[Congressional Bills 104th Congress]
[From the U.S. Government Publishing Office]
[S. 1024 Introduced in Senate (IS)]







104th CONGRESS
  1st Session
                                S. 1024

To amend title XVIII of the Social Security Act to assure fairness and 
 choice to patients under the medicare program, and for other purposes.


_______________________________________________________________________


                   IN THE SENATE OF THE UNITED STATES

                July 12 (legislative day, July 10), 1995

 Mr. Wellstone introduced the following bill; which was read twice and 
                  referred to the Committee on Finance

_______________________________________________________________________

                                 A BILL


 
To amend title XVIII of the Social Security Act to assure fairness and 
 choice to patients under the medicare program, 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 ``Medicare Health Care Quality Act of 
1995''.

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) Table of Contents.--The table of contents of this Act is as 
follows:

Sec. 1. Short title.
Sec. 2. References in Act; table of contents.
Sec. 3. Requirements relating to health professionals.
Sec. 4. Grievance procedures.
Sec. 5. Discrimination.
Sec. 6. Requirement for utilization review program.
Sec. 7. Access.
Sec. 8. Requirements for organization service areas.
Sec. 9. Other enrollee protections.
Sec. 10. Information on eligible organization.
Sec. 11. Enrollment by mail.
Sec. 12. Waiver of certain medicare coinsurance and deductibles not 
                            remuneration.
Sec. 13. Effective date.
SEC. 3. REQUIREMENTS RELATING TO HEALTH PROFESSIONALS.

    Section 1876(c) (42 U.S.C. 1395mm(c)) is amended by adding at the 
end the following new paragraph:
    ``(9)(A) The eligible organization shall credential health 
professionals furnishing health care services through the organization.
    ``(B)(i) The eligible organization shall establish a credentialing 
process. Such process shall ensure that a health professional is 
credentialed prior to that professional being listed as a health 
professional in the eligible organization's marketing materials, in 
accordance with recorded (written or otherwise) policies and 
procedures. The credentialing process shall provide for the review of 
an application for credentialing by the credentialing committee 
established under clause (iii).
    ``(ii) The medical director of the eligible organization, or 
another designated health professional, shall have responsibility for 
the credentialing of health professionals under the organization.
    ``(iii)(I) The eligible organization shall establish a 
credentialing committee that--
            ``(I) is composed of licensed physicians and other health 
        professionals to review credentialing information and 
        supporting documents;
            ``(II) provides input to the eligible organization on the 
        credentialing process and procedures; and
            ``(III) appropriately represents the medical specialties of 
        applicants for credentialing.
    ``(iv)(I) Credentialing decisions under the eligible organization 
shall be based on objective standards with input from providers of 
health services credentialed under the organization. Information 
concerning all application and credentialing policies and procedures 
shall be made available for review by the health professional involved 
upon written request.
    ``(II) The standards referred to in subclause (I) shall include 
determinations as to--
            ``(aa) whether the health professional has a current 
        unrestricted valid license to practice the particular health 
        profession involved;
            ``(bb) whether the health professional has clinical 
        privileges in good standing at the hospital designated by the 
        practitioner and the primary admitting facility, as applicable;
            ``(cc) whether the health professional has a valid DEA or 
        CDS certificate, as applicable;
            ``(dd) whether the health professional has graduated from 
        medical school (allopathic or osteopathic), completed a 
        residency (accredited by the Accreditation Council on Graduate 
        Medical Education or the American Osteopathic Association), or 
        received Board certification (by medical specialty boards 
        recognized by the American Board of Medical Specialties or the 
        American Osteopathic Association), as applicable;
            ``(ee) the work history of the health professional;
            ``(ff) whether the health professional has current, 
        adequate malpractice insurance in accordance with the policy of 
        the eligible organization;
            ``(gg) the professional liability claims history of the 
        health professional;
            ``(hh) whether the health professional has been convicted 
        of a crime or cited by a licensing board for professional 
        misconduct; and
            ``(ii) whether the health professional has any malpractice 
        payments or disciplinary actions registered with the National 
        Practitioner Data Bank under section 427(b) of the Health Care 
        Quality Improvement Act (42 U.S.C. 11134(b)).
    ``(III) A health professional who undergoes the credentialing 
process shall have the right to review the basis information, including 
the sources of that information, that was used to meet the designated 
credentialing criteria.
    ``(C)(i) A health professional who is subject to credentialing 
under this paragraph shall, upon written request, receive from the 
eligible organization any information obtained by the organization 
during the credentialing process that, as determined by the 
credentialing committee, does not meet the credentialing standards of 
the organization, or that varies substantially from the information 
provided to the eligible organization by the health professional.
    ``(ii) The eligible organization shall have a formal, recorded 
(written or otherwise) process by which a health professional may 
submit supplemental information to the credentialing committee if the 
health professional determines that erroneous or misleading information 
has been previously submitted. The health professional may request that 
such information be reconsidered in the evaluation for credentialing 
purposes.
    ``(iii)(I) A health professional is not entitled to be selected or 
retained by the eligible organization as a participating or contracting 
provider whether or not such professional meets the credentialing 
standards established under this paragraph.
    ``(II) If economic considerations, including the health care 
professional's patterns of expenditure per patient, are part of a 
selection decision, objective criteria shall be used in examining such 
considerations and a written description of such criteria shall be 
provided to applicants, participating health professionals, and 
enrollees. Any economic profiling of health professionals must be 
adjusted to recognize case mix, severity of illness, and the age of 
patients of a health professional's practice that may account for 
higher or lower than expected costs, to the extent appropriate data in 
this regard is available to the eligible organization.
    ``(iv)(I) The eligible organization shall develop and implement 
procedures for the reporting, to appropriate authorities, of serious 
quality deficiencies that result in the suspension or termination of a 
contract with a health professional.
    ``(II) The eligible organization shall develop and implement 
policies and procedures under which the organization reviews the 
contract privileges of health professionals who--
            ``(aa) have seriously violated policies and procedures of 
        the eligible organization;
            ``(bb) have lost their privilege to practice with a 
        contracting institutional provider; or
            ``(cc) otherwise pose a threat to the quality of service 
        and care provided to the enrollees of the eligible 
        organization.
At a minimum, the policies and procedures implemented under this 
subparagraph shall meet the requirements of the Health Care Quality 
Improvement Act of 1986.
    ``(III) The policies and procedures implemented under subclause 
(II) shall include requirements for the timely notification of the 
affected health professional of the reasons for the reduction, 
withdrawal, or termination of privileges, and provide the health 
professional with the right to appeal the determination of reduction, 
withdrawal, or termination.
    ``(IV) A written copy of the policies and procedures implemented 
under this paragraph shall be made available to a health professional 
on request prior to the time at which the health professional contracts 
to provide services under the organization.
    ``(D) For purposes of this paragraph, the term `health 
professional' means an individual who is licensed, credited, 
accredited, or otherwise credentialed to provide health care items and 
services as authorized under State law.''.

SEC. 4. GRIEVANCE PROCEDURES.

    Section 1876(c)(5)(A) (42 U.S.C. 1395mm(c)(5)(A)) is amended--
            (1) by adding ``(i)'' after ``(A)''; and
            (2) by adding at the end the following new clause:
    ``(ii) The procedures described under clause (i) shall include--
            ``(I) recorded (written or otherwise) procedures for 
        registering and responding to complaints and grievances in a 
        timely manner;
            ``(II) documentation concerning the substance of 
        complaints, grievances, and actions taken concerning such 
        complaints and grievances, which shall be in writing.
            ``(III) procedures to ensure a resolution of a complaint or 
        grievance;
            ``(IV) the compilation and analysis of complaint and 
        grievance data;
            ``(V) procedures to expedite the complaint process if the 
        complaint involves a dispute about the coverage of an 
        immediately and urgently needed service; and
            ``(VI) procedures to ensure that if an enrollee orally 
        notifies the eligible organization about a complaint, the 
        organization (if requested) must send the enrollee a complaint 
        form that includes the telephone numbers and addresses of 
        member services, a description of the organization's grievance 
        procedure.
    ``(iii) The eligible organization shall adopt an appeals process to 
enable covered individuals to appeal decisions that are adverse to the 
individuals. Such a process shall include--
            ``(I) the right to a review by a grievance panel;
            ``(II) the right to a second review with a different panel, 
        independent from the eligible organization, or to a review 
        through an impartial arbitration process which shall be 
        described in writing by the organization; and
            ``(III) an expedited process for review in emergency cases.
The Secretary shall develop guidelines for the structure and 
requirements applicable to the independent review panel and impartial 
arbitration process described in subclause (II).
    ``(iv) With respect to the complaint, grievance, and appeals 
processes required under this paragraph, the eligible organization 
shall, upon the request of a covered individual, provide the individual 
a written decision concerning a complaint, grievance, or appeal in a 
timely fashion.
    ``(v) The complaint, grievance, and appeals processes established 
in accordance with this paragraph may not be used in any fashion to 
discourage or prevent a covered individual from receiving medically 
necessary care in a timely manner.''.

SEC. 5. DISCRIMINATION.

    Section 1876(c) (42 U.S.C. 1395mm(c)), as amended by section 3, is 
amended by adding at the end the following new paragraph:
    ``(10)(A) The eligible organization may not discriminate or engage 
(directly or through contractual arrangements) in any activity, 
including the selection of service area, that has the effect of 
discriminating against an individual on the basis of race, national 
origin, gender, language, socio-economic status, age, disability, 
health status, or anticipated need for health services.
    ``(B) The eligible organization may not engage in marketing or 
other practices intended to discourage or limit the enrollment of 
individuals on the basis of health condition, geographic area, 
industry, or other risk factors.
    ``(C) The eligible organization may not discriminate in the 
selection of members of the health professional or provider network 
(and in establishing the terms and conditions for membership in the 
network) of the organization based on--
            ``(i) the race, national origin, disability, gender, or age 
        of the health professional;
            ``(ii) the socio-economic status, disability, health 
        status, age, or anticipated need for health services of the 
        patients of the health professional or provider; or
            ``(iii) the health professional or provider's lack of 
        affiliation with, or admitting privileges at, a hospital.
    ``(D) The eligible organization may not discriminate in 
participation, reimbursement, or indemnification against a health 
professional who is acting within the scope of the license, training, 
or certification of the professional under applicable State law solely 
on the basis of the license, training, or certification of the health 
professional. The eligible organization may not discriminate in 
participation, reimbursement, or indemnification against a health 
provider that is providing services within the scope of services that 
it is authorized to perform under State law.''.

SEC. 6. REQUIREMENT FOR UTILIZATION REVIEW PROGRAM.

    Section 1876(c) (42 U.S.C. 1395mm(c)), as amended by sections 3 and 
5, is amended by adding at the end the following new paragraph:
    ``(11)(A) The eligible organization shall have in place a 
utilization review program that meets the requirements of this 
paragraph and that is certified by the Secretary.
    ``(B) The Secretary shall establish standards for the 
establishment, operation, and certification and periodic 
recertification of eligible organization utilization review programs.
    ``(C)(i) The Secretary may certify an eligible organization as 
meeting the standards established under subparagraph (B) if the 
Secretary determines that the eligible organization has met the 
utilization standards required for accreditation as applied by a 
nationally recognized, independent, nonprofit accreditation entity.
    ``(ii) The Secretary shall periodically review the standards used 
by the private accreditation entity to ensure that such standards meet 
or exceed the standards established by the Secretary under this 
paragraph.
    ``(D) The standards developed by the Secretary under subparagraph 
(B) shall require that utilization review programs comply with the 
following:
            ``(i) The eligible organization shall provide a written 
        description of the utilization review program of the 
        organization, including a description of--
                    ``(I) the delegated and nondelegated activities 
                under the program;
                    ``(II) the policies and procedures used under the 
                program to evaluate medical necessity; and
                    ``(III) the clinical review criteria, information 
                sources, and the process used to review and approve the 
                provision of medical services under the program.
            ``(ii) With respect to the administration of the 
        utilization review program, the eligible organization may not 
        employ utilization reviewers or contract with a utilization 
        management organization if the conditions of employment or the 
        contract terms include financial incentives to reduce or limit 
        the medically necessary or appropriate services provided to 
        covered individuals.
            ``(iii) The eligible organization shall develop procedures 
        for periodically reviewing and modifying the utilization review 
        of the organization. Such procedures shall provide for the 
        participation of providers in the eligible organization in the 
        development and review of utilization review policies and 
        procedures.
            ``(iv)(I) A utilization review program shall develop and 
        apply recorded (written or otherwise) utilization review 
        decision protocols. Such protocols shall be based on sound 
        medical evidence.
            ``(II) The clinical review criteria used under the 
        utilization review decision protocols to assess the 
        appropriateness of medical services shall be clearly documented 
        and available to participating health professionals upon 
        request. Such protocols shall include a mechanism for assessing 
        the consistency of the application of the criteria used under 
        the protocols across reviewers, and a mechanism for 
        periodically updating such criteria.
            ``(v)(I) The procedures applied under a utilization review 
        program with respect to the preauthorization and concurrent 
        review of the necessity and appropriateness of medical items, 
        services or procedures, shall require that qualified medical 
        professionals supervise review decisions. With respect to a 
        decision to deny the provision of medical items, services or 
        procedures, a provider licensed in the same field shall conduct 
        a subsequent review to determine the medical appropriateness of 
        such a denial. Physicians from the same medical branch 
        (allopathic or osteopathic medicine) and specialty (recognized 
        by the American Board of Medical Specialties or the American 
        Osteopathic Association) shall be utilized in the review 
        process as needed.
            ``(II) All utilization review decisions shall be made in a 
        timely manner, as determined appropriate when considering the 
        urgency of the situation.
            ``(III) With respect to utilization review, an adverse 
        determination or noncertification of an admission, continued 
        stay, or service shall be clearly documented, including the 
        specific clinical or other reason for the adverse determination 
        or noncertification, and be available to the covered individual 
        or any individual acting on behalf of the covered individual 
        and the affected provider or facility. The eligible 
        organization may not deny or limit coverage with respect to a 
        service that the enrollee has already received solely on the 
        basis of lack of prior authorization or second opinion, to the 
        extent that the service would have otherwise been covered by 
        the organization had such prior authorization or a second 
        opinion been obtained.
            ``(IV) The eligible organization shall provide a covered 
        individual with timely notice of an adverse determination or 
        noncertification of an admission, continued stay, or service. 
        Such a notification shall include information concerning the 
        utilization review program appeals procedure.
            ``(vi) An eligible organization utilization review program 
        shall ensure that requests by covered individuals or physicians 
        for prior authorization of a nonemergency service shall be 
        answered in a timely manner after such request is received. If 
        utilization review personnel are not available in a timely 
        fashion, any medical services provided shall be considered 
        approved.
            ``(vii) A utilization review program shall implement 
        policies and procedures to evaluate the appropriate use of new 
        medical technologies or new applications of established 
        technologies, including medical procedures, drugs, and devices. 
        The program shall ensure that appropriate professionals 
        participate in the development of technology evaluation 
        criteria.
            ``(viii) Where prior authorization for a service or other 
        covered item is obtained under a program under this paragraph, 
        the service shall be considered to be covered unless there was 
        fraud or incorrect information provided at the time such prior 
        authorization was obtained. If a provider supplied the 
        incorrect information that led to the authorization of 
        medically unnecessary care, the provider shall be prohibited 
        from collecting payment directly from the enrollee, and shall 
        reimburse the organization and subscriber for any payments or 
        copayments the provider may have received.
    ``(E)(i) The eligible organization shall, with respect to any 
materials distributed to prospective covered individuals, include a 
summary of the utilization review procedures of the organization.
    ``(ii) The eligible organization shall, with respect to any 
materials distributed to newly covered individuals, include a clear and 
comprehensive description of utilization review procedures of the 
organization and a statement of patient rights and responsibilities 
with respect to such procedures.
    ``(iii) The eligible organization shall disclose to the Secretary 
of the eligible organization utilization review program policies, 
procedures, and reports required by the Secretary for certification.
    ``(iv) The eligible organization shall have a membership card which 
shall have printed on the card the toll-free telephone number that an 
enrollee should call for customer service issues.
    ``(v) The eligible organization shall establish mechanisms to 
evaluate the effects of the utilization review program of the 
organization through the use of member satisfaction data or through 
other appropriate means.''.

SEC. 7. ACCESS.

    (a) In General.--Section 1876(c) (42 U.S.C. 1395mm(c)), as amended 
by sections 3, 5, and 6, is amended by adding at the end the following 
new paragraph:
    ``(12)(A) The eligible organization shall demonstrate that the 
organization has a sufficient number, distribution, and variety of 
qualified health care providers to ensure that all covered health care 
services will be available and accessible in a timely manner to all 
individuals enrolled in the organization.
    ``(B) The eligible organization shall demonstrate that organization 
enrollees have access, when medically or clinically indicated in the 
judgment of the treating health professional, to specialized treatment 
expertise.
    ``(C)(i) Any process established by the eligible organization to 
coordinate care and control costs may not impose an undue burden on 
enrollees with chronic health conditions. The organization shall ensure 
a continuity of care and shall, when medically or clinically indicated 
in the judgment of the treating health professional, ensure direct 
access to relevant specialists for continued care.
    ``(ii) In the case of an enrollee who has a severe, complex, or 
chronic condition, the eligible organization shall determine, based on 
the judgment of the treating health professional, whether it is 
medically or clinically necessary or appropriate to use a care 
coordinator from an interdisciplinary team or a specialist to ensure 
continuity of care.
    ``(D)(i) The requirements of this paragraph may not be waived and 
shall be met in all areas where the eligible organization has 
enrollees, including rural areas.
    ``(ii) If the eligible organization fails to meet the requirements 
of this paragraph, the organization shall arrange for the provision of 
out-of-organization services to enrollees in a manner that provides 
enrollees with access to services in accordance with this paragraph.''.
    (b) Access to Emergency Care Services.--Section 1876(c)(4)(B) (42 
U.S.C. 1395mm(c)(4)(B)) is amended--
            (1) by inserting ``emergency'' before ``services'' the 
        first place it appears;
            (2) by striking ``, if (i)'' and all that follows through 
        ``the organization''; and
            (3) by adding at the end the following new sentence: ``In 
        such subparagraph, `emergency services' are services provided 
        to an individual after the sudden onset of a medical condition 
        that manifests itself by symptoms of sufficient severity 
        (including severe pain) such that the absence of immediate 
        medical attention could reasonably be expected by a prudent 
        layperson (possessing an average knowledge of health and 
        medicine) to result in placing the individual's health in 
        serious jeopardy, the serious impairment of a bodily function, 
        or the serious dysfunction of any bodily organ or part, and 
        includes services provided as a result of a call through the 
        911 emergency system.''.

SEC. 8. REQUIREMENTS FOR ORGANIZATION SERVICE AREAS.

    (a) In General.--Section 1876 (42 U.S.C. 1395mm) is amended by 
adding at the end the following new subsection:
    ``(k)(1) Except as provided in paragraph (2), for purposes of this 
section, if the eligible organization's service area includes any part 
of a metropolitan statistical area, the service area shall include the 
entire metropolitan statistical area (including any area designated by 
the Secretary as a health professional shortage area under section 
332(a)(1)(A) of the Public Health Service Act within such metropolitan 
statistical area).
    ``(2) The Secretary may permit an organization's service area to 
exclude any portion of a metropolitan statistical area (other than the 
central county of such metropolitan statistical area) if--
            ``(A) the organization demonstrates that it lacks the 
        financial or administrative capacity to serve the entire 
        metropolitan statistical area; and
            ``(B) the Secretary finds that the composition of the 
        organization's service area does not reduce the financial risk 
        to the organization of providing services to enrollees because 
        of the health status or other demographic characteristics of 
        individuals residing in the service area (as compared to the 
        health status or demographic characteristics of individuals 
        residing in the portion of the metropolitan statistical area 
        not included in the organization's service area).''.
    (b) Conforming Amendment.--Section 1876(c)(4)(A)(i) (42 U.S.C. 
1395mm(c)(4)(A)(i)) is amended by striking ``the area served by the 
organization'' and inserting ``the organization's service area''.
SEC. 9. OTHER ENROLLEE PROTECTIONS.

    (a) Clarification of Restrictions on Charges for Out-of-Plan 
Services.--
            (1) Inpatient hospital and extended care services.--Section 
        1866(a)(1)(O) (42 U.S.C. 1395cc(a)(1)(O)) is amended in the 
        matter preceding clause (i) by inserting after ``this title'' 
        the following: ``(without regard to whether or not the services 
        are furnished on an emergency basis)''.
            (2) Physicians' services and renal dialysis services.--
        Section 1876(j)(2) (42 U.S.C. 1395mm(j)(2)) is amended by 
        striking ``this setion'' and inserting ``this section (without 
        regard to whether or not the services are furnished on an 
        emergency basis)''.
    (b) Arrangements for Dialysis Services.--Section 1876(c) (42 U.S.C. 
1395mm(c)), as amended by sections 3, 5, 6, and 7 is amended by adding 
at the end the following new paragraph:
    ``(13) Each eligible organization shall assure that enrollees 
requiring renal dialysis services who are temporarily outside of the 
organization's service area (within the United States) have reasonable 
access to such services by--
            ``(A) making such arrangements with providers of services 
        or renal dialysis facilities outside the service area for the 
        coverage of and payment for such services furnished to 
        enrollees as the Secretary determines necessary to assure 
        reasonable access; or
            ``(B) providing for the reimbursement of any provider of 
        services or renal dialysis facility outside the service area 
        for the furnishing of such services to enrollees.''.

SEC. 10. INFORMATION ON ELIGIBLE ORGANIZATION.

    Section 1876(c)(3)(C) (42 U.S.C. 1395mm(c)(3)(C)) is amended--
            (1) by redesignating clauses (i) and (ii) as subclauses (I) 
        and (II);
            (2) by inserting ``(i)'' after ``(C)''; and
            (3) by adding at the end the following new clause:
    ``(ii)(I) The eligible organization shall provide prospective 
covered individuals with written information concerning the terms and 
conditions of the eligible organization to enable such individuals to 
make informed decisions with respect to a certain system of health care 
delivery. Such information shall be standardized so that prospective 
covered individuals may compare the attributes of all such 
organizations offered within the coverage area.
    ``(II) Information provided under this section, whether written or 
oral shall be easily understandable, truthful, linguistically 
appropriate and objective with respect to the terms used. Descriptions 
provided in such information shall be consistent with standards 
developed for medicare supplemental policies under section 1882.
    ``(III) Information required under this clause shall include 
information specific to medicare beneficiaries concerning--
            ``(aa) coverage provisions, benefits, and any exclusions by 
        category of service or product;
            ``(bb) plan loss ratios with an explanation that such 
        ratios reflect the percentage of the premiums expended for 
        health services;
            ``(cc) prior authorization or other review requirements 
        including preauthorization review, concurrent review, post-
        service review, post-payment review, and procedures that may 
        lead the patient to be denied coverage for, or not be provided, 
        a particular service or product;
            ``(dd) an explanation of how organization design impacts 
        enrollees, including information on the financial 
        responsibility of covered individuals for payment for 
        coinsurance or other out-of-plan services;
            ``(ee) covered individual satisfaction statistics, 
        including disenrollment statistics;
            ``(ff) advance directives and organ donation;
            ``(gg) the characteristics and availability of health care 
        professionals and institutions participating in the 
        organization, including descriptions of the financial 
        arrangements or contractual provisions with hospitals, 
        utilization review organizations, physicians, or any other 
        provider of health care services that would affect the services 
        offered, referral or treatment options, or physician's 
        fiduciary responsibility to patients, including financial 
        incentives regarding the provision of medical or other 
        services;
            ``(hh) quality indicators for the organization and for 
        participating health professionals and providers under the 
        organization, including population-based statistics such as 
        immunization rates and other preventive care and health 
        outcomes measures such as survival after surgery, adjusted for 
        case mix; and
            ``(ii) an explanation of the appeals process and the 
        grievance procedure.''.

SEC. 11. ENROLLMENT BY MAIL.

    Section 1876(c)(3) (42 U.S.C. 1395mm(c)(3)) is amended by adding at 
the end the following new subparagraphs:
                    ``(H) Each eligible organization that provides 
                items and services pursuant to a contract under this 
                section shall permit an individual entitled to benefits 
                under part A to obtain enrollment forms and information 
                and to enroll under this section by mail, and no agent 
                of an eligible organization may visit the residence of 
                such an individual for purposes of enrolling the 
                individual under this section or providing enrollment 
                information to the individual other than at the 
                individual's request.
                    ``(I)(i) Each eligible organization that provides 
                items and services pursuant to a contract under this 
                section shall include the information described in 
                clause (ii) in any solicitation for enrollment in such 
                organization sent by mail to an individual entitled to 
                benefits under part A.
                    ``(ii) The information described in this clause 
                is--
                            ``(I) the toll-free number of the health 
                        insurance advisory service program established 
                        under section 4359 of the Omnibus Budget 
                        Reconciliation Act of 1990 (42 U.S.C. 1395b-3); 
                        and
                            ``(II) an appropriate explanation of the 
                        services provided by such program.''.

SEC. 12. WAIVER OF CERTAIN MEDICARE COINSURANCE AND DEDUCTIBLES NOT 
              REMUNERATION.

    (a) In General.--The Secretary of Health and Human Services shall 
modify section 1001.952(k) of title 42, Code of Federal Regulations, to 
provide that the term ``remuneration'' as used in section 1128B of the 
Social Security Act (42 U.S.C. 1320a-7b) does not include any reduction 
or waiver of a coinsurance or deductible amount owed to a provider 
furnishing patient services covered under part B of the medicare 
program under title XVIII of such Act if such reduction or waiver is 
provided under a program that--
            (1) facilitates access to health services for patients, who 
        because of economic circumstances might otherwise refrain from 
        seeking needed health care;
            (2) initially and annually screens patients to determine 
        financial need and eligibility for the program; and
            (3) establishes financial need and eligibility on a case-
        by-case basis and grants such a reduction or waiver only if the 
        beneficiary--
                    (A) has an annual gross income (including Social 
                Security benefits, tax-exempt income, and income from 
                any other source) of 200 percent or less of the Federal 
                poverty level;
                    (B) does not have assets in excess of $30,300, 
                excluding the homestead (as defined in State law) and 
                one automobile;
                    (C) is not eligible for medical assistance under a 
                State plan under title XIX of such Act; and
                    (D) is not enrolled in a prepaid health plan.
    (b) Additional Exclusion.--The modification described in subsection 
(a) shall be in addition to any exclusions contained in such section on 
the date of the enactment of this Act.

SEC. 13. EFFECTIVE DATE.

    The amendments made by this Act shall apply with respect to 
contract years beginning on or after             January 1, 1997.
                                 <all>
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