of the Department of Health and Human Services) 
        approves such statement.
    ``(iv) A person described in this clause is a person that--
            ``(I) is debarred or suspended by the Federal Government, 
        pursuant to the Federal acquisition regulation, from Government 
        contracting and subcontracting, or
            ``(II) is an affiliate (within the meaning of the Federal 
        acquisition regulation) of a person described in subclause 
        (I).''.
            (2) Effective date.--The amendments made by paragraph (1) 
        shall apply to agreements between a State and an entity under 
        section 1903(m) of the Social Security Act entered into or 
        renewed on or after January 1, 1994, without regard to whether 
        regulations to carry out such amendments are promulgated by 
        such date.
    (b) Requirement for State Conflict-Of-Interest Safeguards in 
Medicaid Risk Contracting.--
            (1) In general.--Section 1903(m)(2)(A) (42 U.S.C. 
        1396b(m)(2)(A)), as amended by subsection (a)(1)(A), is 
        amended--
                    (A) by striking ``and'' at the end of clause (xi),
                    (B) by striking the period at the end of clause 
                (xii) and inserting ``; and'', and
                    (C) by adding at the end the following new clause:
            ``(xiii) the State certifies to the Secretary and the 
        Secretary finds that the State has in effect conflict-of-
        interest safeguards with respect to officers and employees of 
        the State who have responsibilities with respect to contracts 
        with organizations under this subsection that are at least as 
        effective as the Federal conflicts-of-interest safeguards 
        provided under section 27 of the Office of Federal Procurement 
        Policy Act that apply with respect to Federal procurement 
        officials who have comparable responsibilities with respect to 
        such contracts.''.
            (2) Effective date.--The amendments made by paragraph (1) 
        shall apply as of July 1, 1994, without regard to whether 
        regulations to carry out such amendments are promulgated by 
        such date.
    (c) Requiring Disclosure of Financial Information.--
            (1) In general.--Section 1903(m)(3), as inserted by 
        subsection (a)(1)(C), is amended by adding at the end the 
        following new subparagraph:
    ``(B) The contract between the State and an entity referred to in 
paragraph (2)(A)(iii) shall provide that--
            ``(i) the entity agrees to report to the State such 
        financial information as the Secretary or the State may require 
        to demonstrate that the entity has a fiscally sound operation; 
        and
            ``(ii) the entity agrees to make available to its enrollees 
        upon reasonable request--
                    ``(I) the information reported under clause (i),
                    ``(II) the information required to be disclosed 
                under sections 1124 and 1126, and
                    ``(III) a description of each transaction, 
                described in subparagraphs (A) through (C) of section 
                1318(a)(3) of the Public Health Service Act, between 
                the entity and a party in interest (as defined in 
                section 1318(b) of such Act).''.
            (2) Effective date.--The amendment made by paragraph (1) 
        shall apply to contract years beginning on or after April 1, 
        1994, without regard to whether regulations to carry out such 
        amendments are promulgated by such date, with respect to 
        information reported or required to be disclosed, or 
        transactions occurring, before, on, or after such date.
    (d) Prohibiting Marketing Fraud.--
            (1) In general.--Section 1903(m)(3), as inserted by 
        subsection (a)(1) and as amended by subsection (c)(1), is 
        amended by adding at the end the following new subparagraph:
    ``(C) The contract between the State and an entity referred to in 
paragraph (2)(A)(iii) shall provide that the entity agrees to comply 
with such procedures and conditions as the Secretary prescribes in 
order to ensure that, before an individual is enrolled or reenrolled 
with the entity, the individual is provided accurate and sufficient 
information to make an informed decision whether or not to enroll or 
reenroll.''.
            (2) Effective date.--The amendment made by paragraph (1) 
        shall apply to contract years that begin on or after April 1, 
        1994.
    (e) Requiring Adequate Provision Against Risk of Insolvency.--
            (1) In general.--Section 1903(m)(1)(A)(ii) (42 U.S.C. 
        1396b(m)(1)(A)(ii)) is amended by inserting ``, which meets 
        such standards as the Secretary shall prescribe,'' after 
        ``satisfactory to the State''.
            (2) Effective date.--The amendment made by paragraph (1) 
        shall apply to contract years beginning on or after January 1, 
        1995.
    (f) Requiring Report on Net Earnings and Additional Benefits.--
            (1) In general.--Section 1903(m)(3), as inserted by 
        subsection (a)(1) and as amended by subsections (c)(1) and 
        (d)(1) is amended by adding at the end the following new 
        subparagraph:
    ``(D) The contract between the State and an entity referred to in 
paragraph (2)(A)(iii) shall provide that the entity shall submit a 
report to the State and the Secretary not later than 12 months after 
the close of a contract year containing--
            ``(i) a financial statement of the entity's net earnings 
        under the contract during the contract year, which statement 
        has been audited using auditing standards established by the 
        Secretary in consultation with the States; and
            ``(ii) a description of any benefits that are in addition 
        to the benefits required to be provided under the contract that 
        were provided during the contract year to members enrolled with 
        the entity and entitled to medical assistance under the 
        plan.''.
            (2) Effective date.--The amendment made by paragraph (1) 
        shall apply to contract years beginning on or after January 1, 
        1994.

SEC. 202. EXTENSION OF MEDICAID WAIVER FOR TENNESSEE PRIMARY CARE 
              NETWORK.

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

SEC. 203. WAIVER OF APPLICATION OF MEDICAID ENROLLMENT MIX REQUIREMENT 
              TO DISTRICT OF COLUMBIA CHARTERED HEALTH PLAN, INC.

    (a) In General.--The Secretary of Health and Human Services shall 
waive the application of the requirement described in section 
1903(m)(2)(A)(ii) of the Social Security Act (42 U.S.C. 
1396b(m)(2)(A)(ii)) to the entity known as the District of Columbia 
Chartered Health Plan, Inc., for the period described in subsection 
(b), if the Secretary determines that the entity is making continuous 
efforts and progress toward achieving compliance with such requirement.
    (b) Period of Applicability.--The period referred to in subsection 
(a) is the period that begins on October 1, 1992, and ends on December 
31, 1995.

SEC. 204. WAIVER OF APPLICATION OF MEDICAID ENROLLMENT MIX REQUIREMENT 
              TO MANAGED HEALTH SERVICES INSURANCE CORPORATION OF 
              MILWAUKEE, WISCONSIN.

    The Secretary of Health and Human Services shall waive the 
application of the requirement described in section 1903(m)(2)(A)(ii) 
of the Social Security Act (42 U.S.C. 1396b(m)(2)(A)(ii)) to the entity 
known as the Managed Health Services Insurance Corporation of 
Milwaukee, Wisconsin until December 31, 1995, if the Secretary 
determines that the entity is making continuous efforts and progress 
toward achieving compliance with such requirement.

SEC. 205. EXTENSION OF MINNESOTA PREPAID MEDICAID DEMONSTRATION 
              PROJECT.

    (a) In General.--Section 507 of the Family Support Act of 1988 
(Public Law 100-485), as amended by section 6411(j) of OBRA-1989 and by 
section 4733 of OBRA-1990, is amended by striking ``1996'' and 
inserting ``1998''.
    (b) Authority To Impose Premium.--
            (1) In general.--Notwithstanding section 1916 of the Social 
        Security Act and subject to paragraph (2), the State of 
        Minnesota may impose a premium on individuals receiving medical 
        assistance under the Minnesota Prepaid Demonstration Project 
        operated under a waiver granted by the Secretary of Health and 
        Human Services under section 1115(a) of the Social Security Act 
        and other individuals eligible under the State's plan for 
        medical assistance under title XIX of such Act.
            (2) Limitation on amount of premium.--In no case may the 
        amount of any premium imposed on an individual receiving 
        medical assistance under the State plan or under the 
        Demonstration Project described in paragraph (1) exceed 10 
        percent of the amount by which the family income (less expenses 
        for the care of a dependent child) of the individual exceeds 
        110 percent of the income official poverty line (as defined by 
        the Office of Management and Budget, and revised annually in 
        accordance with section 673(2) of the Omnibus Budget 
        Reconciliation Act of 1981) applicable to a family of the size 
        involved.

      PART II--HOME AND COMMUNITY-BASED SERVICES WAIVER PROVISIONS

SEC. 211. ELIMINATION OF REQUIREMENT OF PRIOR INSTITUTIONALIZATION WITH 
              RESPECT TO HABILITATION SERVICES FURNISHED UNDER A WAIVER 
              FOR HOME OR COMMUNITY-BASED SERVICES.

    (a) In General.--Section 1915(c)(5) (42 U.S.C. 1396n(c)(5)) is 
amended in the matter preceding subparagraph (A) by striking ``, with 
respect to individuals who receive such services after discharge from a 
nursing facility or intermediate care facility for the mentally 
retarded''.
    (b) Effective Date.--The amendments made by this section shall 
apply to services furnished on or after January 1, 1994.

SEC. 212. RELIEF FROM THIRD PARTY LIABILITY REQUIREMENTS WHEN COST-
              EFFECTIVE.

    (a) In General.--Section 1902(a)(25)(B) (42 U.S.C. 1396a(a)(25)(B)) 
is amended to read as follows--
            ``(B) that in any case where such a legal liability is 
        found to exist after medical assistance has been made 
        available, the State or local agency will seek reimbursement 
        for such assistance to the extent of such legal liability, 
        unless--
                    ``(i) the amount of reimbursement the State can 
                reasonably expect to recover for medical assistance 
                furnished to an individual does not exceed the costs of 
                such recovery, or
                    ``(ii) with respect to case management services (as 
                defined in section 1915(g)(2)), the State demonstrates 
                to the satisfaction of the Secretary that it is not 
                cost-effective in the aggregate to seek such recovery 
                with respect to such services furnished to individuals 
                covered under the State plan, using methods specified 
                by the Secretary which may include a demonstration that 
                such services are not generally covered by health 
                insurers in the State;''.
    (b) Effective Date.--The amendments made by this section shall 
become effective on January 1, 1994.

SEC. 213. STATE EXPENDITURES FOR MEDICAL ASSISTANCE WITH RESPECT TO 
              HOME AND COMMUNITY-BASED SERVICES PROVIDED UNDER A 
              WAIVER.

    (a) In General.--Section 1915(d)(5)(B) (42 U.S.C. 1396n(d)(5)(B)) 
is amended--
            (1) in clause (i), by striking ``times the number of 
        years'' and inserting ``compounded annually for years'';
            (2) in clause (ii), by striking ``times the number of 
        years'' and inserting ``compounded annually for years''; and
            (3) in clause (iv), by striking ``December 22, 1987'' and 
        inserting ``the date of the enactment of the Omnibus Budget 
        Reconciliation Act of 1986''.
    (b) Effective Date.--The amendments made by subsection (a) shall be 
effective as if included in the enactment of OBRA-1987.

                       PART III--OTHER PROVISIONS

SEC. 221. PRESUMPTIVE ELIGIBILITY FOR PREGNANT WOMEN.

    (a) Qualified Provider.--Section 1920(b)(2) (42 U.S.C. 1396r-
1(b)(2)) is amended to read as follows:
            ``(2) the term `qualified provider' means--
                    ``(A) any provider that--
                            ``(i) is eligible for payments under a 
                        State plan approved under this title;
                            ``(ii) provides services of the type 
                        described in subparagraph (A) or (B) of section 
                        1905(a)(2) or in section 1905(a)(9);
                            ``(iii) is determined by the State agency 
                        to be capable of making determinations of the 
                        type described in paragraph (1)(A); and
                            ``(iv)(I) receives funds under section 329, 
                        330, 340, or 340A of the Public Health Service 
                        Act, title V of this Act, or title V of the 
                        Indian Health Care Improvement Act;
                            ``(II) participates in a program 
                        established under section 17 of the Child 
                        Nutrition Act of 1966 or section 4(a) of the 
                        Agriculture and Consumer Protection Act of 
                        1973;
                            ``(III) participates in a State perinatal 
                        program; or
                            ``(IV) is the Indian Health Service or is a 
                        health program or facility operated by a tribe 
                        or tribal organization under the Indian Self-
                        Determination Act (Public Law 93-638); and
                    ``(B) at the option of the State, any individual 
                who is employed by the State and who is determined by 
                the State agency to be capable of making determinations 
                of the type described in paragraph (1)(A).''.
    (b) Effective Date.--The amendments made by this section shall 
apply to payments under title XIX of the Social Security Act for 
calendar quarters beginning on or after January 1, 1994.

SEC. 222. CRITERIA FOR DETERMINING THE AMOUNT OF DISALLOWANCES.

    (a) In General.--
            (1) Criteria for initial determinations.--Section 1903 (42 
        U.S.C. 1396b) is amended by adding at the end the following new 
        subsection:
    ``(x) If the Secretary determines that a disallowance of Federal 
financial participation should be made under this title with respect to 
any item or class of items, the Secretary shall, in making a 
determination with respect to the amount of such disallowance, take 
into account (to the extent the State makes a showing) factors which 
shall include--
            ``(1) whether the amount of the disallowance is reasonably 
        related to the act or omission by the State which is the basis 
        for the disallowance; and
            ``(2) whether the act or omission by the State which is the 
        basis for the disallowance was based on a reasonable 
        interpretation of Federal statutes, Federal regulations, or any 
        written guidance provided by the Secretary.''.
            (2) Criteria for redeterminations.--Section 1116(d) (42 
        U.S.C. 1316(d)) is amended--
                    (A) by striking ``(d)'' and inserting ``(d)(1)''; 
                and
                    (B) by adding at the end the following new 
                paragraph:
    ``(2) In conducting any reconsideration of a disallowance of 
Federal financial participation by the Secretary under title XIX, the 
Departmental Appeals Board of the Department of Health and Human 
Services (or another entity designated by the Secretary), shall, if 
such Board or entity upholds the basis for the disallowance, determine 
whether the amount of the disallowance properly takes into account the 
factors listed in section 1903(x). If the amount of the disallowance 
does not properly take into account such factors, the Board shall 
adjust such amount in accordance with such factors.''.
    (b) Effective Date.--The amendment made by subsection (a) shall 
apply to disallowances made after the date of the enactment of this Act 
and shall take effect without regard to the promulgation of 
implementing regulations.

SEC. 223. INTERMEDIATE SANCTIONS FOR KICKBACK VIOLATIONS.

    (a) Penalty for Kickback Violations.--Section 1128A(a) (42 U.S.C. 
1320a-7a(a)) is amended--
            (1) by striking ``or'' at the end of paragraphs (1) and 
        (2);
            (2) by adding ``or'' at the end of paragraph (3);
            (3) by inserting after paragraph (3) the following new 
        paragraph:
            ``(4) carries out any activity in violation of paragraph 
        (1) or (2) of section 1128B(b) with respect to remuneration 
        relating to a State health care program;'';
            (4) by striking ``given).'' at the end of the first 
        sentence and inserting ``given or, in cases under paragraph 
        (4), $10,000 for each such violation).'';
            (5) in the second sentence, by inserting ``in cases under 
        paragraphs (1), (2), and (3),'' after ``In addition,''; and
            (6) by inserting after the second sentence the following 
        new sentence: ``In cases under paragraph (4), such a person 
        shall be subject to an assessment of not more than twice the 
        total amount of the remuneration offered, paid, solicited, or 
        received in violation of section 1128B(b), determined without 
        regard to whether a portion of such remuneration was offered, 
        paid, solicited, or received for a lawful purpose.''.
    (b) Authorization to Act.--The first sentence of section 
1128A(c)(1) (42 U.S.C. 1320a-7a(c)(1)) is amended by striking the 
period at the end and inserting ``, except that with respect to a 
proceeding relating to a State health program, the Secretary may 
initiate such a proceeding at such time and under such procedures as 
the Secretary determines appropriate unless, within 1 year after the 
date the Secretary presents a case to the Attorney General for 
consideration, the Attorney General brings an action in a district 
court of the United States.''.
    (c) Effective Dates.--
            (1) The amendments made by subsection (a) shall apply to 
        remuneration offered, paid, solicited, or received before, on, 
        or after the date of the enactment of this Act.
            (2) The amendment made by subsection (b) shall apply to 
        cases presented by the Secretary of Health and Human Services 
        for consideration on or after the date of the enactment of this 
        Act.

SEC. 224. TECHNICAL AMENDMENT RELATED TO TAXES ON CERTAIN HEALTH CARE 
              ITEMS AND SERVICES.

    (a) In General.--Section 1903(w)(7)(A)(viii) (42 U.S.C. 
1396b(w)(7)(A)(viii)) is amended by striking the period at the end and 
inserting ``not otherwise subject to a tax described in this 
subsection.''.
    (b) Effective Date.--(1) Except as provided in paragraph (2), the 
amendment made by subsection (a) shall be effective January 1, 1994.
    (2) In the case of a State which the Secretary of Health and Human 
Services determines requires State legislation in order to avoid a 
reduction in Federal financial participation under section 1903(a) of 
the Social Security Act as a result of the amendment made by subsection 
(a), the State shall not be subject to such a reduction before the 
first day of the first calendar quarter beginning after the close of 
the first regular session of the State legislature that begins after 
the date of the enactment of this Act. For purposes of the preceding 
sentence, in the case of a State that has a 2-year legislative session, 
each year of such session shall be deemed to be a separate regular 
session of the State legislature.

SEC. 225. APPLICATION OF MAMMOGRAPHY CERTIFICATION REQUIREMENTS UNDER 
              THE MEDICAID PROGRAM.

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

SEC. 226. NURSING HOME REFORM.

    (a) Suspension of Decertification of Nurse Aide Training and 
Competency Evaluation Programs Based on Extended Surveys.--
            (1) In general.--Section 1919(f)(2)(B)(iii)(I)(b) (42 
        U.S.C. 1396r(f)(2)(B)(iii)(I)(b)) is amended by striking the 
        semicolon and inserting the following: ``, unless the survey 
        shows that the facility is in compliance with the requirements 
        of subsections (b), (c), and (d) of this section;''.
            (2) Effective date.--The amendment made by paragraph (1) 
        shall take effect as if included in the enactment of OBRA-1990.
    (b) Requirements for Consultants Conducting Reviews on Use of 
Drugs.--
            (1) In general.--Section 1919(c)(1)(D) (42 U.S.C. 
        1396r(c)(1)(D)) is amended by adding at the end the following 
        sentence: ``In determining whether such a consultant is 
        qualified to conduct reviews under the preceding sentence, the 
        Secretary shall take into account the needs of nursing 
        facilities under this title to have access to the services of 
        such a consultant on a timely basis.''.
            (2) Effective date.--The amendment made by paragraph (1) 
        shall take effect as if included in the enactment of OBRA-1987.
    (c) Increase in Minimum Amount Required for Separate Deposit of 
Personal Funds.--
            (1) In general.--Section 1919(c)(6)(B)(i) (42 U.S.C. 
        1396r(c)(6)(B)(i)) is amended by striking ``$50'' and inserting 
        ``$100''.
            (2) Effective date.--The amendment made by paragraph (1) 
        shall take effect January 1, 1994.
    (d) Due Process Protections for Nurse Aides.--
            (1) Prohibiting state from including undocumented 
        allegations in nurse aide registry.--Section 1919(e)(2)(B) (42 
        U.S.C. 1396r(e)(2)(B)) is amended by striking the period at the 
        end of the first sentence and inserting the following: ``, but 
        shall not include any allegations of resident abuse or neglect 
        or misappropriation of resident property that are not 
        specifically documented by the State under such subsection.''.
            (2) Due process requirements for rebutting allegations.--
        Section 1919(g)(1)(C) (42 U.S.C. 1396r(g)(1)(C)) is amended by 
        striking the second sentence and inserting the following: ``The 
        State shall, after providing the individual involved with a 
        written notice of the allegations (including a statement of the 
        availability of a hearing for the individual to rebut the 
        allegations) and the opportunity for a hearing on the record, 
        make a written finding as to the accuracy of the 
        allegations.''.
            (3) Effective date.--The amendments made by this subsection 
        shall take effect January 1, 1994.

SEC. 227. INCREASE IN AUTHORIZATION OF APPROPRIATIONS FOR THE MATERNAL 
              AND CHILD HEALTH SERVICES BLOCK GRANT PROGRAM.

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

 Subtitle B--Miscellaneous and Technical Corrections Relating to OBRA-
                                  1990

SEC. 241. EFFECTIVE DATE.

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

SEC. 242. CORRECTIONS RELATING TO SECTION 4401 (DRUG REBATE PROGRAM).

    (a) Section 1927.--(1) Section 1927(a) (42 U.S.C. 1396r-8(a)), as 
inserted by section 4401(a)(3) of OBRA-1990, is amended--
            (A) in paragraph (1)--
                    (i) by amending the second sentence to read as 
                follows: ``Any such agreement entered into prior to May 
                1, 1991, shall be deemed to have been entered into on 
                January 1, 1991, and the amount of the rebate to be 
                paid by the manufacturer under such agreement shall be 
                calculated as if the agreement had been entered into on 
                January 1, 1991.'', and
                    (ii) in the third sentence, by striking ``March'' 
                and inserting ``May'';
            (B) in paragraph (2)--
                    (i) by striking ``first'', and
                    (ii) by striking the period at the end and 
                inserting the following: ``, except that such paragraph 
                (and section 1903(i)(10)(A)) shall not apply to drugs 
                dispensed before May 1, 1991, if the Secretary 
                determines that there were extenuating circumstances 
                with respect to the first calendar quarter of 1991.'';
            (C) by amending paragraph (3) to read as follows:
            ``(3) Authorizing payment for drugs not covered under 
        rebate agreements.--Paragraph (1) and section 1903(i)(10) shall 
        not apply to the dispensing of a covered outpatient drug if--
                    ``(A) the State has made a determination that the 
                availability of such drug is essential to the health of 
                beneficiaries under the State plan;
                    ``(B) the drug has been given a rating of 1-A or 1-
                P by the Food and Drug Administration; and
                    ``(C)(i) the physician has obtained approval for 
                the use of the drug in advance of dispensing such drug 
                in accordance with a prior authorization program 
                described in subsection (d)(5), or
                    ``(ii) the Secretary has reviewed and approved the 
                State's determination under subparagraph (A).''; and
            (D) in paragraph (4)--
                    (i) by striking ``In the case'' and inserting ``(A) 
                In the case'',
                    (ii) by striking ``in compliance with'' and 
                inserting ``in effect under'',
                    (iii) by striking ``such agreement provides for a 
                minimum aggregate rebate of 10 percent of the State's 
                total expenditures under the State plan for coverage of 
                the manufacturer's drugs under this title'' and 
                inserting ``such agreement provides for a minimum 
                aggregate rebate of 10 percent of the sum of the 
                amounts determined under subparagraph (B) for all of 
                the manufacturer's drugs paid for by the State under 
                the agreement'', and
                    (iv) by adding at the end the following new 
                subparagraph:
            ``(B) The amount determined under this subparagraph with 
        respect to a manufacturer's drug paid for by a State under an 
        agreement described in the first sentence of subparagraph (A) 
        is an amount equal to the product of--
                    ``(i) the average manufacturer's price for such 
                drug; and
                    ``(ii) the number of dosage units of such drug paid 
                for by the State under such agreement.''.
    (2) Section 1927(b) (42 U.S.C. 1396r-8(b)), as inserted by section 
4401(a)(3) of OBRA-1990, is amended--
            (A) in paragraph (2)(A), by striking ``during'' and 
        inserting ``for'';
            (B) in paragraph (3)(A)--
                    (i) in clause (i), by striking the open parenthesis 
                before ``for'' and the close parenthesis after 
                ``drugs'',
                    (ii) in clause (i), by striking ``subsection 
                (c)(2)(B)) for covered outpatient drugs'' and inserting 
                ``subsection (c)(1)(C)) for each covered outpatient 
                drug'', and
                    (iii) in clause (ii), by inserting a comma after 
                ``this section'' and after ``1990'';
            (C) in paragraph (3)(B)--
                    (i) by striking ``$100,000'' and inserting 
                ``$10,000'',
                    (ii) by striking ``about charges or prices'', and
                    (iii) by striking ``or knowingly provides false 
                information'';
            (D) in paragraph (3)(C)--
                    (i) in clause (i)--
                            (I) by striking ``increased by'', and
                            (II) by striking ``, and, if'' and 
                        inserting ``. If'',
                    (ii) in clause (ii), by striking ``under this 
                section'' and inserting ``under this section, or a 
                wholesaler or direct seller,'',
                    (iii) in clause (ii), by inserting ``under 
                subparagraph (A) or (B)'' after ``provides false 
                information'', and
                    (iv) in clause (ii), by striking ``Such civil money 
                penalties are'' and inserting ``Any such civil money 
                penalty shall be'';
            (E) in paragraph (3)(D), by striking ``wholesaler,'' the 
        first time it appears and inserting ``wholesaler or the''; and
            (F) in paragraph (4)(B)(i), by adding at the end the 
        following new sentence: ``Failure of a State to provide any 
        advance notice of such a termination as required by regulation 
        shall not affect the State's right to terminate coverage of the 
        drugs affected by such termination as of the effective date of 
        such termination.''.
    (3) Section 1927(d)(3) (42 U.S.C. 1396r-8(d)(3)), as inserted by 
section 4401(a)(3) of OBRA-1990 and as amended by section 13602 of 
OBRA-1993, is amended to read as follows:
            ``(3) Additions to drug listings.--The Secretary shall, by 
        regulation, periodically update the list of drugs or classes of 
        drugs described in paragraph (2), or their medical uses, which 
        the Secretary has determined to be subject to clinical abuse or 
        inappropriate use.''.
    (4) Section 1927(h)(2)(A) (42 U.S.C. 1396r-8(h)(2)(A)), as inserted 
by section 4401(a)(3) of OBRA-1990, is amended by inserting ``develops 
or'' before ``acquires''.
    (5) Section 1927(i) (42 U.S.C. 1396r-8(i)), as inserted by section 
4401(a)(3) of OBRA-1990, is amended--
            (A) in paragraph (1), by striking ``the the operation'' and 
        inserting ``the operation''; and
            (B) in paragraph (2),
                    (i) by striking subparagraph (C); and
                    (ii) by redesignating subparagraphs (D), (E), and 
                (F) as subparagraphs (C), (D), and (E), respectively.
    (6) Section 1927(j) (42 U.S.C. 1396r-8(j)), as inserted by section 
4401(a)(3) of OBRA-1990, is amended to read as follows:
    ``(j) Exemption for Certain Health Maintenance Organizations and 
Hospitals.--
            ``(1) In general.--Except as provided in paragraph (2), the 
        requirements of this section shall not apply with respect to 
        covered outpatient drugs dispensed by--
                    ``(A) a health maintenance organization; or
                    ``(B) a hospital that dispenses covered outpatient 
                drugs using a drug formulary system and bills the State 
                no more than the hospital's purchasing costs for 
                covered outpatient drugs.
            ``(2) Construction in determining best price.--Nothing in 
        paragraph (1) shall be construed as excluding amounts paid by 
        the entities described in such paragraph for covered outpatient 
        drugs from the determination of the best price (as defined in 
        subsection (c)(1)(C)) for such drugs.''.
    (7) Section 1927(k) (42 U.S.C. 1396r-8(k)), as inserted by section 
4401(a)(3) of OBRA-1990, is amended--
            (A) in paragraph (2)--
                    (i) in the matter preceding clause (i) of 
                subparagraph (A), by striking ``paragraph (5)'' and 
                inserting ``subparagraph (D)'';
                    (ii) in subparagraph (A)--
                            (I) in clause (i), by striking ``for safety 
                        and effectiveness'' and by striking ``or which 
                        is approved under section 505(j) of such Act''; 
                        and
                            (II) by striking ``and'' at the end;
                    (iii) in subparagraph (B)--
                            (I) in clause (i), by striking 
                        ``prescription,'' and inserting 
                        ``prescription;'';
                            (II) in clause (ii), by striking ``, and'' 
                        and inserting ``; and''; and
                            (III) by striking ``and'' at the end;
                    (iv) by striking the period at the end of 
                subparagraph (C) and inserting ``; and''; and
                    (v) by adding at the end the following new 
                subparagraph:
                    ``(D) a drug which may be sold without a 
                prescription (commonly referred to as an `over-the-
                counter drug'), if the drug is prescribed by a 
                physician (or other person authorized to prescribe 
                under State law).'';
            (B) in subparagraph (H) of paragraph (3), by inserting 
        ``services'' after ``dialysis'';
            (C) by striking paragraph (4) and redesignating paragraphs 
        (5), (6), (7), (8), and (9) as paragraphs (4), (5), (6), (7), 
        and (8), respectively;
            (D) by amending paragraph (4), as so redesignated, to read 
        as follows:
            ``(4) Manufacturer.--The term `manufacturer' means, with 
        respect to a covered outpatient drug, the entity holding legal 
        title to or possession of the National Drug Code number for 
        such drug.''; and
            (E) in paragraph (6), as so redesignated--
                    (i) in subparagraph (A)(i), by striking ``paragraph 
                (5)'' and inserting ``paragraph (2)(D)'',
                    (ii) in subparagraph (A)(ii), by inserting ``or 
                product licensing application'' after ``application'',
                    (iii) in subparagraph (A)(iv), by inserting ``or 
                product licensing application'' after ``application'',
                    (iv) in subparagraph (A)(iv), by striking 
                ``distributers'' and inserting ``distributors'',
                    (v) in subparagraph (C)(i), by striking 
                ``pharmaceuutically'' and inserting 
                ``pharmaceutically'', and
                    (vi) in subparagraph (C)(iii), by striking ``, 
                provided that'' and inserting ``if''.
    (b) Section 1903.--
            (1) Enhanced match.--Section 1903(a) (42 U.S.C. 1396b(a)) 
        is amended--
                    (A) by striking the period at the end of paragraph 
                (7) and inserting ``; plus''; and
                    (B) by adding at the end the following new 
                paragraph:
            ``(8) 75 per centum of so much of the sums expended under 
        the State plan during calendar years 1991 through 1993 as the 
        Secretary determines attributable to the statewide adoption of 
        a drug use review program which conforms to the requirements of 
        section 1927(g).''.
            (2) Conforming amendments.--Section 1903(a)(3) (42 U.S.C. 
        1396b(a)(3)) is amended--
                    (A) by striking ``and'' at the end of subparagraph 
                (C) and inserting ``plus''; and
                    (B) by striking subparagraph (D).
    (c) Funding.--Section 4401(b)(2) of OBRA-1990 is amended by 
striking the semicolon and all that follows and inserting a period.
    (d) Demonstration Projects.--Section 4401(c)(1) of OBRA-1990 is 
amended--
            (1) in subparagraph (A), by striking ``1992'' and inserting 
        ``1993'';
            (2) in subparagraph (A), by striking ``10'' and inserting 
        ``5'';
            (3) in subparagraph (C), by striking ``regiment'' and 
        inserting ``regimen''; and
            (4) in subparagraph (D), by striking ``1994'' and inserting 
        ``1995''.
    (e) Studies.--Section 4401(d) of OBRA-1990 is amended--
            (1) in paragraph (1)(A), by striking ``other institutional 
        facilities,'' and inserting ``nursing facilities, intermediate 
        care facilities for the mentally retarded,'';
            (2) in paragraph (1)(B), by striking ``under this 
        subsection'' and inserting ``under this paragraph'';
            (3) in paragraph (1)(B)(i), by striking ``under this 
        section'' and inserting ``under section 1927 of the Social 
        Security Act'';
            (4) in paragraph (1)(B)(ii)--
                    (A) by striking ``drug use review'' the second time 
                it appears and inserting ``the type of drug use review 
                that is''; and
                    (B) by striking ``under this section'' and 
                inserting ``under such section'';
            (5) in paragraph (1)(B)(iii), by striking ``under this 
        title'' and inserting ``under title XIX of the Social Security 
        Act'';
            (6) in paragraph (1)(C)--
                    (A) by striking ``May 1, 1991'' and inserting ``May 
                1, 1992'', and
                    (B) by striking ``Committees on Aging of the Senate 
                and the House of Representatives'' and inserting 
                ``Committee on Aging of the Senate'';
            (7) in paragraph (2)--
                    (A) by striking ``By not later than May 1 of each 
                year, the Comptroller'' and inserting ``The 
                Comptroller'';
                    (B) by striking ``Committees on Aging of the Senate 
                and House of Representatives'' and inserting 
                ``Committee on Aging of the Senate'';
                    (C) by striking ``an annual report'' and inserting 
                ``a report''; and
                    (D) by striking ``retail and'';
            (8) in paragraph (3)--
                    (A) in subparagraph (A), by striking ``, acting in 
                consultation with the Comptroller General,'',
                    (B) by indenting subparagraph (B) an additional 2 
                ems;
                    (C) in subparagraph (B), by striking ``December 31, 
                1991, the Secretary and the Comptroller General'' and 
                inserting ``June 1, 1993, the Secretary''; and
                    (D) by striking ``Committees on Aging of the Senate 
                and the House of Representatives'' and inserting 
                ``Committee on Aging of the Senate'';
            (9) in paragraph (4)--
                    (A) in subparagraph (A), by striking ``each'' and 
                by striking the semicolon and inserting a comma;
                    (B) in subparagraph (B), by striking ``December 31, 
                1991'' and inserting ``January 1, 1993''; and
                    (C) in subparagraph (B), by striking ``Committees 
                on Aging of the Senate and the House of 
                Representatives'' and inserting ``Committee on Aging of 
                the Senate'';
            (10) in paragraph (5)--
                    (A) by striking ``Secretary of Health and Human 
                Services'' and inserting ``Comptroller General'',
                    (B) by striking ``under this title'' and inserting 
                ``under State medicaid programs'', and
                    (C) by striking the second sentence and inserting 
                the following new sentence: ``The Comptroller General 
                shall report to the Congress on the study not later 
                than January 1, 1993.''; and
            (11) by striking paragraph (6).

SEC. 243. CORRECTIONS RELATING TO SECTION 4402 (ENROLLMENT UNDER GROUP 
              HEALTH PLANS).

    Section 4402(b) of OBRA-1990 is amended by striking 
``1903(u)(1)(C)(iv) (42 U.S.C. 1396b(u)(1)(C)(iv))'' and inserting 
``1903(u)(1)(D)(iv) (42 U.S.C. 1396b(u)(1)(D)(iv))''.

SEC. 244. CORRECTIONS RELATING TO SECTION 4501 (LOW-INCOME MEDICARE 
              BENEFICIARIES).

    (a) Section 1902(a)(10)(E)(iii) (42 U.S.C. 1396a(a)(10)(E)(iii)), 
as added by section 4501(b)(3) of OBRA-1990, is amended by striking 
``cost sharing'' and inserting ``cost-sharing''.
    (b) Section 1905(p)(4)(B) (42 U.S.C. 1396d(p)(4)(B)), as amended by 
section 4501(c)(1) of OBRA-1990, is amended by striking 
``1902(a)(10)(E)(iii)'' and inserting ``section 1902(a)(10)(E)(iii)''.

SEC. 245. CORRECTIONS RELATING TO SECTION 4601 (CHILD HEALTH).

    (a) Section 1902(a)(10)(A)(i)(VII) (42 U.S.C. 
1396a(a)(10)(A)(i)(VII)), as added by section 4601(a)(10)(A)(iii) of 
OBRA-1990, is amended by striking ``family;'' and inserting ``family; 
and''.
    (b) Section 1902(l) (42 U.S.C. 1396a(l)), as amended by section 
4601(a)(1)(C) of OBRA-1990, is amended--
            (1) in paragraph (1)(C), by striking ``children'' after 
        ``(C)'';
            (2) in paragraph (3), by striking ``(a)(10)(A)(i)(VII),,'' 
        and inserting ``(a)(10)(A)(i)(VII),''; and
            (3) in paragraph (4)(B), by inserting a comma before 
        ``(a)(10)(A)(i)(VI),''.
    (c) Section 1925 (42 U.S.C. 1396r-6), as amended by section 4601(a) 
of OBRA-1990, is amended--
            (1) in subsection (a)(3)(C), by striking ``(i)(VI)'' and 
        inserting ``(i)(VI),'', and
            (2) in subsection (b)(3)(C)(i), by striking ``(i)(IV) 
        (i)(VI) (i)(VII), ,'' and inserting ``(i)(IV), (i)(VI), 
        (i)(VII),''.

SEC. 246. CORRECTIONS RELATING TO SECTION 4602 (OUTREACH LOCATIONS).

    (a) Section 1902(a)(55) (42 U.S.C. 1396a(a)(55)), as added by 
section 4602(a)(3) of OBRA-1990, is amended--
            (1) in the matter preceding subparagraph (A)--
                    (A) by striking ``subsection'' and inserting 
                ``paragraph'', and
                    (B) by striking ``(a)'' each place it appears; and
            (2) in subparagraph (A), by striking ``1905(1)(2)(B)'' and 
        inserting ``1905(l)(2)(B)''.
    (b) Section 1902(l)(1) (42 U.S.C. 1396a(l)(1)) is amended by 
striking ``who are not described in any of subclauses (I) through (III) 
of subsection (a)(10)(A)(i) and''.

SEC. 247. CORRECTIONS RELATING TO SECTION 4604 (PAYMENT FOR HOSPITAL 
              SERVICES FOR CHILDREN UNDER 6 YEARS OF AGE).

    (a) Section 1902(a)(10) (42 U.S.C. 1396a(a)(10)) is amended in 
clause (X) in the matter following subparagraph (F) by striking ``under 
one year of age'' and inserting ``under 6 years of age''.
    (b) Section 1902(s) (42 U.S.C. 1396a(s)), as added by section 
4604(a) of OBRA-1990, is amended to read as follows:
    ``(s) In order to meet the requirements of subsection (a)(56), the 
State plan must provide that payments to hospitals under the plan for 
inpatient services furnished to infants who have not attained the age 
of 1 year (or, in the case of such an individual who is an inpatient on 
his first birthday, until such individual is discharged) shall--
            ``(1) if made on a prospective basis (whether per diem, per 
        case, or otherwise), provide for an outlier adjustment in 
        payment amounts for medically necessary inpatient hospital 
        services involving exceptionally high costs or exceptionally 
        long lengths of stay;
            ``(2) not be limited by the imposition of day limits; and
            ``(3) not be limited by the imposition of dollar limits 
        (other than dollar limits resulting from prospective payments 
        as adjusted pursuant to paragraph (1)).''.
    (c) Section 1923(a)(2)(C) (42 U.S.C. 1396r-4(a)(2)(C)) is amended 
by striking ``provided on or after July 1, 1989,'' and all that follows 
and inserting the following: ``involving exceptionally high costs or 
exceptionally long lengths of stay--
            ``(i) for individuals under 1 year of age, in the case of 
        services provided on or after July 1, 1989, and on or before 
        June 30, 1991; and
            ``(ii) for individuals under 6 years of age, in the case of 
        services provided on or after July 1, 1991.''.

SEC. 248. CORRECTIONS RELATING TO SECTION 4703 (PAYMENT ADJUSTMENTS FOR 
              DISPROPORTIONATE SHARE HOSPITALS).

    (a) Section 1923(c) (42 U.S.C. 1396r-4(c)) is amended--
            (1) in paragraph (2), by striking ``paragraph (b)(3)'' and 
        inserting ``subsection (b)(3)'';
            (2) by striking the period at the end of paragraph (3)(B) 
        and inserting a comma; and
            (3) in the third sentence, by striking ``the payment 
        adjustment described in paragraph (2)'' and inserting ``a 
        payment adjustment described in paragraph (2) or (3)''.
    (b) Effective December 22, 1987, section 1923(d)(2)(A)(ii) (42 
U.S.C. 1396r-4(d)(2)(A)(ii)) is amended by striking ``the date of the 
enactment of this Act'' and inserting ``December 22, 1987''.
    (c) Section 4703(d) of OBRA-1990 is amended by striking 
``412(a)(2)'' and inserting ``4112(a)(2)''.

SEC. 249. CORRECTIONS RELATING TO SECTION 4704 (FEDERALLY-QUALIFIED 
              HEALTH CENTERS).

    (a) Clause (ix) of section 1903(m)(2)(A) (42 U.S.C. 
1396b(m)(2)(A)), as added by section 4704(b)(1)(C) of OBRA-1990, is 
amended--
            (1) by striking ``of such center'' the first place it 
        appears;
            (2) by striking ``federally qualified'' and inserting 
        ``Federally-qualified'';
            (3) by inserting ``section'' before ``1905(a)(2)(C)''; and
            (4) by moving such clause 2 ems to the left.
    (b) Section 1903(m)(2)(B) (42 U.S.C. 1396b(m)(2)(B)), as amended by 
section 4704(b)(2) of OBRA-1990, is amended in the matter preceding 
clause (i) by striking ``except with respect to clause (ix) of 
subparagraph (A),'' and inserting ``(except with respect to clause (ix) 
of such subparagraph)''.
    (c) Section 1905(l)(2) (42 U.S.C. 1396d(l)(2)), as amended by 
section 4704(c) of OBRA-1990 and sections 13606(a) and 13631(f)(2)(B) 
of OBRA-1993, is amended--
            (1) in subparagraph (A)--
                    (A) by striking ``Federally-qualififed'' and 
                inserting ``Federally-qualified'', and
                    (B) by striking ``an patient'' and inserting ``a 
                patient'', and
            (2) in subparagraph (B)--
                    (A) in the matter preceding clause (i), by striking 
                ``a entity'' and inserting ``an entity'',
                    (B) by striking ``or'' at the end of clause (iii),
                    (C) by striking the semicolon at the end of clause 
                (iv) and inserting ``, or'', and
                    (D) by striking ``and includes an outpatient health 
                program'' and all that follows through ``for good cause 
                shown.'' and inserting the following:
            ``(v) is an outpatient health program or facility operated 
        by a tribe or tribal organization under the Indian Self-
        Determination Act (Public Law 93-638) or by an urban Indian 
        organization receiving funds under title V of the Indian Health 
        Care Improvement Act for the provision of primary health 
        services.
In applying clause (ii), the Secretary may waive any requirement 
referred to in such clause for up to 2 years for good cause shown.''.

SEC. 250. CORRECTIONS RELATING TO SECTION 4708 (SUBSTITUTE PHYSICIANS).

    (a) Section 1902(a)(32) (42 U.S.C. 1396a(a)(32)), as added by 
section 4708(a)(3) of OBRA-1990 and as amended by section 13631(e)(1) 
of OBRA-1993, is amended--
            (1) in the matter preceding subparagraph (A), by striking 
        ``except that'' and inserting ``except that (subject to section 
        1903(i)(12))''; and
            (2) by amending subparagraph (C) to read as follows:
                    ``(C) payment may be made to a physician for 
                physicians' services (and services furnished incident 
                to such services) furnished by a second physician to 
                patients of the first physician if (i) the first 
                physician is unavailable to provide the services; (ii) 
                the services are furnished pursuant to an arrangement 
                between the two physicians that (I) is informal and 
                reciprocal, or (II) involves per diem or other fee-for-
                time compensation for such services; (iii) the services 
                are not provided by the second physician over a 
                continuous period of more than 60 days; and (iv) the 
                claim form submitted to the State for such services 
                includes the second physician's unique identifier 
                (provided under the system established under subsection 
                (x)) and indicates that the claim meets the 
                requirements of this subparagraph for payment to the 
                first physician; and''.
    (b) The amendments made by subsection (a) 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. 251. CORRECTIONS RELATING TO SECTION 4711 (HOME AND COMMUNITY CARE 
              FOR FRAIL ELDERLY).

    (a) Section 1929 (42 U.S.C. 1396t), as added by section 4711(b) of 
OBRA-1990, is amended--
            (1) in subsection (c)(2)(F), by moving the second sentence 
        2 ems to the right;
            (2) in subsection (d)(2)(F)(ii), by striking ``they 
        manage'' and inserting ``it manages'';
            (3) in subsection (d)(2)(F)(iii), by inserting ``the agency 
        or organization'' after ``(iii)'';
            (4) in subsection (e)(2)(B), by striking ``fiscal year 
        1989'' and inserting ``fiscal year 1990'';
            (5) in subsection (f)(1), by striking ``Community care'' 
        and inserting ``community care'';
            (6) in subsection (g)(1)--
                    (A) by striking ``settings'' and inserting 
                ``setting''; and
                    (B) in subparagraph (B), by striking ``setting.'' 
                and inserting ``setting in which home and community 
                care under this section is provided.'';
            (7) in subsection (g)(2), by striking ``community care'' 
        the second, third, and fourth place it appears and inserting 
        ``home and community care'';
            (8) in subsection (h)(1)--
                    (A) by amending subparagraph (A) to read as 
                follows:
                    ``(A) a nonresidential setting that serves 8 or 
                more individuals; or''; and
                    (B) in subparagraph (B)--
                            (i) by striking ``more than 8'' and 
                        inserting ``8 or more''; and
                            (ii) by inserting ``(other than merely 
                        board)'' after ``personal services'';
            (9) in subsection (h)(2), by striking ``community care'' 
        the second and third place it appears and inserting ``home and 
        community care'';
            (10) in the first sentence of subsection (j)(1)(A), by 
        striking ``the State may terminate the provider's participation 
        under the State plan and may provide in addition for a civil 
        money penalty'' and inserting ``the State may provide for a 
        civil money penalty and, in addition, may terminate the 
        provider's participation under the State plan'';
            (11) in the first sentence of subsection (j)(2)(B), by 
        striking ``the Secretary may terminate the provider's 
        participation under the State plan and may provide, in 
        addition, for a civil money penalty under subparagraph (C)'' 
        and inserting ``the Secretary may provide for a civil money 
        penalty under subparagraph (C) and, in addition, terminate the 
        provider's participation under the State plan'';
            (12) in subsection (k)(1)(A)(i)--
                    (A) by striking ``(d)(2)(E)'' and inserting 
                ``(d)(2)'', and
                    (B) by striking ``settings,'' and inserting 
                ``settings),'';
            (13) in subsection (l), by striking ``State wideness'' and 
        inserting ``Statewideness'';
            (14) in paragraph (2) of subsection (m) by striking 
        ``Individual Community Care Plan'' and inserting ``individual 
        community care plan''; and
            (15) by adding at the end the following new subsection:
    ``(n) Community Care Setting Defined.--In this section, the term 
`community care setting' means a small community care setting (as 
defined in subsection (g)(1)) or a large community care setting (as 
defined in subsection (h)(1)).''.
    (b) Section 1905(r)(5) (42 U.S.C. 1396d(r)(5)) is amended by 
striking ``section 1905(a)'' and inserting ``subsection (a) (other than 
services described in paragraph (22) or (23) of such subsection)''.
    (c) Section 4711(f) of OBRA-1990 is amended by striking ``Act'' 
each place it appears and inserting ``section''.

SEC. 252. CORRECTIONS RELATING TO SECTION 4712 (COMMUNITY SUPPORTED 
              LIVING ARRANGEMENTS).

    (a) Section 1930 (42 U.S.C. 1396u), as added by section 4712(b)(2) 
of OBRA-1990, is amended--
            (1) in subsection (b)--
                    (A) by striking ``title the term,'' and inserting 
                ``title, the term'',
                    (B) by striking ``guardian'' and inserting 
                ``guardian or'', and
                    (C) by striking ``3 other'' and inserting ``3'';
            (2) in subsection (d)--
                    (A) in the matter preceding paragraph (1), by 
                striking ``program,'' and inserting ``program'', and
                    (B) in the second sentence, by striking ``plan'' 
                each place it appears and inserting ``program''; and
            (3) in subsection (i), by striking ``funds'' and inserting 
        ``Funds''.
    (b) Section 4712(c) of OBRA-1990 is amended--
            (1) in paragraph (1), by inserting ``of section 1930 of the 
        Social Security Act'' after ``subsection (h)''; and
            (2) in paragraph (2), by striking ``this section'' and 
        inserting ``such section''.

SEC. 253. CORRECTION RELATING TO SECTION 4713 (COBRA CONTINUATION 
              COVERAGE).

    (a) Section 1902(a)(10) (42 U.S.C. 1396a(a)(10)) is amended in the 
matter following subparagraph (F) by striking ``COBRA continuation 
premiums'' and inserting ``COBRA premiums''.
    (b) Section 1902(u)(3) (42 U.S.C. 1396a(u)(3)), as added by section 
4713(a)(2) of OBRA-1990, is amended by striking ``title VI'' and 
inserting ``part 6 of subtitle B of title I''.

SEC. 254. CORRECTION RELATING TO SECTION 4716 (MEDICAID TRANSITION FOR 
              FAMILY ASSISTANCE).

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

SEC. 255. CORRECTIONS RELATING TO SECTION 4718 (MEDICALLY NEEDY INCOME 
              LEVELS FOR CERTAIN 1-MEMBER FAMILIES).

    Section 4718(b) of OBRA-1990 is amended by striking ``June 1, 
1989'' and inserting ``July 1, 1989''.

SEC. 256. CORRECTIONS RELATING TO SECTION 4723 (MEDICAID SPEND-DOWN 
              OPTION).

    Section 1903(f)(2) (42 U.S.C. 1396b(f)(2)), as amended by section 
4723(a) of OBRA-1990, is amended by striking ``to the State, provided 
that'' and inserting ``to the State if''.

SEC. 257. CORRECTIONS RELATING TO SECTION 4724 (OPTIONAL STATE 
              DISABILITY DETERMINATIONS).

    Section 1902(v) (42 U.S.C. 1396a(v)), as added by section 4724 of 
OBRA-1990, is amended--
            (1) by striking ``(v)(1)'' and inserting ``(v)''; and
            (2) by striking ``of the Social Security Act''.

SEC. 258. CORRECTION RELATING TO SECTION 4732 (SPECIAL RULES FOR HEALTH 
              MAINTENANCE ORGANIZATIONS).

    Section 1903(m)(2)(F)(i) (42 U.S.C. 1396b(m)(2)(F)(i)), as amended 
by section 4732(b)(2)(B) of OBRA-1990, is amended by striking ``or'' 
before ``with an eligible organization''.

SEC. 259. CORRECTIONS RELATING TO SECTION 4747 (COVERAGE OF HIV-
              POSITIVE INDIVIDUALS).

    Section 4747 of OBRA-1990 is amended--
            (1) in subsection (a)--
                    (A) by striking ``services described in subsection 
                (c)'' and inserting ``services described in subsection 
                (b)(1) (and may provide coverage for services described 
                in subsection (b)(2))'', and
                    (B) by striking ``to individuals'' and inserting 
                ``to individuals who are not otherwise eligible for 
                medical assistance under such title,'';
            (2) by amending subsection (b) to read as follows:
    ``(b) Services Available Under a Demonstration Project.--
            ``(1) Required services.--
                    ``(A) In general.--Services described in this 
                paragraph are the following:
                            ``(i) General and preventive medical care 
                        services, including outpatient care, physician 
                        visits, and clinic visits.
                            ``(ii) Other laboratory and X-ray services.
                            ``(iii) Prescription drugs (including costs 
                        associated with the intravenous administration 
                        of prescription drugs).
                            ``(iv) Case management services.
                    ``(B) Scope of services.--The services described in 
                subparagraph (A) may be limited under a demonstration 
                project only on the basis of medical necessity or the 
                appropriateness of such services.
            ``(2) Optional services.--
                    ``(A) In general.--Services described in this 
                paragraph are the following:
                            ``(i) Counseling and social services.
                            ``(ii) Substance abuse treatment.
                            ``(iii) Health education services.
                            ``(iv) Dental services.
                    ``(B) Scope of services.--A demonstration project 
                may limit the amount, duration, or scope of services 
                described in subparagraph (A).'';
            (3) in subsection (c)--
                    (A) in paragraph (1)--
                            (i) by striking ``with a hospital'' and all 
                        that follows through ``other entity have'' and 
                        inserting ``with an entity which has'', and
                            (ii) by striking ``and have access'' and 
                        all that follows through the end and inserting 
                        ``and has access to data on comparable patients 
                        who have so tested and who are not 
                        participating in the demonstration project.'', 
                        and
                    (B) by striking paragraphs (2) and (3) and 
                redesignating paragraph (4) as paragraph (2);
            (4) in subsection (d), by striking ``paragraph (3)'' and 
        ``paragraph (1)'' and inserting ``subsection (b)'' and 
        ``subsection (a)'', respectively; and
            (5) in subsection (f), by adding at the end the following 
        new sentence: ``Such sums as may be available under the 
        limitation set forth in this paragraph for fiscal year 1993 
        shall be available until expended.''.

SEC. 260. CORRECTION RELATING TO SECTION 4751 (ADVANCED DIRECTIVES).

    Section 1903(m)(1)(A) (42 U.S.C. 1396b(m)(1)(A)), as amended by 
section 4751(b)(1) of OBRA-1990, is amended--
            (1) by striking ``1902(w)'' and inserting ``1902(w) and''; 
        and
            (2) by striking ``1902(a)'' and inserting ``1902(w)''.

SEC. 261. CORRECTIONS RELATING TO SECTION 4752 (PHYSICIANS' SERVICES).

    (a) Paragraph (59) of section 1902(a) (42 U.S.C. 1396a(a)), as 
added by section 4752(c)(1)(C) of OBRA-1990 and as redesignated by 
section 13623(a)(6) of OBRA-1993, is amended by striking ``subsection 
(v)'' and inserting ``subsection (x)''.
    (b) Section 1903(i)(12) (42 U.S.C. 1396b(i)(12)), as inserted by 
section 4752(e) of OBRA-1990 and as redesignated by section 13631(c)(3) 
of OBRA-1993, is amended--
            (1) by amending clause (i) of subparagraph (A) to read as 
        follows:
                            ``(i) is certified in family practice or 
                        pediatrics by the medical specialty board 
                        recognized by the American Board of Medical 
                        Specialties for family practice or pediatrics 
                        or is certified in general practice or 
                        pediatrics by the medical specialty board 
                        recognized by the American Osteopathic 
                        Association,'';
            (2) by amending clause (i) of subparagraph (B) to read as 
        follows:
                            ``(i) is certified in family practice or 
                        obstetrics by the medical specialty board 
                        recognized by the American Board of Medical 
                        Specialties for family practice or obstetrics 
                        or is certified in general practice or 
                        obstetrics by the Medical Specialty Board 
                        recognized by the American Osteopathic 
                        Association,''; and
            (3) in subparagraphs (A) and (B)--
                    (A) by striking ``or'' at the end of clause (v);
                    (B) by redesignating clause (vi) as clause (vii); 
                and
                    (C) by inserting after clause (v) the following new 
                clause:
                            ``(vi) delivers such services in the 
                        emergency department of a hospital 
                        participating in the State plan approved under 
                        this title, or''.

SEC. 262. CORRECTIONS RELATING TO SECTION 4801 (NURSING HOME REFORM).

    (a) Section 1919(b)(3)(C)(i)(I) (42 U.S.C. 1396r(b)(3)(C)(i)(I)), 
as amended by section 4801(e)(3) of OBRA-1990, is amended by striking 
``not to exceed'' before ``14 days''.
    (b) Section 1919(b)(5)(D) (42 U.S.C. 1396r(b)(5)(D)), as amended by 
section 4801(a)(4) of OBRA-1990, is amended by striking the comma 
before ``or a new competency evaluation program.''.
    (c) Section 1919(b)(5)(G) (42 U.S.C. 1396r(b)(5)(G)) is amended by 
striking ``or licensed or certified social worker'' and inserting 
``licensed or certified social worker, registered respiratory 
therapist, or certified respiratory therapy technician''.
    (d) Section 1919(f)(2)(B)(i) (42 U.S.C. 1396r(f)(2)(B)(i)) is 
amended by striking ``facilities,'' and inserting ``facilities (subject 
to clause (iii)),''.
    (e) Section 1919(f)(2)(B)(iii)(I)(c) (42 U.S.C. 
1396r(f)(2)(B)(iii)(I)(c)) is amended by striking ``clauses'' each 
place it appears and inserting ``clause''.
    (f) Section 1919(g)(5)(B) (42 U.S.C. 1396r(g)(5)(B)) is amended by 
striking ``paragraphs'' and inserting ``paragraph''.
    (g) Section 4801(a)(6)(B) of OBRA-1990 is amended--
            (1) by striking ``The amendments'' and inserting ``(i) The 
        amendments'';
            (2) by redesignating clauses (i) through (v) as subclauses 
        (I) through (V); and
            (3) by adding at the end the following new clause:
                    ``(ii) Notwithstanding clause (i) and subject to 
                section 1919(f)(2)(B)(iii)(I) of the Social Security 
                Act (as amended by subparagraph (A)), a State may 
                approve a training and competency evaluation program or 
                a competency evaluation program offered by or in a 
                nursing facility described in clause (i) if, during the 
                previous 2 years, none of the subclauses of clause (i) 
                applied to the facility.''.

SEC. 263. OTHER TECHNICAL CORRECTIONS.

    (a) Section 1905(o)(1)(A) (42 U.S.C. 1396d(o)(1)(A)) is amended--
            (1) in the first sentence, by striking ``intermediate care 
        facility services'' and inserting ``for nursing facility 
        services or intermediate care facility services for the 
        mentally retarded''; and
            (2) in the second sentence, by striking ``or intermediate 
        care facility'' and inserting ``(for purposes of title XVIII), 
        a nursing facility, or an intermediate care facility for the 
        mentally retarded''.
    (b) Section 1915(d) (42 U.S.C. 1396n(d)) is amended--
            (1) by striking ``skilled nursing facility or intermediate 
        care facility'' each place it appears in paragraphs (1), 
        (2)(B), and (2)(C) and inserting ``nursing facility'';
            (2) in paragraph (2)(B)(i), by striking ``skilled nursing 
        or intermediate care facility'' and inserting ``nursing 
        facility'';
            (3) in paragraph (5)(A), by striking ``under'' the second 
        place it appears and inserting ``(or, in the case of waiver 
        years beginning on or after October 1, 1990, with respect to 
        nursing facility services and home and community-based 
        services) under''; and
            (4) in paragraph (5)(B)--
                    (A) in clause (i), by striking ``furnished'' and 
                inserting ``(or, with respect to waiver years beginning 
                on or after October 1, 1990, for nursing facility 
                services) furnished''; and
                    (B) in clause (iii)(I), by striking ``(regardless'' 
                and inserting ``(or, with respect to waiver years 
                beginning on or after October 1, 1990, which comprise 
                nursing facility services) (regardless''.
    (c)(1) Section 1924(h)(1)(A) (42 U.S.C. 1396r-5(h)(1)(A)) is 
amended to read as follows:
                    ``(A)(i) is in a medical institution or nursing 
                facility; or
                    ``(ii) is described in section 
                1902(a)(10)(A)(ii)(VI) (except that for purposes of 
                subsection (d), such term shall include such individual 
                only if the State elects to apply such subsection to 
                the individual); and''.
    (2) The amendments made by this subsection shall apply to home or 
community-based services furnished on or after January 1, 1994.

 Subtitle C--Miscellaneous and Technical Corrections Relating to OBRA-
                                  1993

SEC. 271. EFFECTIVE DATE.

    Except as otherwise provided, the amendments made by this part 
shall take effect as if included in the enactment of OBRA-1993.

SEC. 272. CORRECTIONS RELATING TO SECTION 13601 (PERSONAL CARE 
              SERVICES).

    Section 13601(a)(3) of OBRA-1993 is amended by striking ``comma'' 
and inserting ``period''.

SEC. 273. CORRECTIONS RELATING TO SECTION 13604 (EMERGENCY SERVICES FOR 
              ALIENS).

    Section 13604(b)(2) of OBRA-1993 is amended to read as follows:
    ``(2) The Secretary of Health and Human Services shall not disallow 
expenditures made under section 1903(v)(2) of the Social Security Act 
for care and services relating to organ transplant procedures furnished 
before the date of the enactment of this Act.''.

SEC. 274. CORRECTIONS RELATING TO SECTION 13611 (TRANSFERS OF ASSETS; 
              TREATMENT OF CERTAIN TRUSTS).

    (a) Section 1917(c)(2)(C)(iii) (42 U.S.C. 1396p(c)(2)(C)(iii)), as 
added by section 13611(a)(2)(C)(iv) of OBRA-1993, is amended by 
striking ``all''.
    (b) Section 1917(c)(4) (42 U.S.C. 1396p(c)(4)), as amended by 
section 13611(a)(2)(F), is amended by striking ``resources'' and 
inserting ``assets''.
    (c) Section 13611(e)(3) of OBRA-1993 is amended--
            (1) by striking ``amendment made by subsection (b)'' and 
        inserting ``amendments made by subsections (a) and (b)''; and
            (2) by striking ``such amendment'' and inserting ``such 
        amendments''.

SEC. 275. CORRECTIONS RELATING TO SECTION 13612 (MEDICAID ESTATE 
              RECOVERIES).

    Section 1917(b)(1) (42 U.S.C 1396p(b)(1)), as amended by section 
13612(a) of OBRA-1993, is amended--
            (1) by amending the matter preceding subparagraph (A) to 
        read as follows:
    ``(b)(1) No adjustment or recovery of any medical assistance 
correctly paid on behalf of an individual under the State plan may be 
made, except that the State shall comply with the following:'';
            (2) by amending subparagraph (A) to read as follows:
            ``(A) In the case of an individual described in subsection 
        (a)(1)(B), the State--
                    ``(i) shall seek adjustment or recovery upon the 
                sale of property subject to a lien imposed on account 
                of medical assistance paid on behalf of the individual, 
                and
                    ``(ii) may seek adjustment or recovery from the 
                individual's estate.''; and
            (3) in subparagraph (B)--
                    (A) in clause (i), by striking ``or'' at the end 
                and inserting ``and''; and
                    (B) in clause (ii), by inserting ``additional'' 
                after ``any''.

SEC. 276. CORRECTIONS RELATING TO SECTION 13622 (LIABILITY OF THIRD 
              PARTIES TO PAY FOR CARE AND SERVICES).

    (a) Section 1902(a)(25)(A) (42 U.S.C. 1396a(a)(25)(A)), as amended 
by section 13622(a) of OBRA-1993, is amended by striking ``(as defined 
in section 607(1)'' and inserting ``(including any such plan meeting 
the definition of section 607(1)''.
    (b) Section 1902(a)(25)(I) (42 U.S.C. 1396a(a)(25)(I)), as added by 
section 13622(c) of OBRA-1993, is amended to read as follows:
                    ``(I) assurances satisfactory to the Secretary that 
                the State has in effect laws providing that, to the 
                extent that payment has been made under the State plan 
                of that or any other State for medical assistance for 
                health care items or services furnished to an 
                individual, the State paying such medical assistance is 
                considered to have acquired the rights of such 
                individual to payment by any third party legally liable 
                to pay for such items or services;''.

SEC. 277. CORRECTIONS RELATING TO SECTION 13623 (MEDICAL CHILD 
              SUPPORT).

    (a)(1) Title XIX (42 U.S.C. 1396 et seq.) is amended by 
redesignating section 1908, as added by section 13623(b) of OBRA-1993, 
as section 1909.
    (2) Paragraph (60) of section 1902(a) (42 U.S.C. 1396a(a)), as 
added by section 13623(a) of OBRA-1993, is amended by striking 
``section 1908'' and inserting ``section 1909''.
    (b) Subsection (b) of section 1909, as redesignated by subsection 
(a), is amended by striking ``as defined in section 607(1)'' and 
inserting ``including any such plan meeting the definition of section 
607(1)''.

SEC. 278. CORRECTIONS RELATING TO SECTION 13624 (PHYSICIAN REFERRALS).

    Section 13624(b) of OBRA-1993 is amended by striking ``on or''.

SEC. 279. CORRECTIONS RELATING TO SECTION 13631 (MEDICAID PEDIATRIC 
              IMMUNIZATION PROVISIONS).

    (a) Section 1902(a)(32)(D) (42 U.S.C. 1396(a)(32)(D)), as added by 
section 13631(e)(1) of OBRA-1993, is amended by striking ``(which price 
includes a reasonable amount to cover shipping and the handling of 
returns)'' and inserting ``plus a reasonable amount to cover shipping 
and the handling of returns''.
    (b) Section 1928(d)(3)(B) (42 U.S.C. 1396s(d)(3)(B)), as added by 
section 13631(b)(2) of OBRA-1993, is amended by striking ``and any 
applicable excise tax established under section 4131 of the Internal 
Revenue Code of 1986''.

SEC. 280. CORRECTIONS RELATING TO SECTION 13643 (DEMONSTRATION 
              PROJECTS).

    Effective as if included in the enactment of OBRA-1990, section 
4745 of such Act is amended in subsection (d) by striking ``shall 
commence not later than July 1, 1991 and''.

   TITLE III--INCOME SECURITY, HUMAN RESOURCES, AND RELATED PROGRAMS

            Subtitle A--Child Welfare, Foster Care, Adoption

SEC. 301. REQUIRED PROTECTIONS FOR FOSTER CHILDREN.

    (a) In General.--Section 422(b) (42 U.S.C. 622(b)) is amended--
            (1) by striking ``and'' at the end of paragraph (7);
            (2) by striking the period at the end of paragraph (8) and 
        inserting ``; and''; and
            (3) by adding at the end the following:
            ``(9) provide assurances that the State--
                    ``(A) since June 17, 1980, has completed an 
                inventory of all children who, before the inventory, 
                had been in foster care under the responsibility of the 
                State for 6 months or more, which determined--
                            ``(i) the appropriateness of, and necessity 
                        for, the foster care placement;
                            ``(ii) whether the child could or should be 
                        returned to the parents of the child or should 
                        be freed for adoption or other permanent 
                        placement; and
                            ``(iii) the services necessary to 
                        facilitate the return of the child or the 
                        placement of the child for adoption or legal 
                        guardianship;
                    ``(B) is operating, to the satisfaction of the 
                Secretary--
                            ``(i) a statewide information system from 
                        which can be readily determined the status, 
                        demographic characteristics, location, and 
                        goals for the placement of every child who is 
                        (or, within the immediately preceding 12 
                        months, has been) in foster care;
                            ``(ii) a case review system (as defined in 
                        section 475(5)) for each child receiving foster 
                        care under the supervision of the State;
                            ``(iii) a service program designed to help 
                        children--
                                    ``(I) where appropriate, return to 
                                families from which they have been 
                                removed; or
                                    ``(II) be placed for adoption, with 
                                a legal guardian, or, if adoption or 
                                legal guardianship is determined not to 
                                be appropriate for a child, in some 
                                other planned, permanent living 
                                arrangement; and
                            ``(iv) a preplacement preventive services 
                        program designed to help children at risk of 
                        foster care placement remain with their 
                        families; and
                    ``(C)(i) has reviewed (or within 12 months after 
                the date of the enactment of this paragraph will 
                review) State policies and administrative and judicial 
                procedures in effect for children abandoned at or 
                shortly after birth (including policies and procedures 
                providing for legal representation of such children); 
                and
                    ``(ii) is implementing (or within 24 months after 
                the date of the enactment of this paragraph will 
                implement) such policies and procedures as the State 
                determines, on the basis of the review described in 
                clause (i), to be necessary to enable permanent 
                decisions to be made expeditiously with respect to the 
                placement of such children.''.
    (b) Restriction on Reallotment.--Section 424 (42 U.S.C. 624) is 
amended--
            (1) in the first sentence, by striking ``The amount'' and 
        inserting the following:
    ``(a) In General.--Subject to subsection (b), the amount''; and
            (2) by adding at the end the following:
    ``(b) Exception Relating to Foster Child Protections.--The 
Secretary shall not reallot under subsection (a) of this section any 
amount that is withheld or recovered from a State due to the failure of 
the State to meet the requirements of section 422(b)(9).''.
    (c) Repeal.--Section 427 (42 U.S.C. 627) is hereby repealed.
    (d) Conforming Amendments.--
            (1) Section 423(a) (42 U.S.C. 623(a)) is amended by 
        striking ``and in section 427''.
            (2) Section 425(a)(2) (42 U.S.C. 625(a)(2)) is amended by 
        striking ``the statistical report required by section'' and 
        inserting ``section 422(b)(9) or''.
            (3) Section 472(d) (42 U.S.C. 672(d)) is amended by 
        striking ``427(b)'' and inserting ``422(b)(9)''.
    (e) Effective Date.--The amendments and repeal made by this section 
shall be effective with respect to fiscal years beginning on or after 
October 1, 1995.

SEC. 302. CONFORMITY REVIEWS.

    (a) In General.--Part A of title XI (42 U.S.C. 1301-1320b-13) is 
amended by inserting after section 1122 the following:

``reviews of child and family services programs, and of foster care and 
     adoption assistance programs, for conformity with state plan 
                              requirements

    ``Sec. 1123. (a) In General.--The Secretary, in consultation with 
the State agencies administering the State programs under parts B and E 
of title IV, shall promulgate regulations for the review of such 
programs to determine whether such programs are in substantial 
conformity with--
            ``(1) State plan requirements under such parts B and E,
            ``(2) implementing regulations promulgated by the 
        Secretary, and
            ``(3) the relevant approved State plans.
    ``(b) Elements of Review System.--The regulations referred to in 
subsection (a) shall--
            ``(1) specify the timetable for conformity reviews of State 
        programs, including--
                    ``(A) an initial review of each State program;
                    ``(B) a timely review of a State program following 
                a review in which such program was found not to be in 
                substantial conformity; and
                    ``(C) less frequent reviews of State programs which 
                have been found to be in substantial conformity, but 
                such regulations shall permit the Secretary to 
                reinstate more frequent reviews based on information 
                which indicates that a State program may not be in 
                conformity;
            ``(2) specify the requirements subject to review, and the 
        criteria to be used to measure conformity with such 
        requirements and to determine whether there is a substantial 
        failure to so conform;
            ``(3) specify the method to be used to determine the amount 
        of any Federal matching funds to be withheld (subject to 
        paragraph (4)) due to the State program's failure to so 
        conform, which ensures that--
                    ``(A) such funds will not be withheld with respect 
                to a program, unless it is determined that the program 
                fails substantially to so conform;
                    ``(B) such funds will not be withheld for a failure 
                to so conform resulting from the State's reliance upon 
                and correct use of formal written statements of Federal 
                law or policy provided to the State by the Secretary; 
                and
                    ``(C) the amount of such funds withheld is related 
                to the extent of the failure to so conform; and
            ``(4) require the Secretary, with respect to any State 
        program found to have failed substantially to so conform--
                    ``(A) to afford the State an opportunity to adopt 
                and implement a corrective action plan, approved by the 
                Secretary, designed to end the failure to so conform;
                    ``(B) to make technical assistance available to the 
                State to the extent feasible to enable the State to 
                develop and implement such a corrective action plan;
                    ``(C) to suspend the withholding of any Federal 
                matching funds under this section while such a 
                corrective action plan is in effect; and
                    ``(D) to rescind any such withholding if the 
                failure to so conform is ended by successful completion 
                of such a corrective action plan.
    ``(c) Provisions for Administrative and Judicial Review.--The 
regulations referred to in subsection (a) shall--
            ``(1) require the Secretary, not later than 10 days after a 
        final determination that a program of the State is not in 
        conformity, to notify the State of--
                    ``(A) the basis for the determination; and
                    ``(B) the amount of the Federal matching funds (if 
                any) to be withheld from the State;
            ``(2) afford the State an opportunity to appeal the 
        determination to the Departmental Appeals Board within 60 days 
        after receipt of the notice described in paragraph (1) (or, if 
        later, after failure to continue or to complete a corrective 
        action plan); and
            ``(3) afford the State an opportunity to obtain judicial 
        review of an adverse decision of the Board, within 60 days 
        after the State receives notice of the decision of the Board, 
        by appeal to the district court of the United States for the 
        judicial district in which the principal or headquarters office 
        of the agency responsible for administering the program is 
        located.''.
    (b) Conforming Amendment.--Section 471(b) (42 U.S.C. 671(b)) is 
amended by striking all that follows the first sentence.
    (c) Effective Dates.--
            (1) In general.--Except as provided in paragraph (2), the 
        amendment made by subsection (a) shall take effect on the date 
        of the enactment of this Act.
            (2) Conforming amendment.--The amendment made by subsection 
        (b) shall take effect on October 1, 1995.
            (3) Regulations.--The Secretary shall promulgate the 
        regulations referred to in section 1123(a) of the Social 
        Security Act (as added by this section) not later than January 
        1, 1995, to take effect on October 1, 1995.

SEC. 303. STATES REQUIRED TO REPORT ON MEASURES TAKEN TO COMPLY WITH 
              THE INDIAN CHILD WELFARE ACT.

    (a) State Plan Requirement.--Section 422(b) (42 U.S.C. 622(b)), as 
amended by section 301(a), is amended--
            (1) by striking ``and'' at the end of paragraph (8);
            (2) by striking the period at the end of paragraph (9) and 
        inserting ``; and''; and
            (3) by adding at the end the following:
            ``(10) contain a description, developed after consultation 
        with tribal organizations (as defined in section 4 of the 
        Indian Self-Determination and Education Assistance Act) in the 
        State, of the specific measures taken by the State to comply 
        with the Indian Child Welfare Act.''.
    (b) Effective Date.--The amendments made by subsection (a) shall be 
effective with respect to fiscal years beginning on or after October 1, 
1994.

SEC. 304. CHILD WELFARE TRAINEESHIPS.

    (a) In General.--Subpart 1 of part B of title IV (42 U.S.C. 620-
628) is amended by inserting after section 428 the following:

                      ``child welfare traineeships

    ``Sec. 429. The Secretary may approve an application for a grant to 
a public or nonprofit institution for higher learning to provide 
traineeships with stipends under section 426(a)(1)(C) only if the 
application--
            ``(1) provides assurances that each individual who receives 
        a stipend with such traineeship (in this section referred to as 
        a `recipient') will enter into an agreement with the 
        institution under which the recipient agrees--
                    ``(A) to participate in training at a public or 
                private nonprofit child welfare agency on a regular 
                basis (as determined by the Secretary) for the period 
                of the traineeship;
                    ``(B) to be employed for a period of years 
                equivalent to the period of the traineeship, in a 
                public or private nonprofit child welfare agency in any 
                State, within a period of time (determined by the 
                Secretary in accordance with regulations) after 
                completing the postsecondary education for which the 
                traineeship was awarded;
                    ``(C) to furnish to the institution and the 
                Secretary evidence of compliance with subparagraphs (A) 
                and (B); and
                    ``(D) if the recipient fails to comply with 
                subparagraph (A) or (B) and does not qualify for any 
                exception to this subparagraph which the Secretary may 
                prescribe in regulations, to repay to the Secretary all 
                (or an appropriately prorated part) of the amount of 
                the stipend, plus interest, and, if applicable, 
                reasonable collection fees (in accordance with 
                regulations promulgated by the Secretary);
            ``(2) provides assurances that the institution will--
                    ``(A) enter into agreements with child welfare 
                agencies for onsite training of recipients;
                    ``(B) permit an individual who is employed in the 
                field of child welfare services to apply for a 
                traineeship with a stipend if the traineeship furthers 
                the progress of the individual toward the completion of 
                degree requirements; and
                    ``(C) develop and implement a system that, for the 
                3-year period that begins on the date any recipient 
                completes a child welfare services program of study, 
                tracks the employment record of the recipient, for the 
                purpose of determining the percentage of recipients who 
                secure employment in the field of child welfare 
                services and remain employed in the field.''.
    (b) Conforming Amendment.--Section 426(a)(1)(C) (42 U.S.C. 
626(a)(1)(C)) is amended by inserting ``described in section 429'' 
after ``including traineeships''.
    (c) Applicability.--The amendments made by this section shall apply 
to grants awarded on or after October 1, 1994.

SEC. 305. DISPOSITIONAL HEARING.

    (a) Most Appropriate Setting.--Section 475(5)(A) (42 U.S.C. 
675(5)(A)) is amended by inserting ``and most appropriate'' after 
``(most family like)''.
    (b) Timing of Subsequent Review.--Section 475(5)(C) (42 U.S.C. 
675(5)(C)) is amended by striking ``periodically'' and inserting ``not 
less frequently than every 12 months''.
    (c) Effective Date.--The amendments made by this section shall take 
effect on October 1, 1994.

SEC. 306. ELIMINATION OF FOSTER CARE CEILINGS AND OF AUTHORITY TO 
              TRANSFER UNUSED FOSTER CARE FUNDS TO CHILD WELFARE 
              SERVICES PROGRAMS.

    (a) Repeal.--Subsections (b) and (c) of section 474 (42 U.S.C. 674 
(b) and (c)) are hereby repealed.
    (b) Conforming Amendments.--Section 474 (42 U.S.C. 674) is 
amended--
            (1) in subsection (d)(1)--
                    (A) by striking ``subsections (a), (b), and (c)'' 
                and inserting ``subsection (a)''; and
                    (B) by striking ``the provisions of such 
                subsections'' and inserting ``subsection (a)''; and
            (2) by redesignating subsection (d) as subsection (b).
    (c) Effective Date.--The amendments and repeals made by this 
section shall apply to payments for calendar quarters beginning on or 
after October 1, 1993.

SEC. 307. DEMONSTRATION PROJECTS.

    Part A of title XI (42 U.S.C. 1301-1320b-13) is amended by 
inserting after section 1128B the following:

                        ``demonstration projects

    ``Sec. 1129. (a) In General.--The Secretary may authorize not more 
than 10 States to conduct demonstration projects pursuant to this 
section which the Secretary finds are likely to promote the objectives 
of part B or E of title IV.
    ``(b) Waiver Authority.--The Secretary may waive compliance with 
any requirement of part B or E of title IV which (if applied) would 
prevent a State from carrying out a demonstration project under this 
section or prevent the State from effectively achieving the purpose of 
such a project, except that the Secretary may not waive--
            ``(1) any provision of section 427 (as in effect before 
        October 1, 1995), section 422(b)(9) (as in effect after such 
        date), or section 479; or
            ``(2) any provision of such part E, to the extent that the 
        waiver would impair the entitlement of any qualified child or 
        family to benefits under a State plan approved under such part 
        E.
    ``(c) Treatment as Program Expenditures.--For purposes of parts B 
and E of title IV, the Secretary shall consider the expenditures of any 
State to conduct a demonstration project under this section to be 
expenditures under subpart 1 or 2 of such part B, or under such part E, 
as the State may elect.
    ``(d) Duration of Demonstration.--A demonstration project under 
this section may be conducted for not more than 5 years.
    ``(e) Application.--Any State seeking to conduct a demonstration 
project under this section shall submit to the Secretary an 
application, in such form as the Secretary may require, which 
includes--
            ``(1) a description of the proposed project, the geographic 
        area in which the proposed project would be conducted, the 
        children or families who would be served by the proposed 
        project, and the services which would be provided by the 
        proposed project (which shall provide, where appropriate, for 
        random assignment of children and families to groups served 
        under the project and to control groups);
            ``(2) a statement of the period during which the proposed 
        project would be conducted;
            ``(3) a discussion of the benefits that are expected from 
        the proposed project (compared to a continuation of activities 
        under the approved plan or plans of the State);
            ``(4) an estimate of the costs or savings of the proposed 
        project;
            ``(5) a statement of program requirements for which waivers 
        would be needed to permit the proposed project to be conducted;
            ``(6) a description of the proposed evaluation design; and
            ``(7) such additional information as the Secretary may 
        require.
    ``(f) Evaluations; Report.--Each State authorized to conduct a 
demonstration project under this section shall--
            ``(1) obtain an evaluation by an independent contractor of 
        the effectiveness of the project, using an evaluation design 
        approved by the Secretary which provides for--
                    ``(A) comparison of methods of service delivery 
                under the project, and such methods under a State plan 
                or plans, with respect to efficiency, economy, and any 
                other appropriate measures of program management;
                    ``(B) comparison of outcomes for children and 
                families (and groups of children and families) under 
                the project, and such outcomes under a State plan or 
                plans, for purposes of assessing the effectiveness of 
                the project in achieving program goals; and
                    ``(C) any other information that the Secretary may 
                require; and
            ``(2) provide interim and final evaluation reports to the 
        Secretary, at such times and in such manner as the Secretary 
        may require.
    ``(g) Cost Neutrality.--The Secretary may not authorize a State to 
conduct a demonstration project under this section unless the Secretary 
determines that the total amount of Federal funds that will be expended 
under (or by reason of) the project over its approved term (or such 
portion thereof or other period as the Secretary may find appropriate) 
will not exceed the amount of such funds that would be expended by the 
State under the State plans approved under parts B and E of title IV if 
the project were not conducted.''.

SEC. 308. PLACEMENT ACCOUNTABILITY.

    (a) Case Plan Requirements.--Section 475(5)(A) (42 U.S.C. 
675(5)(A)), as amended by section 305(a), is amended by adding at the 
end the following: ``which--
                            ``(i) if the child has been placed in a 
                        foster family home or child-care institution a 
                        substantial distance from the home of the 
                        parents of the child, or in a State different 
                        from the State in which such home is located, 
                        sets forth the reasons why such placement is in 
                        the best interests of the child, and
                            ``(ii) if the child has been placed in 
                        foster care outside the State in which the home 
                        of the parents of the child is located, 
                        requires that, periodically, but not less 
                        frequently than every 12 months, a caseworker 
                        on the staff of the State agency of the State 
                        in which the home of the parents of the child 
                        is located, or of the State in which the child 
                        has been placed, visit such child in such home 
                        or institution and submit a report on such 
                        visit to the State agency of the State in which 
                        the home of the parents of the child is 
                        located,''.
    (b) Dispositional Hearing.--Section 475(5)(C) (42 U.S.C. 
675(5)(C)), as amended by section 305(b), is amended by inserting 
``and, in the case of a child described in subparagraph (A)(ii), 
whether the out-of-State placement continues to be appropriate and in 
the best interests of the child,'' after ``long-term basis)''.
    (c) Data Collection.--Section 479(c)(3)(C) (42 U.S.C. 679(c)(3)(C)) 
is amended--
            (1) by striking ``and'' at the end of clause (i); and
            (2) by adding at the end the following:
                            ``(iii) children placed in foster care 
                        outside the State which has placement and care 
                        responsibility, and''.
    (d) Effective Dates.--The amendments made by this section shall be 
effective with respect to fiscal years beginning on or after October 1, 
1994.

SEC. 309. PAYMENTS OF STATE CLAIMS FOR FOSTER CARE AND ADOPTION 
              ASSISTANCE.

    (a) In General.--Section 474(b) (42 U.S.C. 674(b)), as redesignated 
by section 306(b)(2), is amended by adding at the end the following:
    ``(4)(A) Within 60 days after receipt of a State claim for 
expenditures pursuant to subsection (a), the Secretary shall allow, 
disallow, or defer such claim.
    ``(B) Within 15 days after a decision to defer such a State claim, 
the Secretary shall notify the State of the reasons for the deferral 
and of the additional information necessary to determine the 
allowability of the claim.
    ``(C) Within 90 days after receiving such necessary information (in 
readily reviewable form), the Secretary shall--
            ``(i) disallow the claim, if able to complete the review 
        and determine that the claim is not allowable, or
            ``(ii) in any other case, allow the claim, subject to 
        disallowance (as necessary)--
                    ``(I) upon completion of the review, if it is 
                determined that the claim is not allowable; or
                    ``(II) on the basis of findings of an audit or 
                financial management review.''.
    (b) Effective Date.--The amendment made by subsection (a) shall be 
effective with respect to claims made on or after the date of the 
enactment of this Act.

SEC. 310. EFFECT OF FAILURE TO CARRY OUT STATE PLAN.

    (a) In General.--Part A of title XI (42 U.S.C. 1301-1320b-13), as 
amended by section 307, is amended by inserting after section 1129 the 
following:

              ``effect of failure to carry out state plan

    ``Sec. 1130. In an action brought to enforce a provision of the 
Social Security Act, such provision is not to be deemed unenforceable 
because of its inclusion in a section of the Act requiring a State plan 
or specifying the required contents of a State plan. This section is 
not intended to limit or expand the grounds for determining the 
availability of private actions to enforce State plan requirements 
other than by overturning any such grounds applied in Suter v. Artist 
M., 112 S. Ct. 1360 (1992), but not applied in prior Supreme Court 
decisions respecting such enforceability: Provided, however, That this 
section is not intended to alter the holding in Suter v. Artist M. that 
section 471(a)(15) of the Act is not enforceable in a private right of 
action.''.
    (b) Applicability.--The amendment made by subsection (a) shall 
apply to actions pending on the date of the enactment of this Act and 
to actions brought on or after such date of enactment.

                 Subtitle B--Child Support Enforcement

SEC. 311. REPORTS TO CREDIT BUREAUS ON PERSONS DELINQUENT IN CHILD 
              SUPPORT PAYMENTS.

    (a) In General.--Section 466(a)(7) (42 U.S.C. 666(a)(7)) is 
amended--
            (1) by striking ``Procedures'' and all that follows through 
        ``request of such agency'' and inserting ``Procedures which 
        require the State to periodically report to consumer reporting 
        agencies (as defined in section 603(f) of the Fair Credit 
        Reporting Act (15 U.S.C. 1681a(f))) the name of any parent 
        residing in the State who owes overdue support and is at least 
        2 months delinquent in the payment of such support and the 
        amount of such delinquency unless the agency requests not to 
        receive such information''; and
            (2) by striking ``(C) a fee'' and all that follows through 
        ``by the State'' and inserting ``(C) such information shall not 
        be made available to (i) a consumer reporting agency which the 
        State determines does not have sufficient capability to 
        systematically and timely make accurate use of such 
        information, or (ii) an entity which has not furnished evidence 
        satisfactory to the State that the entity is a consumer 
        reporting agency''.
    (b) Effective Date.--The amendments made by subsection (a) shall 
take effect on October 1, 1995.

SEC. 312. TECHNICAL AMENDMENTS TO PROVISION ON STATE PATERNITY 
              ESTABLISHMENT PROGRAMS.

    Section 452(g)(2)(A) (42 U.S.C. 652(g)(2)(A)), as amended by 
section 13721(a) of OBRA-1993, is amended--
            (1) in clause (i), by striking ``during the fiscal year'';
            (2) in subclause (I) of clause (ii), by striking ``as of 
        the end of the fiscal year'' and inserting ``in the fiscal year 
        or, at the option of the State, as of the end of such year'';
            (3) in subclause (II) of clause (ii), by striking ``or (E) 
        as of the end of the fiscal year'' and inserting ``in the 
        fiscal year or, at the option of the State, as of the end of 
        such year'';
            (4) in clause (iii), by striking ``during the fiscal 
        year''; and
            (5) in the matter following clause (iii)--
                    (A) by striking ``who were born out of wedlock 
                during the immediately preceding fiscal year'' and 
                inserting ``born out of wedlock'';
                    (B) by striking ``such preceding fiscal year'' both 
                places it appears and inserting ``the preceding fiscal 
                year''; and
                    (C) by striking ``or E'' the second place it 
                appears.

SEC. 313. AGREEMENT TO ASSIST IN LOCATING MISSING CHILDREN UNDER THE 
              PARENT LOCATOR SERVICE.

    (a) In General.--Section 463 (42 U.S.C. 663) is amended by adding 
at the end the following new subsection:
    ``(f) The Secretary shall enter into an agreement with the Attorney 
General of the United States, under which the services of the Parent 
Locator Service established under section 453 shall be made available 
to the Office of Juvenile Justice and Delinquency Prevention upon its 
request to locate any parent or child on behalf of such Office for the 
purpose of--
            ``(1) enforcing any State or Federal law with respect to 
        the unlawful taking or restraint of a child, or
            ``(2) making or enforcing a child custody determination.
The Parent Locator Service shall charge no fees for services requested 
pursuant to this subsection.''.
    (b) Conforming Amendment.--Section 463(c) (42 U.S.C. 663(c)) is 
amended by striking ``(a), (b), or (e)'' and inserting ``(a), (b), (e), 
or (f)''.
    (c) Effective Date.--The amendments made by this section shall take 
effect on October 1, 1994.

                Subtitle C--Supplemental Security Income

SEC. 321. DEFINITION OF DISABILITY FOR CHILDREN UNDER AGE 18 APPLIED TO 
              ALL INDIVIDUALS UNDER AGE 18.

    (a) In General.--Section 1614(a)(3) (42 U.S.C. 1382c(a)(3)) is 
amended--
            (1) in subparagraphs (A) and (H), by striking ``a child'' 
        each place it appears and inserting ``an individual''; and
            (2) in subparagraph (H), by striking ``child'' the second 
        and third place it appears and inserting ``individual''.
    (b) Effective Date.--The amendments made by subsection (a) shall 
apply to determinations made on or after the date of the enactment of 
this Act.

SEC. 322. COMMISSION ON CHILDHOOD DISABILITY.

    (a) Establishment of Commission.--The Secretary of Health and Human 
Services (in this section referred to as the ``Secretary'') shall 
appoint a Commission on the Evaluation of Disability in Children (in 
this section referred to as the ``Commission'').
    (b) Appointment of Members.--(1) The Secretary shall appoint not 
less than 9 but not more than 15 members to the Commission, including--
            (A) recognized experts in the field of medicine, whose work 
        involves--
                    (i) the evaluation and treatment of disability in 
                children,
                    (ii) the study of congenital, genetic, or perinatal 
                disorders in children, or
                    (iii) the measurement of developmental milestones 
                and developmental deficits in children; and
            (B) recognized experts in the fields of--
                    (i) psychology,
                    (ii) education and rehabilitation,
                    (iii) law,
                    (iv) the administration of disability programs,
                    (v) social insurance (including health insurance), 
                and
                    (vi) other fields of expertise that the Secretary 
                determines to be appropriate.
    (2) Members shall be appointed within 90 days after the date of the 
enactment of this Act, without regard to the provisions of title 5, 
United States Code, governing appointments to competitive service.
    (3) Members appointed under this subsection shall serve for a term 
equivalent to the duration of the Commission.
    (4) The Secretary shall designate a member of the Commission to 
serve as Chair of the Commission for a term equivalent to the duration 
of the Commission.
    (c) Administrative Provisions.--(1) Service as a member of the 
Commission by an individual who is not otherwise a Federal employee 
shall not be considered service in an appointive or elective position 
in the Federal Government for the purposes of any provision of title 5, 
United States Code.
    (2) Each member of the Commission who is not a full-time Federal 
employee shall be paid compensation at a rate equal to the daily 
equivalent of the rate of basic pay in effect for Level IV of the 
Executive Schedule for each day (including travel time) the member 
attends meetings or otherwise performs the duties of the Commission.
    (3) While away from their homes or regular places of business on 
the business of the Commission, each member who is not a full-time 
Federal employee may be allowed travel expenses, including per diem in 
lieu of subsistence, as authorized by section 5703 of title 5, United 
States Code, for persons employed intermittently in the Government 
service.
    (d) Assistance to Commission.--The Commission may engage such 
technical assistance from individuals skilled in medical and other 
aspects of childhood disability as may be necessary to carry out the 
functions of the Commission. The Secretary shall make available to the 
Commission such secretarial, clerical, and other assistance as the 
Commission may require to carry out the functions of the Commission.
    (e) Study by the Commission.--(1) The Commission shall conduct a 
study, in consultation with the National Academy of Sciences, of the 
effects of the definition of ``disability'' under title XVI of the 
Social Security Act (42 U.S.C. 1382 et seq.) in effect on the date of 
enactment of this Act, as such definition applies to determining 
whether a child under the age of 18 is eligible to receive benefits 
under such title, the appropriateness of such definition, and the 
advantages and disadvantages of using any alternative definition of 
disability in determining whether a child under age 18 is eligible to 
receive benefits under such title.
    (2) The study described in paragraph (1) shall include issues of--
            (A) whether the need by families for assistance in meeting 
        high costs of medical care for children with serious physical 
        or mental impairments, whether or not they are eligible for 
        disability benefits under title XVI of the Social Security Act, 
        might appropriately be met through expansion of Federal health 
        assistance programs (including the program of medical 
        assistance under title XIX of such Act); and
            (B) such other issues that the Secretary determines to be 
        appropriate.
    (f) Report.--Not later than September 1, 1995, the Commission shall 
prepare a report and submit such report to the Committee on Ways and 
Means of the House of Representatives and the Committee on Finance of 
the Senate which shall summarize the results of the study described in 
subsection (e) and include any recommendations that the Commission 
determines to be appropriate.
    (g) Termination of Commission.--The Commission shall terminate on 
September 30, 1995.

SEC. 323. EXEMPTION FROM PASS-ALONG REQUIREMENTS.

    (a) In General.--Section 1618 (42 U.S.C. 1382g) is amended by 
adding at the end the following new subsection:
    ``(h) For purposes of determining under subsection (b) of this 
section whether a State's expenditures for supplementary payments in 
the twelve-month period beginning on the effective date of any increase 
in the level of supplemental security income benefits are not less than 
its expenditures for such payments in the preceding twelve-month 
period, the Secretary, in computing the State's expenditures, shall 
disregard, pursuant to the one-time election of such State, all 
expenditures by such State for retroactive supplementary payments that 
are required to be made in connection with the retroactive supplemental 
security income benefits referred to in section 5041 of the Omnibus 
Budget Reconciliation Act of 1990.''.
    (b) Effective Date.--The amendment made by subsection (a) shall be 
effective on, before, and after the date of the enactment of this Act.

          Subtitle D--Aid to Families With Dependent Children

SEC. 331. SIMPLIFICATION OF INCOME AND ELIGIBILITY VERIFICATION SYSTEM.

    Paragraph (1)(A) of section 1137(d) (42 U.S.C. 1320b-7(d)) is 
amended to read as follows:
            ``(1)(A) The State shall require, as a condition of an 
        individual's eligibility for benefits under a program listed in 
        subsection (b), a declaration in writing, under penalty of 
        perjury--
                    ``(i) by the individual,
                    ``(ii) in the case in which eligibility for program 
                benefits is determined on a family or household basis, 
                by any adult member of such individual's family or 
                household (as applicable), or
                    ``(iii) in the case of an individual born into a 
                family or household receiving benefits under such 
                program, by any adult member of such family or 
                household no later than the next redetermination of 
                eligibility of such family or household following the 
                birth of such individual,
        stating whether the individual is a citizen or national of the 
        United States, and, if that individual is not a citizen or 
        national of the United States, that the individual is in a 
        satisfactory immigration status.''.

SEC. 332. MEASUREMENT AND REPORTING OF WELFARE RECEIPT.

    (a) Congressional Policy.--The Congress hereby declares that--
            (1) it is the policy and responsibility of the Federal 
        Government to reduce the rate at which and the degree to which 
        families depend on income from welfare programs and the 
        duration of welfare receipt, consistent with other essential 
        national goals;
            (2) it is the policy of the United States to strengthen 
        families, to ensure that children grow up in families that are 
        economically self-sufficient and that the life prospects of 
        children are improved, and to underscore the responsibility of 
        parents to support their children;
            (3) the Federal Government should help welfare recipients 
        as well as individuals at risk of welfare receipt to improve 
        their education and job skills, to obtain child care and other 
        necessary support services, and to take such other steps as may 
        be necessary to assist them to become financially independent; 
        and
            (4) it is the purpose of this section to provide the public 
        with generally accepted measures of welfare receipt so that it 
        can track such receipt over time and determine whether progress 
        is being made in reducing the rate at which and, to the extent 
        feasible, the degree to which, families depend on income from 
        welfare programs and the duration of welfare receipt.
    (b) Development of Welfare Indicators and Predictors.--The 
Secretary of Health and Human Services (in this section referred to as 
the ``Secretary'') in consultation with the Secretary of Agriculture 
shall--
            (1) develop--
                    (A) indicators of the rate at which and, to the 
                extent feasible, the degree to which, families depend 
                on income from welfare programs and the duration of 
                welfare receipt; and
                    (B) predictors of welfare receipt;
            (2) assess the data needed to report annually on the 
        indicators and predictors, including the ability of existing 
        data collection efforts to provide such data and any additional 
        data collection needs; and
            (3) not later than 2 years after the date of the enactment 
        of this section, provide an interim report containing 
        conclusions resulting from the development and assessment 
        described in paragraphs (1) and (2), to--
                    (A) the Committee on Ways and Means of the House of 
                Representatives;
                    (B) the Committee on Education and Labor of the 
                House of Representatives;
                    (C) the Committee on Agriculture of the House of 
                Representatives;
                    (D) the Committee on Energy and Commerce of the 
                House of Representatives;
                    (E) the Committee on Finance of the Senate;
                    (F) the Committee on Labor and Human Resources of 
                the Senate; and
                    (G) the Committee on Agriculture, Nutrition, and 
                Forestry of the Senate.
    (c) Advisory Board on Welfare Indicators.--
            (1) Establishment.--There is established an Advisory Board 
        on Welfare Indicators (in this subsection referred to as the 
        ``Board'').
            (2) Composition.--The Board shall be composed of 12 members 
        with equal numbers to be appointed by the House of 
        Representatives, the Senate, and the President. The Board shall 
        be composed of experts in the fields of welfare research and 
        welfare statistical methodology, representatives of State and 
        local welfare agencies, and organizations concerned with 
        welfare issues.
            (3) Vacancies.--Any vacancy occurring in the membership of 
        the Board shall be filled in the same manner as the original 
        appointment for the position being vacated. The vacancy shall 
        not affect the power of the remaining members to execute the 
        duties of the Board.
            (4) Duties.--Duties of the Board shall include--
                    (A) providing advice and recommendations to the 
                Secretary on the development of indicators of the rate 
                at which and, to the extent feasible, the degree to 
                which, families depend on income from welfare programs 
                and the duration of welfare receipt; and
                    (B) providing advice on the development and 
                presentation of annual reports required under 
                subsection (d).
            (5) Travel expenses.--Members of the Board shall not be 
        compensated, but shall receive travel expenses, including per 
        diem in lieu of subsistence, at rates authorized for employees 
        of agencies under subchapter I of chapter 57 of title 5, United 
        States Code, for each day the member is engaged in the 
        performance of duties away from the home or regular place of 
        business of the member.
            (6) Detail of federal employees.--The Secretary shall 
        detail, without reimbursement, any of the personnel of the 
        Department of Health and Human Services to the Board to assist 
        the Board in carrying out its duties. Any detail shall not 
        interrupt or otherwise affect the civil service status or 
        privileges of the Federal employee.
            (7) Voluntary service.--Notwithstanding section 1342 of 
        title 31, United States Code, the Board may accept the 
        voluntary services provided by a member of the Board.
            (8) Termination of board.--The Board shall be terminated at 
        such time as the Secretary determines the duties described in 
        paragraph (4) have been completed, but in any case prior to the 
        submission of the first report required under subsection (d).
    (d) Annual Welfare Indicators Report.--
            (1) Preparation.--The Secretary shall prepare annual 
        reports on welfare receipt in the United States.
            (2) Coverage.--The report shall include analysis of 
        families and individuals receiving assistance under means-
        tested benefit programs, including the program of aid to 
        families with dependent children under part A of title IV of 
        the Social Security Act (42 U.S.C. 601 et seq.), the food stamp 
        program under the Food Stamp Act of 1977 (7 U.S.C. 2011 et 
        seq.), and the Supplemental Security Income program under title 
        XVI of the Social Security Act (42 U.S.C. 1381 et seq.), or as 
        general assistance under programs administered by State and 
        local governments.
            (3) Contents.--Each report shall set forth for each of the 
        means-tested benefit programs described in paragraph (2)--
                    (A) indicators of--
                            (i) the rate at which and, to the extent 
                        feasible, the degree to which, families depend 
                        on income from welfare programs, and
                            (ii) the duration of welfare receipt;
                    (B) trends in indicators;
                    (C) predictors of welfare receipt;
                    (D) the causes of welfare receipt;
                    (E) patterns of multiple program receipt;
                    (F) such other information as the Secretary deems 
                relevant; and
                    (G) such recommendations for legislation, which 
                shall not include proposals to reduce eligibility 
                levels or impose barriers to program access, as the 
                Secretary may determine to be necessary or desirable to 
                reduce--
                            (i) the rate at which and the degree to 
                        which families depend on income from welfare 
                        programs, and
                            (ii) the duration of welfare receipt.
            (4) Submission.--The Secretary shall submit such a report 
        not later than 3 years after the date of the enactment of this 
        section and annually thereafter, to the committees specified in 
        subsection (b)(3)(C). Each such report shall be transmitted 
        during the first 60 days of each regular session of Congress.
    (e) Short Title.--This section may be cited as the ``Welfare 
Indicators Act of 1993''.

SEC. 333. NEW HOPE DEMONSTRATION PROJECT.

    (a) In General.--The Secretary of Health and Human Services (in 
this section referred to as the ``Secretary'') shall provide for a 
demonstration project for a qualified program to be conducted in 
Milwaukee, Wisconsin, in accordance with this section.
    (b) Payments.--For each calendar quarter in which there is a 
qualified program approved under this subsection, the Secretary shall 
pay to the operator of the qualified program, for no more than 20 
calendar quarters, an amount equal to the aggregate amount that would 
otherwise have been payable to the State with respect to participants 
in the program for such calendar quarter, in the absence of the 
program, for cash assistance and child care under part A of title IV of 
the Social Security Act, for medical assistance under title XIX of such 
Act, and for administrative expenses related to such assistance. The 
amount payable to the operator of the program under this section shall 
not include the costs of evaluating the effects of the program.
    (c) Demonstration Project Described.--For purposes of this section, 
the term ``qualified program'' means a program operated--
            (1) by The New Hope Project, Inc., a private, not-for-
        profit corporation incorporated under the laws of the State of 
        Wisconsin (in this section referred to as the ``operator''), 
        which offers low-income residents of Milwaukee, Wisconsin, 
        employment, wage supplements, child care, health care, and 
        counseling and training for job retention or advancement; and
            (2) in accordance with an application submitted by the 
        operator of the program and approved by the Secretary based on 
        the Secretary's determination that the application satisfies 
        the requirements of subsection (d).
    (d) Contents of Application.--The operator of the qualified program 
shall provide, in its application to conduct a demonstration project 
for the program, that the following terms and conditions will be met:
            (1) The operator will develop and implement an evaluation 
        plan designed to provide valid and reliable information on the 
        impact and implementation of the program. The evaluation plan 
        will include adequately sized groups of project participants 
        and control groups assigned at random.
            (2) The operator will develop and implement a plan 
        addressing the services and assistance to be provided by the 
        program, the timing and determination of payments from the 
        Secretary to the operator of the program, and the roles and 
        responsibilities of the Secretary and the operator with respect 
        to meeting the requirements of this paragraph.
            (3) The operator will specify a reliable methodology for 
        determining expenditures to be paid to the operator by the 
        Secretary, with assistance from the Secretary in calculating 
        the amount that would otherwise have been payable to the State 
        in the absence of the program, pursuant to subsection (b).
            (4) The operator will issue an interim and final report on 
        the results of the evaluation described in paragraph (1) to the 
        Secretary at such times as required by the Secretary.
    (e) Effective Date.--This section shall take effect on the first 
day of the first calendar quarter that begins after the date of the 
enactment of this Act.

SEC. 334. DELAY IN REQUIREMENT THAT OUTLYING AREAS OPERATE AN AFDC-UP 
              PROGRAM.

    (a) In General.--Section 401(g)(2) of the Family Support Act of 
1988 (42 U.S.C. 602 note; 102 Stat. 2396) is amended by striking 
``October 1, 1992'' and inserting ``the date of the repeal of the 
limitations contained in section 1108(a) of the Social Security Act on 
payments to such jurisdictions for purposes of making maintenance 
payments under parts A and E of title IV of such Act''.
    (b) Effective Date.--The amendment made by subsection (a) shall 
take effect as if included in the provision of the Family Support Act 
of 1988 to which the amendment relates at the time such provision 
became law.

SEC. 335. NEW YORK STATE CHILD SUPPORT DEMONSTRATION PROGRAM.

    (a) Extension.--Section 9122(g)(1) of OBRA-1987 is amended by 
striking ``five'' and inserting ``10''.
    (b) Payment of Evaluation Costs.--Section 9122(b) of OBRA-1987 is 
amended by adding at the end the following new flush sentence: 
``Payment to the State under this section shall not include the costs 
of evaluating the effects of the program.''.
    (c) Effective Dates.--
            (1) Extension.--The amendment made by subsection (a) shall 
        take effect on the date of the enactment of this Act.
            (2) Payment.--The amendment made by subsection (b) shall 
        take effect on April 1, 1994.

SEC. 336. STATE OPTION TO USE RETROSPECTIVE BUDGETING WITHOUT MONTHLY 
              REPORTING.

    (a) In General.--Section 402(a)(13) (42 U.S.C. 602(a)(13)) is 
amended--
            (1) by striking all that precedes subparagraph (A) and 
        inserting the following:
            ``(13) provide, at the option of the State and with respect 
        to such category or categories as the State may select and 
        identify in the State plan, that--''; and
            (2) in each of subparagraphs (A) and (B), by striking ``, 
        in the case of families who are required to report monthly to 
        the State agency pursuant to paragraph (14)''.
    (b) Effective Date.--The amendment made by subsection (a) shall 
take effect on October 1, 1993, and shall apply to payments under part 
A of title IV of the Social Security Act for fiscal year 1993 and such 
payments for succeeding fiscal years.

                        Subtitle E--JOBS Program

SEC. 341. EXPANSION OF COVERAGE FOR INDIAN TRIBES.

    (a) In General.--Section 482(i)(2)(A) (42 U.S.C. 682(i)(2)(A)) is 
amended by striking ``members of such Indian tribe receiving aid to 
families with dependent children'' and inserting ``Indians receiving 
aid to families with dependent children who reside on the reservation 
or within the designated service area''.
    (b) Effective Date.--The amendment made by subsection (a) shall 
take effect on October 1, 1994.

SEC. 342. REPORT TO THE CONGRESS WITH RESPECT TO PERFORMANCE STANDARDS 
              IN THE JOBS PROGRAM.

    Section 487(a) (42 U.S.C. 687(a)) is amended--
            (1) by striking ``3'' and inserting ``4'';
            (2) in paragraph (1), by inserting ``criteria for'' after 
        ``develop'';
            (3) in paragraph (2), by striking ``for'' and inserting 
        ``with respect to''; and
            (4) in the second sentence, by striking ``under this 
        subsection'' and inserting ``with respect to the program under 
        this part''.

                   Subtitle F--Unemployment Insurance

SEC. 351. EXTENSION OF REPORTING DATE FOR ADVISORY COUNCIL.

    In the case of the first Advisory Council on Unemployment 
Compensation established under section 908 of the Social Security Act 
(42 U.S.C. 1108), subsection (f) of such section 908 shall be applied--
            (1) by substituting ``3rd year'' for ``second year'' in 
        paragraph (1), and
            (2) by substituting ``February 1, 1995'' for ``February 1, 
        1994'' in paragraph (2).

SEC. 352. TECHNICAL AMENDMENT TO UNEMPLOYMENT TRUST FUND.

    Paragraph (1) of section 905(b) (42 U.S.C. 1105(b)) is amended to 
read as follows:
    ``(b)(1) Except as provided in paragraph (3), the Secretary of the 
Treasury shall transfer (as of the close of each month), from the 
employment security administration account to the extended unemployment 
compensation account established by subsection (a), an amount equal to 
20 percent of the amount by which--
            ``(A) the transfers to such account pursuant to section 
        901(b)(2) during such month, exceed
            ``(B) the payments during such month from the employment 
        security administration account pursuant to section 901(b)(3) 
        and (d).
If for any month the payments referred to in subparagraph (B) exceed 
the transfers referred to in subparagraph (A), proper adjustments shall 
be made in the amounts subsequently transferred.''.

                      Subtitle G--Other Provisions

SEC. 361. EXTENSION OF DEMONSTRATION TO EXPAND JOB OPPORTUNITIES.

    (a) In General.--Section 505 of the Family Support Act of 1988 (42 
U.S.C. 1315 note; 102 Stat. 2404) is amended--
            (1) in subsection (e), by striking ``3-year period'' and 
        inserting ``5-year period'',
            (2) in subsection (f)(2), by striking ``January 1, 1993'' 
        and inserting ``January 1, 1995'', and
            (3) in subsection (g), by striking ``1991, and 1992'' and 
        inserting ``1991, 1992, 1993, 1994, and 1995''.
    (b) Effective Date.--The amendments made by subsection (a) shall 
take effect on October 1, 1993.

SEC. 362. EARLY CHILDHOOD DEVELOPMENT PROJECTS.

    Section 501(a) of the Family Support Act of 1988 (42 U.S.C. 1315 
note; 102 Stat. 2400) is amended by adding at the end the following:
    ``(4) For grants to States to conduct demonstration projects under 
this subsection, there are authorized to be appropriated not to exceed 
$3,000,000 for each of the fiscal years 1994 through 1998.''.

SEC. 363. REALLOCATION OF FUNDS UNDER TITLE XX FOR EMPOWERMENT AND 
              ENTERPRISE GRANTS.

    Section 2007 (42 U.S.C. 1397f), as added by section 13761 of OBRA-
1993, is amended--
            (1) by redesignating subsection (e) as subsection (f); and
            (2) by inserting after subsection (d) the following new 
        subsection:
    ``(e) Reallocation of Remaining Funds.--
            ``(1) Remitted amounts.--The amount specified in section 
        2003(c) for any fiscal year is hereby increased by the total of 
        the amounts remitted during the fiscal year pursuant to 
        subsection (d) of this section.
            ``(2) Amounts not paid to the states.--The amount specified 
        in section 2003(c) for fiscal year 1998 is hereby increased by 
        the amount made available for grants under this section that 
        has not been paid to any State by the end of fiscal year 
        1997.''.

SEC. 364. CORRECTIONS RELATED TO THE INCOME SECURITY AND HUMAN 
              RESOURCES PROVISIONS OF THE OBRA-1990.

    (a) Amendment Related to Section 5035(a)(2).--Section 5035(a)(2) of 
OBRA-1990 is amended by striking ``a semicolon'' and inserting ```; 
and'''.
    (b) Amendment Related to Section 5040.--Section 1631(n) (42 U.S.C. 
1383(n)) is amended by striking ``subsection'' and inserting 
``section''.
    (c) Amendment Related to Section 5051(a).--Section 402(a)(14) (42 
U.S.C. 602(a)(14)) is amended to read as follows:
            ``(14) at the option of the State and with respect to such 
        category or categories as the State may select and identify in 
        the plan, provide that--
                    ``(A) the State agency will require each family to 
                which the State provides (or, but for paragraph (22) or 
                (32), would provide) aid to families with dependent 
                children, as a condition to the continued receipt of 
                such aid (or to continuing to be deemed to be a 
                recipient of such aid), to report to the State agency 
                monthly (or less frequently in the case of such 
                categories of recipients as the State may select) on--
                            ``(i) the income of the family, the 
                        composition of the family, and other relevant 
                        circumstances during the prior month; and
                            ``(ii) the income and resources the family 
                        expects to receive, or any changes in 
                        circumstances affecting continued eligibility 
                        for, or amount of benefits, the family expects 
                        to occur, in that month or in future months; 
                        and
                    ``(B) in addition to any action that may be 
                appropriate based on other reports or information 
                received by the State agency, the State agency will--
                            ``(i) take prompt action to adjust the 
                        amount of assistance payable, as may be 
                        appropriate, on the basis of the information 
                        contained in the report (or upon the failure of 
                        the family to submit a timely report); and
                            ``(ii) give the family an appropriate 
                        explanatory notice concurrent with any action 
                        taken under clause (i);''.
    (d) Repeal of Provision Inadvertently Included.--Section 5057 of 
OBRA-1990, and the amendment made by such section, are hereby repealed, 
and section 1139(d) of the Social Security Act shall be applied and 
administered as if such section 5057 had never been enacted.
    (e) Amendment Related to Section 5105(d)(1)(B).--Subparagraphs (E) 
and (F) of section 1631(a)(2) (42 U.S.C. 1383(a)(2)) are amended to 
read as follows:
    ``(E) In cases where the negligent failure of the Secretary to 
investigate or monitor a representative payee results in misuse of 
benefits by the representative payee, the Secretary shall make payment 
to the beneficiary or the beneficiary's representative payee of an 
amount equal to such misused benefits. The Secretary shall make a good 
faith effort to obtain restitution from the terminated representative 
payee.
    ``(F) The Secretary shall include as a part of the annual report 
required under section 704 information with respect to the 
implementation of the preceding provisions of this paragraph, 
including--
            ``(i) the number of cases in which the representative payee 
        was changed;
            ``(ii) the number of cases discovered where there has been 
        a misuse of funds;
            ``(iii) how any such cases were dealt with by the 
        Secretary;
            ``(iv) the final disposition of such cases (including any 
        criminal penalties imposed); and
            ``(v) such other information as the Secretary determines to 
        be appropriate.''.
    (f) Amendment Related to Section 5105(a)(1)(B).--The second 
paragraph of section 1631(a) (42 U.S.C. 1383(a)) is amended by striking 
``(A)(i) Payments'' and inserting ``(2)(A)(i) Payments''.
    (g) Amendments Related to Section 5105(b).--Section 1631(a)(2)(C) 
(42 U.S.C. 1383(a)(2)(C)) is amended--
            (1) in clause (i), by striking ``to representative'' and 
        inserting ``to a representative'';
            (2) by striking clause (ii);
            (3) by redesignating clauses (iii), (iv), and (v) as 
        clauses (ii), (iii), and (iv), respectively; and
            (4) in clause (iv) (as so redesignated), by striking 
        ``(iii), and (iv)'' and inserting ``and (iii)''.
    (h) Amendments Related to Section 5107(a)(2)(B).--Section 
1631(c)(1)(B) (42 U.S.C. 1383(c)(1)(B)) is amended by striking 
``paragraph (1)'' each place such term appears and inserting 
``subparagraph (A)''.
    (i) Amendment Related to Section 5109(a)(2).--Section 1631 (42 
U.S.C. 1383) is amended by redesignating the subsection (n) added by 
section 5109(a)(2) of OBRA-1990, as subsection (o).
    (j) Amendments Related to Section 11115(b)(2).--Section 11115(b)(2) 
of OBRA-1990 is amended--
            (1) in subparagraph (A), by striking ``paragraph (8)'' and 
        inserting ``paragraph (9)'';
            (2) in subparagraph (B), by striking ``paragraph (9)'' and 
        inserting ``paragraph (10)''; and
            (3) in subparagraph (C), by redesignating the new paragraph 
        added thereby as paragraph (11).
    (k) Effective Date.--Each amendment made by this section shall take 
effect as if included in the provision of OBRA-1990 to which the 
amendment relates at the time such provision became law.

SEC. 365. TECHNICAL CORRECTIONS RELATED TO THE HUMAN RESOURCE AND 
              INCOME SECURITY PROVISIONS OF THE OBRA-1989.

    (a) Amendment Relating to Section 8004(a).--Section 408(m)(2)(A) 
(42 U.S.C. 608(m)(2)(A)) is amended by striking ``a fiscal'' and 
inserting ``the fiscal''.
    (b) Amendment Relating to Section 8006(a).--Section 473(a)(6)(B) 
(42 U.S.C. 673(a)(6)(B)) is amended by striking ``474(a)(3)(B)'' and 
inserting ``474(a)(3)(C)''.
    (c) Amendment Relating to Section 8007(b)(3).--Subparagraph (D) of 
section 475(5) (42 U.S.C. 675(5)(D)) is amended by moving such 
subparagraph 2 ems to the right so that the left margin of such 
subparagraph is aligned with the left margin of subparagraph (C) of 
such section.
    (d) Effective Date.--Each amendment made by this section shall take 
effect as if the amendment had been included in the provision of OBRA-
1989 to which the amendment relates, at the time the provision became 
law.

SEC. 366. TECHNICAL CORRECTION RELATED TO THE HUMAN RESOURCE AND INCOME 
              SECURITY PROVISIONS OF THE OBRA-1993.

    (a) Amendment Relating to Section 13713(a).--Section 473(a)(6)(B) 
(42 U.S.C. 673(a)(6)(B)) is amended by striking ``474(a)(3)(C)'' and 
inserting ``474(a)(3)(E)''.
    (b) Effective Date.--The amendment made by this section shall take 
effect as if the amendment had been included in the provision of OBRA-
1993 to which the amendment relates, at the time the provision became 
law.

SEC. 367. ELIMINATION OF OBSOLETE PROVISIONS RELATING TO TREATMENT OF 
              THE EARNED INCOME TAX CREDIT.

    (a) Treatment of EITC as Earned Income.--Section 1612(a)(1) (42 
U.S.C. 1382a(a)(1)) is amended by striking subparagraph (C) and by 
redesignating subparagraphs (D) and (E) as subparagraphs (C) and (D), 
respectively.
    (b) Adjustment of Benefits Due to Treatment of EITC as Earned 
Income.--Section 1631(b) (42 U.S.C. 1383(b)) is amended by striking 
paragraph (3) and by redesignating paragraphs (4) and (5) as paragraphs 
(3) and (4), respectively.

SEC. 368. REDESIGNATION OF CERTAIN PROVISIONS.

    Section 1631(e)(6) (42 U.S.C. 1383(e)(6)) is amended by 
redesignating subparagraphs (1) and (2) as subparagraphs (A) and (B), 
respectively.
S 1668 PCS----2
S 1668 PCS----3
S 1668 PCS----4
S 1668 PCS----5
S 1668 PCS----6
S 1668 PCS----7
S 1668 PCS----8
S 1668 PCS----9
S 1668 PCS----10
S 1668 PCS----11
S 1668 PCS----12
S 1668 PCS----13
S 1668 PCS----14
S 1668 PCS----15
S 1668 PCS----16
S 1668 PCS----17
S 1668 PCS----18
S 1668 PCS----19