[Congressional Record Volume 146, Number 112 (Wednesday, September 20, 2000)]
[Senate]
[Pages S8823-S8864]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]
STATEMENTS ON INTRODUCED BILLS AND JOINT RESOLUTIONS
Mr. FEINGOLD:
S. 3075. A bill to repeal the provisions of law that provide
automatic pay adjustments for Members of Congress, the Vice President,
certain senior executive officers, and Federal judges, and for other
purposes; to the Committee on Governmental Affairs.
congressional pay adjustment legislation
Mr. FEINGOLD. Mr. President, I rise to introduce a bill that would
put an end to automatic cost-of-living adjustments for Congressional
pay.
As my Colleagues are aware, it is an unusual thing to have the power
to raise our own pay. Few people have that ability. Most of our
constituents do not have that power. And that this power is so unusual
is good reason for the Congress to exercise that power openly, and to
exercise it subject to regular procedures that include debate,
amendment, and a vote on the Record.
Earlier today, the Senate voted down the conference report on the
Legislative Branch appropriations bill. As I noted during the debate on
that bill, by considering the Treasury-Postal appropriations bill as
part of that conference report, shielded as it was from amendment, the
Senate blocked any opportunity to force an open debate of a $3,800 pay
raise next year for every Member of the Senate and the House of
Representatives. This process of pay raises without accountability must
end.
The stealth pay raise technique being employed this year began with a
change Congress enacted in the Ethics Reform Act of 1989. In section
704 of that Act, Members of Congress voted to make themselves entitled
to an annual raise equal to half a percentage point less than the
employment cost index, one measure of inflation. Many times, Congress
has voted to deny itself the raise, and Congress traditionally does
that on the Treasury-Postal appropriations bill.
And by bringing the Treasury-Postal Appropriations bill to the Senate
floor for the first time this week in a conference report, without
Senate floor consideration, the majority leadership prevented anyone
from offering an amendment on that bill to block the pay raise. The
majority leadership tried to make it impossible even to put Senators on
record in an up-or-down vote directly for or against the pay raise. The
majority nearly perfected the technique of the stealth pay raise.
And the majority also made it impossible to link this Congressional
pay raise directly to other pay issues of importance to the American
people. The majority made it impossible to consider, among other
things, an amendment that would have delayed the Congressional pay
raise until working Americans get a much-needed raise in the minimum
wage.
The majority leadership thus appears to believe that cost-of-living
adjustments make sense for Senators and Congressmen, but that cost-of-
living adjustments do not make sense for working people making the
minimum wage.
The process that gives Senators and Congressmen an automatic cost-of-
living adjustment makes it easier for the majority leadership to block
the Senate from rectifying this injustice. If the Senate had to debate
and vote on a bill to raise its pay, a Senator could offer an amendment
that would point out inequities like this.
The question of how and whether Members of Congress can raise their
own pay was one that our Founders considered from the beginning of our
Nation. In August of 1789, as part of the package of 12 amendments
advocated by James Madison that included what has become our Bill of
Rights, the House of Representatives passed an amendment to the
Constitution providing that Congress could not raise its pay without an
intervening election. Almost exactly 211 years ago, on September 9,
1789, the Senate passed that amendment. In late September of 1789,
Congress submitted the amendments to the states.
Although the amendment on pay raises languished for two centuries, in
the 1980s, a campaign began to ratify it. While I was a member of the
Wisconsin state Senate, I was proud to help ratify the amendment. Its
approval by the Michigan legislature on May 7, 1992, gave it the needed
approval by three-fourths of the states.
The 27th Amendment to the Constitution now states: ``No law, varying
the compensation for the services of the senators and representatives,
shall take effect, until an election of representatives shall have
intervened.''
I try to honor that limitation in my own practices. In my own case,
throughout my 6-year term, I accept only the rate of pay that Senators
receive on the date on which I was sworn in as a Senator. And I return
to the Treasury any additional income Senators get, whether from a
cost-of-living adjustment or a pay raise we vote for ourselves. I don't
take a raise until my boss, the people of Wisconsin, give me one at the
ballot box. That is the spirit of the 27th Amendment.
Now, this year's procedural device allowing another pay raise to go
into effect without a recorded vote does not violate the letter of the
Constitution. But stealth pay raises like the one that the Senate
allowed this year certainly violate the spirit of that amendment.
Mr. President, this practice must end. To address it, I am
introducing this bill to end the automatic cost-of-living adjustment
for Congressional pay. Senators and Congressmen should have to vote up-
or-down to raise Congressional pay.
[[Page S8824]]
The majority has sought to prevent votes on pay raises. My bill would
simply require us to vote in the open. We owe our constituents no less.
I urge my Colleagues to support this bill.
Mr. President, I ask unanimous consent to print the bill in the
Record.
There being no objection, the bill was ordered to be printed in the
Record, as follows:
S. 3075
Be it enacted by the Senate and House of Representatives of
the United States of America in Congress assembled,
SECTION 1. ELIMINATION OF AUTOMATIC PAY ADJUSTMENTS FOR
FEDERAL OFFICIALS.
(a) Members of Congress.--
(1) In general.--Paragraph (2) of section 601(a) of the
Legislative Reorganization Act of 1946 (2 U.S.C. 31) is
repealed.
(2) Technical and conforming amendments.--Section 601(a)(1)
of such Act is amended--
(A) by striking ``(a)(1)'' and inserting ``(a)'';
(B) by redesignating subparagraphs (A), (B), and (C) as
paragraphs (1), (2), and (3), respectively; and
(C) by striking ``as adjusted by paragraph (2) of this
subsection'' and inserting ``adjusted as provided by law''.
(b) Vice President.--Section 104 of title 3, United States
Code, is amended--
(1) in subsection (a)--
(A) by striking ``(a)'';
(B) in the first sentence by striking ``as adjusted under
this section'' and inserting ``adjusted as provided by law'';
and
(C) by striking the second and third sentences; and
(2) by striking subsection (b).
(c) Executive Schedule Positions.--
(1) In general.--Section 5318 of title 5, United States
Code, is repealed.
(2) Technical and conforming amendments.--
(A) The table of sections for chapter 53 of title 5, United
States Code, is amended by striking the item relating to
section 5318.
(B) Sections 5312, 5313, 5314, 5315, and 5316 of title 5,
United States Code, are each amended by striking ``as
adjusted by section 5318 of this title'' and inserting
``adjusted as provided by law''.
(d) Justices and Judges.--
(1) In general.--Section 461 of title 28, United States
Code, is repealed.
(2) Technical and conforming amendments.--
(A) The table of sections for chapter 21 of title 28,
United States Code, is amended by striking the item relating
to section 461.
(B) Sections 5, 44(d), 135, and 252 of title 28, United
States Code, are each amended by striking ``as adjusted by
section 461 of this title'' and inserting ``adjusted as
provided by law''.
(C) Section 371(b)(2) of title 28, United States Code, is
amended in the second sentence by striking ``under section
461 of this title'' and inserting ``as provided by law''.
(e) Effective Dates.--This section shall take effect on
February 1, 2001.
______
Mr. LUGAR (for himself, Mr. Schumer, Ms. Collins, and Mr.
Feingold):
S. 3076. A bill to establish an undergraduate grant program of the
Department of State to assist students of limited financial means from
the United States to pursue studies abroad; to the Committee on Foreign
Relations.
international academic opportunity act of 2000
Mr. LUGAR. Mr. President, I rise to introduce the International
Academic Opportunity Act of 2000. I'm pleased to be joined by Senators
Schumer, Collins, and Feingold in introducing this important piece of
legislation.
Our bill attempts to address a gap in U.S. institutions of higher
education among undergraduate students who wish to study abroad but who
lack the financial means to do so. Specifically, our bill would
establish an undergraduate grant program in the Department of State for
the purpose of assisting American students with limited financial means
to pursue studies abroad. It would provide grants for eligible students
of up to $5,000 toward the cost of studying overseas for up to one
academic year. These grants would be made available from existing
appropriations, so we are not requesting any new funds to administer
the program.
The program would be administered by the Department of State and
funded through the 150 International Affairs budget. Global education
is a foreign policy and national security issue, not only an education
matter. During the cold war period and now, international education is
part of the glue that helps to hold alliances together, that promotes
cooperative bilateral relationships, that enhances international trade
and business and narrows the psychological distance between counties
and cultures. Our target population are the many students who wish to
study abroad but who are unable to do so because of financial
limitations. Our bill attempts to remedy this gap in American higher
education.
To qualify for these grants, an individual must be a student in good
standing at a United States institution of higher education, must have
been accepted for up to one academic year of study at an institution of
higher education outside the United States or be in a study program
abroad approved by the student's home institution, and must be a
citizen or national of the United States. Priority would be given to
those who have a demonstrated financial need and who meet these other
eligibility requirements.
It is my understanding that this proposal has been endorsed by the
American Council on Education, the Association of State College and
Universities, the Alliance for International Education and Cultural
Exchange, NAFSA (Association of International Educators), the Institute
of International Education, the American Councils for International
Education: ACTR/ACCELS, and other educational associations and
organizations involved in promoting and implementing international
exchanges and higher education.
Mr. President, there are roughly five foreign students studying in
the United States for every one U.S. student studying abroad. Only one
percent of our total university population in the United States--about
15 million--studies abroad. This imbalance is troubling and should be
rectified. 95 percent of the world's population--and all potential
trading partners and customers for U.S. exports--live outside the
United States. We need to improve the availability and the means for
more students, scholars and practitioners to study abroad--in
institutions of higher learning, to engage in language studies, to
conduct field research, and to participate in international exchanges.
There is extensive research which indicates that experience in study
abroad programs produces significant measurable language improvement,
typically raising students from survival level skills to real fluency.
Research also shows that alumni of study abroad programs view that
experience as critical to their career choices and to the performances
of their jobs.
In a globalized economy, our ability to understand, communicate, and
conduct international commerce and other forms of cross-national and
cross-cultural interactions hinge on our ability to understand and work
effectively with other societies. Globalization makes the imperative of
knowing and understanding the rest of the world more compelling than
ever. The global economic and technology revolutions have helped
redefine our nation's economic security. The opening of markets, the
expansion of international trade, the extraordinary effects of Internet
technology, and the need for American business to compete around the
world require a larger global vision that can be advanced through
expanded contacts and international education.
In order to make our program successful, other countries need to
improve their exchange programs to attract American students by making
more classroom space available, more and better housing, and improved
language capabilities. For our part, we need to do more to encourage
undergraduate students to explore the challenges and opportunities of
living abroad in another culture, of being exposed to different values
and different mores.
I believe this bill merits special attention. The costs are minimal,
it adds no new funding to the already-strained appropriations for
international affairs and it addresses the needs of those undergraduate
American students who wish to study abroad but cannot ordinarily do so
because they lack the financial means.
I hope my colleagues will support this initiative.
I ask that the full text of the bill be printed in the Record.
There being no objection, the bill was ordered to be printed in the
Record, as follows:
S. 3076
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 ``International Academic
Opportunity Act of 2000''.
[[Page S8825]]
SEC. 2. STATEMENT OF PURPOSE.
It is the purpose of this Act to establish an undergraduate
grant program for students of limited financial means from
the United States to enable such students to study abroad.
Such foreign study is intended to broaden the outlook and
better prepare such students of demonstrated financial need
to assume significant roles in the increasingly global
economy.
SEC. 3. ESTABLISHMENT OF GRANT PROGRAM FOR FOREIGN STUDY BY
AMERICAN COLLEGE STUDENTS OF LIMITED FINANCIAL
MEANS.
(a) Establishment.--Subject to the availability of
appropriations and under the authorities of the Mutual
Educational and Cultural Exchange Act of 1961, the Secretary
of State shall establish and carry out a program in each
fiscal year to award grants of up to $5,000, to individuals
who meet the requirements of subsection (b), toward the cost
of up to one academic year of undergraduate study abroad.
Grants under this Act shall be known as the ``Benjamin A.
Gilman International Scholarships''.
(b) Eligibility.--An individual referred to in subsection
(a) is an individual who--
(1) is a student in good standing at an institution of
higher education in the United States (as defined in section
101(a) of the Higher Education Act of 1965);
(2) has been accepted for up to one academic year of
study--
(A) at an institution of higher education outside the
United States (as defined by section 102(b) of the Higher
Education Act of 1965); or
(B) on a program of study abroad approved for credit by the
student's home institution;
(3) is receiving any need-based student assistance under
title IV of the Higher Education Act of 1965; and
(4) is a citizen or national of the United States.
(c) Application and Selection.--
(1) Grant application and selection shall be carried out
through accredited institutions of higher education in the
United States or a combination of such institutions under
such procedures as are established by the Secretary of State.
(2) In considering applications for grants under this
section--
(A) consideration of financial need shall include the
increased costs of study abroad; and
(B) priority consideration shall be given to applicants who
are receiving Federal Pell Grants under title IV of the
Higher Education Act of 1965.
SEC. 4. REPORT TO CONGRESS.
The Secretary of State shall report annually to the
Congress concerning the grant program established under this
Act. Each such report shall include the following information
for the preceding year:
(1) The number of participants.
(2) The institutions of higher education in the United
States that participants attended.
(3) The institutions of higher education outside the United
States participants attended during their year of study
abroad.
(4) The areas of study of participants.
SEC. 5. AUTHORIZATION OF APPROPRIATIONS.
There are authorized to be appropriated $1,500,000 for each
fiscal year to carry out this Act.
SEC. 6. EFFECTIVE DATE.
This Act shall take effect October 1, 2000.
______
By Mr. MOYNIHAN (for himself, Mr. Daschle, Mr. Rockefeller, Mr.
Breaux, Mr. Graham, Mr. Kerrey, Mr. Robb, Mr. Kennedy, Mr.
Akaka, Mr. Bingaman, Mrs. Boxer, Mr. Cleland, Mr. Dodd, Mr.
Dorgan, Mr. Edwards, Mr. Hollings, Mr. Inouye, Mr. Johnson, Mr.
Kerry, Ms. Landrieu, Mr. Leahy, Mr. Levin, Mrs. Lincoln, Ms.
Mikulski, Mr. Miller, Mrs. Murray, Mr. Reed, Mr. Sarbanes, Mr.
Schumer, Mr. Torricelli, and Mr. Wellstone):
S. 3077. A bill to amend the Social Security Act to make corrections
and refinements in the Medicare, Medicaid, and SCHIP health insurance
programs, as revised by the Balanced Budget Act of 1997 and the
Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999,
and for other purposes; to the Committee on Finance.
Balanced Budget Refinement Act of 2000
Mr. MOYNIHAN. Mr. President, I am pleased to join with Senator
Daschle and many of my Democratic colleagues in sponsoring the Balanced
Budget Refinement Act of 2000 (BBRA-2000). First, a few words on the
genesis of this bill.
As part of the effort to balance the Federal Budget, the Balanced
Budget Act of 1997 (BBA) provided for reduction in Medicare payments
for medical services. At the time of enactment, the Congressional
Budget Office (CBO) estimated that these provisions would reduce
Medicare outlays by $112 billion over 5 years. We now know that these
BBA cuts have been much larger than originally anticipated.
Hospital industry representatives and other providers of health care
services have asserted that the magnitude of the reductions are having
unintended consequences which are seriously impacting the quantity and
quality of health care services available to our citizens.
Last year, the Congress address some of those unintended
consequences, by enacting the Balanced Budget Refinement Act (BBRA),
which added back $16 billion over 5 years in payments to various
Medicare providers, including: Teaching Hospitals; Hospital Outpatient
Departments; Medicare HMOs (Health Maintenance Organizations); Skilled
Nursing Facilities; Rural Health Providers; and Home Health Agencies.
However, Members of Congress are continuing to hear from providers
who argue that the 1997 reductions are still having serious
unanticipated consequences.
To respond to these continuing problems, the President last June
proposed additional BBA relief in the amount of $21 billion over the
next 5 years. On July 27, Senator Daschle and I announced the outlines
of a similar, but more substantial, Senate Democratic BBA relief
package that would provide about $40 billion over 5 years in relief to
health care providers and beneficiaries. Today, along with many of our
colleagues, Senator Daschle and I are introducing this package as the
Balanced Budget Refinement Act of 2000 (BBRA-2000).
Before I submit for the record a summary of this legislation, I want,
in particular, to highlight that our legislation would prevent further
reductions in payments to our Nation's teaching hospitals. The BBA,
unwisely in my view, enacted a multi-year schedule of cuts in payments
by Medicare to academic medical centers. These cuts would seriously
impair the cutting edge research conducted by teaching hospitals, as
well as impair their ability to train doctors and to serve so many of
our nation's indigent.
Last year, in the BBRA, we mitigated the scheduled reductions in
fiscal years 2000 and 2001. The package we are introducing today, would
cancel any further reductions in what we call ``Indirect Medical
Education payments,'' thereby restoring nearly $2.7 billion over 5
years ($6.9 billion over 10 years) to our Nation's teaching hospitals.
I have stood before my colleagues on countless occasions to bring
attention to the financial plight of medical schools and teaching
hospitals. Yet, I regret that the fate of the 144 accredited medical
schools and 1416 graduate medical education teaching institutions still
remains uncertain. The proposals in our Democratic BBRA-2000 package
will provide critically needed financing in the short-run.
In the long-run, however, we need to restructure the financing of
graduate medical education along the lines I have proposed in the
Graduate Medical Education Trust Fund Act (S. 210). What is needed is
explicit and dedicated funding for these institutions, which will
ensure that the United States continues to lead the world in this era
of medical discovery. The Graduate Medical Education Trust Fund Act
would require that the public sector, through the Medicare and Medicaid
programs, and the private sector through an assessment on health
insurance premiums, provide broad-based financial support for graduate
medical education. S. 210 would roughly double current funding levels
for Graduate Medical Education and would establish a Medical Education
Advisory Commission to make recommendations on the operation of the
Medical Education Trust Fund, on alternative payment sources for
funding graduate medical education and teaching hospitals, and on
policies designed to maintain superior research and educational
capacities.
In addition to restoring much needed funding to our Nation's teaching
hospitals, BBRA-2000 would add back funding in many vital areas of
health care. Key provisions of the bill we are introducing today would:
provide full market basket (inflation) adjustments to hospitals for
2001 and 2002; prevent further reductions in Indirect Medical Education
(IME) payments to teaching hospitals; target additional relief to rural
hospitals; eliminate cuts in payments to hospitals for handling large
numbers of low-income patients (referred to as ``disproportionate share
[[Page S8826]]
(DSH) hospital payments''); repeal the scheduled 15 percent cut in
payments to home health agencies; provide a full market basket
(inflation) adjustment to skilled nursing facilities; assist
beneficiaries through preventive benefits and smaller coinsurance
payments; provide increased payments to Medicare manager care plans
(HMOs); and improve eligibility and enrollment processes in Medicaid
and the State Children's Health Insurance Program (SCHIP).
Mr. President, I ask unanimous consent that the bill language, a
summary of the bill, and several letters of support which I send to the
desk, be placed in the Record at the conclusion of my statement. I
would like to thank Kyle Kinner and Kirsten Beronio of the minority
health staff of the Finance Committee for their efforts in assembling
this legislation.
S. 3077
Be it enacted by the Senate and House of Representatives of
the United States of America in Congress assembled,
SECTION 1. SHORT TITLE; AMENDMENTS TO SOCIAL SECURITY ACT;
REFERENCES TO OTHER ACTS; TABLE OF CONTENTS.
(a) Short Title.--This Act may be cited as the ``Medicare,
Medicaid, and SCHIP Balanced Budget Refinement Act of 2000''.
(b) 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.
(c) References to Other Acts.--In this Act:
(1) The balanced budget act of 1997.--The term ``BBA''
means the Balanced Budget Act of 1997 (Public Law 105-33; 111
Stat. 251).
(2) The medicare, medicaid, and schip balanced budget
refinement act of 1999.--The term ``BBRA'' means the
Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act
of 1999 (113 Stat. 1501A-321), as enacted into law by section
1000(a)(6) of Public Law 106-113.
(d) Table of Contents.--The table of contents of this Act
is as follows:
Sec. 1. Short title; amendments to Social Security Act; references to
other Acts; table of contents.
TITLE I--PROVISIONS RELATING TO PART A
Subtitle A--Skilled Nursing Facilities
Sec. 101. Eliminating reduction in skilled nursing facility (SNF)
market basket update.
Sec. 102. Revision of BBRA increase for skilled nursing facilities in
fiscal years 2001 and 2002.
Sec. 103. MedPAC study on payment updates for skilled nursing
facilities; authority of Secretary to make adjustments.
Subtitle B--PPS Hospitals
Sec. 111. Revision of reduction of indirect graduate medical education
payments.
Sec. 112. Eliminating reduction in PPS hospital payment update.
Sec. 113. Eliminating reduction in disproportionate share hospital
(DSH) payments.
Sec. 114. Equalizing the threshold and updating payment formulas for
disproportionate share hospitals.
Sec. 115. Care for low-income patients.
Sec. 116. Modification of payment rate for Puerto Rico hospitals.
Sec. 117. MedPAC study on hospital area wage indexes.
Subtitle C--PPS Exempt Hospitals
Sec. 121. Treatment of certain cancer hospitals.
Sec. 122. Payment adjustment for inpatient services in rehabilitation
hospitals.
Subtitle D--Hospice Care
Sec. 131. Revision in payments for hospice care.
Subtitle E--Other Provisions
Sec. 141. Hospitals required to comply with bloodborne pathogens
standard.
Sec. 142. Informatics and data systems grant program.
Sec. 143. Relief from medicare part A late enrollment penalty for group
buy-in for State and local retirees.
Subtitle F--Transitional Provisions
Sec. 151. Reclassification of certain counties and areas for purposes
of reimbursement under the medicare program.
Sec. 152. Calculation and application of wage index floor for a certain
area.
TITLE II--PROVISIONS RELATING TO PART B
Subtitle A--Hospital Outpatient Services
Sec. 201. Reduction of effective HOPD coinsurance rate to 20 percent by
2014.
Sec. 202. Application of transitional corridor to certain hospitals
that did not submit a 1996 cost report.
Sec. 203. Permanent guarantee of pre-BBA payment levels for outpatient
services furnished by children's hospitals.
Subtitle B--Provisions Relating to Physicians
Sec. 211. Loan deferment for residents.
Sec. 212. GAO studies and reports on medicare payments.
Sec. 213. MedPAC study on the resource-based practice expense system.
Subtitle C--Ambulance Services
Sec. 221. Election to forego phase-in of fee schedule for ambulance
services.
Sec. 222. Prudent layperson standard for emergency ambulance services.
Sec. 223. Elimination of reduction in inflation adjustments for
ambulance services.
Sec. 224. Study and report on the costs of rural ambulance services.
Sec. 225. Interim payments for rural ground ambulance services until
regulation implemented.
Sec. 226. GAO study and report on the costs of emergency and medical
transportation services.
Subtitle D--Preventive Services
Sec. 231. Elimination of deductibles and coinsurance for preventive
benefits.
Sec. 232. Counseling for cessation of tobacco use.
Sec. 233. Coverage of glaucoma detection tests.
Sec. 234. Medical nutrition therapy services for beneficiaries with
diabetes, a cardiovascular disease, or a renal disease.
Sec. 235. Studies on preventive interventions in primary care for older
Americans.
Sec. 236. Institute of Medicine 5-year medicare prevention benefit
study and report.
Sec. 237. Fast-track consideration of prevention benefit legislation.
Subtitle E--Other Services
Sec. 241. Revision of moratorium in caps for therapy services.
Sec. 242. Revision of coverage of immunosuppressive drugs.
Sec. 243. State accreditation of diabetes self-management training
programs.
Sec. 244. Elimination of reduction in payment amounts for durable
medical equipment and oxygen and oxygen equipment.
Sec. 245. Standards regarding payment for certain orthotics and
prosthetics.
Sec. 246. National limitation amount equal to 100 percent of national
median for new pap smear technologies and other new
clinical laboratory test technologies.
Sec. 247. Increased medicare payments for certified nurse-midwife
services.
Sec. 248. Payment for administration of drugs.
Sec. 249. MedPAC study on in-home infusion therapy nursing services.
TITLE III--PROVISIONS RELATING TO PARTS A AND B
Subtitle A--Home Health Services
Sec. 301. Elimination of 15 percent reduction in payment rates under
the prospective payment system for home health services.
Sec. 302. Exclusion of certain nonroutine medical supplies under the
PPS for home health services.
Sec. 303. Permitting home health patients with Alzheimer's disease or a
related dementia to attend adult day-care.
Sec. 304. Standards for home health branch offices.
Sec. 305. Treatment of home health services provided in certain
counties.
Subtitle B--Direct Graduate Medical Education
Sec. 311. Not counting certain geriatric residents against graduate
medical education limitations.
Sec. 312. Program of payments to children's hospitals that operate
graduate medical education programs.
Sec. 313. Authority to include costs of training of clinical
psychologists in payments to hospitals.
Sec. 314. Treatment of certain newly established residency programs in
computing medicare payments for the costs of medical
education.
Subtitle C--Miscellaneous Provisions
Sec. 321. Waiver of 24-month waiting period for medicare coverage of
individuals disabled with amyotrophic lateral sclerosis
(ALS).
TITLE IV--RURAL PROVIDER PROVISIONS
Subtitle A--Critical Access Hospitals
Sec. 401. Payments to critical access hospitals for clinical diagnostic
laboratory tests.
Sec. 402. Revision of payment for professional services provided by a
critical access hospital.
Sec. 403. Permitting critical access hospitals to operate PPS exempt
distinct part psychiatric and rehabilitation units.
[[Page S8827]]
Subtitle B--Medicare Dependent, Small Rural Hospital Program
Sec. 411. Making the medicare dependent, small rural hospital program
permanent.
Sec. 412. Option to base eligibility for medicare dependent, small
rural hospital program on discharges during any of the 3
most recent audited cost reporting periods.
Subtitle C--Sole Community Hospitals
Sec. 421. Extension of option to use rebased target amounts to all sole
community hospitals.
Sec. 422. Deeming a certain hospital as a sole community hospital.
Subtitle D--Other Rural Hospital Provisions
Sec. 431. Exemption of hospital swing-bed program from the PPS for
skilled nursing facilities.
Sec. 432. Permanent guarantee of pre-BBA payment levels for outpatient
services furnished by rural hospitals.
Sec. 433. Treatment of certain physician pathology services.
Subtitle E--Other Rural Provisions
Sec. 441. Revision of bonus payments for services furnished in health
professional shortage areas.
Sec. 442. Provider-based rural health clinic cap exemption.
Sec. 443. Payment for certain physician assistant services.
Sec. 444. Bonus payments for rural home health agencies in 2001 and
2002.
Sec. 445. Exclusion of clinical social worker services and services
performed under a contract with a rural health clinic or
federally qualified health center from the PPS for SNFs.
Sec. 446. Coverage of marriage and family therapist services provided
in rural health clinics.
Sec. 447. Capital infrastructure revolving loan program.
Sec. 448. Grants for upgrading data systems.
Sec. 449. Relief for financially distressed rural hospitals.
Sec. 450. Refinement of medicare reimbursement for telehealth services.
Sec. 451. MedPAC study on low-volume, isolated rural health care
providers.
TITLE V--PROVISIONS RELATING TO PART C (MEDICARE+CHOICE PROGRAM) AND
OTHER MEDICARE MANAGED CARE PROVISIONS
Sec. 501. Restoring effective date of elections and changes of
elections of Medicare+Choice plans.
Sec. 502. Special Medigap enrollment antidiscrimination provision for
certain beneficiaries.
Sec. 503. Increase in national per capita Medicare+Choice growth
percentage in 2001 and 2002.
Sec. 504. Allowing movement to 50:50 percent blend in 2002.
Sec. 505. Delay from July to November 2000, in deadline for offering
and withdrawing Medicare+Choice plans for 2001.
Sec. 506. Amounts in medicare trust funds available for Secretary's
share of Medicare+Choice education and enrollment-related
costs.
Sec. 507. Revised terms and conditions for extension of medicare
community nursing organization (CNO) demonstration
project.
Sec. 508. Modification of payment rules for certain frail elderly
medicare beneficiaries.
TITLE VI--PROVISIONS RELATING TO INDIVIDUALS WITH END-STAGE RENAL
DISEASE
Sec. 601. Update in renal dialysis composite rate.
Sec. 602. Revision of payment rates for ESRD patients enrolled in
Medicare+Choice plans.
Sec. 603. Permitting ESRD beneficiaries to enroll in another
Medicare+Choice plan if the plan in which they are
enrolled is terminated.
Sec. 604. Coverage of certain vascular access services for ESRD
beneficiaries provided by ambulatory surgical centers.
Sec. 605. Collection and analysis of information on the satisfaction of
ESRD beneficiaries with the quality of and access to
health care under the medicare program.
TITLE VII--ACCESS TO CARE IMPROVEMENTS THROUGH MEDICAID AND SCHIP
Sec. 701. New prospective payment system for Federally-qualified health
centers and rural health clinics.
Sec. 702. Transitional medical assistance.
Sec. 703. Application of simplified SCHIP procedures under the medicaid
program.
Sec. 704. Presumptive eligibility.
Sec. 705. Improvements to the maternal and child health services block
grant.
Sec. 706. Improving access to medicare cost-sharing assistance for low-
income beneficiaries.
Sec. 707. Breast and cervical cancer prevention and treatment.
TITLE VIII--OTHER PROVISIONS
Sec. 801. Appropriations for Ricky Ray Hemophilia Relief Fund.
Sec. 802. Increase in appropriations for special diabetes programs for
children with type I diabetes and Indians.
Sec. 803. Demonstration grants to improve outreach, enrollment, and
coordination of programs and services to homeless
individuals and families.
Sec. 804. Protection of an HMO enrollee to receive continuing care at a
facility selected by the enrollee.
Sec. 805. Grants to develop and establish real choice systems change
initiatives.
TITLE I--PROVISIONS RELATING TO PART A
Subtitle A--Skilled Nursing Facilities
SEC. 101. ELIMINATING REDUCTION IN SKILLED NURSING FACILITY
(SNF) MARKET BASKET UPDATE.
(a) Elimination of Reduction.--Section 1888(e)(4)(E)(ii)
(42 U.S.C. 1395yy(e)(4)(E)(ii)) is amended--
(1) in subclause (I), by adding ``and'' at the end;
(2) by striking subclause (II); and
(3) by redesignating subclause (III) as subclause (II).
(b) Special Rule for Payment for Skilled Nursing Facility
Services for Fiscal Year 2001.--Notwithstanding the
amendments made by subsection (a), for purposes of making
payments for covered skilled nursing facility services under
section 1888(e) of the Social Security Act (42 U.S.C.
1395yy(e)) for fiscal year 2001, the Federal per diem rate
referred to in paragraph (4)(E)(ii) of such section--
(1) for the period beginning on October 1, 2000, and ending
on March 31, 2001, shall be the rate determined in accordance
with subclause (II) of such paragraph as in effect on the day
before the date of enactment of this Act; and
(2) for the period beginning on April 1, 2001, and ending
on September 30, 2001, shall be the rate computed for fiscal
year 2000 pursuant to subclause (I) of such paragraph
increased by the skilled nursing facility market basket
percentage change for fiscal year 2001 plus 1 percentage
point.
SEC. 102. REVISION OF BBRA INCREASE FOR SKILLED NURSING
FACILITIES IN FISCAL YEARS 2001 AND 2002.
(a) Revision.--Section 101(d) of BBRA (113 Stat. 1501A-325)
is amended--
(1) in paragraph (1)--
(A) by striking ``4.0 percent for each such fiscal year''
and inserting ``the applicable percent (as defined in
paragraph (3)) for each such fiscal year (or portion of such
year)''; and
(2) by adding at the end the following new paragraph:
``(3) Applicable percent defined.--For purposes of this
subsection, the term `applicable percent' means, with respect
to services provided during--
``(A) the period beginning on October 1, 2000, and ending
on March 31, 2001, 4.0 percent;
``(B) the period beginning on April 1, 2001, and ending on
September 30, 2001, 8.0 percent; and
``(C) fiscal year 2002, 6.0 percent.
(b) Effective Date.--The amendments made by subsection (a)
shall take effect as if included in the enactment of section
101 of BBRA (113 Stat. 1501A-324).
SEC. 103. MEDPAC STUDY ON PAYMENT UPDATES FOR SKILLED NURSING
FACILITIES; AUTHORITY OF SECRETARY TO MAKE
ADJUSTMENTS.
(a) Study.--The Medicare Payment Advisory Commission
established under section 1805 of the Social Security Act (42
U.S.C. 1395b-6) (in this section referred to as ``MedPAC'')
shall conduct a study of nursing home costs to determine the
adequacy of payment rates (including updates to such rates)
under the medicare program under title XVIII of such Act (42
U.S.C. 1395 et seq.) (in this section referred to as the
``medicare program'') for items and services furnished by
skilled nursing facilities. In conducting such study, MedPAC
shall use data on actual costs and cost increases.
(b) Report.--Not later than 12 months after the date of
enactment of this Act, MedPAC shall submit a report to the
Secretary of Health and Human Services and Congress on the
study conducted under subsection (a), including a description
of the methodology and calculations used by the Health Care
Financing Administration to establish the original payment
level under the prospective payment system for skilled
nursing facility services under section 1888(e) of the Social
Security Act (42 U.S.C. 1395yy(e)) and to annually update
payments under the medicare program for items and services
furnished by skilled nursing facilities, together with
recommendations regarding methods to ensure that all input
variables, including the labor costs, the intensity of
services, and the changes in science and technology that are
specific to such facilities, are adequately accounted for.
(c) Authority of Secretary to Make Adjustments.--
Notwithstanding any other provision of law, the Secretary of
Health and Human Services may make adjustments to payments
under the prospective payment system under section 1888(e) of
the Social Security Act (42 U.S.C. 1395yy(e)) for covered
skilled nursing facility services to reflect any necessary
adjustments to such payments as is appropriate as a result of
the study conducted under subsection (a).
[[Page S8828]]
(d) Publication.--
(1) In general.--Not later than April 1, 2002, the
Secretary of Health and Human Services shall publish for
public comment a description of--
(A) whether the Secretary will make any adjustments
pursuant to subsection (c); and
(B) if so, the form of such adjustments.
(2) Final form.--Not later than August 1, 2002, the
Secretary of Health and Human Services shall publish the
description described in paragraph (1) in final form.
Subtitle B--PPS Hospitals
SEC. 111. REVISION OF REDUCTION OF INDIRECT GRADUATE MEDICAL
EDUCATION PAYMENTS.
(a) Revision.--
(1) In general.--Section 1886(d)(5)(B)(ii) (42 U.S.C.
1395ww(d)(5)(B)(ii)) is amended--
(A) in subclause (IV), by adding ``and'' at the end; and
(B) by striking subclauses (V) and (VI) and inserting the
following new subclause:
``(V) on or after October 1, 2000, `c' is equal to 1.6.''.
(2) Technical amendments.--Section 1886(d)(5)(B) (42 U.S.C.
1395ww(d)(5)(B)), as amended by paragraph (1), is amended--
(A) by realigning the left margins of clauses (ii) and (v)
so as to align with the left margin of clause (i); and
(B) by realigning the left margins of subclauses (I)
through (V) of clause (ii) appropriately.
(b) Special Adjustment for Purposes of Maintaining 6.5
Percent IME Payment for Fiscal Year 2001.--Notwithstanding
paragraph (5)(B)(ii)(V) of section 1886(d) of the Social
Security Act (42 U.S.C. 1395ww(d)(5)(B)(ii)(V)), as amended
by subsection (a), for purposes of making payments for
subsection (d) hospitals (as defined in paragraph (1)(B) of
such section) with indirect costs of medical education, the
indirect teaching adjustment factor referred to in paragraph
(5)(B)(ii) of such section shall be determined--
(1) for discharges occurring on or after October 1, 2000,
and before April 1, 2001, pursuant to such paragraph as in
effect on the day before the date of enactment of this Act;
and
(2) for discharges occurring on or after April 1, 2001, and
before October 1, 2001, by substituting ``1.66'' for ``1.6''
in subclause (V) of such paragraph (as so amended).
(c) Conforming Amendment Relating to Determination of
Standardized Amount.--Section 1886(d)(2)(C)(i) (42 U.S.C.
1395ww(d)(2)(C)(i)) is amended--
(1) by inserting a comma after ``Balanced Budget Act of
1997''; and
(2) by inserting ``, or any payment under such paragraph
resulting from the application of section 111(b) of the
Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act
of 2000'' after ``Balanced Budget Refinement Act of 1999''.
SEC. 112. ELIMINATING REDUCTION IN PPS HOSPITAL PAYMENT
UPDATE.
(a) In General.--Section 1886(b)(3)(B)(i) (42 U.S.C.
1395ww(b)(3)(B)(i)) is amended--
(1) in subclause (XV), by adding ``and'' at the end;
(2) by striking subclauses (XVI) and (XVII);
(3) by redesignating subclause (XVIII) as subclause (XVI);
and
(4) in subclause (XVI), as so redesignated, by striking
``fiscal year 2003'' and inserting ``fiscal year 2001''.
(b) Special Rule for Payment for Inpatient Hospital
Services for Fiscal Year 2001.--Notwithstanding the
amendments made by subsection (a), for purposes of making
payments for fiscal year 2001 for inpatient hospital services
furnished by subsection (d) hospitals (as defined in section
1886(d)(1)(B) of the Social Security Act (42 U.S.C.
1395ww(d)(1)(B))), the ``applicable percentage increase''
referred to in section 1886(b)(3)(B)(i) of such Act (42
U.S.C. 1395ww(b)(3)(B)(i))--
(1) for discharges occurring on or after October 1, 2000,
and before April 1, 2001, shall be determined in accordance
with subclause (XVI) of such section as in effect on the day
before the date of enactment of this Act; and
(2) for discharges occurring on or after April 1, 2001, and
before October 1, 2001, shall be equal to--
(A) the market basket percentage increase plus 1.1
percentage points for hospitals (other than sole community
hospitals) in all areas; and
(B) the market basket percentage increase for sole
community hospitals.
SEC. 113. ELIMINATING REDUCTION IN DISPROPORTIONATE SHARE
HOSPITAL (DSH) PAYMENTS.
(a) Elimination of Reduction.--
(1) In general.--Section 1886(d)(5)(F)(ix) (42 U.S.C.
1395ww(d)(5)(F)(ix)) is amended--
(A) in subclause (III), by striking ``during each of fiscal
years 2000 and 2001'' and inserting ``during fiscal year
2000'';
(B) by striking subclause (IV);
(C) by redesignating subclause (V) as subclause (IV); and
(D) in subclause (IV), as so redesignated, by striking
``during fiscal year 2003'' and inserting ``during fiscal
year 2001''.
(2) Effective date.--The amendments made by this subsection
shall apply to discharges occurring on or after October 1,
2000.
(b) Special Rule for DSH Payment for Fiscal Year 2001.--
Notwithstanding the amendments made by subsection (a)(1), for
purposes of making disproportionate share payments for
subsection (d) hospitals (as defined in section 1886(d)(1)(B)
of the Social Security Act (42 U.S.C. 1395ww(d)(1)(B))) for
fiscal year 2001, the additional payment amount otherwise
determined under clause (ii) of section 1886(d)(5)(F) of the
Social Security Act (42 U.S.C. 1395ww(d)(5)(F))--
(1) for discharges occurring on or after October 1, 2000,
and before April 1, 2001, shall be adjusted as provided by
clause (ix)(III) of such section as in effect on the day
before the date of enactment of this Act; and
(2) for discharges occurring on or after April 1, 2001, and
before October 1, 2001, shall be increased by 3 percent.
(c) Conforming Amendments Relating to Determination of
Standardized Amount.--Section 1886(d)(2)(C)(iv) (42 U.S.C.
1395ww(d)(2)(C)(iv)), is amended--
(1) by striking ``Act of 1989 or'' and inserting ``Act of
1989,''; and
(2) by inserting ``, or the enactment of section 113(b) of
the Medicare, Medicaid, and SCHIP Balanced Budget Refinement
Act of 2000'' after ``Omnibus Budget Reconciliation Act of
1990''.
SEC. 114. EQUALIZING THE THRESHOLD AND UPDATING PAYMENT
FORMULAS FOR DISPROPORTIONATE SHARE HOSPITALS.
(a) Application of Uniform 15 Percent Threshold.--Section
1886(d)(5)(F)(v) (42 U.S.C. 1395ww(d)(5)(F)(v)) is amended by
striking ``exceeds--'' and all that follows and inserting
``exceeds 15 percent.''.
(b) Change in Payment Percentage Formulas.--Section
1886(d)(5)(F)(viii) (42 U.S.C. 1395ww(d)(5)(F)(viii)) is
amended to read as follows:
``(viii) The formula used to determine the disproportionate
share adjustment percentage for a cost reporting period for a
hospital described in subclause (II), (III), or (IV) of
clause (iv) is--
``(I) in the case of such a hospital with a
disproportionate patient percentage (as defined in clause
(vi)) that does not exceed 20.2, (P-15)(.65) + 2.5;
``(II) in the case of such a hospital with a
disproportionate patient percentage (as so defined) that
exceeds 20.2 but does not exceed 25.2, (P-20.2)(.825) + 5.88;
``(III) except as provided in subclause (IV), in the case
of such a hospital with a disproportionate patient percentage
(as so defined) that exceeds 25.2, the disproportionate share
adjustment percentage = 10; and
``(IV) in the case of such a hospital with a
disproportionate patient percentage (as so defined) that
exceeds 30.0 and that is described in clause (iv)(III), (P-
30)(.6) + 10;
where `P' is the hospital's disproportionate patient
percentage (as so defined).''.
(c) Conforming Amendments.--Section 1886(d)(5)(F)(iv) (42
U.S.C. 1395ww(d)(5)(F)(iv)) is amended--
(1) in subclause (I), by striking ``is described in the
second sentence of clause (v)'' and inserting ``is located in
a rural area and has 500 or more beds'';
(2) by amending subclause (II) to read as follows:
``(II) is located in an urban area and has less than 100
beds, or is located in a rural area and has less than 500
beds and is not described in subclause (III) or (IV), is
equal to the percent determined in accordance with the
applicable formula described in clause (viii);'';
(3) by striking subclauses (III) and (IV);
(4) by redesignating subclauses (V) and (VI) as subclauses
(III) and (IV), respectively;
(5) in subclause (III) (as so redesignated), by striking
``and is not classified as a sole community hospital under
subparagraph (D),''; and
(6) in subclause (IV) (as so redesignated), by striking
``10 percent'' and inserting ``equal to the percent
determined in accordance with the applicable formula
described in clause (viii)''.
(d) Effective Date.--The amendments made by this section
shall apply to discharges occurring on or after April 1,
2001.
SEC. 115. CARE FOR LOW-INCOME PATIENTS.
(a) Freeze in Medicaid DSH Allotments.--
(1) In general.--Section 1923(f) (42 U.S.C. 1396r-4(f)) is
amended--
(A) by redesignating paragraph (4) as paragraph (5); and
(B) by inserting after paragraph (3), the following new
paragraph:
``(4) Special rule for fiscal years 2001 through 2008.--
With respect to each of fiscal years 2001 through 2008--
``(A) paragraph (2) shall be applied--
``(i) by substituting--
``(I) in the heading, `2001' for `2002';
``(II) in the matter preceding the table, `2001 (and the
DSH allotment for a State for fiscal year 2001 is the same as
the DSH allotment for the State for fiscal year 2000, as
determined under the following table)' for `2002'; and
``(ii) without regard to the columns in the table relating
to FY 01 and FY 02 (fiscal years 2001 and 2002); and
``(B) paragraph (3) shall be applied by substituting--
``(i) in the heading, `2002' for `2003';
``(ii) in subparagraph (A), `2002' for `2003'.''.
(2) Repeal; applicability.--Effective October 1, 2008, the
amendments made by paragraph (1) are repealed and section
1923(f) of the Social Security Act (42 U.S.C. 1396r-4(f))
shall be applied and administered as if such amendments had
not been enacted.
(b) Increase in DSH Allotments for the District of
Columbia.--
(1) In general.--Each of the entries in the table in
section 1923(f)(2) (42 U.S.C. 1396r-4(f)(2)) relating to the
District of Columbia for FY 98 (fiscal year 1998), for FY 99
(fiscal year 1999), for FY 00 (fiscal year 2000), for FY
[[Page S8829]]
01 (fiscal year 2001), and for FY 02 (fiscal year 2002) are
amended by striking the amount otherwise specified and
inserting ``43.4''.
(2) Effective date.--The amendments made by paragraph (1)
shall take effect as if included in the enactment of section
4721(a) of BBA (111 Stat. 511).
(c) Optional Eligibility of Certain Alien Pregnant Women
and Children for Medicaid and SCHIP.--
(1) Medicaid.--Section 1903(v) (42 U.S.C. 1396b(v)) is
amended--
(A) in paragraph (1), by striking ``paragraph (2)'' and
inserting ``paragraphs (2) and (4)''; and
(B) by adding at the end the following new paragraph:
``(4)(A) A State may elect (in a plan amendment under this
title) to provide medical assistance under this title,
notwithstanding sections 401(a), 402(b), 403, and 421 of the
Personal Responsibility and Work Opportunity Reconciliation
Act of 1996, for aliens who are lawfully residing in the
United States (including battered aliens described in section
431(c) of such Act) and who are otherwise eligible for such
assistance, within any of the following eligibility
categories:
``(i) Pregnant women.--Women during pregnancy (and during
the 60-day period beginning on the last day of the
pregnancy).
``(ii) Children.--Children (as defined under such plan),
including optional targeted low-income children described in
section 1905(u)(2)(B).
``(B) In the case of a State that has elected to provide
medical assistance to a category of aliens under subparagraph
(A), no action may be brought under an affidavit of support
against any sponsor of such an alien on the basis of
provision of assistance to such category.''.
(2) SCHIP.--Section 2107(e)(1) (42 U.S.C. 1397gg(e)(1)) is
amended by adding at the end the following new subparagraph:
``(D) Section 1903(v)(4)(A)(ii) (relating to optional
coverage of permanent resident alien children), but only if
the State has in effect an election under that same
eligibility category for purposes of title XIX.''.
(3) Effective date.--The amendments made by this section
take effect on October 1, 2000, and apply to medical
assistance and child health assistance furnished on or after
such date.
SEC. 116. MODIFICATION OF PAYMENT RATE FOR PUERTO RICO
HOSPITALS.
(a) Modification of Payment Rate.--Section 1886(d)(9)(A)
(42 U.S.C. 1395ww(d)(9)(A)) is amended--
(1) in clause (i), by striking ``October 1, 1997, 50
percent ('' and inserting ``October 1, 2000, 25 percent (for
discharges between October 1, 1997, and September 30, 2000,
50 percent,''; and
(2) in clause (ii), in the matter preceding subclause (I),
by striking ``after October 1, 1997, 50 percent ('' and
inserting ``after October 1, 2000, 75 percent (for discharges
between October 1, 1997, and September 30, 2000, 50
percent,''.
(b) Special Rule for Payment for Fiscal Year 2001.--
(1) In general.--Notwithstanding the amendment made by
subsection (a), for purposes of making payments for the
operating costs of inpatient hospital services of a section
1886(d) Puerto Rico hospital for fiscal year 2001, the amount
referred to in the matter preceding clause (i) of section
1886(d)(9)(A) of the Social Security Act (42 U.S.C.
1395ww(d)(9)(A))--
(A) for discharges occurring on or after October 1, 2000,
and before April 1, 2001, shall be determined in accordance
with such section as in effect on the day before the date of
enactment of this Act; and
(B) for discharges occurring on or after April 1, 2001, and
before October 1, 2001, shall be determined--
(i) using 0 percent of the Puerto Rico adjusted DRG
prospective payment rate referred to in clause (i) of such
section; and
(ii) using 100 percent of the discharge-weighted average
referred to in clause (ii) of such section.
(2) Section 1886(d) puerto rico hospital.--For purposes of
this subsection, the term ``section 1886(d) Puerto Rico
hospital'' has the meaning given the term ``subsection (d)
Puerto Rico hospital'' in the last sentence of section
1886(d)(9)(A) of the Social Security Act (42 U.S.C.
1395ww(d)(9)(A)).
SEC. 117. MEDPAC STUDY ON HOSPITAL AREA WAGE INDEXES.
(a) Study.--
(1) In general.--The Medicare Payment Advisory Commission
established under section 1805 of the Social Security Act (42
U.S.C. 1395b-6) (in this section referred to as ``MedPAC'')
shall conduct a study on the hospital area wage indexes used
in making payments to hospitals under section 1886(d) of the
Social Security Act (42 U.S.C. 1395ww(d)), including an
assessment of the accuracy of those indexes in reflecting
geographic differences in wage and wage-related costs of
hospitals.
(2) Considerations.--In conducting the study under
paragraph (1), MedPAC shall consider--
(A) the appropriate method for determining hospital area
wage indexes;
(B) the appropriate portion of hospital payments that
should be adjusted by the applicable area wage index;
(C) the appropriate method for adjusting the wage index by
occupational mix; and
(D) the feasibility and impact of making changes (as
determined appropriate by MedPAC) to the methods used to
determine such indexes, including the need for a data system
required to implement such changes.
(b) Report.--Not later than 18 months after the date of
enactment of this Act, MedPAC shall submit a report to the
Secretary of Health and Human Services and Congress on the
study conducted under subsection (a) together with such
recommendations for legislation and administrative action as
MedPAC determines appropriate.
Subtitle C--PPS Exempt Hospitals
SEC. 121. TREATMENT OF CERTAIN CANCER HOSPITALS.
(a) In General.--Section 1886(d)(1)(B)(v) of the Social
Security Act (42 U.S.C. 1395ww(d)(1)(B)(v)) is amended--
(1) in subclause (I), by striking ``or'' at the end;
(2) in subclause (II), by striking the semicolon at the end
and inserting ``, or''; and
(3) by adding at the end the following:
``(III) a hospital that was recognized as a clinical cancer
research center by the National Cancer Institute of the
National Institutes of Health as of February 18, 1998, that
has never been reimbursed for inpatient hospital services
pursuant to a reimbursement system under a demonstration
project under section 1814(b), that is a freestanding
facility organized primarily for treatment of and research on
cancer and is not a unit of another hospital, that as of the
date of enactment of this subclause, is licensed for 162
acute care beds, and that demonstrates for the 4-year period
ending on June 30, 1999, that at least 50 percent of its
total discharges have a principal finding of neoplastic
disease, as defined in subparagraph (E);''.
(b) Conforming Amendment.--Section 1886(d)(1)(E) of the
Social Security Act (42 U.S.C. 1395ww(d)(1)(E)) is amended by
striking ``For purposes of subparagraph (B)(v)(II)'' and
inserting ``For purposes of subclauses (II) and (III) of
subparagraph (B)(v)''.
(c) Payment.--
(1) Application to cost reporting periods.--Any
classification by reason of section 1886(d)(1)(B)(v)(III) of
the Social Security Act (as added by subsection (a)) shall
apply to 12-month cost reporting periods beginning on or
after July 1, 1999.
(2) Base year.--Notwithstanding the provisions of section
1886(b)(3)(E) of such Act (42 U.S.C. 1395ww(b)(3)(E)) or
other provisions to the contrary, the base cost reporting
period for purposes of determining the target amount for any
hospital classified by reason of section
1886(d)(1)(B)(v)(III) of such Act (as added by subsection
(a)) shall be the 12-month cost reporting period beginning on
July 1, 1995.
(3) Deadline for payments.--Any payments owed to a hospital
by reason of this subsection shall be made expeditiously, but
in no event later than 1 year after the date of enactment of
this Act.
SEC. 122. PAYMENT ADJUSTMENT FOR INPATIENT SERVICES IN
REHABILITATION HOSPITALS.
(a) Option To Apply Prospective Payment System During
Transition Period.--Section 1886(j)(1)(A) (42 U.S.C.
1395ww(j)(1)(A)) is amended in the matter preceding subclause
(i) by inserting ``the greater of the prospective payment
rate determined in paragraph (3)(A) or'' after ``is equal
to''.
(b) Increase in Prospective Payment Percentage During
Transition Period.--Section 1886(j)(1)(A)(ii)(I) (42 U.S.C.
1395ww(j)(1)(A)(ii)(I)) is amended by inserting ``102 percent
of'' before ``the per unit''.
(c) Effective Date.--The amendments made by this section
shall take effect as if included in the enactment of section
4421 of BBA (111 Stat. 410).
Subtitle D--Hospice Care
SEC. 131. REVISION IN PAYMENTS FOR HOSPICE CARE.
(a) Increase.--Section 1814(i)(1)(C) of the Social Security
Act (42 U.S.C. 1395f(i)(1)(C)) is amended--
(1) in clause (i), by adding at the end the following new
sentence: ``With respect to routine home care and other
services included in hospice care furnished during fiscal
year 2001, the payment rates for such care and services for
such fiscal year shall be 110 percent of such rates as would
otherwise be in effect for such fiscal year (taking into
account the increase under clause (ii) but not taking into
account the increase under section 131 of the Medicare,
Medicaid, and SCHIP Balanced Budget Refinement Act of 1999),
and such payment rates shall be used in determining payments
for such care and services furnished in a subsequent fiscal
year under clause (ii).''; and
(2) in clause (ii), by striking ``during a subsequent
fiscal year'' and inserting ``during a fiscal year beginning
after September 30, 1990''.
(b) Eliminating Reduction in Update.--Section
1814(i)(1)(C)(ii) of the Social Security Act (42 U.S.C.
1395f(i)(1)(C)(ii)) is amended--
(1) in subclause (VI), by striking ``through 2002'' and
inserting ``through 2000''; and
(2) in subclause (VII), by striking ``for a subsequent
fiscal year'' and inserting ``for fiscal year 2001 and each
subsequent fiscal year''.
(c) Special Rule for Payment for Hospice Care for Fiscal
Year 2001.--Notwithstanding the amendments made by
subsections (a) and (b), for purposes of making payments
under section 1814(i)(1)(C) of the Social Security Act (42
U.S.C. 1395f(i)(1)(C)) for routine home care and other
services included in hospice care furnished during fiscal
year 2001, such payment rates shall be determined--
[[Page S8830]]
(1) for the period beginning on October 1, 2000, and ending
on March 31, 2001, in accordance with such section as in
effect on the day before the date of enactment of this Act;
and
(2) for the period beginning on April 1, 2001, and ending
on September 30, 2001--
(A) by substituting ``120 percent'' for ``110 percent'' in
the second sentence of clause (i) of such section (as added
by subsection (a)(1)); and
(B) as if the increase under subclause (ii)(VII) (as
amended by subsection (b)) for fiscal year 2001 was equal to
the market basket increase for the fiscal year plus 1.0
percentage point.
Subtitle E--Other Provisions
SEC. 141. HOSPITALS REQUIRED TO COMPLY WITH BLOODBORNE
PATHOGENS STANDARD.
(a) Agreements With Hospitals.--Section 1866(a)(1) (42
U.S.C. 1395cc(a)(1)) is amended--
(1) in subparagraph (R), by striking ``and'' at the end;
(2) in subparagraph (S), by striking the period at the end
and inserting ``, and''; and
(3) by inserting after subparagraph (S) the following new
subparagraph:
``(T) in the case of hospitals that are not otherwise
subject to regulation by the Occupational Safety and Health
Administration, to comply with the Bloodborne Pathogens
standard under section 1910.1030 of title 29 of the Code of
Federal Regulations.''.
(b) Effective Date.--The amendments made by this section
shall apply to agreements in effect on or after the date that
is 1 year after the date of enactment of this Act.
SEC. 142. INFORMATICS AND DATA SYSTEMS GRANT PROGRAM.
(a) Grants to Hospitals.--
(1) In general.--The Secretary of Health and Human Services
(in this section referred to as the ``Secretary'') shall
establish a program to make grants to hospitals that have
submitted applications in accordance with subsection (c) to
assist such hospitals in offsetting the costs related to--
(A) developing and implementing standardized clinical
health care informatics systems designed to improve medical
care and reduce adverse events and health care complications
resulting from medication errors; and
(B) establishing data systems to comply with the
administrative simplification requirements under part C of
title XI of the Social Security Act (42 U.S.C. 1320d et
seq.).
(2) Costs.--For purposes of paragraph (1), the term
``costs'' shall include costs associated with--
(A) purchasing computer software and hardware; and
(B) providing education and training to hospital staff on
computer information systems.
(3) Duration.--The authority of the Secretary to make
grants under this section shall terminate on September 30,
2011.
(4) Limitation.--A hospital that has received a grant under
section 1611 of the Public Health Service Act (as added by
section 447 of this Act) is not eligible to receive a grant
under this section.
(b) Special Consideration for Large Urban Hospitals.--In
awarding grants under this section, the Secretary shall give
special consideration to hospitals located in large urban
areas (as defined for purposes of section 1886(d) of the
Social Security Act (42 U.S.C. 1395ww(d)).
(c) Application.--A hospital seeking a grant under this
section shall submit an application to the Secretary at such
time and in such form and manner as the Secretary specifies.
(d) Reports.--
(1) Information.--A hospital receiving a grant under this
section shall furnish the Secretary with such information as
the Secretary may require to--
(A) evaluate the project for which the grant is made; and
(B) ensure that the grant is expended for the purposes for
which it is made.
(2) Timing of submission.--
(A) Interim reports.--The Secretary shall report to the
Committee on Ways and Means of the House of Representatives
and the Committee on Finance of the Senate at least annually
on the grant program established under this section,
including in such report information on the number of grants
made, the nature of the projects involved, the geographic
distribution of grant recipients, and such other matters as
the Secretary deems appropriate.
(B) Final report.--The Secretary shall submit a final
report to such committees not later than 180 days after the
completion of all of the projects for which a grant is made
under this section.
(e) Authorization of Appropriations.--There are authorized
to be appropriated from the Federal Hospital Insurance Trust
Fund under section 1817 of the Social Security Act (42 U.S.C.
1395i) $25,000,000 for each of the fiscal years 2001 through
2011 for the purposes of making grants under this section.
SEC. 143. RELIEF FROM MEDICARE PART A LATE ENROLLMENT PENALTY
FOR GROUP BUY-IN FOR STATE AND LOCAL RETIREES.
Section 1818(d) (42 U.S.C. 1395i-2(d)) is amended by adding
at the end the following new paragraph:
``(6)(A) In the case where a State, a political subdivision
of a State, or an agency or instrumentality of a State or
political subdivision thereof determines to pay, for the life
of each individual, the monthly premiums due under paragraph
(1) on behalf of each of the individuals in a qualified State
or local government retiree group who meets the conditions of
subsection (a), the amount of any increase otherwise
applicable under section 1839(b) (as modified by subsection
(c)(6) of this section) with respect to the monthly premium
for benefits under this part for an individual who is a
member of such group shall be reduced by the total amount of
taxes paid under section 3101(b) of the Internal Revenue Code
of 1986 by such individual and under section 3111(b) by the
employers of such individual on behalf of such individual
with respect to employment (as defined in section 3121(b) of
such Code).
``(B) For purposes of this paragraph, the term `qualified
State or local government retiree group' means all of the
individuals who retire prior to a specified date that is
before January 1, 2002, from employment in 1 or more
occupations or other broad classes of employees of--
``(i) the State;
``(ii) a political subdivision of the State; or
``(iii) an agency or instrumentality of the State or
political subdivision of the State.''.
Subtitle F--Transitional Provisions
SEC. 151. RECLASSIFICATION OF CERTAIN COUNTIES AND AREAS FOR
PURPOSES OF REIMBURSEMENT UNDER THE MEDICARE
PROGRAM.
(a) Fiscal Years 2002 Through 2004.--Notwithstanding any
other provision of law, effective for discharges occurring
during fiscal years 2002, 2003, and 2004, for purposes of
making payments under section 1886(d) of the Social Security
Act (42 U.S.C. 1395ww(d))--
(1) Iredell County, North Carolina is deemed to be located
in the Charlotte-Gastonia-Rock Hill, North Carolina-South
Carolina Metropolitan Statistical Area; and
(2) the large urban area of New York, New York is deemed to
include Orange County, New York (including hospitals that
have been reclassified into such county).
For purposes of that section, any reclassification under this
subsection shall be treated as a decision of the Medicare
Geographic Classification Review Board under paragraph (10)
of that section.
(b) Fiscal Years 2001 Through 2003.--Notwithstanding any
other provision of law, effective for discharges occurring
during fiscal years 2001, 2002, and 2003, for purposes of
making payments under section 1886(d) of the Social Security
Act (42 U.S.C. 1395ww(d))--
(1) the Jackson, Michigan Metropolitan Statistical Area is
deemed to be located in the Ann Arbor, Michigan Metropolitan
Statistical Area;
(2) Tangipahoa Parish, Louisiana is deemed to be located in
the New Orleans, Louisiana Metropolitan Statistical Area; and
(3) the large urban area of New York, New York is deemed to
include Duchess County, New York.
For purposes of that section, any reclassification under this
subsection shall be treated as a decision of the Medicare
Geographic Classification Review Board under paragraph (10)
of that section.
(c) Technical Correction to BBRA.--
(1) In general.--Section 152 of BBRA (113 Stat. 1501A-334)
is amended--
(A) in subsection (a)(2), by inserting ``(including
hospitals that have been reclassified into such county)''
after ``such county''; and
(B) in subsection (b)(2), by inserting ``(including
hospitals that have been reclassified into such county)''
after ``Orange County, New York''; and
(2) Effective date.--The amendments made by paragraph (1)
shall take effect as if included in the enactment of section
152 of BBRA (113 Stat. 1501A-334).
SEC. 152. CALCULATION AND APPLICATION OF WAGE INDEX FLOOR FOR
A CERTAIN AREA.
Notwithstanding any other provision of section 1886(d) of
the Social Security Act (42 U.S.C. 1395ww(d)), for discharges
occurring during fiscal year 2000, the Secretary of Health
and Human Services shall calculate and apply the wage index
for the Barnstable-Yarmouth Metropolitan Statistical Area
under that section as if the Jordan Hospital were classified
in such area for purposes of payment under that section for
such fiscal year. Such recalculation shall not affect the
wage index for any other area.
TITLE II--PROVISIONS RELATING TO PART B
Subtitle A--Hospital Outpatient Services
SEC. 201. REDUCTION OF EFFECTIVE HOPD COINSURANCE RATE TO 20
PERCENT BY 2019.
Section 1833(t)(3)(B)(ii) (42 U.S.C. 1395l(t)(3)(B)(ii)) is
amended--
(1) by striking ``If the'' and inserting:
``(I) In general.--If the''; and
(2) by adding at the end the following new subclause:
``(II) Accelerated phase-in.--The Secretary shall estimate,
prior to January 1, 2002, the unadjusted copayment amount for
each such service (or groups of such services). If the
Secretary estimates such unadjusted copayment amount to be
greater than 20 percent for any such service (or group of
such services) on or after January 1, 2019, the Secretary
shall, for services furnished beginning on or after January
1, 2002, reduce the unadjusted copayment amount for such
service (or group of such services) in equal increments each
year, from the amount applicable in 2001, by an amount
estimated by the Secretary such that the unadjusted copayment
amount shall equal 20 percent beginning on or after January
1, 2019.''.
[[Page S8831]]
SEC. 202. APPLICATION OF TRANSITIONAL CORRIDOR TO CERTAIN
HOSPITALS THAT DID NOT SUBMIT A 1996 COST
REPORT.
(a) In General.--Section 1833(t)(7)(F)(ii)(I) (42 U.S.C.
1395l(t)(7)(F)(ii)(I)) is amended by inserting ``(or, in the
case of a hospital that did not submit a cost report for such
period, during the first cost reporting period ending in a
year after 1996 and before 2001 for which the hospital
submitted a cost report)'' after ``1996''.
(b) Effective Date.--The amendment made by subsection (a)
shall take effect as if included in the enactment of section
202 of BBRA.
SEC. 203. PERMANENT GUARANTEE OF PRE-BBA PAYMENT LEVELS FOR
OUTPATIENT SERVICES FURNISHED BY CHILDREN'S
HOSPITALS.
(a) In General.--Section 1833(t)(7)(D) (42 U.S.C.
1395l(t)(7)(D)), as amended by section 432, is amended--
(1) in the heading, by inserting ``, children's,'' after
``small rural''; and
(2) by striking ``section 1886(d)(1)(B)(v)'' and inserting
``clause (iii) or (v) of section 1886(d)(1)(B)''.
(b) Effective Date.--The amendments made by subsection (a)
shall apply to services provided on or after the date that is
1 year after the date of enactment of this Act.
Subtitle B--Provisions Relating to Physicians
SEC. 211. LOAN DEFERMENT FOR RESIDENTS.
(a) Fairness in Medical Student Loan Financing.--
(1) Eligibility requirements.--Section 427(a)(2)(C)(iii) of
the Higher Education Act of 1965 (20 U.S.C.
1077(a)(2)(C)(iii)) is amended by inserting before the
semicolon the following: ``, except that for a medical
student such period shall not exceed the full initial
residency period''.
(2) Insurance program agreements.--Section
428(b)(1)(M)(iii) of the Higher Education Act of 1965 (20
U.S.C. 1078(b)(1)(M)(iii)) is amended by inserting before the
semicolon the following: ``, except that for a medical
student such period shall not exceed the full initial
residency period''.
(3) Deferment eligibility.--Section 455(f)(2)(C) of the
Higher Education Act of 1965 (20 U.S.C. 1087e(f)(2)(C)) is
amended by inserting before the period the following: ``,
except that for a medical student such period shall not
exceed the full initial residency period''.
(4) Contents of loan agreement.--Section 464(c)(2)(A)(iii)
of the Higher Education Act of 1965 (20 U.S.C.
1087dd(c)(2)(A)(iii)) is amended by inserting before the
semicolon the following: ``, except that for a medical
student such period shall not exceed the full initial
residency period''.
(b) Fairness in Economic Hardship Determination.--Section
435(o)(1)(B) of the Higher Education Act of 1965 (20 U.S.C.
1085(o)(1)(B)) is amended to read as follows:
``(B) such borrower is working full time and has a Federal
educational debt burden that equals or exceeds 20 percent of
such borrower's adjusted gross income, and the difference
between such borrower's adjusted gross income minus such
burden is less than 250 percent of the greater of--
``(i) the annual earnings of an individual earning the
minimum wage under section 6 of the Fair Labor Standards Act
of 1938; or
``(ii) 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 Community Service Block
Grant Act) applicable to a family of 2; or''.
SEC. 212. GAO STUDIES AND REPORTS ON MEDICARE PAYMENTS.
(a) GAO Study on HCFA Post-Payment Audit Process.--
(1) Study.--The Comptroller General of the United States
shall conduct a study of the post-payment audit process under
the medicare program under title XVIII of the Social Security
Act (42 U.S.C. 1395 et seq.) (in this section referred to as
the ``medicare program'') as such process applies to
physicians, including the proper level of resources that the
Health Care Financing Administration should devote to
educating physicians regarding--
(A) coding and billing;
(B) documentation requirements; and
(C) the calculation of overpayments.
(2) Report.--Not later than 18 months after the date of
enactment of this Act, the Comptroller General shall submit a
report to the Secretary of Health and Human Services and
Congress on the study conducted under paragraph (1) together
with specific recommendations for changes or improvements in
the post-payment audit process described in such paragraph.
(b) GAO Study on Administration and Oversight.--
(1) Study.--The Comptroller General of the United States
shall conduct a study on the aggregate effects of regulatory,
audit, oversight, and paperwork burdens on physicians and
other health care providers participating in the medicare
program.
(2) Report.--Not later than 18 months after the date of
enactment of this Act, the Comptroller General shall submit a
report to the Secretary of Health and Human Services and
Congress on the study conducted under paragraph (1) together
with recommendations regarding any area in which--
(A) a reduction in paperwork, an ease of administration, or
an appropriate change in oversight and review may be
accomplished; or
(B) additional payments or education are needed to assist
physicians and other health care providers in understanding
and complying with any legal or regulatory requirements.
SEC. 213. MEDPAC STUDY ON THE RESOURCE-BASED PRACTICE EXPENSE
SYSTEM.
(a) Study.--The Medicare Payment Advisory Commission
established under section 1805 of the Social Security Act (42
U.S.C. 1395b-6) (in this section referred to as ``MedPAC'')
shall conduct a study of the refinements to the practice
expense relative value units during the transition to a
resource-based practice expense system for physician payments
under the medicare program under title XVIII of the Social
Security Act (42 U.S.C. 1395 et seq.) (in this section
referred to as the ``medicare program'').
(b) Report.--Not later than July 1, 2001, MedPAC shall
submit a report to the Secretary of Health and Human Services
and Congress on the study conducted under subsection (a)
together with recommendations regarding--
(1) any change or adjustment that is appropriate to ensure
full access to a spectrum of care for beneficiaries under the
medicare program; and
(2) the appropriateness of payments to physicians.
Subtitle C--Ambulance Services
SEC. 221. ELECTION TO FOREGO PHASE-IN OF FEE SCHEDULE FOR
AMBULANCE SERVICES.
Section 1834(l) (42 U.S.C. 1395m(l)) is amended by adding
at the end the following new paragraph:
``(8) Election to forego phase-in of fee schedule.--
``(A) In general.--If the Secretary provides for a phase-in
of the fee schedule established under this subsection, a
supplier of ambulance services may make an election to
receive payments based only on such fee schedule at any time
during such phase-in, and the Secretary shall begin to make
payments to the supplier based only on such fee schedule not
later than the date that is 60 days after the date on which
the supplier notifies the Secretary of such election.
``(B) Waiver of budget neutrality.--The Secretary shall
apply paragraph (3)(A) as if this paragraph had not been
enacted.''.
SEC. 222. PRUDENT LAYPERSON STANDARD FOR EMERGENCY AMBULANCE
SERVICES.
(a) In General.--Section 1861(s)(7) (42 U.S.C. 1395x(s)(7))
is amended by inserting before the semicolon at the end the
following: ``, except that such regulations shall not fail to
treat ambulance services as medical and other health services
solely because the ultimate diagnosis of the individual
receiving the ambulance services results in a conclusion that
ambulance services were not necessary, as long as the request
for ambulance services is made after the sudden onset of a
medical condition that would be classified as an emergency
medical condition (as defined in section 1852(d)(3)(B)).''.
(b) Effective Date.--The amendment made by this section
shall apply with respect to ambulance services provided on or
after October 1, 2000.
SEC. 223. ELIMINATION OF REDUCTION IN INFLATION ADJUSTMENTS
FOR AMBULANCE SERVICES.
Subparagraphs (A) and (B) of section 1834(l)(3) (42 U.S.C.
1395m(l)(3)(A)) are each amended by striking ``reduced in the
case of 2001 and 2002 by 1.0 percentage points'' and
inserting ``increased in the case of 2001 by 1.0 percentage
point''.
SEC. 224. STUDY AND REPORT ON THE COSTS OF RURAL AMBULANCE
SERVICES.
(a) Study.--The Secretary of Health and Human Services (in
this section referred to as the ``Secretary''), in
consultation with the Office of Rural Health Policy, shall
conduct a study of the means by which rural areas with low
population densities can be identified for the purpose of
designating areas in which the cost of providing ambulance
services would be expected to be higher than similar services
provided in more heavily populated areas because of low
usage. Such study shall also include an analysis of the
additional costs of providing ambulance services in areas
designated under the previous sentence.
(b) Report.--Not later than June 30, 2001, the Secretary
shall submit a report to Congress on the study conducted
under subsection (a), together with a regulation based on
that study which adjusts the fee schedule payment rates for
ambulance services provided in low density rural areas based
on the increased cost of providing such services in such
areas.
SEC. 225. INTERIM PAYMENTS FOR RURAL GROUND AMBULANCE
SERVICES UNTIL REGULATION IMPLEMENTED.
(a) Interim Payments.--Section 1834(l) (42 U.S.C.
1395m(l)), as amended by section 221, is amended by adding at
the end the following new paragraph:
``(9) Interim payments for rural ground ambulance
services.--Until such time as the fee schedule established
under this subsection is modified by the regulation described
in section 224(b) of the Medicare, Medicaid, and SCHIP
Balanced Budget Refinement Act of 2000, the amount of payment
under this subsection for ground ambulance services provided
in a rural area (as defined in section 1886(d)(2)(D)) shall
be the greater of--
``(A) the amount determined under the fee schedule
established under this subsection (without regard to any
phase-in established pursuant to paragraph (2)(E)); or
``(B) the amount that would have been paid for such
services if the amendments made by
[[Page S8832]]
section 4531(b) of the Balanced Budget Act of 1997 had not
been enacted;
as adjusted for inflation in the manner described in
paragraph (3)(B). For purposes of this paragraph, an
ambulance trip shall be considered to have been provided in a
rural area only if the transportation of the patient
originated in a rural area.''.
(b) Conforming Amendments.--Section 1833(a)(1) (42 U.S.C.
1395l(a)(1)) is amended--
(1) in subparagraph (R)--
(A) by inserting ``except as provided in subparagraph
(T),'' before ``with respect''; and
(B) by striking ``and'' at the end; and
(2) in subparagraph (S), by striking the semicolon at the
end and inserting ``, and (T) with respect to ambulance
services described in section 1834(l)(9), the amount paid
shall be 80 percent of the lesser of the actual charge for
the services or the amount determined under such section;''.
(c) Effective Date.--The amendments made by this section
shall apply with respect to services provided on and after
January 1, 2001.
SEC. 226. GAO STUDY AND REPORT ON THE COSTS OF EMERGENCY AND
MEDICAL TRANSPORTATION SERVICES.
(a) Study.--The Comptroller General of the United States
shall conduct a study of the costs of providing emergency and
medical transportation services across the range of acuity
levels of conditions for which such transportation services
are provided.
(b) Report.--Not later than 18 months after the date of
enactment of this Act, the Comptroller General shall submit a
report to the Secretary of Health and Human Services and
Congress on the study conducted under subsection (a),
together with recommendations for any changes in methodology
or payment level necessary to fairly compensate suppliers of
emergency and medical transportation services and to ensure
the access of beneficiaries under the medicare program under
title XVIII of the Social Security Act (42 U.S.C. 1395 et
seq.) to such services.
Subtitle D--Preventive Services
SEC. 231. ELIMINATION OF DEDUCTIBLES AND COINSURANCE FOR
PREVENTIVE BENEFITS.
(a) In General.--Section 1833 (42 U.S.C. 1395l) is amended
by inserting after subsection (o) the following new
subsection:
``(p) Deductibles and Coinsurance Waived for Preventive
Benefits.--The Secretary may not require the payment of any
deductible or coinsurance under subsection (a) or (b) of any
individual enrolled for coverage under this part for any of
the following preventive health care items and services:
``(1) Blood-testing strips, lancets, and blood glucose
monitors for individuals with diabetes described in section
1861(n).
``(2) Diabetes outpatient self-management training services
(as defined in section 1861(qq)(1)).
``(3) Pneumococcal, influenza, and hepatitis B vaccines and
administration described in section 1861(s)(10).
``(4) Screening mammography (as defined in section
1861(jj)).
``(5) Screening pap smear and screening pelvic exam (as
defined in paragraphs (1) and (2) of section 1861(nn),
respectively).
``(6) Bone mass measurement (as defined in section
1861(rr)(1)).
``(7) Prostate cancer screening test (as defined in section
1861(oo)(1)).
``(8) Colorectal cancer screening test (as defined in
section 1861(pp)(1)).''.
(b) Waiver of Coinsurance.--Section 1833(a)(1)(B) (42
U.S.C. 1395l(a)(1)(B)) is amended to read as follows: ``(B)
with respect to preventive health care items and services
described in subsection (p), the amounts paid shall be 100
percent of the fee schedule or other basis of payment under
this title,''.
(c) Waiver of Deductible.--Section 1833(b)(1) (42 U.S.C.
1395l(b)(1)) is amended to read as follows: ``(1) such
deductible shall not apply with respect to preventive health
care items and services described in subsection (p),''.
(d) Adding ``Lancet'' to Definition of DME.--Section
1861(n) (42 U.S.C. 1395x(n)) is amended by striking ``blood-
testing strips and blood glucose monitors'' and inserting
``blood-testing strips, lancets, and blood glucose
monitors''.
(e) Conforming Amendments.--
(1) Elimination of coinsurance for clinical diagnostic
laboratory tests.--Paragraphs (1)(D)(i) and (2)(D)(i) of
section 1833(a) (42 U.S.C. 1395l(a)) are each amended--
(A) by striking ``basis or which'' and inserting ``basis,
which''; and
(B) by inserting ``, or which are described in subsection
(p)'' after ``critical access hospital''.
(2) Elimination of coinsurance for certain dme.--Section
1834(a)(1)(A) (42 U.S.C. 1395m(a)(1)(A)) is amended by
inserting ``(or 100 percent, in the case of such an item
described in section 1833(p))'' after ``80 percent''.
(3) Elimination of coinsurance for screening mammography.--
Section 1834(c)(1)(C) (42 U.S.C. 1395m(c)(1)(C)) is amended
by striking ``80 percent'' and inserting ``100 percent''.
(4) Elimination of deductibles and coinsurance for
colorectal cancer screening tests.--Section 1834(d) (42
U.S.C. 1395m(d)) is amended--
(A) in paragraph (2)(C)--
(i) by striking clause (ii);
(ii) by striking ``Facility payment limit.--'' and all that
follows through ``Notwithstanding'' and inserting ``Facility
payment limit.--Notwithstanding''; and
(iii) by redesignating subclauses (I) and (II) as clauses
(i) and (ii), respectively; and
(B) in paragraph (3)(C)--
(i) by striking clause (ii); and
(ii) by striking ``Facility payment Limit.--'' and all that
follows through ``Notwithstanding'' and inserting ``Facility
payment limit.--Notwithstanding''.
(f) Effective Date.--The amendments made by this section
shall apply to items and services furnished on or after July
1, 2001.
SEC. 232. COUNSELING FOR CESSATION OF TOBACCO USE.
(a) Coverage.--Section 1861(s)(2) (42 U.S.C. 1395x(s)(2))
is amended--
(1) in subparagraph (S), by striking ``and'' at the end;
(2) in subparagraph (T), by inserting ``and'' at the end;
and
(3) by adding at the end the following new subparagraph:
``(U) counseling for cessation of tobacco use (as defined
in subsection (uu)) for individuals who have a history of
tobacco use;''.
(b) Services Described.--Section 1861 (42 U.S.C. 1395x) is
amended by adding at the end the following new subsection:
``Counseling for Cessation of Tobacco Use
``(uu)(1) Except as provided in paragraph (2), the term
`counseling for cessation of tobacco use' means diagnostic,
therapy, and counseling services for cessation of tobacco use
which are furnished--
``(A) by or under the supervision of a physician; or
``(B) by any other health care professional who is legally
authorized to furnish such services under State law (or the
State regulatory mechanism provided by State law) of the
State in which the services are furnished, as would otherwise
be covered if furnished by a physician or as an incident to a
physician's professional service.
``(2) The term `counseling for cessation of tobacco use'
does not include coverage for drugs or biologicals that are
not otherwise covered under this title.''.
(c) Elimination of Cost-Sharing.--
(1) Elimination of coinsurance.--Section 1833(a)(1) (42
U.S.C. 1395l(a)(1)), as amended by section 225(b), is
amended--
(A) by striking ``and'' before ``(T)''; and
(B) by inserting before the semicolon at the end the
following: ``, and (U) with respect to counseling for
cessation of tobacco use (as defined in section 1861(uu)),
the amount paid shall be 100 percent of the lesser of the
actual charge for the services or the amount determined by a
fee schedule established by the Secretary for the purposes of
this subparagraph''.
(2) Elimination of deductible.--The first sentence of
section 1833(b) (42 U.S.C. 1395l(b)) is amended--
(A) by striking ``and'' before ``(6)''; and
(B) by inserting before the period the following: ``, and
(7) such deductible shall not apply with respect to
counseling for cessation of tobacco use (as defined in
section 1861(uu))''.
(d) Effective Date.--The amendments made by this section
shall apply to services furnished on or after July 1, 2001.
SEC. 233. COVERAGE OF GLAUCOMA DETECTION TESTS.
(a) In General.--Section 1861 (42 U.S.C. 1395x), as amended
by section 232, is amended--
(1) in subsection (s)(2)--
(A) in subparagraph (T), by striking ``and'' at the end;
(B) in subparagraph (U), by inserting ``and'' at the end;
and
(C) by adding at the end the following new subparagraph:
``(V) glaucoma detection tests (as defined in subsection
(vv));''; and
(2) by adding at the end the following new subsection:
``Glaucoma Detection Tests
``(vv) The term `glaucoma detection test' means all of the
following conducted for the purpose of early detection of
glaucoma:
``(1) A dilated eye examination with an intraocular
pressure measurement.
``(2) Direct ophthalmoscopy or slit-lamp biomicroscopic
examination.''.
(b) Limitation on Eligibility and Frequency.--Section 1834
(42 U.S.C. 1395m) is amended by adding at the end the
following new subsection:
``(m) Limitation on Coverage of Glaucoma Detection Tests.--
``(1) In general.--Notwithstanding any other provision of
this part, with respect to expenses incurred for glaucoma
detection tests (as defined in section 1861(vv)), payment may
be made only for glaucoma detection tests conducted--
``(A) for individuals described in paragraph (2); and
``(B) consistent with the frequency permitted under
paragraph (3).
``(2) Individuals eligible for benefit.--Individuals
described in this paragraph are as follows:
``(A) Individuals who are 60 years of age or older and who
have a family history of glaucoma.
``(B) Other individuals who are at high risk (as determined
by the Secretary) of developing glaucoma.
``(3) Frequency limit.--
``(A) In general.--Subject to subparagraph (B), payment may
not be made under this part for a glaucoma detection test
performed for an individual within 23 months following the
month in which a glaucoma detection test was performed under
this part for the individual.
[[Page S8833]]
``(B) Exception.--The Secretary may permit a glaucoma
detection test to be covered on a more frequent basis than
that provided under subparagraph (A) under such circumstances
as the Secretary determines to be appropriate.''.
(c) No Application of Deductible.--Section 1833(b)(5) (42
U.S.C. 1395l(b)(5)) is amended by inserting ``or with respect
to glaucoma detection tests (as defined in section
1861(vv))'' after ``1861(jj))''.
(d) Conforming Amendments.--Section 1862(a) (42 U.S.C.
1395y(a)) is amended--
(1) in paragraph (1)--
(A) in subparagraph (H), by striking ``and'' at the end;
(B) in subparagraph (I), by striking the semicolon at the
end and inserting ``, and''; and
(C) by adding at the end the following new subparagraph:
``(J) in the case of glaucoma detection tests (as defined
in section 1861(vv)), which are furnished to an individual
not described in paragraph (2) of section 1834(m) or which
are performed more frequently than is covered under paragraph
(3) of such section;''; and
(2) in paragraph (7), by striking ``or (H)'' and inserting
``(H), or (I)''.
(e) Effective Date.--The amendments made by this section
apply to tests provided on or after July 1, 2001.
SEC. 234. MEDICAL NUTRITION THERAPY SERVICES FOR
BENEFICIARIES WITH DIABETES, A CARDIOVASCULAR
DISEASE, OR A RENAL DISEASE.
(a) Coverage.--Section 1861(s)(2) (42 U.S.C. 1395x(s)(2)),
as amended by section 233(a), is amended--
(1) in subparagraph (U) by striking ``and'' at the end;
(2) in subparagraph (V) by inserting ``and'' at the end;
and
(3) by adding at the end the following new subparagraph:
``(W) medical nutrition therapy services (as defined in
subsection (ww)(1)) in the case of a beneficiary with
diabetes, a cardiovascular disease (including congestive
heart failure, arteriosclerosis, hyperlipidemia,
hypertension, and hypercholesterolemia), or a renal
disease;''.
(b) Services Described.--Section 1861 (42 U.S.C. 1395x), as
amended by section 233(a), is amended by adding at the end
the following new subsection:
``Medical Nutrition Therapy Services; Registered Dietitian or Nutrition
Professional
``(ww)(1) The term `medical nutrition therapy services'
means nutritional diagnostic, therapy, and counseling
services for the purpose of disease management which are
furnished by a registered dietitian or nutrition professional
(as defined in paragraph (2)) pursuant to a referral by a
physician (as defined in subsection (r)(1)).
``(2) Subject to paragraph (3), the term `registered
dietitian or nutrition professional' means an individual
who--
``(A) holds a baccalaureate or higher degree granted by a
regionally accredited college or university in the United
States (or an equivalent foreign degree) with completion of
the academic requirements of a program in nutrition or
dietetics, as accredited by an appropriate national
accreditation organization recognized by the Secretary for
this purpose;
``(B) has completed at least 900 hours of supervised
dietetics practice under the supervision of a registered
dietitian or nutrition professional; and
``(C)(i) is licensed or certified as a dietitian or
nutrition professional by the State in which the services are
performed; or
``(ii) in the case of an individual in a State that does
not provide for such licensure or certification, meets such
other criteria as the Secretary establishes.
``(3) Subparagraphs (A) and (B) of paragraph (2) shall not
apply in the case of an individual who, as of the date of
enactment of this subsection, is licensed or certified as a
dietitian or nutrition professional by the State in which
medical nutrition therapy services are performed.''.
(c) Payment.--Section 1833(a)(1) (42 U.S.C. 1395l(a)(1)),
as amended by section 232(c)(1), is amended--
(1) by striking ``and'' before ``(U)''; and
(2) by inserting before the semicolon at the end the
following: ``, and (V) with respect to medical nutrition
therapy services (as defined in section 1861(ww)), the amount
paid shall be 85 percent of the lesser of the actual charge
for the services or the amount determined under the fee
schedule established under section 1848(b) for the same
services if furnished by a physician''.
(d) Effective Date.--The amendments made by this section
apply to services furnished on or after July 1, 2001.
SEC. 235. STUDIES ON PREVENTIVE INTERVENTIONS IN PRIMARY CARE
FOR OLDER AMERICANS.
(a) Studies.--The Secretary of Health and Human Services,
acting through the United States Preventive Services Task
Force, shall conduct a series of studies designed to identify
preventive interventions that can be delivered in the primary
care setting that are most valuable to older Americans.
(b) Mission Statement.--The mission statement of the United
States Preventive Services Task Force is amended to include
the evaluation of services that are of particular relevance
to older Americans.
(c) Report.--Not later than 1 year after the date of
enactment of this Act, and annually thereafter, the Secretary
of Health and Human Services shall submit a report to
Congress on the conclusions of the studies conducted under
subsection (a), together with recommendations for such
legislation and administrative actions as the Secretary
considers appropriate.
SEC. 236. INSTITUTE OF MEDICINE 5-YEAR MEDICARE PREVENTION
BENEFIT STUDY AND REPORT.
(a) Study.--
(1) In general.--The Secretary of Health and Human Services
shall contract with the Institute of Medicine of the National
Academy of Sciences to conduct a comprehensive study of
current literature and best practices in the field of health
promotion and disease prevention among medicare beneficiaries
including the issues described in paragraph (2) and to submit
the report described in subsection (b).
(2) Issues studied.--The study required under paragraph (1)
shall include an assessment of--
(A) whether each covered benefit is--
(i) medically effective; and
(ii) a cost-effective benefit or a cost-saving benefit;
(B) utilization of covered benefits (including any barriers
to or incentives to increase utilization); and
(C) quality of life issues associated with both health
promotion and disease prevention benefits covered under the
medicare program and those that are not covered under such
program that would affect all medicare beneficiaries.
(b) Report.--
(1) In general.--Not later than 5 years after the date of
enactment of this section, and every fifth year thereafter,
the Institute of Medicine of the National Academy of Sciences
shall submit to the President a report that contains a
detailed statement of the findings and conclusions of the
study conducted under subsection (a) and the recommendations
for legislation described in paragraph (2).
(2) Recommendations for legislation.--The Institute of
Medicine of the National Academy of Sciences, in consultation
with the Partnership for Prevention, shall develop
recommendations in legislative form that--
(A) prioritize the preventive benefits under the medicare
program; and
(B) modify preventive benefits offered under the medicare
program based on the study conducted under subsection (a).
(c) Transmission to Congress.--
(1) In general.--On the day on which the report described
in subsection (b) is submitted to the President, the
President shall transmit the report and recommendations in
legislative form described in subsection (b)(2) to Congress.
(2) Delivery.--Copies of the report and recommendations in
legislative form required to be transmitted to Congress under
paragraph (1) shall be delivered--
(A) to both Houses of Congress on the same day;
(B) to the Clerk of the House of Representatives if the
House is not in session; and
(C) to the Secretary of the Senate if the Senate is not in
session.
(d) Definitions.--In this section:
(1) Cost-effective benefit.--The term ``cost-effective
benefit'' means a benefit or technique that has--
(A) been subject to peer review;
(B) been described in scientific journals; and
(C) demonstrated value as measured by unit costs relative
to health outcomes achieved.
(2) Cost-saving benefit.--The term ``cost-saving benefit''
means a benefit or technique that has--
(A) been subject to peer review;
(B) been described in scientific journals; and
(C) caused a net reduction in health care costs for
medicare beneficiaries.
(3) Medically effective.--The term ``medically effective''
means, with respect to a benefit or technique, that the
benefit or technique has been--
(A) subject to peer review;
(B) described in scientific journals; and
(C) determined to achieve an intended goal under normal
programmatic conditions.
(4) Medicare beneficiary.--The term ``medicare
beneficiary'' means any individual who is entitled to
benefits under part A or enrolled under part B of the
medicare program, including any individual enrolled in a
Medicare+Choice plan offered by a Medicare+Choice
organization under part C of such program.
(5) Medicare program.--The term ``medicare program'' means
the health benefits program under title XVIII of the Social
Security Act (42 U.S.C. 1395 et seq.).
SEC. 237. FAST-TRACK CONSIDERATION OF PREVENTION BENEFIT
LEGISLATION.
(a) Rules of House of Representatives and Senate.--This
section is enacted by Congress--
(1) as an exercise of the rulemaking power of the House of
Representatives and the Senate, respectively, and is deemed a
part of the rules of each House of Congress, but--
(A) is applicable only with respect to the procedure to be
followed in that House of Congress in the case of an
implementing bill (as defined in subsection (d)); and
(B) supersedes other rules only to the extent that such
rules are inconsistent with this section; and
(2) with full recognition of the constitutional right of
either House of Congress to change the rules (so far as
relating to the procedure of that House of Congress) at any
time, in the same manner and to the same
[[Page S8834]]
extent as in the case of any other rule of that House of
Congress.
(b) Introduction and Referral.--
(1) Introduction.--
(A) In general.--Subject to paragraph (2), on the day on
which the President transmits the report pursuant to section
236(c) to the House of Representatives and the Senate, the
recommendations in legislative form transmitted by the
President with respect to such report shall be introduced as
a bill (by request) in the following manner:
(i) House of representatives.--In the House of
Representatives, by the Majority Leader, for himself and the
Minority Leader, or by Members of the House of
Representatives designated by the Majority Leader and
Minority Leader.
(ii) Senate.--In the Senate, by the Majority Leader, for
himself and the Minority Leader, or by Members of the Senate
designated by the Majority Leader and Minority Leader.
(B) Special rule.--If either House of Congress is not in
session on the day on which such recommendations in
legislative form are transmitted, the recommendations in
legislative form shall be introduced as a bill in that House
of Congress, as provided in subparagraph (A), on the first
day thereafter on which that House of Congress is in session.
(2) Referral.--Such bills shall be referred by the
presiding officers of the respective Houses to the
appropriate committee, or, in the case of a bill containing
provisions within the jurisdiction of 2 or more committees,
jointly to such committees for consideration of those
provisions within their respective jurisdictions.
(c) Consideration.--After the recommendations in
legislative form have been introduced as a bill and referred
under subsection (b), such implementing bill shall be
considered in the same manner as an implementing bill is
considered under subsections (d), (e), (f), and (g) of
section 151 of the Trade Act of 1974 (19 U.S.C. 2191).
(d) Implementing Bill Defined.--In this section, the term
``implementing bill'' means only the recommendations in
legislative form of the Institute of Medicine of the National
Academy of Sciences described in section 236(b)(2),
transmitted by the President to the House of Representatives
and the Senate under section 236(c), and introduced and
referred as provided in subsection (b) as a bill of either
House of Congress.
(e) Counting of Days.--For purposes of this section, any
period of days referred to in section 151 of the Trade Act of
1974 shall be computed by excluding--
(1) the days on which either House of Congress is not in
session because of an adjournment of more than 3 days to a
day certain or an adjournment of Congress sine die; and
(2) any Saturday and Sunday, not excluded under paragraph
(1), when either House is not in session.
Subtitle E--Other Services
SEC. 241. REVISION OF MORATORIUM IN CAPS FOR THERAPY
SERVICES.
(a) Extension of Moratorium.--Section 1833(g)(4) (42 U.S.C.
1395l(g)(4)) is amended by striking ``during 2000 and 2001''
and inserting ``during the period beginning on January 1,
2000, and ending on the date that is 18 months after the date
the Secretary submits the report required under section
4541(d)(2) of the Balanced Budget Act of 1997 to Congress''.
(b) Extension of Reporting Date.--Section 4541(d)(2) of BBA
(42 U.S.C. 1395l note), as amended by section 221(c) of BBRA
(113 Stat. 1501A-351), is amended by striking ``January 1,
2001'' and inserting ``January 1, 2002''.
SEC. 242. REVISION OF COVERAGE OF IMMUNOSUPPRESSIVE DRUGS.
(a) Revision.--
(1) In general.--Section 1861(s)(2)(J) (42 U.S.C.
1395x(s)(2)(J)) is amended to read as follows:
``(J) prescription drugs used in immunosuppressive therapy
furnished--
``(i) on or after the date of enactment of the Medicare,
Medicaid, and SCHIP Balanced Budget Refinement Act of 2000
and before January 1, 2004, to an individual who has received
an organ transplant; and
``(ii) on or after January 1, 2004, to an individual who
receives an organ transplant for which payment is made under
this title, but only in the case of drugs furnished within 36
months after the date of the transplant procedure.''.
(2) Conforming amendments.--
(A) Extended coverage.--Section 1832 (42 U.S.C. 1395k) is
amended--
(i) by striking subsection (b); and
(ii) by redesignating subsection (c) as subsection (b).
(B) Pass-through; report.--Subsections (c) and (d) of
section 227 of BBRA (113 Stat. 1501A-355) are repealed.
(3) Effective date.--The amendments made by this subsection
shall apply to drugs furnished on or after the date of
enactment of this Act.
(b) Extension of Certain Secondary Payer Requirements.--
Section 1862(b)(1)(C) (42 U.S.C. 1395y(b)(1)(C)) is amended
by adding at the end the following: ``With regard to
immunosuppressive drugs furnished on or after the date of
enactment of the Medicare, Medicaid, and SCHIP Balanced
Budget Refinement Act of 2000 and before January 1, 2004,
this subparagraph shall be applied without regard to any time
limitation.''.
SEC. 243. STATE ACCREDITATION OF DIABETES SELF-MANAGEMENT
TRAINING PROGRAMS.
Section 1861(qq)(2) of the Social Security Act (42 U.S.C.
1395xx(qq)(2)) is amended--
(1) in the matter preceding subparagraph (A), by striking
``paragraph (1)--'' and inserting ``paragraph (1):'';
(2) in subparagraph (A)--
(A) by striking ``a `certified provider' '' and inserting
``A `certified provider' ''; and
(B) by striking ``; and'' and inserting a period; and
(3) in subparagraph (B)--
(A) by striking ``a physician, or such other individual''
and inserting ``(i) A physician, or such other individual'';
(B) by inserting ``(I)'' before ``meets applicable
standards'';
(C) by inserting ``(II)'' before ``is recognized'';
(D) by inserting ``, or by a program described in clause
(ii),'' after ``recognized by an organization that represents
individuals (including individuals under this title) with
diabetes''; and
(E) by adding at the end the following new clause:
``(ii) Notwithstanding any reference to `a national
accreditation body' in section 1865(b), for purposes of
clause (i), a program described in this clause is a program
operated by a State for the purposes of accrediting diabetes
self-management training programs, if the Secretary
determines that such State program has established quality
standards that meet or exceed the standards established by
the Secretary under clause (i) or the standards originally
established by the National Diabetes Advisory Board and
subsequently revised as described in clause (i).''.
SEC. 244. ELIMINATION OF REDUCTION IN PAYMENT AMOUNTS FOR
DURABLE MEDICAL EQUIPMENT AND OXYGEN AND OXYGEN
EQUIPMENT.
(a) Update for Covered Items.--Section 1834(a)(14)(C) (42
U.S.C. 1395m(a)(14)(C)) is amended by striking ``through
2002'' and inserting ``through 2000''.
(b) Orthotics and Prosthetics.--Section 1834(h)(4)(A)(v)
(42 U.S.C. 1395m(h)(4)(A)(v)) is amended by striking
``through 2002'' and inserting ``through 2000''.
(c) Parenteral and Enteral Nutrients, Supplies, and
Equipment.--Section 4551(b) of BBA (42 U.S.C. 1395m note) is
amended by striking ``through 2002'' and inserting ``through
2000''.
(d) Oxygen and Oxygen Equipment.--Section 1834(a)(9)(B) (42
U.S.C. 1395m(a)(9)(B)) is amended--
(1) in clause (v), by striking ``and'' at the end;
(2) in clause (vi)--
(A) by striking ``each subsequent year'' and inserting
``2000''; and
(B) by striking the period at the end and inserting ``;
and''; and
(3) by adding at the end the following new clause:
``(vii) for 2001 and each subsequent year, the amount
determined under this subparagraph for the preceding year
increased by the covered item update for such subsequent
year.''.
(e) Conforming Amendment.--Section 228 of BBRA (113 Stat.
1501A-356) is repealed.
SEC. 245. STANDARDS REGARDING PAYMENT FOR CERTAIN ORTHOTICS
AND PROSTHETICS.
(a) Standards.--
(1) In general.--Section 1834(h)(1) (42 U.S.C. 1395m(h)(1))
is amended by adding at the end the following:
``(F) Establishment of standards for certain items.--
``(i) In general.--No payment shall be made for an
applicable item unless such item is provided by a qualified
practitioner or a qualified supplier under the system
established by the Secretary under clause (iii). For purposes
of the preceding sentence, if a qualified practitioner or a
qualified supplier contracts with an entity to provide an
applicable item, then no payment shall be made for such item
unless the entity is also a qualified supplier.
``(ii) Definitions.--In this subparagraph--
``(I) Applicable item.--The term `applicable item' means
orthotics and prosthetics that require education, training,
and experience to custom fabricate such item. Such term does
not include shoes and shoe inserts.
``(II) Qualified practitioner.--The term `qualified
practitioner' means a physician or health professional who
meets any of the following requirements:
``(aa) The physician or health professional is specifically
trained and educated to provide or manage the provision of
custom-designed, fabricated, modified, and fitted orthotics
and prosthetics, and is either certified by the American
Board for Certification in Orthotics and Prosthetics, Inc.,
certified by the Board for Orthotist/Prosthetist
Certification, or credentialed and approved by a program that
the Secretary determines, in consultation with appropriate
experts in orthotics and prosthetics, has training and
education standards that are necessary to provide applicable
items.
``(bb) The physician or health professional is licensed in
orthotics or prosthetics by the State in which the applicable
item is supplied, but only if the Secretary determines that
the mechanisms used by the State to provide such licensure
meet standards determined appropriate by the Secretary.
``(cc) The physician or health professional has completed
at least 10 years practice in the provision of applicable
items. A physician or health professional may not qualify as
a qualified practitioner under the preceding sentence with
respect to an applicable item if the item was provided on or
after January 1, 2005.
[[Page S8835]]
``(III) Qualified supplier.--The term `qualified supplier'
means any entity that is--
``(aa) accredited by the American Board for Certification
in Orthotics and Prosthetics, Inc. or the Board for
Orthotist/Prosthetist Certification; or
``(bb) accredited and approved by a program that the
Secretary determines has accreditation and approval standards
that are essentially equivalent to those of such Board.
``(iii) System.--The Secretary, in consultation with
appropriate experts in orthotics and prosthetics, shall
establish a system under which the Secretary shall--
``(I) determine which items are applicable items and
formulate a list of such items;
``(II) review the applicable items billed under the coding
system established under this title; and
``(III) limit payment for applicable items pursuant to
clause (i).''.
(2) Effective date.--The amendment made by paragraph (1)
shall apply to items provided on or after January 1, 2003.
(b) Revision of Definition of Orthotics.--
(1) In general.--Section 1861(s)(9) (42 U.S.C. 1395x(s)(9))
is amended by inserting ``(including such braces that are
used in conjunction with, or as components of, other medical
or non-medical equipment when provided by a qualified
practitioner (as defined in subclause (II) of section
1834(h)(1)(F))) or a qualified supplier (as defined in
subclause (III) of such section)'' after ``braces''.
(2) Effective date.--The amendment made by paragraph (1)
shall apply to items provided on or after January 1, 2003.
SEC. 246. NATIONAL LIMITATION AMOUNT EQUAL TO 100 PERCENT OF
NATIONAL MEDIAN FOR NEW PAP SMEAR TECHNOLOGIES
AND OTHER NEW CLINICAL LABORATORY TEST
TECHNOLOGIES.
Section 1833(h)(4)(B)(viii) (42 U.S.C.
1395l(h)(4)(B)(viii)) is amended by inserting before the
period at the end the following: ``(or 100 percent of such
median in the case of a clinical diagnostic laboratory test
performed on or after January 1, 2001, that the Secretary
determines is a new test for which no limitation amount has
previously been established under this subparagraph)''.
SEC. 247. INCREASED MEDICARE PAYMENTS FOR CERTIFIED NURSE-
MIDWIFE SERVICES.
(a) Amount of Payment.--Section 1833(a)(1)(K) (42 U.S.C.
1395l(a)(1)(K)) is amended by striking ``65 percent of the
prevailing charge that would be allowed for the same service
performed by a physician, or, for services furnished on or
after January 1, 1992, 65 percent'' and inserting ``85
percent''.
(b) Effective Date.--The amendment made by subsection (a)
shall apply to services furnished on or after January 1,
2001.
SEC. 248. PAYMENT FOR ADMINISTRATION OF DRUGS.
(a) Review of Chemotherapy Administration Practice Expenses
RVUs.--The Secretary of Health and Human Services shall
review the resource-based practice expense component of
relative value units under the physician fee schedule under
section 1848 of the Social Security Act (42 U.S.C. 1395w-4)
for chemotherapy administration services to determine if such
units should be increased.
(b) More Accurate Chemotherapy Drug Payments Tied to
Increases in Chemotherapy Administration Payments.--If the
Secretary of Health and Human Services determines, as a
result of the review under subsection (a), that the resource-
based practice expense relative value units for chemotherapy
administration services should be increased, the Secretary--
(1) may implement such increases for such services, but
only if the Secretary simultaneously implements more accurate
average wholesale prices for chemotherapy drugs (but in no
case shall such simultaneous implementation occur prior to
January 1, 2002); and
(2) if the Secretary implements such increases for such
services, shall do so without taking into account the
requirement under the physician fee schedule under section
1848(c)(2)(B)(ii)(II) of the Social Security Act (42 U.S.C.
1395w-4(c)(2)(B)(ii)(II)).
(c) Blood Clotting Drug-Related Activities.--
(1) Coverage.--Section 1861(s)(2)(I) (42 U.S.C.
1395x(s)(2)(I)) is amended--
(A) by striking ``and'' after ``supervision,''; and
(B) by inserting the following before the semicolon: ``,
and the costs (pursuant to section 1834(n)) incurred by
suppliers of such factors''.
(2) Payments.--Section 1834 (42 U.S.C. 1395m), as amended
by section 233(b), is amended by adding at the end the
following new subsection:
``(n) Payment for Blood Clotting Drug-Related Activities.--
``(1) In general.--The Secretary shall make payments in
accordance with paragraph (2) to suppliers of blood clotting
factors (as described in section 1861(s)(2)(I)) to cover the
costs (such as shipping, storage, inventory control, or other
costs specified by the Secretary) incurred by such suppliers
in furnishing such factors to individuals enrolled under this
part.
``(2) Payment amount.--The amount of payment for furnishing
such blood clotting factors (as so described) shall be an
amount equal to 80 percent of the lesser of--
``(A) the actual charge for the furnishing of such factors;
or
``(B) an amount equal to 10 cents (or such other amount
determined appropriate by the Secretary) per unit of such
factor furnished.''.
(3) Effective date.--The amendments made by this subsection
shall apply to blood clotting factors (as described in
section 1861(s)(2)(I) of the Social Security Act (42 U.S.C.
1395x(s)(2)(I))) furnished on or after the date that the
Secretary of Health and Human Services implements more
accurate average wholesale prices for such factors.
SEC. 249. MEDPAC STUDY ON IN-HOME INFUSION THERAPY NURSING
SERVICES.
(a) Study.--The Medicare Payment Advisory Commission
established under section 1805 of the Social Security Act (42
U.S.C. 1395b-6) (in this section referred to as ``MedPAC'')
shall conduct a study on the provision of in-home infusion
therapy nursing services, including a review of any
documentation of clinical efficacy for those services and any
costs associated with providing those services.
(b) Report.--Not later than 18 months after the date of
enactment of this Act, MedPAC shall submit a report to the
Secretary of Health and Human Services and Congress on the
study and review conducted under subsection (a) together with
recommendations regarding the establishment of a payment
methodology for in-home infusion therapy nursing services
that ensures the continuing access of beneficiaries under the
medicare program under title XVIII of the Social Security Act
(42 U.S.C. 1395 et seq.) to those services.
TITLE III--PROVISIONS RELATING TO PARTS A AND B
Subtitle A--Home Health Services
SEC. 301. ELIMINATION OF 15 PERCENT REDUCTION IN PAYMENT
RATES UNDER THE PROSPECTIVE PAYMENT SYSTEM FOR
HOME HEALTH SERVICES.
(a) In General.--Section 1895(b)(3)(A) (42 U.S.C.
1395fff(b)(3)(A)) is amended to read as follows:
``(A) Initial basis.--Under such system the Secretary shall
provide for computation of a standard prospective payment
amount (or amounts). Such amount (or amounts) shall initially
be based on the most current audited cost report data
available to the Secretary and shall be computed in a manner
so that the total amounts payable under the system for the
12-month period beginning on the date the Secretary
implements the system shall be equal to the total amount that
would have been made if the system had not been in effect and
if section 1861(v)(1)(L)(ix) had not been enacted. Each such
amount shall be standardized in a manner that eliminates the
effect of variations in relative case mix and area wage
adjustments among different home health agencies in a budget
neutral manner consistent with the case mix and wage level
adjustments provided under paragraph (4)(A). Under the
system, the Secretary may recognize regional differences or
differences based upon whether or not the services or agency
are in an urbanized area.''.
(b) Effective Date.--The amendment made by subsection (a)
shall take effect as if included in the enactment of BBRA.
SEC. 302. EXCLUSION OF CERTAIN NONROUTINE MEDICAL SUPPLIES
UNDER THE PPS FOR HOME HEALTH SERVICES.
(a) Exclusion.--
(1) In general.--Section 1895 (42 U.S.C. 1395fff) is
amended by adding at the end the following new subsection:
``(e) Exclusion of Nonroutine Medical Supplies.--
``(1) In general.--Notwithstanding the preceding provisions
of this section, in the case of all nonroutine medical
supplies (as defined by the Secretary) furnished by a home
health agency during a year (beginning with 2001) for which
payment is otherwise made on the basis of the prospective
payment amount under this section, payment under this section
shall be based instead on the lesser of--
``(A) the actual charge for the nonroutine medical supply;
or
``(B) the amount determined under the fee schedule
established by the Secretary for purposes of making payment
for such items under part B for nonroutine medical supplies
furnished during that year.
``(2) Budget neutrality adjustment.--The Secretary shall
provide for an appropriate proportional reduction in payments
under this section so that beginning with fiscal year 2001,
the aggregate amount of such reductions is equal to the
aggregate increase in payments attributable to the exclusion
effected under paragraph (1).''.
(2) Conforming amendment.--Section 1895(b)(1) of the Social
Security Act (42 U.S.C. 1395fff(b)(1)) is amended by striking
``The Secretary'' and inserting ``Subject to subsection (e),
the Secretary''.
(3) Effective date.--The amendments made by this subsection
shall apply to supplies furnished on or after January 1,
2001.
(b) Exclusion from Consolidated Billing.--
(1) In general.--For items provided during the applicable
period, the Secretary of Health and Human Services shall
administer the medicare program under title XVIII of the
Social Security Act (42 U.S.C. 1395 et seq.) as if--
[[Page S8836]]
(A) section 1842(b)(6)(F) of such Act (42 U.S.C.
1395u(b)(6)(F)) was amended by striking ``(including medical
supplies described in section 1861(m)(5), but excluding
durable medical equipment to the extent provided for in such
section)'' and inserting ``(excluding medical supplies and
durable medical equipment described in section 1861(m)(5))'';
and
(B) section 1862(a)(21) of such Act (42 U.S.C.
1395y(a)(21)) was amended by striking ``(including medical
supplies described in section 1861(m)(5), but excluding
durable medical equipment to the extent provided for in such
section)'' and inserting ``(excluding medical supplies and
durable medical equipment described in section 1861(m)(5))''.
(2) Applicable period defined.--For purposes of paragraph
(1), the term ``applicable period'' means the period
beginning on January 1, 2001, and ending on the later of--
(A) the date that is 18 months after the date of enactment
of this Act; or
(B) the date determined appropriate by the Secretary of
Health and Human Services.
(c) Study on Exclusion of Certain Nonroutine Medical
Supplies Under the PPS for Home Health Services.--
(1) Study.--The Secretary of Health and Human Services (in
this subsection referred to as the ``Secretary'') shall
conduct a study to identify any nonroutine medical supply
that may be appropriately and cost-effectively excluded from
the prospective payment system for home health services under
section 1895 of the Social Security Act (42 U.S.C. 1395fff).
Specifically, the Secretary shall consider whether wound care
and ostomy supplies should be excluded from such prospective
payment system.
(2) Report.--Not later than 18 months after the date of
enactment of this Act, the Secretary shall submit to the
committees of jurisdiction of the House of Representatives
and the Senate a report on the study conducted under
paragraph (1), including a list of any nonroutine medical
supplies that should be excluded from the prospective payment
system for home health services under section 1895 of the
Social Security Act (42 U.S.C. 1395fff).
(d) Exclusion of Other Nonroutine Medical Supplies.--Upon
submission of the report under subsection (c)(2), the
Secretary shall (if necessary) revise the definition of
nonroutine medical supply, as defined for purposes of section
1895(e) (as added by subsection (a)), based on the list of
nonroutine medical supplies included in such report.
SEC. 303. PERMITTING HOME HEALTH PATIENTS WITH ALZHEIMER'S
DISEASE OR A RELATED DEMENTIA TO ATTEND ADULT
DAY-CARE.
(a) In General.--Sections 1814(a) and 1835(a) of the Social
Security Act (42 U.S.C. 1395f(a); 1395n(a)) are each amended
in the last sentence by inserting ``(including regularly
participating, for the purpose of therapeutic treatment for
Alzheimer's disease or a related dementia, in an adult day-
care program that is licensed, certified, or accredited by a
State to furnish adult day-care services in the State)''
before the period.
(b) Effective Date.--The amendments made by subsection (a)
shall apply to items and services provided on or after
October 1, 2001.
SEC. 304. STANDARDS FOR HOME HEALTH BRANCH OFFICES.
(a) In General.--Section 1861(o) (42 U.S.C. 1395x(o)) is
amended by adding at the end the following new sentences:
``For purposes of this subsection, a home health agency may
provide services through a single site or through a branch
office. For purposes of the preceding sentence, the term
`branch office' means a service site for home health services
that is controlled and supervised by a home health agency.''.
(b) Establishment of Standards.--
(1) In general.--The Secretary of Health and Human Services
(in this subsection referred to as the ``Secretary'') shall
establish, using a negotiated rulemaking process under
subchapter III of chapter 5 of title 5, United States Code,
standards for the operation of a branch office (as defined in
the last sentence of section 1861(o) of the Social Security
Act (42 U.S.C. 1395x(o)), as added by subsection (a)).
(2) Requirements.--In establishing standards under
paragraph (1), the Secretary shall--
(A) provide for the special treatment of any home health
agency or branch office--
(i) that is located in a frontier area; or
(ii) with any other special circumstance that the Secretary
determines is appropriate; and
(B) allow the use of technology used by the home health
agency to supervise the branch office.
(3) Consultation.--The Secretary shall establish the
regulations under this subsection in consultation with
representatives of the home health industry.
SEC. 305. TREATMENT OF HOME HEALTH SERVICES PROVIDED IN
CERTAIN COUNTIES.
(a) In General.--Notwithstanding any other provision of
law, effective for home health services provided under the
prospective payment system under section 1895 of the Social
Security Act (42 U.S.C. 1395fff) during fiscal year 2001 in
an applicable county, the geographic adjustment factors
applicable in such year to hospitals physically located in
such county under section 1886(d) of such Act (42 U.S.C.
1395ww(d)) (including the factors applicable to such
hospitals by reason of any reclassification or deemed
reclassification) shall be deemed to apply to such services
instead of the area wage adjustment factors that would
otherwise be applicable to such services under section
1895(b)(4)(C) of such Act (42 U.S.C. 1395fff(b)(4)(C)).
(b) Applicable County Defined.--For purposes of subsection
(a), the term ``applicable county'' means any of the
following counties:
(1) Duchess County, New York.
(2) Orange County, New York.
(3) Clinton County, New York.
(4) Ulster County, New York.
(5) Otsego County, New York.
(6) Cayuga County, New York.
(7) St. Jefferson County, New York.
Subtitle B--Direct Graduate Medical Education
SEC. 311. NOT COUNTING CERTAIN GERIATRIC RESIDENTS AGAINST
GRADUATE MEDICAL EDUCATION LIMITATIONS.
For cost reporting periods beginning on or after October 1,
2000, and before October 1, 2005, in applying the limitations
regarding the total number of full-time equivalent interns
and residents in the field of allopathic or osteopathic
medicine under subsections (d)(5)(B)(v) and (h)(4)(F) of
section 1886 of the Social Security Act (42 U.S.C. 1395ww)
for a hospital, the Secretary of Health and Human Services
shall not take into account a maximum of 3 interns or
residents in the field of geriatric medicine to the extent
the hospital increases the number of geriatric interns or
residents above the number of such interns or residents for
the hospital's most recent cost reporting period ending
before October 1, 2000.
SEC. 312. PROGRAM OF PAYMENTS TO CHILDREN'S HOSPITALS THAT
OPERATE GRADUATE MEDICAL EDUCATION PROGRAMS.
Part A of title XI (42 U.S.C. 1301 et seq.) is amended by
adding after section 1150 the following new section:
``program of payments to children's hospitals that operate graduate
medical education programs
``Sec. 1150A. (a) Payments.--The Secretary shall make 2
payments under this section to each children's hospital for
each of fiscal years 2002 through 2005, 1 for the direct
expenses and the other for the indirect expenses associated
with operating approved graduate medical residency training
programs.
``(b) Amount of Payments.--
``(1) In general.--Subject to paragraph (2), the amounts
payable under this section to a children's hospital for an
approved graduate medical residency training program for a
fiscal year are each of the following amounts:
``(A) Direct expense amount.--The amount determined under
subsection (c) for direct expenses associated with operating
approved graduate medical residency training programs.
``(B) Indirect expense amount.--The amount determined under
subsection (d) for indirect expenses associated with the
treatment of more severely ill patients and the additional
costs relating to teaching residents in such programs.
``(2) Capped amount.--
``(A) In general.--The total of the payments made to
children's hospitals under subparagraph (A) or (B) of
paragraph (1) in a fiscal year shall not exceed the funds
appropriated under paragraph (1) or (2), respectively, of
subsection (f) for such payments for that fiscal year.
``(B) Pro rata reductions of payments for direct
expenses.--If the Secretary determines that the amount of
funds appropriated under subsection (f)(1) for a fiscal year
is insufficient to provide the total amount of payments
otherwise due for such periods under paragraph (1)(A), the
Secretary shall reduce the amounts so payable on a pro rata
basis to reflect such shortfall.
``(c) Amount of Payment for Direct Graduate Medical
Education.--
``(1) In general.--The amount determined under this
subsection for payments to a children's hospital for direct
graduate expenses relating to approved graduate medical
residency training programs for a fiscal year is equal to the
product of--
``(A) the updated per resident amount for direct graduate
medical education, as determined under paragraph (2); and
``(B) the average number of full-time equivalent residents
in the hospital's graduate approved medical residency
training programs (as determined under section 1886(h)(4))
during the fiscal year.
``(2) Updated per resident amount for direct graduate
medical education.--The updated per resident amount for
direct graduate medical education for a hospital for a fiscal
year is an amount determined as follows:
``(A) Determination of hospital single per resident
amount.--The Secretary shall compute for each hospital
operating an approved graduate medical education program
(regardless of whether or not it is a children's hospital) a
single per resident amount equal to the average (weighted by
number of full-time equivalent residents) of the primary care
per resident amount and the non-primary care per resident
amount computed under section 1886(h)(2) for cost reporting
periods ending during fiscal year 1997.
``(B) Determination of wage and non-wage-related proportion
of the single per resident amount.--The Secretary shall
estimate the average proportion of the single per resident
amounts computed under subparagraph (A) that is attributable
to wages and wage-related costs.
``(C) Standardizing per resident amounts.--The Secretary
shall establish a
[[Page S8837]]
standardized per resident amount for each such hospital--
``(i) by dividing the single per resident amount computed
under subparagraph (A) into a wage-related portion and a non-
wage-related portion by applying the proportion determined
under subparagraph (B);
``(ii) by dividing the wage-related portion by the factor
applied under section 1886(d)(3)(E) for discharges occurring
during fiscal year 1999 for the hospital's area; and
``(iii) by adding the non-wage-related portion to the
amount computed under clause (ii).
``(D) Determination of national average.--The Secretary
shall compute a national average per resident amount equal to
the average of the standardized per resident amounts computed
under subparagraph (C) for such hospitals, with the amount
for each hospital weighted by the average number of full-time
equivalent residents at such hospital.
``(E) Application to individual hospitals.--The Secretary
shall compute for each such hospital that is a children's
hospital a per resident amount--
``(i) by dividing the national average per resident amount
computed under subparagraph (D) into a wage-related portion
and a non-wage-related portion by applying the proportion
determined under subparagraph (B);
``(ii) by multiplying the wage-related portion by the
factor described in subparagraph (C)(ii) for the hospital's
area; and
``(iii) by adding the non-wage-related portion to the
amount computed under clause (ii).
``(F) Updating rate.--The Secretary shall update such per
resident amount for each such children's hospital by the
estimated percentage increase in the Consumer Price Index for
all urban consumers (U.S. city average) during the period
beginning October 1997, and ending with the midpoint of the
Federal fiscal year for which payments are made.
``(d) Amount of Payment for Indirect Medical Education.--
``(1) In general.--The amount determined under this
subsection for payments to a children's hospital for indirect
expenses associated with the treatment of more severely ill
patients and the additional costs related to the teaching of
residents for a fiscal year is equal to an amount determined
appropriate by the Secretary.
``(2) Factors.--In determining the amount under paragraph
(1), the Secretary shall--
``(A) take into account variations in case mix and regional
wage levels among children's hospitals and the number of
full-time equivalent residents in the hospitals' approved
graduate medical residency training programs; and
``(B) assure that the aggregate of the payments for
indirect expenses associated with the treatment of more
severely ill patients and the additional costs related to the
teaching of residents under this section in a fiscal year are
equal to the amount appropriated for such expenses for the
fiscal year involved under subsection (f)(2).
``(e) Making of Payments.--
``(1) Interim payments.--The Secretary shall determine,
before the beginning of each fiscal year involved for which
payments may be made for a hospital under this section, the
amounts of the payments for direct graduate medical education
and indirect medical education for such fiscal year and shall
(subject to paragraph (2)) make the payments of such amounts
in 26 equal interim installments during such period. Such
interim payments to each individual hospital shall be based
on the number of residents reported in the hospital's most
recently filed medicare cost report prior to the application
date for the Federal fiscal year for which the interim
payment amounts are established.
``(2) Withholding.--
``(A) In general.--Subject to subparagraph (B), the
Secretary shall withhold 25 percent from each interim
installment for direct and indirect graduate medical
education paid under paragraph (1).
``(B) Reduction of withholding.--The Secretary shall reduce
the percent withheld from each installment pursuant to
subparagraph (A) if the Secretary determines that such
reduced percent will provide the Secretary with a reasonable
level of assurance that most hospitals will not be overpaid
on an interim basis.
``(3) Reconciliation.--Prior to the end of each fiscal
year, the Secretary shall determine any changes to the number
of residents reported by a hospital and shall use that number
of residents to determine the final amount payable to the
hospital for the current fiscal year for both direct expense
and indirect expense amounts. Based on such determination,
the Secretary shall recoup any overpayments made or pay any
balance due to the extent possible. In the event that a
hospital's interim payments were greater than the final
amount to which it is entitled, the Secretary shall have the
option of recouping that excess amount in determining the
amount to be paid in the subsequent year to that hospital.
The final amount so determined shall be considered a final
intermediary determination for purposes of applying section
1878 and shall be subject to review under that section in the
same manner as the amount of payment under section 1886(d) is
subject to review under such section.
``(f) Authorization of Appropriations.--
``(1) Direct graduate medical education.--
``(A) In general.--There are appropriated, out of any money
in the Treasury not otherwise appropriated, for payments
under subsection (b)(1)(A) for each of fiscal years 2002
through 2005, $95,000,000.
``(B) Carryover of excess.--The amounts appropriated under
subparagraph (A) for each fiscal year shall remain available
for obligation through the end of the subsequent fiscal year.
``(2) Indirect medical education.--There are appropriated,
out of any money in the Treasury not otherwise appropriated,
for payments under subsection (b)(1)(A) for each of fiscal
years 2002 through 2005, $190,000,000.
``(g) Definitions.--In this section:
``(1) Approved graduate medical residency training
program.--The term `approved graduate medical residency
training program' has the meaning given the term `approved
medical residency training program' in section 1886(h)(5)(A).
``(2) Children's hospital.--The term `children's hospital'
means a hospital with a medicare payment agreement and which
is excluded from the medicare inpatient prospective payment
system pursuant to section 1886(d)(1)(B)(iii) and its
accompanying regulations.
``(3) Direct graduate medical education costs.--The term
`direct graduate medical education costs' has the meaning
given such term in section 1886(h)(5)(C).''.
SEC. 313. AUTHORITY TO INCLUDE COSTS OF TRAINING OF CLINICAL
PSYCHOLOGISTS IN PAYMENTS TO HOSPITALS.
Effective for cost reporting periods beginning on or after
October 1, 1999, for purposes of payments to hospitals under
the medicare program under title XVIII of the Social Security
Act (42 U.S.C. 1395 et seq.) for costs of approved
educational activities (as defined in section 413.85 of title
42 of the Code of Federal Regulations), such approved
educational activities shall include the clinical portion of
professional educational training programs, recognized by the
Secretary, for clinical psychologists.
SEC. 314. TREATMENT OF CERTAIN NEWLY ESTABLISHED RESIDENCY
PROGRAMS IN COMPUTING MEDICARE PAYMENTS FOR THE
COSTS OF MEDICAL EDUCATION.
(a) In General.--Section 1886(h)(4)(H) (42 U.S.C.
1395ww(h)(4)(H)) is amended by adding at the end the
following new clause:
``(v) Treatment of certain newly established programs.--Any
hospital that has received payments under this subsection for
a cost reporting period ending before January 1, 1995, and
that operates an approved medical residency training program
established on or after August 5, 1997, shall be treated as
meeting the requirements for an adjustment under the rules
prescribed pursuant to clause (i) with respect to such
program if--
``(I) such program received accreditation from the American
Council of Graduate Medical Education not later than August
5, 1998;
``(II) such program was in operation (with 1 or more
residents in training) as of January 1, 2000;
``(III) such hospital is located in an area that is
contiguous to a rural area and serves individuals from such
rural area; and
``(IV) such hospital serves a medical service area with a
population that is less than 500,000.''.
(b) Effective Date.--The amendment made by subsection (a)
shall take effect as if included in the enactment of section
4623 of BBA (111 Stat. 477).
Subtitle C--Miscellaneous Provisions
SEC. 321. WAIVER OF 24-MONTH WAITING PERIOD FOR MEDICARE
COVERAGE OF INDIVIDUALS DISABLED WITH
AMYOTROPHIC LATERAL SCLEROSIS (ALS).
(a) In General.--Section 226 (42 U.S.C. 426) is amended--
(1) by redesignating subsection (h) as subsection (j) and
by moving such subsection to the end of the section; and
(2) by inserting after subsection (g) the following new
subsection:
``(h) For purposes of applying this section in the case of
an individual medically determined to have amyotrophic
lateral sclerosis (ALS), the following special rules apply:
``(1) Subsection (b) shall be applied as if there were no
requirement for any entitlement to benefits, or status, for a
period longer than 1 month.
``(2) The entitlement under such subsection shall begin
with the first month (rather than twenty-fifth month) of
entitlement or status.
``(3) Subsection (f) shall not be applied.''.
(b) Conforming Amendment.--Section 1837 (42 U.S.C. 1395p)
is amended by adding at the end the following new subsection:
``(j) In applying this section in the case of an individual
who is entitled to benefits under part A pursuant to the
operation of section 226(h), the following special rules
apply:
``(1) The initial enrollment period under subsection (d)
shall begin on the first day of the first month in which the
individual satisfies the requirement of section 1836(1).
``(2) In applying subsection (g)(1), the initial enrollment
period shall begin on the first day of the first month of
entitlement to disability insurance benefits referred to in
such subsection.''.
(c) Effective Date.--The amendments made by this section
shall apply to benefits for months beginning after the date
of enactment of this Act.
[[Page S8838]]
TITLE IV--RURAL PROVIDER PROVISIONS
Subtitle A--Critical Access Hospitals
SEC. 401. PAYMENTS TO CRITICAL ACCESS HOSPITALS FOR CLINICAL
DIAGNOSTIC LABORATORY TESTS.
(a) Payment on Cost Basis Without Beneficiary Cost-
Sharing.--
(1) In general.--Section 1833(a)(6) (42 U.S.C. 1395l(a)(6))
is amended by inserting ``(including clinical diagnostic
laboratory services furnished by a critical access
hospital)'' after ``outpatient critical access hospital
services''.
(2) No beneficiary cost-sharing.--
(A) In general.--Section 1834(g) (42 U.S.C. 1395m(g)) is
amended by inserting ``(except that in the case of clinical
diagnostic laboratory services furnished by a critical access
hospital the amount of payment shall be equal to 100 percent
of the reasonable costs of the critical access hospital in
providing such services)'' before the period at the end.
(B) BBRA amendment.--Section 1834(g) (42 U.S.C. 1395m(g)),
as amended by section 403(d) of BBRA (113 Stat. 1501A-371),
is amended--
(i) in paragraph (1), by inserting ``(except that in the
case of clinical diagnostic laboratory services furnished by
a critical access hospital the amount of payment shall be
equal to 100 percent of the reasonable costs of the critical
access hospital in providing such services)'' after ``such
services''; and
(ii) in paragraph (2)(A), by inserting ``(except that in
the case of clinical diagnostic laboratory services furnished
by a critical access hospital the amount of payment shall be
equal to 100 percent of the reasonable costs of the critical
access hospital in providing such services)'' before the
period at the end.
(b) Conforming Amendments.--Paragraphs (1)(D)(i) and
(2)(D)(i) of section 1833(a) (42 U.S.C. 1395l(a)(1)(D)(i);
1395l(a)(2)(D)(i)) are each amended by striking ``or which
are furnished on an outpatient basis by a critical access
hospital''.
(c) Technical Amendment.--Section 403(d)(2) of BBRA (113
Stat. 1501A-371) is amended by striking ``subsection (a)''
and inserting ``paragraph (1)''.
(d) Effective Dates.--
(1) In general.--Except as provided in paragraph (2), the
amendments made by this section shall apply to services
furnished on or after November 29, 1999.
(2) BBRA and technical amendments.--The amendments made by
subsections (a)(2)(B) and (c) shall take effect as if
included in the enactment of section 403(d) of BBRA (113
Stat. 1501A-371).
SEC. 402. REVISION OF PAYMENT FOR PROFESSIONAL SERVICES
PROVIDED BY A CRITICAL ACCESS HOSPITAL.
(a) In General.--Section 1834(g)(2)(B) (42 U.S.C.
1395m(g)(2)(B)), as amended by section 403(d) of BBRA (113
Stat. 1501A-371), is amended by inserting ``120 percent of''
after ``hospital services,''.
(b) Effective Date.--The amendment made by subsection (a)
shall take effect as if included in the enactment of section
403(d) of BBRA (113 Stat. 1501A-371).
SEC. 403. PERMITTING CRITICAL ACCESS HOSPITALS TO OPERATE PPS
EXEMPT DISTINCT PART PSYCHIATRIC AND
REHABILITATION UNITS.
(a) Criteria for Designation as a Critical Access
Hospital.--Section 1820(c)(2)(B)(iii) (42 U.S.C. 1395i-
4(c)(2)(B)(iii)) is amended by inserting ``excluding any
psychiatric or rehabilitation unit of the facility which is a
distinct part of the facility,'' before ``provides not''.
(b) Definition of PPS Exempt Distinct Part Psychiatric and
Rehabilitation Units.--Section 1886(d)(1)(B) (42 U.S.C.
1395ww(d)(1)(B)) is amended by inserting before the last
sentence the following new sentence: ``In establishing such
definition, the Secretary may not exclude from such
definition a psychiatric or rehabilitation unit of a critical
access hospital which is a distinct part of such hospital
solely because such hospital is exempt from the prospective
payment system under this section.''.
(c) Effective Date.--The amendments made by this section
shall take effect on the date of enactment of this Act.
Subtitle B--Medicare Dependent, Small Rural Hospital Program
SEC. 411. MAKING THE MEDICARE DEPENDENT, SMALL RURAL HOSPITAL
PROGRAM PERMANENT.
(a) Payment Methodology.--Section 1886(d)(5)(G) (42 U.S.C.
1395ww(d)(5)(G)) is amended--
(1) in clause (i), by striking ``and before October 1,
2006,''; and
(2) in clause (ii)(II), by striking ``and before October 1,
2006,''.
(b) Conforming Amendments.--
(1) Target amount.--Section 1886(b)(3)(D) (42 U.S.C.
1395ww(b)(3)(D)) is amended--
(A) in the matter preceding clause (i), by striking ``and
before October 1, 2006,''; and
(B) in clause (iv), by striking ``through fiscal year
2005,'' and inserting ``or any subsequent fiscal year,''.
(2) Permitting hospitals to decline reclassification.--
Section 13501(e)(2) of the Omnibus Budget Reconciliation Act
of 1993 (42 U.S.C. 1395ww note), as amended by section
404(b)(2) of BBRA (113 Stat. 1501A-372), is amended by
striking ``or fiscal year 2000 through fiscal year 2005'' and
inserting ``fiscal year 2000, or any subsequent fiscal
year,''.
SEC. 412. OPTION TO BASE ELIGIBILITY FOR MEDICARE DEPENDENT,
SMALL RURAL HOSPITAL PROGRAM ON DISCHARGES
DURING ANY OF THE 3 MOST RECENT AUDITED COST
REPORTING PERIODS.
(a) In General.--Section 1886(d)(5)(G)(iv)(IV) (42 U.S.C.
1395ww(d)(5)(G)(iv)(IV)) is amended by inserting ``, or any
of the 3 most recent audited cost reporting periods,'' after
``1987''.
(b) Effective Date.--The amendment made by this section
shall apply with respect to cost reporting periods beginning
on or after the date of enactment of this Act.
Subtitle C--Sole Community Hospitals
SEC. 421. EXTENSION OF OPTION TO USE REBASED TARGET AMOUNTS
TO ALL SOLE COMMUNITY HOSPITALS.
(a) In General.--Section 1886(b)(3)(I)(i) (42 U.S.C.
1395ww(b)(3)(I)(i)) is amended--
(1) in the matter preceding subclause (I)--
(A) by striking ``that for its cost reporting period
beginning during 1999 is paid on the basis of the target
amount applicable to the hospital under subparagraph (C) and
that elects (in a form and manner determined by the
Secretary) this subparagraph to apply to the hospital''; and
(B) by striking ``substituted for such target amount'' and
inserting ``substituted, if such substitution results in a
greater payment under this section for such hospital, for the
amount otherwise determined under subsection (d)(5)(D)(i)'';
(2) in subclause (I), by striking ``target amount otherwise
applicable'' and all that follows through ``target amount')''
and inserting ``the amount otherwise applicable to the
hospital under subsection (d)(5)(D)(i) (referred to in this
clause as the `subsection (d)(5)(D)(i) amount')''; and
(3) in each of subclauses (II) and (III), by striking
``subparagraph (C) target amount'' and inserting ``subsection
(d)(5)(D)(i) amount''.
(b) Effective Date.--The amendments made by this section
shall take effect as if included in the enactment of section
405 of BBRA (113 Stat. 1501A-372).
SEC. 422. DEEMING A CERTAIN HOSPITAL AS A SOLE COMMUNITY
HOSPITAL.
Notwithstanding any other provision of law, for purposes of
discharges occurring on or after October 1, 2000, the
Greensville Memorial Hospital located in Emporia, Virginia
shall be deemed to have satisfied the travel and time
criteria under section 1886(d)(5)(D)(iii)(II) of the Social
Security Act (42 U.S.C. 1395ww(d)(5)(D)(iii)(II)) for
classification as a sole community hospital.
Subtitle D--Other Rural Hospital Provisions
SEC. 431. EXEMPTION OF HOSPITAL SWING-BED PROGRAM FROM THE
PPS FOR SKILLED NURSING FACILITIES.
(a) Exemption for Medicare Swing-Bed Hospitals.--
(1) In general.--Section 1888(e)(7) (42 U.S.C.
1395yy(e)(7)(A)) is amended--
(A) in the heading, by striking ``Transition'' and
inserting ``Exemption'';
(B) by striking subparagraph (A) and inserting the
following new subparagraph:
``(A) In general.--The prospective payment system under
this subsection shall not apply to items and services
provided by a facility described in subparagraph (B).''; and
(C) in subparagraph (B), by striking ``, for which
payment'' and all that follows before the period.
(2) Effective date.--The amendments made by paragraph (1)
shall take effect as if included in the enactment of section
4432 of BBA (111 Stat. 414).
(b) Change in Effective Date of BBRA Amendments.--
(1) In general.--Section 408(c) of BBRA (113 Stat. 1501A-
375) is amended by striking ``the date that is'' and all that
follows and inserting ``January 1, 2001.''.
(2) Effective date.--The amendment made by paragraph (1)
shall take effect as if included in the enactment of section
408 of BBRA (113 Stat. 1501A-375).
SEC. 432. PERMANENT GUARANTEE OF PRE-BBA PAYMENT LEVELS FOR
OUTPATIENT SERVICES FURNISHED BY RURAL
HOSPITALS.
(a) In General.--Section 1833(t)(7)(D), as amended by
section 203, is amended to read as follows:
``(D) Hold harmless provisions for small rural and cancer
hospitals.--In the case of a hospital located in a rural area
and that has not more than 100 beds or a hospital described
in section 1886(d)(1)(B)(v), for covered OPD services for
which the PPS amount is less than the pre-BBA amount, the
amount of payment under this subsection shall be increased by
the amount of such difference.''.
(b) Effective Date.--The amendment made by subsection (a)
shall take effect as if included in the enactment of section
202 of BBRA (111 Stat. 1501A-342).
SEC. 433. TREATMENT OF CERTAIN PHYSICIAN PATHOLOGY SERVICES.
(a) In General.--Section 1848(i) (42 U.S.C. 1395w-4(i)) is
amended by adding at the end the following new paragraph:
``(4) Treatment of certain physician pathology services.--
``(A) In general.--Notwithstanding any other provision of
law, when an independent laboratory furnishes the technical
component of a physician pathology service with respect to a
fee-for-service medicare beneficiary who is a patient of a
grandfathered hospital, such component shall be treated as a
service for which payment shall be made to the laboratory
under this section and not as--
``(i) an inpatient hospital service for which payment is
made to the hospital under section 1886(d); or
[[Page S8839]]
``(ii) a hospital outpatient service for which payment is
made to the hospital under the prospective payment system
under section 1834(t).
``(B) Definitions.--In this paragraph:
``(i) Grandfathered hospital.--The term `grandfathered
hospital' means a hospital that had an arrangement with an
independent laboratory--
``(I) that was in effect as of July 22, 1999; and
``(II) under which the laboratory furnished the technical
component of physician pathology services with respect to
patients of the hospital and submitted a claim for payment
for such component to a carrier with a contract under section
1842 (and not to the hospital).
``(ii) Fee-for-service medicare beneficiary.--The term
`fee-for-service medicare beneficiary' means an individual
who is not enrolled--
``(I) in a Medicare+Choice plan under part C;
``(II) in a plan offered by an eligible organization under
section 1876;
``(III) with a PACE provider under section 1894;
``(IV) in a medicare managed care demonstration project; or
``(V) in the case of a service furnished to an individual
on an outpatient basis, in a health care prepayment plan
under section 1833(a)(1)(A).''.
(b) Effective Date.--The amendment made by this section
shall apply to services furnished on or after January 1,
2001.
Subtitle E--Other Rural Provisions
SEC. 441. REVISION OF BONUS PAYMENTS FOR SERVICES FURNISHED
IN HEALTH PROFESSIONAL SHORTAGE AREAS.
(a) Expansion of Bonus Payments To Include Physician
Assistant and Nurse Practitioner Services.--Section 1833(m)
(42 U.S.C. 1395l(m)) is amended--
(1) by inserting ``(or services furnished by a physician
assistant or nurse practitioner that would be physicians'
services if furnished by a physician)'' after ``physicians'
services'';
(2) by inserting ``, physician assistant (in the case of a
physician assistant described in subparagraph (C)(ii) of
section 1842(b)(6)), or nurse practitioner'' after
``physician''; and
(3) by striking ``clause (A) of section 1842(b)(6)'' and
inserting ``subparagraphs (A) and (C)(i) of such section''.
(b) Elimination of Requirement To Make Bonus Payments on
Monthly or Quarterly Basis.--Section 1833(m) (42 U.S.C.
1395l(m)) is amended by striking ``(on a monthly or quarterly
basis)''.
(c) Effective Dates.--
(1) In general.--The amendments made by subsection (a)
shall apply to services furnished on or after July 1, 2001.
(2) Monthly or quarterly payments.--The amendment made by
subsection (b) shall apply to services furnished on or after
the first day of the first calendar quarter beginning at
least 240 days after the date of enactment of this Act.
SEC. 442. PROVIDER-BASED RURAL HEALTH CLINIC CAP EXEMPTION.
(a) In General.--The matter in section 1833(f) (42 U.S.C.
1395l(f)) preceding paragraph (1) is amended by striking
``with less than 50 beds'' and inserting ``with an average
daily patient census that does not exceed 50''.
(b) Effective Date.--The amendment made by subparagraph (A)
shall apply to services furnished on or after January 1,
2001.
SEC. 443. PAYMENT FOR CERTAIN PHYSICIAN ASSISTANT SERVICES.
(a) Payment for Certain Physician Assistant Services.--
Section 1842(b)(6)(C) (42 U.S.C. 1395u(b)(6)(C)) is amended
by striking ``for such services provided before January 1,
2003,''.
(b) Effective Date.--The amendment made by subsection (a)
shall take effect on the date of enactment of this Act.
SEC. 444. BONUS PAYMENTS FOR RURAL HOME HEALTH AGENCIES IN
2001 AND 2002.
(a) Increase in Payment Rates for Rural Agencies in 2001
and 2002.--Section 1895(b) (42 U.S.C. 1395fff(b)) is amended
by adding at the end the following new paragraph:
``(7) Additional payment amount for services furnished in
rural areas in 2001 and 2002.--In the case of home health
services furnished in a rural area (as defined in section
1886(d)(2)(D)) during 2001 or 2002, the Secretary shall
provide for an addition or adjustment to the payment amount
otherwise made under this section for services furnished in a
rural area in an amount equal to 10 percent of the amount
otherwise determined under this subsection.''.
(b) Waiving Budget Neutrality.--Section 1895(b)(3) (42
U.S.C. 1395fff(b)(3)) is amended by adding at the end the
following new subparagraph:
``(D) No adjustment for additional payments for rural
services.--The Secretary shall not reduce the standard
prospective payment amount (or amounts) under this paragraph
applicable to home health services furnished during a period
to offset the increase in payments resulting from the
application of paragraph (7) (relating to services furnished
in rural areas).''.
SEC. 445. EXCLUSION OF CLINICAL SOCIAL WORKER SERVICES AND
SERVICES PERFORMED UNDER A CONTRACT WITH A
RURAL HEALTH CLINIC OR FEDERALLY QUALIFIED
HEALTH CENTER FROM THE PPS FOR SNFS.
(a) In General.--Section 1888(e)(2)(A)(ii) (42 U.S.C.
1395yy(e)(2)(A)(ii)) is amended--
(1) in the first sentence, by inserting ``clinical social
worker services,'' after ``qualified psychologist
services,''; and
(2) by inserting after the first sentence the following:
``Services described in this clause also include services
that are provided by a physician, a physician assistant, a
nurse practitioner, a certified nurse midwife, a qualified
psychologist, or a clinical social worker who is employed, or
otherwise under contract, with a rural health clinic or a
Federally qualified health center.''.
(b) Effective Date.--The amendments made by this section
shall apply to services provided on or after the date which
is 60 days after the date of enactment of this Act.
SEC. 446. COVERAGE OF MARRIAGE AND FAMILY THERAPIST SERVICES
PROVIDED IN RURAL HEALTH CLINICS.
(a) Coverage of Marriage and Family Therapist Services.--
(1) Provision of services in rural health clinics.--Section
1861(aa)(1)(B) (42 U.S.C. 1395x(aa)(1)(B)) is amended by
striking ``Secretary)'' and inserting ``Secretary), by a
marriage and family therapist (as defined in subsection
(xx)(2)),''.
(2) Marriage and family therapist services defined.--
Section 1861 (42 U.S.C. 1395x), as amended by section 234(b),
is amended by adding at the end the following new subsection:
``Marriage and Family Therapist Services
``(xx)(1) The term `marriage and family therapist services'
means services performed by a marriage and family therapist
(as defined in paragraph (2)) for the diagnosis and treatment
of mental illnesses, which the marriage and family therapist
is legally authorized to perform under State law (or the
State regulatory mechanism provided by State law) of the
State in which such services are performed, as would
otherwise be covered if furnished by a physician or as an
incident to a physician's professional service, but only if
no facility or other provider charges or is paid any amounts
with respect to the furnishing of such services.
``(2) The term `marriage and family therapist' means an
individual who--
``(A) possesses a master's or doctoral degree which
qualifies for licensure or certification as a marriage and
family therapist pursuant to State law;
``(B) after obtaining such degree has performed at least 2
years of clinical supervised experience in marriage and
family therapy; and
``(C)(i) is licensed or certified as a marriage and family
therapist in the State in which marriage and family therapist
services are performed; or
``(ii) in the case of a State that does not provide for
such licensure or certification, meets such other criteria as
the Secretary establishes.''.
(b) Effective Date.--The amendments made by this section
shall apply with respect to services furnished on or after
January 1, 2002.
SEC. 447. CAPITAL INFRASTRUCTURE REVOLVING LOAN PROGRAM.
(a) In General.--Part A of title XVI of the Public Health
Service Act (42 U.S.C. 300q et seq.) is amended by adding at
the end the following new section:
``capital infrastructure revolving loan program
``Sec. 1603. (a) Authority To Make and Guarantee Loans.--
``(1) Authority to make loans.--The Secretary may make
loans from the fund established under section 1602(d) to any
rural entity for projects for capital improvements,
including--
``(A) the acquisition of land necessary for the capital
improvements;
``(B) the renovation or modernization of any building;
``(C) the acquisition or repair of fixed or major movable
equipment; and
``(D) such other project expenses as the Secretary
determines appropriate.
``(2) Authority to guarantee loans.--
``(A) In general.--The Secretary may guarantee the payment
of principal and interest for loans to rural entities for
projects for capital improvements described in paragraph (1)
to non-Federal lenders.
``(B) Interest subsidies.--In the case of a guarantee of
any loan to a rural entity under subparagraph (A)(i), the
Secretary may pay to the holder of such loan and for and on
behalf of the project for which the loan was made, amounts
sufficient to reduce by not more than 3 percentage points of
the net effective interest rate otherwise payable on such
loan.
``(b) Amount of Loan.--The principal amount of a loan
directly made or guaranteed under subsection (a) for a
project for capital improvement may not exceed $5,000,000.
``(c) Funding Limitations.--
``(1) Government credit subsidy exposure.--The total of the
Government credit subsidy exposure under the Credit Reform
Act of 1990 scoring protocol with respect to the loans
outstanding at any time with respect to which guarantees have
been issued, or which have been directly made, under
subsection (a) may not exceed $50,000,000 per year.
``(2) Total amounts.--Subject to paragraph (1), the total
of the principal amount of all loans directly made or
guaranteed under subsection (a) may not exceed $250,000,000
per year.
``(d) Additional Assistance.--
``(1) Nonrepayable grants.--Subject to paragraph (2), the
Secretary may make a
[[Page S8840]]
grant to a rural entity, in an amount not to exceed $50,000,
for purposes of capital assessment and business planning.
``(2) Limitation.--The cumulative total of grants awarded
under this subsection may not exceed $2,500,000 per year.
``(e) Termination of Authority.--The Secretary may not
directly make or guarantee any loan under subsection (a) or
make a grant under subsection (d) after September 30,
2005.''.
(b) Rural Entity Defined.--Section 1624 of the Public
Health Service Act (42 U.S.C. 300s-3) is amended by adding at
the end the following new paragraph:
``(15)(A) The term `rural entity' includes--
``(i) a rural health clinic, as defined in section
1861(aa)(2) of the Social Security Act;
``(ii) any medical facility with at least 1, but less than
50, beds that is located in--
``(I) a county that is not part of a metropolitan
statistical area; or
``(II) a rural census tract of a metropolitan statistical
area (as determined under the most recent modification of the
Goldsmith Modification, originally published in the Federal
Register on February 27, 1992 (57 Fed. Reg. 6725));
``(iii) a hospital that is classified as a rural, regional,
or national referral center under section 1886(d)(5)(C) of
the Social Security Act; and
``(iv) a hospital that is a sole community hospital (as
defined in section 1886(d)(5)(D)(iii) of the Social Security
Act).
``(B) For purposes of subparagraph (A), the fact that a
clinic, facility, or hospital has been geographically
reclassified under the medicare program under title XVIII of
the Social Security Act shall not preclude a hospital from
being considered a rural entity under clause (i) or (ii) of
subparagraph (A).''.
(c) Conforming Amendments.--Section 1602 of the Public
Health Service Act (42 U.S.C. 300q-2) is amended--
(1) in subsection (b)(2)(D), by inserting ``or
1603(a)(2)(B)'' after ``1601(a)(2)(B)''; and
(2) in subsection (d)--
(A) in paragraph (1)(C), by striking ``section
1601(a)(2)(B)'' and inserting ``sections 1601(a)(2)(B) and
1603(a)(2)(B)''; and
(B) in paragraph (2)(A), by inserting ``or 1603(a)(2)(B)''
after ``1601(a)(2)(B)''.
SEC. 448. GRANTS FOR UPGRADING DATA SYSTEMS.
(a) In General.--Part B of title XVI of the Public Health
Service Act (42 U.S.C. 300r et seq.) is amended by adding at
the end the following new section:
``grants for upgrading data systems
``Sec. 1611. (a) Grants to Hospitals.--
``(1) In general.--The Secretary shall establish a program
to make grants to hospitals that have submitted applications
in accordance with subsection (c) to assist eligible small
rural hospitals in offsetting the costs of establishing data
systems--
``(A) required to--
``(i) implement prospective payment systems under title
XVIII of the Social Security Act; and
``(ii) comply with the administrative simplification
requirements under part C of title XI of such Act; or
``(B) to reduce medication errors.
``(2) Costs.--For purposes of paragraph (1), the term
`costs' shall include costs associated with--
``(A) purchasing computer software and hardware; and
``(B) providing education and training to hospital staff on
computer information systems.
``(3) Limitation.--A hospital that has received a grant
under section 142 of the Medicare, Medicaid, and SCHIP
Balanced Budget Refinement Act of 2000 is not eligible to
receive a grant under this section.
``(b) Eligible Small Rural Hospital Defined.--For purposes
of this section, the term `eligible small rural hospital'
means a non-Federal, short-term general acute care hospital
that--
``(1) is located in a rural area, as defined for purposes
of section 1886(d) of the Social Security Act; and
``(2) has less than 50 beds.
``(c) Application.--A hospital seeking a grant under this
section shall submit an application to the Secretary at such
time and in such form and manner as the Secretary specifies.
``(d) Amount of Grant.--A grant to a hospital under this
section may not exceed $100,000.
``(e) Reports.--
``(1) Information.--A hospital receiving a grant under this
section shall furnish the Secretary with such information as
the Secretary may require to--
``(A) evaluate the project for which the grant is made; and
``(B) ensure that the grant is expended for the purposes
for which it is made.
``(2) Timing of submission.--
``(A) Interim reports.--The Secretary shall report to the
Committee on Commerce of the House of Representatives and the
Committee on Health, Education, Labor, and Pensions of the
Senate at least annually on the grant program established
under this section, including in such report information on
the number of grants made, the nature of the projects
involved, the geographic distribution of grant recipients,
and such other matters as the Secretary deems appropriate.
``(B) Final report.--The Secretary shall submit a final
report to such committees not later than 180 days after the
completion of all of the projects for which a grant is made
under this section.
``(f) Authorization of Appropriations.--There are
authorized to be appropriated such sums as may be necessary
for grants under this section.''.
(b) Conforming Amendment.--Section 1820(g)(3) (42 U.S.C.
1395i-4(g)(3)) is repealed.
SEC. 449. RELIEF FOR FINANCIALLY DISTRESSED RURAL HOSPITALS.
Title III of the Public Health Service Act (42 U.S.C. 241
et seq.) is amended by inserting after section 330D the
following new section:
``SEC. 330E. RELIEF FOR FINANCIALLY DISTRESSED RURAL
HOSPITALS.
``(a) Grants to Small Rural Hospitals.--The Secretary,
acting through the Health Resources and Services
Administration, may award grants to eligible small rural
hospitals that have submitted applications in accordance with
subsection (c) to provide relief for financial distress that
has a negative impact on access to care for beneficiaries
under the medicare program under title XVIII of the Social
Security Act (42 U.S.C. 1395 et seq.) that reside in a rural
area.
``(b) Eligible Small Rural Hospital Defined.--For purposes
of this paragraph, the term `eligible small rural hospital'
means a non-Federal, short-term general acute care hospital
that--
``(1) is located in a rural area (as defined for purposes
of section 1886(d) of the Social Security Act (42 U.S.C.
1395ww(d))); and
``(2) has less than 50 beds.
``(c) Application and Approval.--
``(1) Application.--Each eligible small rural hospital that
desires to receive a grant under this paragraph shall submit
an application to the Secretary, at such time, in such form
and manner, and accompanied by such additional information as
the Secretary may reasonably require.
``(2) Approval.--The Secretary shall approve applications
submitted under paragraph (1) based on a methodology
developed by the Secretary in consultation with the Office of
Rural Health Policy.
``(d) Amount of Grant.--A grant to an eligible small rural
hospital under this paragraph may not exceed $250,000.
``(e) Use of Funds.--
``(1) In general.--Except as provided in paragraph (2), an
eligible small rural hospital may use amounts received under
a grant under this section to temporarily offset financial
operating losses, with emphasis on those losses attributable
to reimbursement formula changes that resulted from the
Balanced Budget Act of 1997, in order to ensure continued
operation and short-term sustainability or to address
emergency physical capital needs that might otherwise result
in closure.
``(2) Prohibited uses.--A hospital may not use funds
received under a grant under this section for new
construction, the purchase of medical equipment, or for
computer software or hardware.
``(f) Report.--
``(1) Information.--A hospital receiving a grant under this
section shall furnish the Secretary with such information as
the Secretary may require to evaluate the project for which
the grant is made and to ensure that the grant is expended
for the purposes for which it is made.
``(2) Reporting.--
``(A) Annual reports.--
``(i) In general.--Not later than December 31 of each year
(beginning with 2001), the Secretary shall submit a report to
the committees of jurisdiction of the House of
Representatives and the Senate on the grant program
established under this section.
``(ii) Information included.--The report submitted under
clause (i) shall include information on the number of grants
made, the nature of the projects involved, the geographic
distribution of grant recipients, and such other information
as the Secretary determines is appropriate.
``(B) Final report.--Not later than 180 days after the
completion of all of the projects for which a grant is made
under this section, the Secretary shall submit a final report
on the grant program established under this section to the
committees described in subparagraph (A).
``(g) Appropriations.--There are appropriated, out of any
money in the Treasury not otherwise appropriated, for making
grants under this section $25,000,000 for each of the fiscal
years 2001 through 2005.''.
SEC. 450. REFINEMENT OF MEDICARE REIMBURSEMENT FOR TELEHEALTH
SERVICES.
(a) Revision of Telehealth Payment Methodology and
Elimination of Fee-Sharing Requirement.--Section 4206(b) of
the Balanced Budget Act of 1997 (42 U.S.C. 1395l note) is
amended to read as follows:
``(b) Methodology for Determining Amount of Payments.--
``(1) In general.--The Secretary shall pay to--
``(A) the physician or practitioner at a distant site that
provides an item or service under subsection (a) an amount
equal to the amount that such physician or provider would
have been paid had the item or service been provided without
the use of a telecommunications system; and
``(B) the originating site a facility fee for facility
services furnished in connection with such item or service.
``(2) Application of part b coinsurance and deductible.--
Any payment made under this section shall be subject to the
coinsurance and deductible requirements under subsections
(a)(1) and (b) of section 1833 of the Social Security Act (42
U.S.C. 1395l).
``(3) Definitions.--In this subsection:
``(A) Distant site.--The term `distant site' means the site
at which the physician or
[[Page S8841]]
practitioner is located at the time the item or service is
provided via a telecommunications system.
``(B) Facility fee.--The term `facility fee' means an
amount equal to--
``(i) for 2000 and 2001, $20; and
``(ii) for a subsequent year, the facility fee under this
subsection for the previous year increased by the percentage
increase in the MEI (as defined in section 1842(i)(3)) for
such subsequent year.
``(C) Originating site.--
``(i) In general.--The term `originating site' means the
site described in clause (ii) at which the eligible
telehealth beneficiary under the medicare program is located
at the time the item or service is provided via a
telecommunications system.
``(ii) Sites described.--The sites described in this
paragraph are as follows:
``(I) On or before January 1, 2002, the office of a
physician or a practitioner, a critical access hospital, a
rural health clinic, and a Federally qualified health center.
``(II) On or before January 1, 2003, a hospital, a skilled
nursing facility, a comprehensive outpatient rehabilitation
facility, a renal dialysis facility, an ambulatory surgical
center, an Indian Health Service facility, and a community
mental health center.''.
(b) Elimination of Requirement for Telepresenter.--Section
4206 of the Balanced Budget Act of 1997 (42 U.S.C. 1395l
note) is amended--
(1) in subsection (a), by striking ``, notwithstanding that
the individual physician'' and all that follows before the
period at the end; and
(2) by adding at the end the following new subsection:
``(e) Telepresenter Not Required.--Nothing in this section
shall be construed as requiring an eligible telehealth
beneficiary to be presented by a physician or practitioner
for the provision of an item or service via a
telecommunications system.''.
(c) Reimbursement for Medicare Beneficiaries Who Do Not
Reside in a HPSA.--Section 4206(a) of the Balanced Budget Act
of 1997 (42 U.S.C. 1395l note), as amended by subsection (b),
is amended--
(1) by striking ``In General.--Not later than'' and
inserting the following: ``Telehealth Services Reimbursed.--
``(1) In general.--Not later than'';
(2) by striking ``furnishing a service for which payment''
and all that follows before the period and inserting ``to an
eligible telehealth beneficiary''; and
(3) by adding at the end the following new paragraph:
``(2) Eligible telehealth beneficiary defined.--In this
section, the term `eligible telehealth beneficiary' means a
beneficiary under the medicare program under title XVIII of
the Social Security Act (42 U.S.C. 1395 et seq.) that resides
in--
``(A) an area that is designated as a health professional
shortage area under section 332(a)(1)(A) of the Public Health
Service Act (42 U.S.C. 254e(a)(1)(A));
``(B) a county that is not included in a Metropolitan
Statistical Area; or
``(C) an inner-city area that is medically underserved (as
defined in section 330(b)(3) of the Public Health Service Act
(42 U.S.C. 254b(b)(3))).''.
(d) Telehealth Coverage for Direct Patient Care.--
(1) In general.--Section 4206 of the Balanced Budget Act of
1997 (42 U.S.C. 1395l note), as amended by subsection (c), is
amended--
(A) in subsection (a)(1), by striking ``professional
consultation via telecommunications systems with a
physician'' and inserting ``items and services for which
payment may be made under such part that are furnished via a
telecommunications system by a physician''; and
(B) by adding at the end the following new subsection:
``(f) Coverage of Items and Services.--Payment for items
and services provided pursuant to subsection (a) shall
include payment for professional consultations, office
visits, office psychiatry services, including any service
identified as of July 1, 2000, by HCPCS codes 99241-99275,
99201-99215, 90804-90815, and 90862.''.
(2) Study and report regarding additional items and
services.--
(A) Study.--The Secretary of Health and Human Services
shall conduct a study to identify items and services in
addition to those described in section 4206(f) of the
Balanced Budget Act of 1997 (as added by paragraph (1)) that
would be appropriate to provide payment under title XVIII of
the Social Security Act (42 U.S.C. 1395 et seq.).
(B) Report.--Not later than 2 years after the date of
enactment of this Act, the Secretary shall submit a report to
Congress on the study conducted under subparagraph (A)
together with such recommendations for legislation that the
Secretary determines are appropriate.
(e) All Physicians and Practitioners Eligible for
Telehealth Reimbursement.--Section 4206(a) of the Balanced
Budget Act of 1997 (42 U.S.C. 1395l note), as amended by
subsection (d), is amended--
(1) in paragraph (1), by striking ``(described in section
1842(b)(18)(C) of such Act (42 U.S.C. 1395u(b)(18)(C))''; and
(2) by adding at the end the following new paragraph:
``(3) Practitioner defined.--For purposes of paragraph (1),
the term `practitioner' includes--
``(A) a practitioner described in section 1842(b)(18)(C) of
the Social Security Act (42 U.S.C. 1395u(b)(18)(C)); and
``(B) a physical, occupational, or speech therapist.''.
(f) Telehealth Services Provided Using Store-and-Forward
Technologies.--Section 4206(a)(1) of the Balanced Budget Act
of 1997 (42 U.S.C. 1395l note), as amended by subsection (e),
is amended by adding at the end the following new paragraph:
``(4) Use of store-and-forward technologies.--For purposes
of paragraph (1), in the case of any Federal telemedicine
demonstration program in Alaska or Hawaii, the term
`telecommunications system' includes store-and-forward
technologies that provide for the asynchronous transmission
of health care information in single or multimedia
formats.''.
(g) Construction Relating to Home Health Services.--Section
4206(a) of the Balanced Budget Act of 1997 (42 U.S.C. 1395l
note), as amended by subsection (f), is amended by adding at
the end the following new paragraph:
``(5) Construction relating to home health services.--
``(A) In general.--Nothing in this section or in section
1895 of the Social Security Act (42 U.S.C. 1395fff) shall be
construed as preventing a home health agency that is
receiving payment under the prospective payment system
described in such section from furnishing a home health
service via a telecommunications system.
``(B) Limitation.--The Secretary shall not consider a home
health service provided in the manner described in
subparagraph (A) to be a home health visit for purposes of--
``(i) determining the amount of payment to be made under
the prospective payment system established under section 1895
of the Social Security Act (42 U.S.C. 1395fff); or
``(ii) any requirement relating to the certification of a
physician required under section 1814(a)(2)(C) of such Act
(42 U.S.C. 1395f(a)(2)(C)).''.
(h) Five-Year Application.--The amendments made by this
section shall apply to items and services provided on or
after April 1, 2001, and before April 1, 2006.
SEC. 451. MEDPAC STUDY ON LOW-VOLUME, ISOLATED RURAL HEALTH
CARE PROVIDERS.
(a) Study.--The Medicare Payment Advisory Commission
established under section 1805 of the Social Security Act (42
U.S.C. 1395b-6) (in this section referred to as ``MedPAC'')
shall conduct a study on the effect of low patient and
procedure volume on the financial status of low-volume,
isolated rural health care providers participating in the
medicare program under title XVIII of the Social Security Act
(42 U.S.C. 1395 et seq.).
(b) Report.--Not later than 18 months after the date of
enactment of this Act, MedPAC shall submit a report to the
Secretary of Health and Human Services and Congress on the
study conducted under subsection (a) indicating--
(1) whether low-volume, isolated rural health care
providers are having, or may have, significantly decreased
medicare margins or other financial difficulties resulting
from any of the payment methodologies described in subsection
(c);
(2) whether the status as a low-volume, isolated rural
health care provider should be designated under the medicare
program and any criteria that should be used to qualify for
such a status; and
(3) any changes in the payment methodologies described in
subsection (c) that are necessary to provide appropriate
reimbursement under the medicare program to low-volume,
isolated rural health care providers (as designated pursuant
to paragraph (2)).
(c) Payment Methodologies Described.--The payment
methodologies described in this subsection are the following:
(1) The prospective payment system for hospital outpatient
department services under section 1833(t) of the Social
Security Act (42 U.S.C. 1395l).
(2) The fee schedule for ambulance services under section
1834(l) of such Act (42 U.S.C. 1395m(l)).
(3) The prospective payment system for inpatient hospital
services under section 1886 of such Act (42 U.S.C. 1395ww).
(4) The prospective payment system for routine service
costs of skilled nursing facilities under section 1888(e) of
such Act (42 U.S.C. 1395yy(e)).
(5) The prospective payment system for home health services
under section 1895 of such Act (42 U.S.C. 1395fff).
TITLE V--PROVISIONS RELATING TO PART C (MEDICARE+CHOICE PROGRAM) AND
OTHER MEDICARE MANAGED CARE PROVISIONS
SEC. 501. RESTORING EFFECTIVE DATE OF ELECTIONS AND CHANGES
OF ELECTIONS OF MEDICARE+CHOICE PLANS.
(a) Open Enrollment.--Section 1851(f)(2) (42 U.S.C. 1395w-
21(f)(2)) is amended by striking ``, except that if such
election or change is made after the 10th day of any calendar
month, then the election or change shall not take effect
until the first day of the second calendar month following
the date on which the election or change is made''.
(b) Effective Date.--The amendment made by this section
shall apply to elections and changes of coverage made on or
after January 1, 2001.
[[Page S8842]]
SEC. 502. SPECIAL MEDIGAP ENROLLMENT ANTIDISCRIMINATION
PROVISION FOR CERTAIN BENEFICIARIES.
(a) Disenrollment Window in Accordance With Beneficiary's
Circumstance.--Section 1882(s)(3) (42 U.S.C. 1395ss(s)(3)) is
amended--
(1) in subparagraph (A), in the matter following clause
(iii), by striking ``, subject to subparagraph (E), seeks to
enroll under the policy not later than 63 days after the date
of termination of enrollment described in such subparagraph''
and inserting ``seeks to enroll under the policy during the
period specified in subparagraph (E)''; and
(2) by striking subparagraph (E) and inserting the
following new subparagraph:
``(E) For purposes of subparagraph (A), the time period
specified in this subparagraph is--
``(i) in the case of an individual described in
subparagraph (B)(i), the period beginning on the date the
individual receives a notice of termination or cessation of
all supplemental health benefits (or, if no such notice is
received, notice that a claim has been denied because of such
a termination or cessation) and ending on the date that is 63
days after the applicable notice;
``(ii) in the case of an individual described in clause
(ii), (iii), (v), or (vi) of subparagraph (B) whose
enrollment is terminated involuntarily, the period beginning
on the date that the individual receives a notice of
termination and ending on the date that is 63 days after the
date the applicable coverage is terminated;
``(iii) in the case of an individual described in
subparagraph (B)(iv)(I), the period beginning on the earlier
of (I) the date that the individual receives a notice of
termination, a notice of the issuer's bankruptcy or
insolvency, or other such similar notice, if any, and (II)
the date that the applicable coverage is terminated, and
ending on the date that is 63 days after the date the
coverage is terminated;
``(iv) in the case of an individual described in clause
(ii), (iii), (iv)(II), (iv)(III), (v), or (vi) of
subparagraph (B) who disenrolls voluntarily, the period
beginning on the date that is 60 days before the effective
date of the disenrollment and ending on the date that is 63
days after such effective date; and
``(v) in the case of an individual described in
subparagraph (B) but not described in the preceding
provisions of this subparagraph, the period beginning on the
effective date of the disenrollment and ending on the date
that is 63 days after such effective date.''.
(b) Extended Medigap Access for Interrupted Trial
Periods.--Section 1882(s)(3) (42 U.S.C. 1395ss(s)(3)), as
amended by subsection (a), is amended by adding at the end
the following new subparagraph:
``(F) For purposes of this paragraph--
``(i) in the case of an individual described in
subparagraph (B)(v) (or deemed to be so described, pursuant
to this subparagraph) whose enrollment with an organization
or provider described in subclause (II) of such subparagraph
is involuntarily terminated within the first 12 months of
such enrollment, and who, without an intervening enrollment,
enrolls with another such organization or provider, such
subsequent enrollment shall be deemed to be an initial
enrollment described in such subparagraph; and
``(ii) in the case of an individual described in clause
(vi) of subparagraph (B) (or deemed to be so described,
pursuant to this subparagraph) whose enrollment with a plan
or in a program described in clause (v)(II) of such
subparagraph is involuntarily terminated within the first 12
months of such enrollment, and who, without an intervening
enrollment, enrolls in another such plan or program, such
subsequent enrollment shall be deemed to be an initial
enrollment described in clause (vi) of such subparagraph.''.
SEC. 503. INCREASE IN NATIONAL PER CAPITA MEDICARE+CHOICE
GROWTH PERCENTAGE IN 2001 AND 2002.
Section 1853(c)(6)(B) of the Social Security Act (42 U.S.C.
1395w-23(c)(6)(B)) is amended--
(1) in clause (iv), by striking ``for 2001, 0.5 percentage
points'' and inserting ``for 2001, 0 percentage points''; and
(2) in clause (v), by striking ``for 2002, 0.3 percentage
points'' and inserting ``for 2002, 0 percentage points''.
SEC. 504. ALLOWING MOVEMENT TO 50:50 PERCENT BLEND IN 2002.
Section 1853(c)(2) of the Social Security Act (42 U.S.C.
1395w-23(c)(2)) is amended--
(1) by striking the period at the end of subparagraph (F)
and inserting a semicolon; and
(2) by adding after and below subparagraph (F) the
following:
``except that a Medicare+Choice organization may elect to
apply subparagraph (F) (rather than subparagraph (E)) for
2002.''.
SEC. 505. DELAY FROM JULY TO NOVEMBER 2000, IN DEADLINE FOR
OFFERING AND WITHDRAWING MEDICARE+CHOICE PLANS
FOR 2001.
Notwithstanding any other provision of law, the deadline
for a Medicare+Choice organization to withdraw the offering
of a Medicare+Choice plan under part C of title XVIII of the
Social Security Act (or otherwise to submit information
required for the offering of such a plan) for 2001 is delayed
from July 1, 2000, to November 1, 2000, and any such
organization that provided notice of withdrawal of such a
plan during 2000 before the date of enactment of this Act may
rescind such withdrawal at any time before November 1, 2000.
SEC. 506. AMOUNTS IN MEDICARE TRUST FUNDS AVAILABLE FOR
SECRETARY'S SHARE OF MEDICARE+CHOICE EDUCATION
AND ENROLLMENT-RELATED COSTS.
(a) Relocation of Provisions.--Section 1857(e)(2) (42
U.S.C. 1395w-27(e)(2)) is amended to read as follows:
``(2) Cost-sharing in enrollment-related costs.--A
Medicare+Choice organization shall pay the fee established by
the Secretary under section 1851(j)(3)(A).''.
(b) Funding for Education and Enrollment Activities.--
Section 1851 (42 U.S.C. 1395w-21) is amended by adding at the
end the following new subsection:
``(j) Funding for Beneficiary Education and Enrollment
Activities.--
``(1) Secretary's estimate of total costs.--The Secretary
shall annually estimate the total cost for a fiscal year of
carrying out this section, section 4360 of the Omnibus Budget
Reconciliation Act of 1990 (relating to the health insurance
counseling and assistance program), and related activities.
``(2) Total amount available.--The total amount available
to the Secretary for a fiscal year for the costs of the
activities described in paragraph (1) shall be equal to the
lesser of--
``(A) the amount estimated for such fiscal year under
paragraph (1); or
``(B) for--
``(i) fiscal year 2001, $130,000,000; and
``(ii) fiscal year 2002 and each subsequent fiscal year,
the amount for the previous fiscal year, adjusted to account
for inflation, any change in the number of beneficiaries
under this title, and any other relevant factors.
``(3) Cost-sharing in enrollment-related costs.--
``(A) Amounts from medicare+choice organizations.--
``(i) In general.--The Secretary is authorized to charge a
fee to each Medicare+Choice organization with a contract
under this part that is equal to the organization's pro rata
share (as determined by the Secretary) of the Medicare+Choice
portion (as defined in clause (ii)) of the total amount
available under paragraph (2) for a fiscal year. Any amounts
collected shall be available without further appropriation to
the Secretary for the costs of the activities described in
paragraph (1).
``(ii) Medicare+choice portion defined.--For purposes of
clause (i), the term `Medicare+Choice portion' means, for a
fiscal year, the ratio, as estimated by the Secretary, of--
``(I) the average number of individuals enrolled in
Medicare+Choice plans during the fiscal year; to
``(II) the average number of individuals entitled to
benefits under parts A, and enrolled under part B, during the
fiscal year.
``(B) Secretary's share.--
``(i) Amounts available from trust funds.--The Secretary's
share of expenses shall be payable from funds in the Federal
Hospital Insurance Trust Fund and the Federal Supplementary
Medical Insurance Trust Fund, in such proportion as the
Secretary shall deem to be fair and equitable after taking
into consideration the expenses attributable to the
administration of this part with respect to part A and B. The
Secretary shall make such transfers of moneys between such
Trust Funds as may be appropriate to settle accounts between
the Trust Funds in cases where expenses properly payable from
one such Trust Fund have been paid from the other such Trust
Fund.
``(ii) Secretary's share of expenses defined.--For purposes
of clause (i), the term `Secretary's share of expenses'
means, for a fiscal year, an amount equal to--
``(I) the total amount available to the Secretary under
paragraph (2) for the fiscal year; less
``(II) the amount collected under subparagraph (A) for the
fiscal year.''.
SEC. 507. REVISED TERMS AND CONDITIONS FOR EXTENSION OF
MEDICARE COMMUNITY NURSING ORGANIZATION (CNO)
DEMONSTRATION PROJECT.
(a) In General.--Section 532 of BBRA (42 U.S.C. 1395mm
note) is amended--
(1) in subsection (a), by striking the second sentence; and
(2) by striking subsection (b) and inserting the following
new subsections:
``(b) Terms and Conditions.--
``(1) January through september 2000.--For the 9-month
period beginning with January 2000, any such demonstration
project shall be conducted under the same terms and
conditions as applied to such demonstration during 1999.
``(2) October 2000 through december 2001.--For the 15-month
period beginning with October 2000, any such demonstration
project shall be conducted under the same terms and
conditions as applied to such demonstration during 1999,
except that the following modifications shall apply:
``(A) Basic capitation rate.--The basic capitation rate
paid for services covered under the project (other than case
management services) per enrollee per month shall be basic
capitation rate paid for such services for 1999, reduced by
10 percent in the case of the demonstration sites located in
Arizona, Minnesota, and Illinois, and 15 percent for the
demonstration site located in New York.
``(B) Targeted case management fee.--A case management fee
shall be paid only for enrollees who are classified as
`moderate' or `at risk' through a baseline health assessment
(as required for Medicare+Choice plans under section 1852(e)
of the Social Security Act (42 U.S.C. 1395ww-22(e)).
[[Page S8843]]
``(C) Greater uniformity in clinical features among
sites.--Each project shall implement for each site--
``(i) protocols for periodic telephonic contact with
enrollees based on--
``(I) the results of such standardized written health
assessment; and
``(II) the application of appropriate care planning
approaches;
``(ii) disease management programs for targeted diseases
(such as congestive heart failure, arthritis, diabetes, and
hypertension) that are highly prevalent in the enrolled
populations;
``(iii) systems and protocols to track enrollees through
hospitalizations, including pre-admission planning,
concurrent management during inpatient hospital stays, and
post-discharge assessment, planning, and follow-up; and
``(iv) standardized patient educational materials for
specified diseases and health conditions.
``(D) Quality improvement.--Each project shall implement at
each site once during the 15-month period--
``(i) enrollee satisfaction surveys; and
``(ii) reporting on specified quality indicators for the
enrolled population.
``(c) Evaluation.--
``(1) Preliminary report.--Not later than July 1, 2001, the
Secretary of Health and Human Services shall submit to the
Committees on Ways and Means and Commerce of the House of
Representatives and the Committee on Finance of the Senate a
preliminary report that--
``(A) evaluates such demonstration projects for the period
beginning July 1, 1997, and ending December 31, 1999, on a
site-specific basis with respect to the impact on per
beneficiary spending, specific health utilization measures,
and enrollee satisfaction; and
``(B) includes a similar evaluation of such projects for
the portion of the extension period that occurs after
September 30, 2000.
``(2) Final report.--Not later than July 1, 2002, the
Secretary shall submit a final report to such Committees on
such demonstration projects. Such report shall include the
same elements as the preliminary report required by paragraph
(1), but for the period after December 31, 1999.
``(3) Methodology for spending comparisons.--Any evaluation
of the impact of the demonstration projects on per
beneficiary spending included in such reports shall be based
on a comparison of--
``(A) data for all individuals who--
``(i) were enrolled in such demonstration projects as of
the first day of the period under evaluation; and
``(ii) were enrolled for a minimum of 6 months thereafter;
with
``(B) data for a matched sample of individuals who are
enrolled under part B of title XVIII of the Social Security
Act (42 U.S.C. 1395j et seq.) and who are not enrolled in
such a project, in a Medicare+Choice plan under part C of
such title (42 U.S.C. 1395w-21 et seq.), a plan offered by an
eligible organization under section 1876 of such Act (42
U.S.C. 1395mm), or a health care prepayment plan under
section 1833(a)(1)(A) of such Act (42 U.S.C.
1395l(a)(1)(A)).''.
(b) Effective Date.--The amendments made by subsection (a)
shall be effective as if included in the enactment of section
532 of BBRA (42 U.S.C. 1395mm note).
SEC. 508. MODIFICATION OF PAYMENT RULES FOR CERTAIN FRAIL
ELDERLY MEDICARE BENEFICIARIES.
(a) Modification of Payment Rules.--Section 1853 (42 U.S.C.
1395w-23) is amended--
(1) in subsection (a)--
(A) in paragraph (1)(A), by striking ``subsections (e),
(g), and (i)'' and inserting ``subsections (e), (g), (i), and
(j)'';
(B) in paragraph (3)(D), by inserting ``paragraph (4) and''
after ``Subject to''; and
(C) by adding at the end the following new paragraph:
``(4) Exemption from risk-adjustment system for frail
elderly beneficiaries enrolled in specialized programs.--
``(A) In general.--In applying the risk-adjustment factors
established under paragraph (3) during the period described
in subparagraph (B), the limitation under paragraph
(3)(C)(ii)(I) shall apply to a frail elderly Medicare+Choice
beneficiary (as defined in subsection (j)(3)) who is enrolled
in a Medicare+Choice plan under a specialized program for the
frail elderly (as defined in subsection (j)(2)) during the
entire period.
``(B) Period of application.--The period described in this
subparagraph begins with January 2001, and ends with the
first month for which the Secretary certifies to Congress
that a comprehensive risk adjustment methodology under
paragraph (3)(C) that takes into account the factors
described in subsection (j)(1)(B) is being fully
implemented.''; and
(2) by adding at the end the following new subsection:
``(j) Special Rules for Frail Elderly Enrolled in
Specialized Programs for the Frail Elderly.--
``(1) Development and implementation of new payment
system.--
``(A) In general.--The Secretary shall develop and
implement (as soon as possible after the date of enactment of
the Medicare, Medicaid, and SCHIP Balanced Budget Refinement
Act of 2000), during the period described in subsection
(a)(4)(B), a payment methodology for frail elderly
Medicare+Choice beneficiaries enrolled in a Medicare+Choice
plan under a specialized program for the frail elderly (as
defined in paragraph (2)(A)).
``(B) Factors described.--The methodology developed and
implemented under subparagraph (A) shall take into account
the prevalence, mix, and severity of chronic conditions among
frail elderly Medicare+Choice beneficiaries and shall
include--
``(i) medical diagnostic factors from all provider settings
(including hospital and nursing facility settings);
``(ii) functional indicators of health status; and
``(iii) such other factors as may be necessary to achieve
appropriate payments for plans serving such beneficiaries.
``(2) Specialized program for the frail elderly defined.--
``(A) In general.--In this part, the term `specialized
program for the frail elderly' means a program that the
Secretary determines--
``(i) is offered under this part as a distinct part of a
Medicare+Choice plan;
``(ii) primarily enrolls frail elderly Medicare+Choice
beneficiaries; and
``(iii) has a clinical delivery system that is specifically
designed to serve the special needs of such beneficiaries and
to coordinate short-term and long-term care for such
beneficiaries through the use of a team described in
subparagraph (B) and through the provision of primary care
services to such beneficiaries by means of such a team at the
nursing facility involved.
``(B) Specialized team described.--A team described in this
subparagraph--
``(i) includes--
``(I) a physician; and
``(II) a nurse practitioner or geriatric care manager; and
``(ii) has as members individuals who--
``(I) have special training in the care and management of
the frail elderly beneficiaries; and
``(II) specialize in the care and management of such
beneficiaries.
``(3) Frail elderly medicare+choice beneficiary defined.--
In this part, the term `frail elderly Medicare+Choice
beneficiary' means a Medicare+Choice eligible individual
who--
``(A) is residing in a skilled nursing facility (as defined
in section 1819(a)) or a nursing facility (as defined in
section 1919(a)) for an indefinite period and without any
intention of residing outside the facility; and
``(B) has a severity of condition that makes the individual
frail (as determined under guidelines approved by the
Secretary).''.
(b) Effective Date.--The amendments made by this section
shall take effect on the date of enactment of this Act.
TITLE VI--PROVISIONS RELATING TO INDIVIDUALS WITH END-STAGE RENAL
DISEASE
SEC. 601. UPDATE IN RENAL DIALYSIS COMPOSITE RATE.
(a) In General.--The last sentence of section 1881(b)(7)
(42 U.S.C. 1395rr(b)(7)) is amended by striking ``, and for
such services'' and all that follows before the period at the
end and inserting the following: ``, for such services
furnished during 2001, by 2.4 percent above such composite
rate payment amounts for such services furnished on December
31, 2000, for such services furnished during 2002 and 2003,
by 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 above such
composite rate payment amounts for such services furnished on
December 31 of the previous year, and for such services
furnished during a subsequent year, by the ESRD market basket
percentage increase above such composite rate payment amounts
for such services furnished on December 31 of the previous
year''.
(b) ESRD Market Basket Percentage Increase Defined.--
Section 1881(b) (42 U.S.C. 1395rr(b)) is amended by adding at
the end the following new paragraph:
``(12)(A) For purposes of this title, the term `ESRD market
basket percentage increase' means, with respect to a calendar
year, the percentage (estimated by the Secretary before the
beginning of such year) by which--
``(i) the cost of the mix of goods and services included in
the provision of dialysis services (which may include the
costs described in subparagraph (D) as determined appropriate
by the Secretary) that is determined based on an index of
appropriately weighted indicators of changes in wages and
prices which are representative of the mix of goods and
services included in such dialysis services for the calendar
year; exceeds
``(ii) the cost of such mix of goods and services for the
preceding calendar year.
``(B) In determining the percentage under subparagraph (A),
the Secretary may take into account any increase in the costs
of furnishing the mix of goods and services described in such
subparagraph resulting from--
``(i) the adoption of scientific and technological
innovations used to provide dialysis services; and
``(ii) changes in the manner or method of delivering
dialysis services.
``(C) The Secretary shall periodically review and update
(as necessary) the items and services included in the mix of
goods and services used to determine the percentage under
subparagraph (A).
``(D) The costs described in this subparagraph include--
``(i) labor, including direct patient care costs and
administrative labor costs, vacation and holiday pay, payroll
taxes, and employee benefits;
[[Page S8844]]
``(ii) other direct costs, including drugs, supplies, and
laboratory fees;
``(iii) overhead, including medical director fees,
temporary services, general and administrative costs,
interest expenses, and bad debt;
``(iv) capital, including rent, real estate taxes,
depreciation, utilities, repairs, and maintenance; and
``(v) such other allowable costs as the Secretary may
specify.''.
SEC. 602. REVISION OF PAYMENT RATES FOR ESRD PATIENTS
ENROLLED IN MEDICARE+CHOICE PLANS.
(a) In General.--Section 1853(a)(1)(B) (42 U.S.C. 1395w-
23(a)(1)(B)) is amended by adding at the end the following:
``In establishing such rates the Secretary shall provide for
appropriate adjustments to increase each rate to reflect the
demonstration rate (including any risk-adjustment associated
with such rate) of the social health maintenance organization
end-stage renal disease demonstrations established by section
2355 of the Deficit Reduction Act of 1984 (Public Law 98-369;
98 Stat. 1103), as amended by section 13567(b) of the Omnibus
Budget Reconciliation Act of 1993 (Public Law 103-66; 107
Stat. 608), and shall compute such rates by not taking into
account individuals with kidney transplants and individuals
in which the program under this title is a secondary payer to
another payer (or payers) pursuant to section 1862(b).''.
(b) Effective Date.--The amendment made by subsection (a)
shall apply to payments for months beginning with January
2002.
(c) Publication.--The Secretary of Health and Human
Services, not later than 6 months after the date of enactment
of this Act, shall publish for public comment a description
of the appropriate adjustments described in the last sentence
of section 1853(a)(1)(B) of the Social Security Act (42
U.S.C. 1395w-23(a)(1)(B)), as added by subsection (a). The
Secretary shall publish in final form such adjustments by not
later than July 1, 2001, so that the amendment made by
subsection (a) is implemented on a timely basis consistent
with subsection (b).
SEC. 603. PERMITTING ESRD BENEFICIARIES TO ENROLL IN ANOTHER
MEDICARE+CHOICE PLAN IF THE PLAN IN WHICH THEY
ARE ENROLLED IS TERMINATED.
(a) In General.--Section 1851(a)(3)(B) (42 U.S.C. 1395w-
21(a)(3)(B)) is amended by striking ``except that'' and all
that follows and inserting the following: ``except that--
``(i) an individual who develops end-stage renal disease
while enrolled in a Medicare+Choice plan may continue to be
enrolled in that plan; and
``(ii) in the case of such an individual who is enrolled in
a Medicare+Choice plan under clause (i) (or subsequently
under this clause), if the enrollment is discontinued under
circumstances described in section 1851(e)(4)(A) then the
individual will be treated as a `Medicare+Choice eligible
individual' for purposes of electing to continue enrollment
in another Medicare+Choice plan.''.
(b) Effective Date.--
(1) In general.--The amendment made by subsection (a) shall
apply to terminations and discontinuations occurring on or
after the date of enactment of this Act.
(2) Application to prior plan terminations.--Clause (ii) of
section 1851(a)(3)(B) of the Social Security Act (as inserted
by subsection (a)) also shall apply to individuals whose
enrollment in a Medicare+Choice plan was terminated or
discontinued after December 31, 1997, and before the date of
enactment of this Act. In applying this paragraph, such an
individual shall be treated, for purposes of part C of title
XVIII of the Social Security Act, as having discontinued
enrollment in such a plan as of the date of enactment of this
Act.
SEC. 604. COVERAGE OF CERTAIN VASCULAR ACCESS SERVICES FOR
ESRD BENEFICIARIES PROVIDED BY AMBULATORY
SURGICAL CENTERS.
(a) In General.--The matter following subparagraph (B) of
section 1833(i)(1) (42 U.S.C. 1395l(i)(1)) is amended by
adding at the end the following new sentence: ``Such lists
shall include the procedures identified as of July 30, 1999,
by vascular access codes 34101, 34111, 34490, 35190, 35458,
35460, 35475, 35476, 35903, 36005, 36010, 36011, 36120,
36140, 36145, 36215-36218, 36831-36834, 37201, 37204-37208,
37250, 37251, and 49423.''.
(b) Effective Date.--The amendment made by subsection (a)
shall apply to vascular access services furnished on or after
January 1, 2000.
SEC. 605. COLLECTION AND ANALYSIS OF INFORMATION ON THE
SATISFACTION OF ESRD BENEFICIARIES WITH THE
QUALITY OF AND ACCESS TO HEALTH CARE UNDER THE
MEDICARE PROGRAM.
(a) Collection of Information.--The Secretary shall collect
information on the satisfaction of each ESRD medicare
beneficiary with the quality of health care under the
original fee-for-service medicare program and the
Medicare+Choice program, and the access of each beneficiary
to that care.
(b) Analysis of Collected Information.--
(1) In general.--The Secretary shall conduct an analysis of
the information collected under subsection (a) to determine--
(A) the kinds of health care that each non-dialysis health
care provider provides to each ESRD medicare beneficiary for
the treatment of end-stage renal disease and each
comorbidity;
(B) the effect of the availability of supplemental
insurance on the use by beneficiary of health care;
(C) the perceptions of each beneficiary regarding the
access of that beneficiary to health care; and
(D) the quality of health care provided to each ESRD
medicare beneficiary enrolled under the Medicare+Choice
program compared to each beneficiary enrolled under the
original fee-for-service medicare program.
(2) Considerations.--In conducting the analysis under
paragraph (1), the Secretary shall consider--
(A) the feasibility of routinely collecting information on
the satisfaction of each ESRD medicare beneficiary with
dialysis and non-dialysis health care;
(B) whether to collect information using disease specific
questions or generic questions (similar to those used in
conducting the Medicare Current Beneficiary Survey);
(C) how well collected information detects access problems
within each specific group of ESRD medicare beneficiaries,
including beneficiaries without supplemental insurance and
beneficiaries that reside in a rural area; and
(D) each obstacle that a health care provider may face in
offering each type of dialysis service.
(c) Availability of Information and Analysis.--Not later
than January 1 of each year (beginning in 2002) the Secretary
shall make the information collected under subsection (a) and
the analysis conducted under subsection (b) available to the
public.
(d) Definitions.--In this section:
(1) ESRD medicare beneficiary.--The term ``ESRD medicare
beneficiary'' means an individual eligible for benefits under
the medicare program that has end-stage renal disease
(including an individual enrolled in a Medicare+Choice plan
offered by a Medicare+Choice organization under the
Medicare+Choice program).
(2) Medicare+choice program.--The term ``Medicare+Choice
program'' means the program established under part C of title
XVIII of the Social Security Act (42 U.S.C. 1395w-21 et
seq.).
(3) Original fee-for-service medicare program.--The term
``original fee-for-service medicare program'' means the
health benefits program under parts A and B title XVIII of
the Social Security Act (42 U.S.C. 1395 et seq.).
(4) Secretary.--The term ``Secretary'' means the Secretary
of Health and Human Services, acting through the
Administrator of the Health Care Financing Administration.
TITLE VII--ACCESS TO CARE IMPROVEMENTS THROUGH MEDICAID AND SCHIP
SEC. 701. NEW PROSPECTIVE PAYMENT SYSTEM FOR FEDERALLY-
QUALIFIED HEALTH CENTERS AND RURAL HEALTH
CLINICS.
(a) In General.--Section 1902(a) (42 U.S.C. 1396a(a)) is
amended--
(1) in paragraph (13)--
(A) in subparagraph (A), by adding ``and'' at the end;
(B) in subparagraph (B), by striking ``and'' at the end;
and
(C) by striking subparagraph (C); and
(2) by inserting after paragraph (14) the following new
paragraph:
``(15) for payment for services described in subparagraph
(B) or (C) of section 1905(a)(2) under the plan in accordance
with subsection (aa);''.
(b) New Prospective Payment System.--Section 1902 (42
U.S.C. 1396a) is amended by adding at the end the following:
``(aa) Payment for Services Provided by Federally-Qualified
Health Centers and Rural Health Clinics.--
``(1) In general.--Beginning with fiscal year 2001 and each
succeeding fiscal year, the State plan shall provide for
payment for services described in section 1905(a)(2)(C)
furnished by a Federally-qualified health center and services
described in section 1905(a)(2)(B) furnished by a rural
health clinic in accordance with the provisions of this
subsection.
``(2) Fiscal year 2001.--Subject to paragraph (4), for
services furnished during fiscal year 2001, the State plan
shall provide for payment for such services in an amount
(calculated on a per visit basis) that is equal to 100
percent of the costs of the center or clinic of furnishing
such services during fiscal year 2000 which are reasonable
and related to the cost of furnishing such services, or based
on such other tests of reasonableness as the Secretary
prescribes in regulations under section 1833(a)(3), or, in
the case of services to which such regulations do not apply,
the same methodology used under section 1833(a)(3), adjusted
to take into account any increase in the scope of such
services furnished by the center or clinic during fiscal year
2001.
``(3) Fiscal year 2002 and succeeding fiscal years.--
Subject to paragraph (4), for services furnished during
fiscal year 2002 or a succeeding fiscal year, the State plan
shall provide for payment for such services in an amount
(calculated on a per visit basis) that is equal to the amount
calculated for such services under this subsection for the
preceding fiscal year--
``(A) increased by the percentage increase in the MEI (as
defined in section 1842(i)(3)) applicable to primary care
services (as defined in section 1842(i)(4)) for that fiscal
year; and
``(B) adjusted to take into account any increase in the
scope of such services furnished by the center or clinic
during that fiscal year.
``(4) Establishment of initial year payment amount for new
centers or clinics.--
[[Page S8845]]
In any case in which an entity first qualifies as a
Federally-qualified health center or rural health clinic
after fiscal year 2000, the State plan shall provide for
payment for services described in section 1905(a)(2)(C)
furnished by the center or services described in section
1905(a)(2)(B) furnished by the clinic in the first fiscal
year in which the center or clinic so qualifies in an amount
(calculated on a per visit basis) that is equal to 100
percent of the costs of furnishing such services during such
fiscal year in accordance with the regulations and
methodology referred to in paragraph (2). For each fiscal
year following the fiscal year in which the entity first
qualifies as a Federally-qualified health center or rural
health clinic, the State plan shall provide for the payment
amount to be calculated in accordance with paragraph (3).
``(5) Administration in the case of managed care.--In the
case of services furnished by a Federally-qualified health
center or rural health clinic pursuant to a contract between
the center or clinic and a managed care entity (as defined in
section 1932(a)(1)(B)), the State plan shall provide for
payment to the center or clinic (at least quarterly) by the
State of a supplemental payment equal to the amount (if any)
by which the amount determined under paragraphs (2), (3), and
(4) of this subsection exceeds the amount of the payments
provided under the contract.
``(6) Alternative payment methodologies.--Notwithstanding
any other provision of this section, the State plan may
provide for payment in any fiscal year to a Federally-
qualified health center for services described in section
1905(a)(2)(C) or to a rural health clinic for services
described in section 1905(a)(2)(B) in an amount which is
determined under an alternative payment methodology that--
``(A) is agreed to by the State and the center or clinic;
and
``(B) results in payment to the center or clinic of an
amount which is at least equal to the amount otherwise
required to be paid to the center or clinic under this
section.''.
(c) Conforming Amendments.--
(1) Section 4712 of BBA (111 Stat. 508) is amended by
striking subsection (c).
(2) Section 1915(b) (42 U.S.C. 1396n(b)) is amended by
striking ``1902(a)(13)(E)'' and inserting ``1902(a)(15),
1902(aa),''.
(d) Effective Date.--The amendments made by this section
take effect on October 1, 2000, and apply to services
furnished on or after such date.
SEC. 702. TRANSITIONAL MEDICAL ASSISTANCE.
(a) Making Provision Permanent.--
(1) In general.--Subsection (f) of section 1925 (42 U.S.C.
1396r-6) is repealed.
(2) Conforming amendment.--Section 1902(e)(1) (42 U.S.C.
1396a(e)(1)) is repealed.
(b) State Option of Initial 12-Month Eligibility.--Section
1925 (42 U.S.C. 1396r-6) is amended--
(1) in subsection (a), by adding at the end the following
new paragraph:
``(5) Option of 12-month initial eligibility period.--A
State may elect to treat any reference in this subsection to
a 6-month period (or 6 months) as a reference to a 12-month
period (or 12 months). In the case of such an election,
subsection (b) shall not apply.''; and
(2) in subsection (b)(1), by inserting ``and subsection
(a)(5)'' after ``paragraph (3)''.
(c) Simplification Options.--
(1) Removal of administrative reporting requirements for
additional 6-month extension.--Section 1925(b) (42 U.S.C.
1396r-6(b)) is amended--
(A) in paragraph (2)--
(i) in the heading, by striking ``and reporting'';
(ii) by striking subparagraph (B);
(iii) in subparagraph (A)(i)--
(I) by striking ``(I)'' and all that follows through
``(II)'' and inserting ``(i)'';
(II) by striking ``, and (III)'' and inserting ``and
(ii)''; and
(III) by redesignating such subparagraph as subparagraph
(A) (with appropriate indentation); and
(iv) in subparagraph (A)(ii)--
(I) by striking ``notify the family of the reporting
requirement under subparagraph (B)(ii) and a statement of''
and inserting ``provide the family with notification of'';
and
(II) by redesignating such subparagraph as subparagraph (B)
(with appropriate indentation);
(B) in paragraph (3)(A)--
(i) in clause (iii)--
(I) in the heading, by striking ``reporting and test'';
(II) by striking subclause (I); and
(III) by redesignating subclauses (II) and (III) as
subclauses (I) and (II), respectively; and
(ii) by striking the last 3 sentences; and
(C) in paragraph (3)(B), by striking ``subparagraph
(A)(iii)(II)'' and inserting ``subparagraph (A)(iii)(I)''.
(2) Exemption for states covering needy families up to 185
percent of poverty.--Section 1925 (42 U.S.C. 1396r-6), as
amended by subsection (a), is amended--
(A) in each of subsections (a)(1) and (b)(1), by inserting
``but subject to subsection (f),'' after ``Notwithstanding
any other provision of this title,''; and
(B) by adding at the end the following new subsection:
``(f) Exemption for State Covering Needy Families Up to 185
Percent of Poverty.--At State option, the provisions of this
section shall not apply to a State that uses the authority
under section 1931(b)(2)(C) to make medical assistance
available under the State plan under this title, at a
minimum, to all individuals described in section 1931(b)(1)
in families with gross incomes (determined without regard to
work-related child care expenses of such individuals) at or
below 185 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.''.
(3) State option to elect shorter period for requirement
for receipt of medical assistance as a condition of
eligibility for transitional medical assistance.--Section
1925(a)(1) (42 U.S.C. 1396r-6(a)(1)) is amended by inserting
``(or such shorter period as the State may elect)'' after
``3''.
(d) Application of Notice of Eligibility to All Families
Leaving Welfare.--Section 1925(a) (42 U.S.C. 1396r-6(a)), as
amended by subsection (b)(1), is amended by adding at the end
the following new paragraph:
``(6) Notice of eligibility for medical assistance to all
families leaving tanf.--Each State shall notify each family
which was receiving assistance under the State program funded
under part A of title IV and which is no longer eligible for
such assistance, of the potential eligibility of the family
and any individual members of such family for medical
assistance under this title or child health assistance under
title XXI. Such notice shall include a statement that the
family does not have to be receiving assistance under the
State program funded under part A of title IV in order to be
eligible for such medical assistance or child health
assistance.''.
(e) Enrollment Data.--Section 1925 (42 U.S.C. 1396r-6), as
amended by subsection (c)(2)(B), is amended by adding at the
end the following new subsection:
``(g) Enrollment Data.--The Secretary annually shall obtain
from each State with a State plan approved under this title
enrollment data regarding--
``(1) the number of adults and children who--
``(A) receive medical assistance under this title based on
eligibility under section 1931;
``(B) at the time they were first determined to be eligible
for such medical assistance, also received cash assistance
under the State program funded under part A of title IV; and
``(C) subsequently ceased to receive assistance under such
State program due to increased earnings or increased child
support income;
``(2) the percentage of the adults and children described
in paragraph (1) who receive transitional medical assistance
under this section or otherwise remain enrolled in the
program under this title; and
``(3) the percentage of such adults and children that
receive such transitional medical assistance for more than 6
months or that remain enrolled in the program under this
title for more than 6 months after such adults or children
ceased to receive assistance under the State program funded
under part A of title IV.''.
(f) Effective Date.--The amendments made by this section
take effect on October 1, 2000.
SEC. 703. APPLICATION OF SIMPLIFIED SCHIP PROCEDURES UNDER
THE MEDICAID PROGRAM.
(a) Coordination With Medicaid.--
(1) In general.--Section 1902(l) (42 U.S.C. 1396a(l)) is
amended--
(A) in paragraph (3), by inserting ``subject to paragraph
(5)'', after ``Notwithstanding subsection (a)(17),''; and
(B) by adding at the end the following new paragraph:
``(5) With respect to determining the eligibility of
individuals under 19 years of age for medical assistance
under subsection (a)(10)(A)(i)(IV), (a)(10)(A)(i)(VI),
(a)(10)(A)(i)(VII), (a)(10)(A)(ii)(IX), or
(a)(10)(A)(ii)(XIV), notwithstanding any other provision of
this title, if the State has established a State child health
plan under title XXI, or expanded coverage beyond the income
eligibility standards required for such individuals under
this title under a waiver granted under section 1115--
``(A) the State may not apply a resource standard if the
State does not apply such a standard under such child health
plan or section 1115 waiver with respect to such individuals;
``(B) the State shall use the same simplified eligibility
form (including, if applicable, permitting application other
than in person) as the State uses under such State child
health plan or section 1115 waiver with respect to such
individuals;
``(C) the State shall provide for initial eligibility
determinations and redeterminations of eligibility using the
same verification policies, forms, and frequency as the State
uses for such purposes under such State child health plan or
section 1115 waiver with respect to such individuals; and
``(D) the State shall not require a face-to-face interview
for purposes of initial eligibility determinations and
redeterminations unless the State required such an interview
for such purposes under such child health plan or section
1115 waiver with respect to such individuals.''.
(2) Effective date.--The amendments made by paragraph (1)
take effect on October 1, 2000, and apply to eligibility
determinations and redeterminations made on or after such
date.
[[Page S8846]]
(b) Automatic Reassessment of Eligibility for Title XXI and
Medicaid Benefits for Children Losing Medicaid or Title XXI
Eligibility.--
(1) Loss of medicaid eligibility.--Section 1902(a) of the
Social Security Act (42 U.S.C. 1396a(a)) is amended--
(A) by striking the period at the end of paragraph (65) and
inserting ``; and'', and
(B) by inserting after paragraph (65) the following new
paragraph:
``(66) provide, by not later than the first day of the
first month that begins more than 1 year after the date of
the enactment of this paragraph and in the case of a State
with a State child health plan under title XXI, that before
medical assistance to a child (or a parent of a child) is
discontinued under this title, a determination of whether the
child (or parent) is eligible for benefits under title XXI
shall be made and, if determined to be so eligible, the child
(or parent) shall be automatically enrolled in the program
under such title without the need for a new application and
without being asked to provide any information that is
already available to the State.''.
(2) Loss of title xxi eligibility.--Section 2102(b)(3) (42
U.S.C. 1397bb(b)(3)) is amended by redesignating
subparagraphs (D) and (E) as subparagraphs (E) and (F),
respectively, and by inserting after subparagraph (C) the
following new subparagraph:
``(D) that before health assistance to a child (or a parent
of a child) is discontinued under this title, a determination
of whether the child (or parent) is eligible for benefits
under title XIX is made and, if determined to be so eligible,
the child (or parent) is automatically enrolled in the
program under such title without the need for a new
application and without being asked to provide any
information that is already available to the State;''.
(3) Effective date.--The amendments made by paragraphs (1)
and (2) apply to individuals who lose eligibility under the
medicaid program under title XIX, or under a State child
health insurance plan under title XXI, respectively, of the
Social Security Act (42 U.S.C. 1396 et seq.; 1397aa et seq.)
on or after the date that is 60 days after the date of the
enactment of this Act.
SEC. 704. PRESUMPTIVE ELIGIBILITY.
(a) Additional Entities Qualified To Determine Presumptive
Eligibility for Low-Income Children.--
(1) Medicaid.--Section 1920A(b)(3)(A)(i) (42 U.S.C. 1396r-
1a(b)(3)(A)(i)) is amended--
(A) by striking ``or (II)'' and inserting ``, (II)''; and
(B) by inserting ``eligibility of a child for medical
assistance under the State plan under this title, or
eligibility of a child for child health assistance under the
program funded under title XXI, (III) is an elementary school
or secondary school, as such terms are defined in section
14101 of the Elementary and Secondary Education Act of 1965
(20 U.S.C. 8801), an elementary or secondary school operated
or supported by the Bureau of Indian Affairs, a State child
support enforcement agency, a child care resource and
referral agency, an organization that is providing emergency
food and shelter under a grant under the Stewart B. McKinney
Homeless Assistance Act, or a State office or entity involved
in enrollment in the program under this title, under part A
of title IV, under title XXI, or that determines eligibility
for any assistance or benefits provided under any program of
public or assisted housing that receives Federal funds,
including the program under section 8 or any other section of
the United States Housing Act of 1937 (42 U.S.C. 1437 et
seq.), or (IV) any other entity the State so deems, as
approved by the Secretary'' before the semicolon.
(2) Application under schip.--
(A) In general.--Section 2107(e)(1) (42 U.S.C.
1397gg(e)(1)) is amended by adding at the end the following
new subparagraph:
``(D) Section 1920A (relating to presumptive
eligibility).''.
(B) Exception from limitation on administrative expenses.--
Section 2105(c)(2) (42 U.S.C. 1397ee(c)(2)) is amended by
adding at the end the following new subparagraph:
``(C) Exception for presumptive eligibility expenditures.--
The limitation under subparagraph (A) on expenditures shall
not apply to expenditures attributable to the application of
section 1920A (pursuant to section 2107(e)(1)(D)), regardless
of whether the child is determined to be ineligible for the
program under this title or title XIX.''.
(3) Technical amendments.--Section 1920A (42 U.S.C. 1396r-
1a) is amended--
(A) in subsection (b)(3)(A)(ii), by striking ``paragraph
(1)(A)'' and inserting ``paragraph (2)(A)''; and
(B) in subsection (c)(2), in the matter preceding
subparagraph (A), by striking ``subsection (b)(1)(A)'' and
inserting ``subsection (b)(2)(A)''.
(b) Elimination of SCHIP Funding Offset for Exercise of
Presumptive Eligibility Option.--
(1) In general.--Section 2104(d) (42 U.S.C. 1397dd(d)) is
amended by striking ``the sum of--'' and all that follows
through ``(2)'' and conforming the margins of all that
remains accordingly.
(2) Effective date.--The amendment made by paragraph (1)
takes effect October 1, 2000, and applies to allotments under
title XXI of the Social Security Act (42 U.S.C. 1397aa et
seq.) for fiscal year 2001 and each succeeding fiscal year
thereafter.
SEC. 705. IMPROVEMENTS TO THE MATERNAL AND CHILD HEALTH
SERVICES BLOCK GRANT.
(a) Increase in Authorization of Appropriations.--Section
501(a) (42 U.S.C. 701(a)) is amended in the matter preceding
paragraph (1) by striking ``$705,000,000 for fiscal year
1994'' and inserting ``$1,000,000,000 for fiscal year 2001''.
(b) Coordination With Medicaid and SCHIP.--
(1) Schip.--Section 505(a)(5)(F) (42 U.S.C. 705(a)(5)(F))
is amended--
(A) in clause (ii), by inserting ``and in the coordination
of the administration of the State program under title XXI
with the care and services available under this title, as
required under subsections (b)(3)(G) and (c)(2) of section
2102'' before the comma; and
(B) in clause (iv), by striking ``and infants who are
eligible for medical assistance under subparagraph (A) or (B)
of section 1902(l)(1)'' and inserting ``, infants, and
children who are eligible for medical assistance under
section 1902(l)(1), and children who are eligible for child
health assistance under the State program under title XXI''.
(2) Conforming amendments to schip.--Section 2102(b)(3) (42
U.S.C. 1397bb(b)(3)), as amended by section 703(b)(2), is
amended--
(A) by striking ``and'' at the end of subparagraph (E);
(B) by striking the period at the end of subparagraph (F)
and inserting ``; and''; and
(C) by adding at the end the following new subparagraph:
``(G) that operations and activities under this title are
developed and implemented in consultation and coordination
with the program operated by the State under title V with
respect to outreach and enrollment, benefits and services,
service delivery standards, public health and social service
agency relationships, and quality assurance and data
reporting.''.
(c) Effective Date.--The amendments made by this section
take effect on October 1, 2000.
SEC. 706. IMPROVING ACCESS TO MEDICARE COST-SHARING
ASSISTANCE FOR LOW-INCOME BENEFICIARIES.
(a) Increase in SLMB Eligibility.--
(1) In general.--Section 1902(a)(10)(E) (42 U.S.C.
1396a(a)(10)(E)) is amended--
(A) in clause (iii), by striking ``and 120 percent in
1995'' and inserting ``, 120 percent in 1995 through 2000,
and 135 percent in 2001''; and
(B) in clause (iv), by striking ``2002)--'' and all that
follows through ``(II) for'' and inserting ``2002) for''.
(2) Conforming amendment.--Section 1933(c)(2)(A) (42 U.S.C.
1396u-3(c)(2)(A)) is amended by striking ``sum of--'' and all
that follows through ``(ii) the''''.
(3) Effective date.--The amendments made by this subsection
take effect on January 1, 2001, and with respect to the
amendment made by paragraph (2), applies to allocations
determined under section 1933(c) of the Social Security Act
(42 U.S.C. 1396u-3(c)) for the last 3 quarters of fiscal year
2001 and all of fiscal year 2002.
(b) Index of Assets Test to Inflation.--Section
1905(p)(1)(C) (42 U.S.C. 1396d(p)(1)(C)) is amended by
inserting ``, increased (beginning with 2001 and each year
thereafter) by the percentage increase (if any) in the
Consumer Price Index for All Urban Consumers (United States
city average)'' before the period.
(c) Increased Effort To Provide Medicare Beneficiaries With
Medicare Cost-Sharing Under the Medicaid Program.--
(1) In general.--Section 1902(a) (42 U.S.C. 1396a(a)), as
amended by section 703(b)(1)(A), is amended--
(A) in paragraph (65), by striking ``and'' at the end;
(B) in paragraph (66), by striking the period and inserting
``; and''; and
(C) by inserting after paragraph (66) the following new
paragraph:
``(67) provide for the determination of eligibility for
medicare cost-sharing (as defined in section 1905(p)(3)) for
individuals described in paragraph (10)(E) and, if eligible
for such medicare cost-sharing, for the enrollment of such
individuals at any hospital, clinic, or similar entity at
which State or local agency personnel are stationed for the
purpose of determining the eligibility of individuals for
medical assistance under the State plan or providing outreach
services to eligible or potentially eligible individuals.''.
(2) Effective date.--The amendments made by this paragraph
shall take effect on the date of enactment of this Act.
(d) Presumptive Eligibility of Certain Low-Income
Individuals for Medicare Cost-Sharing Under the QMB or SLMB
Program.--Title XIX (42 U.S.C. 1396 et seq.) is amended by
inserting after section 1920A the following new section:
``presumptive eligibility of certain low-income individuals
``Sec. 1920B. (a) A State plan approved under section 1902
shall provide for making medical assistance with respect to
medicare cost-sharing covered under the State plan available
to a low-income individual on the date the low-income
individual becomes entitled to benefits under part A of title
XVIII during a presumptive eligibility period.
``(b) For purposes of this section:
``(1) The term `low-income individual' means an individual
who at the age of 65 years is described--
``(A) in section 1902(a)(10)(E)(i), or
``(B) in section 1902(a)(10)(E)(iii).
``(2) The term `medicare cost-sharing'--
[[Page S8847]]
``(A) with respect to an individual described in paragraph
(1)(A), has the meaning given such term in section
1905(p)(3); and
``(B) with respect to an individual described in paragraph
(1)(B), has the meaning given such term in section
1905(p)(3)(A).
``(3) The term `presumptive eligibility period' means, with
respect to a low-income individual, the period that--
``(A) begins with the date on which a qualified entity
determines, on the basis of preliminary information, that the
income and resources of the individual do not exceed the
applicable income and resource level of eligibility under the
State plan, and
``(B) ends with (and includes) the earlier of--
``(i) the day on which a determination is made with respect
to the eligibility of the low-income individual for medical
assistance for medical cost-sharing under the State plan, or
``(ii) in the case of a low-income individual on whose
behalf an application is not filed by the last day of the
month following the month during which the entity makes the
determination referred to in subparagraph (A), such last day.
``(4)(A) Subject to subparagraph (B), the term `qualified
entity' means any of the following:
``(i) Qualified individuals within the Social Security
Administration.
``(ii) An entity determined by the State agency to be
capable of making determinations of the type described in
paragraph (3).
``(B) The Secretary may issue regulations further limiting
those entities that may become qualified entities in order to
prevent fraud and abuse and for other reasons.
``(c)(1) The State agency, after consultation with the
Secretary, shall provide qualified entities with--
``(A) such forms as are necessary for an application to be
made on behalf of a low-income individual for medical
assistance for medical cost-sharing under the State plan, and
``(B) information on how to assist low-income individuals
and other persons in completing and filing such forms.
``(2) A qualified entity that determines under subsection
(b)(2)(A) that a low-income individual is presumptively
eligible for medical assistance for medical cost-sharing
under a State plan shall--
``(A) notify the State agency of the determination within 5
working days after the date on which the determination is
made, and
``(B) inform the low-income individual at the time the
determination is made that an application for medical
assistance for medical cost-sharing under the State plan is
required to be made by not later than the last day of the
month following the month during which the determination is
made.
``(3) In the case of a low-income individual who is
determined by a qualified entity to be presumptively eligible
for medical assistance for medical cost-sharing under a State
plan, the low-income individual shall make application for
medical assistance for medical cost-sharing under such plan
by not later than the last day of the month following the
month during which the determination is made.
``(d) Notwithstanding any other provision of this title,
medical assistance for medicare cost-sharing that--
``(1) is furnished to a low-income individual during a
presumptive eligibility period under the State plan; and
``(2) is included in the services covered by a State plan;
shall be treated as medical assistance provided by such plan
for purposes of section 1903.''.
SEC. 707. BREAST AND CERVICAL CANCER PREVENTION AND
TREATMENT.
(a) Coverage as Optional Categorically Needy Group.--
(1) In general.--Section 1902(a)(10)(A)(ii) (42 U.S.C.
1396a(a)(10)(A)(ii)) is amended--
(A) in subclause (XVI), by striking ``or'' at the end;
(B) in subclause (XVII), by adding ``or'' at the end; and
(C) by adding at the end the following:
``(XVIII) who are described in subsection (aa) (relating to
certain breast or cervical cancer patients);''.
(2) Group described.--Section 1902 (42 U.S.C. 1396a) is
amended by adding at the end the following:
``(aa) Individuals described in this subsection are
individuals who--
``(1) are not described in subsection (a)(10)(A)(i);
``(2) have not attained age 65;
``(3) have been screened for breast and cervical cancer
under the Centers for Disease Control and Prevention breast
and cervical cancer early detection program established under
title XV of the Public Health Service Act (42 U.S.C. 300k et
seq.) in accordance with the requirements of section 1504 of
that Act (42 U.S.C. 300n) and need treatment for breast or
cervical cancer; and
``(4) are not otherwise covered under creditable coverage,
as defined in section 2701(c) of the Public Health Service
Act (42 U.S.C. 300gg(c)).''.
(3) Limitation on benefits.--Section 1902(a)(10) (42 U.S.C.
1396a(a)(10)) is amended in the matter following subparagraph
(G)--
(A) by striking ``and (XIII)'' and inserting ``(XIII)'';
and
(B) by inserting ``, and (XIV) the medical assistance made
available to an individual described in subsection (aa) who
is eligible for medical assistance only because of
subparagraph (A)(10)(ii)(XVIII) shall be limited to medical
assistance provided during the period in which such an
individual requires treatment for breast or cervical cancer''
before the semicolon.
(4) Conforming amendments.--Section 1905(a) (42 U.S.C.
1396d(a)) is amended in the matter preceding paragraph (1)--
(A) in clause (xi), by striking ``or'' at the end;
(B) in clause (xii), by adding ``or'' at the end; and
(C) by inserting after clause (xii) the following:
``(xiii) individuals described in section 1902(aa),''.
(b) Presumptive Eligibility.--
(1) In general.--Title XIX (42 U.S.C. 1396 et seq.) is
amended by inserting after section 1920A the following:
``presumptive eligibility for certain breast or cervical cancer
patients
``Sec. 1920B. (a) State Option.--A State plan approved
under section 1902 may provide for making medical assistance
available to an individual described in section 1902(aa)
(relating to certain breast or cervical cancer patients)
during a presumptive eligibility period.
``(b) Definitions.--For purposes of this section:
``(1) Presumptive eligibility period.--The term
`presumptive eligibility period' means, with respect to an
individual described in subsection (a), the period that--
``(A) begins with the date on which a qualified entity
determines, on the basis of preliminary information, that the
individual is described in section 1902(aa); and
``(B) ends with (and includes) the earlier of--
``(i) the day on which a determination is made with respect
to the eligibility of such individual for services under the
State plan; or
``(ii) in the case of such an individual who does not file
an application by the last day of the month following the
month during which the entity makes the determination
referred to in subparagraph (A), such last day.
``(2) Qualified entity.--
``(A) In general.--Subject to subparagraph (B), the term
`qualified entity' means any entity that--
``(i) is eligible for payments under a State plan approved
under this title; and
``(ii) is determined by the State agency to be capable of
making determinations of the type described in paragraph
(1)(A).
``(B) Regulations.--The Secretary may issue regulations
further limiting those entities that may become qualified
entities in order to prevent fraud and abuse and for other
reasons.
``(C) Rule of construction.--Nothing in this paragraph
shall be construed as preventing a State from limiting the
classes of entities that may become qualified entities,
consistent with any limitations imposed under subparagraph
(B).
``(c) Administration.--
``(1) In general.--The State agency shall provide qualified
entities with--
``(A) such forms as are necessary for an application to be
made by an individual described in subsection (a) for medical
assistance under the State plan; and
``(B) information on how to assist such individuals in
completing and filing such forms.
``(2) Notification requirements.--A qualified entity that
determines under subsection (b)(1)(A) that an individual
described in subsection (a) is presumptively eligible for
medical assistance under a State plan shall--
``(A) notify the State agency of the determination within 5
working days after the date on which the determination is
made; and
``(B) inform such individual at the time the determination
is made that an application for medical assistance under the
State plan is required to be made by not later than the last
day of the month following the month during which the
determination is made.
``(3) Application for medical assistance.--In the case of
an individual described in subsection (a) who is determined
by a qualified entity to be presumptively eligible for
medical assistance under a State plan, the individual shall
apply for medical assistance under such plan by not later
than the last day of the month following the month during
which the determination is made.
``(d) Payment.--Notwithstanding any other provision of this
title, medical assistance that--
``(1) is furnished to an individual described in subsection
(a)--
``(A) during a presumptive eligibility period; and
``(B) by a entity that is eligible for payments under the
State plan; and
``(2) is included in the care and services covered by the
State plan,
shall be treated as medical assistance provided by such plan
for purposes of clause (4) of the first sentence of section
1905(b).''.
(2) Conforming amendments.--
(A) Section 1902(a)(47) (42 U.S.C. 1396a(a)(47)) is amended
by inserting before the semicolon at the end the following:
``and provide for making medical assistance available to
individuals described in subsection (a) of section 1920B
during a presumptive eligibility period in accordance with
such section''.
(B) Section 1903(u)(1)(D)(v) (42 U.S.C. 1396b(u)(1)(D)(v))
is amended--
(i) by striking ``or for'' and inserting ``, for''; and
[[Page S8848]]
(ii) by inserting before the period the following: ``, or
for medical assistance provided to an individual described in
subsection (a) of section 1920B during a presumptive
eligibility period under such section''.
(c) Enhanced Match.--The first sentence of section 1905(b)
(42 U.S.C. 1396d(b)) is amended--
(1) by striking ``and'' before ``(3)''; and
(2) by inserting before the period at the end the
following: ``, and (4) the Federal medical assistance
percentage shall be equal to the enhanced FMAP described in
section 2105(b) with respect to medical assistance provided
to individuals who are eligible for such assistance only on
the basis of section 1902(a)(10)(A)(ii)(XVIII)''.
(d) Effective Date.--The amendments made by this section
apply to medical assistance for items and services furnished
on or after October 1, 2000, without regard to whether final
regulations to carry out such amendments have been
promulgated by such date.
TITLE VIII--OTHER PROVISIONS
SEC. 801. APPROPRIATIONS FOR RICKY RAY HEMOPHILIA RELIEF
FUND.
Section 101(e) of the Ricky Ray Hemophilia Relief Fund Act
of 1998 (42 U.S.C. 300c-22 note) is amended by adding at the
end the following: ``There is appropriated to the Fund
$475,000,000 for fiscal year 2001, to remain available until
expended.''.
SEC. 802. INCREASE IN APPROPRIATIONS FOR SPECIAL DIABETES
PROGRAMS FOR CHILDREN WITH TYPE I DIABETES AND
INDIANS.
(a) Special Diabetes Programs for Children With Type I
Diabetes.--Section 330B(b) of the Public Health Service Act
(42 U.S.C. 254c-2(b)) is amended--
(1) by striking ``Notwithstanding'' and inserting the
following:
``(1) Transferred funds.--Notwithstanding''; and
(2) by adding at the end the following:
``(2) Appropriations.--For the purpose of making grants
under this section, there are appropriated, out of any money
in the Treasury not otherwise appropriated--
``(A) $70,000,000 for each of fiscal years 2001 and 2002
(which shall be combined with amounts transferred under
paragraph (1) for each such fiscal years); and
``(B) $100,000,000 for each of fiscal years 2003 through
2005.''.
(b) Special Diabetes Programs for Indians.--Section 330C(c)
of the Public Health Service Act (42 U.S.C. 254c-3(c)) is
amended--
(1) by striking ``Notwithstanding'' and inserting the
following:
``(1) Transferred funds.--Notwithstanding'';
(2) by adding at the end the following:
``(2) Appropriations.--For the purpose of making grants
under this section, there are appropriated, out of any money
in the Treasury not otherwise appropriated--
``(A) $70,000,000 for each of fiscal years 2001 and 2002
(which shall be combined with amounts transferred under
paragraph (1) for each such fiscal years); and
``(B) $100,000,000 for each of fiscal years 2003 through
2005.''.
SEC. 803. DEMONSTRATION GRANTS TO IMPROVE OUTREACH,
ENROLLMENT, AND COORDINATION OF PROGRAMS AND
SERVICES TO HOMELESS INDIVIDUALS AND FAMILIES.
(a) Authority.--The Secretary of Health and Human Services
may award demonstration grants to not more than 7 States (or
other qualified entities) to conduct innovative programs that
are designed to improve outreach to homeless individuals and
families under the programs described in subsection (b) with
respect to enrollment of such individuals and families under
such programs and the provision of services (and coordinating
the provision of such services) under such programs.
(b) Programs for Homeless Described.--The programs
described in this subsection are as follows:
(1) Medicaid.--The program under title XIX of the Social
Security Act (42 U.S.C. 1396 et seq.).
(2) SCHIP.--The program under title XXI of such Act (42
U.S.C. 1397aa et seq.).
(3) TANF.--The program under part of A of title IV of such
Act (42 U.S.C. 601 et seq.).
(4) Maternal and child health block grants.--The program
under title V of the Social Security Act (42 U.S.C. 701 et
seq.).
(5) Mental health and substance abuse block grants.--The
program under part B of title XIX of the Public Health
Service Act (42 U.S.C. 300x-1 et seq.).
(6) HIV/AIDS care grants.--The program under part B of
title XXVI of the Public Health Service Act (42 U.S.C. 300ff-
21 et seq.).
(7) Food stamp program.--The program under the Food Stamp
Act of 1977 (7 U.S.C. 2011 et seq.).
(8) Workforce investment act.--The program under the
Workforce Investment Act of 1999 (29 U.S.C. 2801 et seq.).
(9) Welfare-to-work.--The welfare-to-work program under
section 403(a)(5) of the Social Security Act (42 U.S.C.
603(a)(5)).
(10) Other programs.--Other public and private benefit
programs that serve low-income individuals.
(c) Appropriations.--For the purposes of carrying out this
section, there are appropriated, out of any funds in the
Treasury not otherwise appropriated, $10,000,000, to remain
available until expended.
SEC. 804. PROTECTION OF AN HMO ENROLLEE TO RECEIVE CONTINUING
CARE AT A FACILITY SELECTED BY THE ENROLLEE.
(a) Amendments to the Employee Retirement Income Security
Act of 1974.--
(1) In general.--Subpart B of part 7 of subtitle B of title
I of the Employee Retirement Income Security Act of 1974 (29
U.S.C. 1185 et seq.) is amended by adding at the end the
following new section:
``SEC. 714. ENSURING CHOICE FOR CONTINUING CARE.
``(a) In General.--With respect to health insurance
coverage provided to participants or beneficiaries through a
managed care organization under a group health plan, or
through a health insurance issuer providing health insurance
coverage in connection with a group health plan, such plan or
issuer may not deny coverage for services provided to such
participant or beneficiary by a continuing care retirement
community, skilled nursing facility, or other qualified
facility in which the participant or beneficiary resided
prior to a hospitalization, regardless of whether such
organization is under contract with such community or
facility if the requirements described in subsection (b) are
met.
``(b) Requirements.--The requirements of this subsection
are that--
``(1) the service involved is a service for which the
managed care organization involved would be required to
provide or pay for under its contract with the participant or
beneficiary if the continuing care retirement community,
skilled nursing facility, or other qualified facility were
under contract with the organization;
``(2) the participant or beneficiary involved--
``(A) resided in the continuing care retirement community,
skilled nursing facility, or other qualified facility prior
to being hospitalized;
``(B) had a contractual or other right to return to the
facility after hospitalization; and
``(C) elects to return to the facility after
hospitalization, whether or not the residence of the
participant or beneficiary after returning from the hospital
is the same part of the facility in which the beneficiary
resided prior to hospitalization;
``(3) the continuing care retirement community, skilled
nursing facility, or other qualified facility has the
capacity to provide the services the participant or
beneficiary needs; and
``(4) the continuing care retirement community, skilled
nursing facility, or other qualified facility is willing to
accept substantially similar payment under the same terms and
conditions that apply to similarly situated health care
facility providers under contract with the organization
involved.
``(c) Services To Prevent Hospitalization.--A group health
plan or health insurance issuer to which this section applies
may not deny payment for a skilled nursing service provided
to a participant or beneficiary by a continuing care
retirement community, skilled nursing facility, or other
qualified facility in which the participant or beneficiary
resides, without a preceding hospital stay, regardless of
whether the organization is under contract with such
community or facility, if--
``(1) the plan or issuer has determined that the service is
necessary to prevent the hospitalization of the participant
or beneficiary; and
``(2) the service to prevent hospitalization is provided as
an additional benefit as described in section 417.594 of
title 42, Code of Federal Regulations, and would otherwise be
covered as provided for in subsection (b)(1).
``(d) Rights of Spouses.--A group health plan or health
insurance issuer to which this section applies shall not deny
payment for services provided by a skilled nursing facility
for the care of a participant or beneficiary, regardless of
whether the plan or issuer is under contract with such
facility, if the spouse of the participant or beneficiary is
already a resident of such facility and the requirements
described in subsection (b) are met.
``(e) Exceptions.--Subsection (a) shall not apply--
``(1) where the attending acute care provider and the
participant or beneficiary (or a designated representative of
the participant or beneficiary where the participant or
beneficiary is physically or mentally incapable of making an
election under this paragraph) do not elect to pursue a
course of treatment necessitating continuing care; or
``(2) unless the community or facility involved--
``(A) meets all applicable licensing and certification
requirements of the State in which it is located; and
``(B) agrees to reimbursement for the care of the
participant or beneficiary at a rate similar to the rate
negotiated by the managed care organization with similar
providers of care for similar services.
``(f) Prohibitions.--A group health plan and a health
insurance issuer providing health insurance coverage in
connection with a group health plan may not--
``(1) deny to an individual eligibility, or continued
eligibility, to enroll or to renew coverage with a managed
care organization under the plan, solely for the purpose of
avoiding the requirements of this section;
``(2) provide monetary payments or rebates to enrollees to
encourage such enrollees to accept less than the minimum
protections available under this section;
``(3) penalize or otherwise reduce or limit the
reimbursement of an attending physician because such
physician provided care to a participant or beneficiary in
accordance with this section; or
[[Page S8849]]
``(4) provide incentives (monetary or otherwise) to an
attending physician to induce such physician to provide care
to a participant or beneficiary in a manner inconsistent with
this section.
``(g) Rules of Construction.--
``(1) HMO not offering benefits.--This section shall not
apply with respect to any managed care organization under a
group health plan, or through a health insurance issuer
providing health insurance coverage in connection with a
group health plan, that does not provide benefits for stays
in a continuing care retirement community, skilled nursing
facility, or other qualified facility.
``(2) Cost-sharing.--Nothing in this section shall be
construed as preventing a managed care organization under a
group health plan, or through a health insurance issuer
providing health insurance coverage in connection with a
group health plan, from imposing deductibles, coinsurance, or
other cost-sharing in relation to benefits for care in a
continuing care facility.
``(h) Preemption; Exception for Health Insurance Coverage
in Certain States.--
``(1) In general.--The requirements of this section shall
not apply with respect to health insurance coverage to the
extent that a State law (as defined in section 2723(d)(1) of
the Public Health Service Act) applies to such coverage and
is described in any of the following subparagraphs:
``(A) Such State law requires such coverage to provide for
referral to a continuing care retirement community, skilled
nursing facility, or other qualified facility in a manner
that is more protective of participants or beneficiaries than
the provisions of this section.
``(B) Such State law expands the range of services or
facilities covered under this section and is otherwise more
protective of the rights of participants or beneficiaries
than the provisions of this section.
``(2) Construction.--Section 731(a)(1) shall not be
construed to provide that any requirement of this section
applies with respect to health insurance coverage, to the
extent that a State law described in paragraph (1) applies to
such coverage.
``(i) Penalties.--A participant or beneficiary may enforce
the provisions of this section in an appropriate Federal
district court. An action for injunctive relief or damages
may be commenced on behalf of the participant or beneficiary
by the participant's or beneficiary's legal representative.
The court may award reasonable attorneys' fees to the
prevailing party. If a beneficiary dies before conclusion of
an action under this section, the action may be maintained by
a representative of the participant's or beneficiary's
estate.
``(j) Definitions.--In this section:
``(1) Attending acute care provider.--The term `attending
acute care provider' means anyone licensed or certified under
State law to provide health care services who is operating
within the scope of such license and who is primarily
responsible for the care of the enrollee.
``(2) Continuing care retirement community.--The term
`continuing care retirement community' means an organization
that provides or arranges for the provision of housing and
health-related services to an older person under an agreement
effective for the life of the person or for a specified
period greater than 1 year.
``(3) Managed care organization.--The term `managed care
organization' means an organization that provides
comprehensive health services to participants or
beneficiaries, directly or under contract or other agreement,
on a prepayment basis to such individuals. For purposes of
this section, the following shall be considered as managed
care organizations:
``(A) A Medicare+Choice plan authorized under section
1851(a) of the Social Security Act (42 U.S.C. 1395w-21(a)).
``(B) Any other entity that manages the cost, utilization,
and delivery of health care through the use of predetermined
periodic payments to health care providers employed by or
under contract or other agreement, directly or indirectly,
with the entity.
``(4) Other qualified facility.--The term `other qualified
facility' means any facility that can provide the services
required by the participant or beneficiary consistent with
State and Federal law.
``(5) Skilled nursing facility.--The term `skilled nursing
facility' means a facility that meets the requirements of
section 1819 of the Social Security Act (42 U.S.C. 1395i-
3).''.
(2) Clerical amendment.--The table of contents in section 1
of the Employee Retirement Income Security Act of 1974 is
amended by inserting after the items relating to subpart B of
part 7 of subtitle B of title I the following new item:
``Sec. 714. Ensuring choice for continuing care.''.
(3) Effective date.--The amendments made by this section
shall apply with respect to plan years beginning on or after
January 1, 2001.
(b) Amendment to the Public Health Service Act Relating to
the Group Market.--
(1) In general.--Subpart 2 of part A of title XXVII of the
Public Health Service Act (42 U.S.C. 300gg-4 et seq.) is
amended by adding at the end the following new section:
``SEC. 2707. ENSURING CHOICE FOR CONTINUING CARE.
``(a) In General.--With respect to health insurance
coverage provided to enrollees through a managed care
organization under a group health plan, or through a health
insurance issuer providing health insurance coverage in
connection with a group health plan, such plan or issuer may
not deny coverage for services provided to such enrollee by a
continuing care retirement community, skilled nursing
facility, or other qualified facility in which the enrollee
resided prior to a hospitalization, regardless of whether
such organization is under contract with such community or
facility if the requirements described in subsection (b) are
met.
``(b) Requirements.--The requirements of this subsection
are that--
``(1) the service involved is a service for which the
managed care organization involved would be required to
provide or pay for under its contract with the enrollee if
the continuing care retirement community, skilled nursing
facility, or other qualified facility were under contract
with the organization;
``(2) the enrollee involved--
``(A) resided in the continuing care retirement community,
skilled nursing facility, or other qualified facility prior
to being hospitalized;
``(B) had a contractual or other right to return to the
facility after hospitalization; and
``(C) elects to return to the facility after
hospitalization, whether or not the residence of the enrollee
after returning from the hospital is the same part of the
facility in which the beneficiary resided prior to
hospitalization;
``(3) the continuing care retirement community, skilled
nursing facility, or other qualified facility has the
capacity to provide the services the enrollee needs; and
``(4) the continuing care retirement community, skilled
nursing facility, or other qualified facility is willing to
accept substantially similar payment under the same terms and
conditions that apply to similarly situated health care
facility providers under contract with the organization
involved.
``(c) Services To Prevent Hospitalization.--A group health
plan or health insurance issuer to which this section applies
may not deny payment for a skilled nursing service provided
to an enrollee by a continuing care retirement community,
skilled nursing facility, or other qualified facility in
which the enrollee resides, without a preceding hospital
stay, regardless of whether the plan or issuer is under
contract with such community or facility, if--
``(1) the plan or issuer has determined that the service is
necessary to prevent the hospitalization of the enrollee; and
``(2) the service to prevent hospitalization is provided as
an additional benefit as described in section 417.594 of
title 42, Code of Federal Regulations, and would be covered
as provided for in subsection (b)(1).
``(d) Rights of Spouses.--A group health plan or health
insurance issuer to which this section applies shall not deny
payment for services provided by a skilled nursing facility
for the care of an enrollee, regardless of whether the plan
or issuer is under contract with such facility, if the spouse
of the enrollee is already a resident of such facility and
the requirements described in subsection (b) are met.
``(e) Exceptions.--Subsection (a) shall not apply--
``(1) where the attending acute care provider and the
enrollee (or a designated representative of the enrollee
where the enrollee is physically or mentally incapable of
making an election under this paragraph) do not elect to
pursue a course of treatment necessitating continuing care;
or
``(2) unless the community or facility involved--
``(A) meets all applicable licensing and certification
requirements of the State in which it is located; and
``(B) agrees to reimbursement for the care of the enrollee
at a rate similar to the rate negotiated by the managed care
organization with similar providers of care for similar
services.
``(f) Prohibitions.--A group health plan and a health
insurance issuer providing health insurance coverage in
connection with a group health plan may not--
``(1) deny to an individual eligibility, or continued
eligibility, to enroll or to renew coverage with a managed
care organization under the plan, solely for the purpose of
avoiding the requirements of this section;
``(2) provide monetary payments or rebates to enrollees to
encourage such enrollees to accept less than the minimum
protections available under this section;
``(3) penalize or otherwise reduce or limit the
reimbursement of an attending physician because such
physician provided care to an enrollee in accordance with
this section; or
``(4) provide incentives (monetary or otherwise) to an
attending physician to induce such physician to provide care
to an enrollee in a manner inconsistent with this section.
``(g) Rules of Construction.--
``(1) HMO not offering benefits.--This section shall not
apply with respect to any managed care organization under a
group health plan, or through a health insurance issuer
providing health insurance coverage in connection with a
group health plan, that does not provide benefits for stays
in a continuing care retirement community, skilled nursing
facility, or other qualified facility.
``(2) Cost-sharing.--Nothing in this section shall be
construed as preventing a managed care organization under a
group health plan, or through a health insurance issuer
[[Page S8850]]
providing health insurance coverage in connection with a
group health plan, from imposing deductibles, coinsurance, or
other cost-sharing in relation to benefits for care in a
continuing care facility.
``(h) Preemption; Exception for Health Insurance Coverage
in Certain States.--
``(1) In general.--The requirements of this section shall
not apply with respect to health insurance coverage to the
extent that a State law (as defined in section 2723(d)(1))
applies to such coverage and is described in any of the
following subparagraphs:
``(A) Such State law requires such coverage to provide for
referral to a continuing care retirement community, skilled
nursing facility, or other qualified facility in a manner
that is more protective of the enrollee than the provisions
of this section.
``(B) Such State law expands the range of services or
facilities covered under this section and is otherwise more
protective of enrollee rights than the provisions of this
section.
``(2) Construction.--Section 2723(a)(1) shall not be
construed to provide that any requirement of this section
applies with respect to health insurance coverage, to the
extent that a State law described in paragraph (1) applies to
such coverage.
``(i) Penalties.--An enrollee may enforce the provisions of
this section in an appropriate Federal district court. An
action for injunctive relief or damages may be commenced on
behalf of the enrollee by the enrollee's legal
representative. The court may award reasonable attorneys'
fees to the prevailing party. If a beneficiary dies before
conclusion of an action under this section, the action may be
maintained by a representative of the enrollee's estate.
``(j) Definitions.--In this section:
``(1) Attending acute care provider.--The term `attending
acute care provider' means anyone licensed or certified under
State law to provide health care services who is operating
within the scope of such license and who is primarily
responsible for the care of the enrollee.
``(2) Continuing care retirement community.--The term
`continuing care retirement community' means an organization
that provides or arranges for the provision of housing and
health-related services to an older person under an agreement
effective for the life of the person or for a specified
period greater than 1 year.
``(3) Managed care organization.--The term `managed care
organization' means an organization that provides
comprehensive health services to enrollees, directly or under
contract or other agreement, on a prepayment basis to such
individuals. For purposes of this section, the following
shall be considered as managed care organizations:
``(A) A Medicare+Choice plan authorized under section
1851(a) of the Social Security Act (42 U.S.C. 1395w-21(a)).
``(B) Any other entity that manages the cost, utilization,
and delivery of health care through the use of predetermined
periodic payments to health care providers employed by or
under contract or other agreement, directly or indirectly,
with the entity.
``(4) Other qualified facility.--The term `other qualified
facility' means any facility that can provide the services
required by the enrollee consistent with State and Federal
law.
``(5) Skilled nursing facility.--The term `skilled nursing
facility' means a facility that meets the requirements of
section 1819 of the Social Security Act (42 U.S.C. 1395i-
3).''.
(2) Effective date.--The amendment made by this section
shall apply with respect to group health plans for plan years
beginning on or after January 1, 2001.
(c) Amendments to the Public Health Service Act Relating to
the Individual Market.--
(1) In general.--The first subpart 3 of part B of title
XXVII of the Public Health Service Act (42 U.S.C. 300gg-51 et
seq.) (relating to other requirements) is amended--
(A) by redesignating such subpart as subpart 2; and
(B) by adding at the end the following new section:
``SEC. 2753. ENSURING CHOICE FOR CONTINUING CARE.
``The provisions of section 2707 shall apply to health
maintenance organization coverage offered by a health
insurance issuer in the individual market in the same manner
as they apply to such coverage offered by a health insurance
issuer in connection with a group health plan in the small or
large group market.''.
(2) Effective date.--The amendment made by this section
shall apply with respect to health insurance coverage
offered, sold, issued, renewed, in effect, or operated in the
individual market on or after January 1, 2001.
SEC. 805. GRANTS TO DEVELOP AND ESTABLISH REAL CHOICE SYSTEMS
CHANGE INITIATIVES.
(a) Establishment.--
(1) In general.--The Secretary of Health and Human Services
(in this section referred to as the ``Secretary'') shall
award grants described in subsection (b) to States to support
real choice systems change initiatives that establish
specific action steps and specific timetables to achieve
enduring system improvements and to provide consumer-
responsive long-term services and supports to eligible
individuals in the most integrated setting appropriate based
on the unique strengths and needs of the individual, the
priorities and concerns of the individual (or, as
appropriate, the individual's representative), and the
individual's desires with regard to participation in
community life.
(2) Eligibility.--To be eligible for a grant under this
section, a State shall--
(A) establish a Consumer Task Force in accordance with
subsection (d); and
(B) submit an application at such time, in such manner, and
containing such information as the Secretary may determine.
The application shall be jointly developed and signed by the
designated State official and the chairperson of such Task
Force, acting on behalf of and at the direction of the Task
Force.
(3) Definition of state.--In this section, the term
``State'' means each of the 50 States, the District of
Columbia, Puerto Rico, Guam, the United States Virgin
Islands, American Samoa, and the Commonwealth of the Northern
Mariana Islands.
(b) Grants for Real Choice Systems Change Initiatives.--
(1) In general.--From funds appropriated under subsection
(f), the Secretary shall award grants to States to--
(A) support the establishment, implementation, and
operation of the State real choice systems change initiatives
described in subsection (a); and
(B) conduct outreach campaigns regarding the existence of
such initiatives.
(2) Determination of awards; state allotments.--The
Secretary shall develop a formula for the distribution of
funds to States for each fiscal year under subsection (a).
Such formula shall give preference to States that have a
higher need for assistance, as determined by the Secretary,
based on indicators such as a relatively higher proportion of
long-term services and supports furnished to individuals in
an institutional setting but who have a plan described in an
application submitted under subsection (a)(2).
(c) Authorized Activities.--A State that receives a grant
under this section shall use the funds made available through
the grant to accomplish the purposes described in subsection
(a) and, in accomplishing such purposes, may carry out any of
the following systems change activities:
(1) Needs assessment and data gathering.--The State may use
funds to conduct a statewide needs assessment that may be
based on data in existence on the date on which the
assessment is initiated and may include information about the
number of individuals within the State who are receiving
long-term services and supports in unnecessarily segregated
settings, the nature and extent to which current programs
respond to the preferences of individuals with disabilities
to receive services in home and community-based settings as
well as in institutional settings, and the expected change in
demand for services provided in home and community settings
as well as institutional settings.
(2) Institutional bias: remedies and promotion of community
participation.--The State may use funds to identify, develop,
and implement strategies for modifying policies, practices,
and procedures that unnecessarily bias the provision of long-
term services and supports toward institutional settings and
away from home and community-based settings, including
policies, practices, and procedures governing statewideness,
comparability in amount, duration, and scope of services,
financial eligibility, individualized functional assessments
and screenings (including individual and family involvement),
knowledge about service options, and promotion of self-
direction of services and community-integrated living and
service arrangements that facilitate participation in
community life to the fullest extent possible and desired by
the individual.
(3) Over medicalization of services.--The State may use
funds to identify, develop, and implement strategies for
modifying policies, practices, and procedures that
unnecessarily bias the provision of long-term services and
supports by health care professionals to the extent that
quality services and supports can be provided by other
qualified individuals, including policies, practices, and
procedures governing service authorization, case management,
and service coordination, service delivery options, quality
controls, and supervision and training.
(4) Interagency coordination; single point of entry.--The
State may support activities to identify and coordinate
Federal and State policies, resources, and services, relating
to the provision of long-term services and supports,
including the convening of interagency work groups and the
entering into of interagency agreements that provide for a
single point of entry with one-stop access for long-term
support services and the design and implementation of a
coordinated screening and assessment system for all persons
eligible for long-term services and supports.
(5) Training and technical assistance.--The State may carry
out directly, or may provide support to a public or private
entity to carry out training and technical assistance
activities that are provided for individuals with
disabilities, and, as appropriate, their representatives,
attendants, and other personnel (including professionals,
paraprofessionals, volunteers, and other members of the
community).
(6) Public awareness.--The State may support a public
awareness program that is designed to provide information
relating to the availability of choices available to
individuals with disabilities for receiving long-
[[Page S8851]]
term services and support in the most integrated setting
appropriate.
(7) Transitional costs.--The State may use funds to provide
transitional costs such as rent and utility deposits, first
months's rent and utilities, bedding, basic kitchen supplies,
and other necessities required for an individual to make the
transition from an institutional facility to a community-
based home setting where the individual resides.
(8) Task force.--The State may use funds to support the
operation of the Consumer Task Force established under
subsection (d).
(9) Demonstrations of new approaches.--The State may use
funds to conduct, on a time-limited basis, the demonstration
of new approaches to accomplishing the purposes described in
subsection (a)(1).
(10) Improvement in the quality of services and supports.--
The State may use funds to improve the quality of services
and supports provided to individuals with disabilities and
their families.
(11) Other activities.--The State may use funds for any
systems change activities that are not described in any of
the preceding paragraphs of this subsection and that are
necessary for developing, implementing, or evaluating the
comprehensive statewide system of community-integrated long-
term services and supports.
(d) Consumer Task Force.--
(1) Establishment and duties.--To be eligible to receive a
grant under this section, each State shall establish a
Consumer Task Force (referred to in this section as the
``Task Force'') to assist the State in the development,
implementation, and evaluation of real choice systems change
initiatives.
(2) Appointment.--Members of the Task Force shall be
appointed by the Chief Executive Officer of the State in
accordance with the requirements of paragraph (3), after the
solicitation of recommendations from representatives of
organizations representing a broad range of individuals with
disabilities and organizations interested in individuals with
disabilities.
(3) Composition.--
(A) In general.--The Task Force shall represent a broad
range of individuals with disabilities from diverse
backgrounds and shall include representatives from
Developmental Disabilities Councils, Mental Health Councils,
State Independent Living Centers and Councils, Commissions on
Aging, organizations that provide services to individuals
with disabilities and consumers of long-term services and
supports.
(B) Individuals with disabilities.--A majority of the
members of the Task Force shall be individuals with
disabilities or the representatives of such individuals.
(C) Limitation.--The Task Force shall not include employees
of any State agency providing services to individuals with
disabilities other than employees of agencies described in
the Developmental Disabilities Assistance and Bill of Rights
Act (42 U.S.C. 6000 et seq.) or the Protection and Advocacy
for Mentally Ill Individuals Act of 1986 (42 U.S.C. 10801 et
seq.).
(e) Availability of Funds.--
(1) Funds allotted to states.--Funds allotted to a State
under a grant made under this section for a fiscal year shall
remain available until expended.
(2) Funds not allotted to states.--Funds not allotted to
States in the fiscal year for which they are appropriated
shall remain available in succeeding fiscal years for
allotment by the Secretary using the allotment formula
established by the Secretary under subsection (b)(2).
(f) Annual Report.--A State that receives a grant under
this section shall submit an annual report to the Secretary
on the use of funds provided under the grant. Each report
shall include the number and percentage increase in the
number of eligible individuals in the State who receive long-
term services and supports in the most integrated setting
appropriate, including through community attendant services
and supports and other community-based settings.
(g) Funding.--
(1) Fiscal year 2001.--For the purpose of making grants
under this section, there are appropriated, out of any funds
in the Treasury not otherwise appropriated, $50,000,000 for
fiscal year 2001.
(2) Fiscal year 2002 and thereafter.--There is authorized
to be appropriated such sums as may be necessary to carry out
this section for fiscal year 2002 and each fiscal year
thereafter.
____
There being no objection, the material was ordered to be printed in
the Record, as follows:
Balanced Budget Refinement Act of 2000--Summary
The Balanced Budget Act (BBA) of 1997 made some important
changes in Medicare payment policy and contributed to our
current period of budget surpluses through significant cost
savings in Medicare. CBO originally estimated the Medicare
spending cuts at $112 billion over 5 years. Some of the
policies enacted in the BBA, however, cut payments to
providers more significantly than expected--in some cases
more than double the expected amount--and threaten the
survival of institutions and services vital to seniors and
their communities throughout the country.
The Congress addressed some of those unintended
consequences last year, by enacting the Balanced Budget
Refinement Act (BBRA), which added back $16 billion over 5
years in payments to various Medicare providers.
However, Congress is continuing to hear serious concerns
from health care providers and beneficiaries in our States--
particularly teaching hospitals and hospitals serving people
who are uninsured or underinsured, as well as concerns from
skilled nursing facilities, rural health providers, home
health agencies, and Medicare managed care providers.
In light of the projected $700 billion on-budget surplus
over the next 5 years and the problems facing vital health
care services, the Congress should enact an additional,
significant package of BBA adjustments and beneficiary
protections. Senate Democrats are therefore today introducing
the Balanced Budget Refinement Act of 2000 (BBRA-2000), which
is a package of payment adjustments and access to care
provisions amounting to about $40 billion over 5 years.
Hospitals. A significant portion of the BBA spending
reductions have impacted hospitals. According to the Medicare
Payment Advisory Commission (MedPAC), ``Hospitals' financial
status deteriorated significantly in 1998 and 1999,'' the
years following enactment of BBA. BBRA-2000 would address the
most pressing problems facing hospitals by:
Fully restoring, for fiscal years `01 and `02, inpatient
market basket payments to keep up with increases in hospital
costs, an improvement that will help all hospitals.
Preventing implementation of further reductions in (IME)
payment rates for vital teaching hospitals--which are on the
cutting edge of medical research and provide essential care
to a large proportion of indigent patients. Support for
medical training and research at independent children's
hospitals is also included in the Democratic proposal.
Targeting additional relief to rural hospitals (Critical
Access Hospitals, Medicare Dependent Hospitals, and Sole
Community Hospitals) and making it easier for them to qualify
for disproportionate share payments under Medicare.
Providing additional support for hospitals with a
disproportionate share of indigent patients, including
elimination of scheduled reductions in Medicare and Medicaid
disproportionate share (DSH) payments, and extending Medicaid
to legal immigrant children and pregnant women, as well as
providing State Children's Health Insurance Program (SCHIP)
coverage to these children.
Establishing a grant program to assist hospitals in their
transition to a more data intensive care-delivery model.
Providing Puerto Rico hospitals with a more favorable
payment rate (specifically, the inpatient operating blend
rate) as MedPAC data suggests is warranted.
Home Health. The BBA hit home agencies particularly hard.
Home health spending dropped 45 percent between 1997 and
1999, while the number of home health declined by more than
2000 over that period. MedPAC has cautioned against
implementing next year the scheduled 15 percent reduction in
payments. BBRA-2000 would:
Repeal the scheduled 15 percent cut in home health
payments, delay for at least two years the inclusion of
medical supplies in the home health prospective payment
system (PPS), and provide a 10-percent upward adjustment in
rural home health payments for two years to address the
special needs of rural home health agencies in the transition
to PPS. BBRA-2000 would also provide an exception for ``very
rural'' home health agencies under the branch office
definition.
Provide full update payments (inflation) for medical
equipment, oxygen, and other suppliers.
Skilled Nursing Facilities (SNFs). The BBA was expected to
reduce payments to skilled nursing facilities by about $9.5
billion. The actual reduction in payments to SNFs over the
period is estimated to be significantly larger. BBRA-2000
would:
Allow nursing home payments to keep up with increases in
costs through a full market basket update for SNFs for FY
2001 and FY 2002, and market basket plus two percent for
additional payments.
Further delay caps on the amount of physical/speech therapy
and occupational therapy a patient can receive while the
Secretary completes a scheduled study on this issue.
Rural. Rural providers typically serve a larger proportion
of Medicare beneficiaries and are more adversely affected by
reductions in Medicare payments. In addition to the rural
relief measures noted above (under ``hospitals''), BBRA-2000
addresses the unique situation faced in rural areas through a
number of measures, including: a permanent ``hold-harmless''
exemption for small rural hospitals from the Medicare
Outpatient PPS; assistance for rural home health agencies; a
capital loan fund to improve infrastructure of small rural
facilities; assistance to develop technology related to new
prospective payment systems; bonus payments for providers who
serve independent hospitals; ensuring rural facilities can
continue to offer quality lab services to beneficiaries; and
specific provisions to assist Rural Health Clinics.
Hospice. Payments to hospics have not kept up with the cost
of providing care because of the cost of prescription drugs,
the therapies now used in end-of-life care, as well as
decreasing lengths of stay. Hospice base rates have not been
increased since 1989. BBRA-220 would provide significant
additional funding for hospice services to account for their
increasing costs, including full market basket updates for
fiscal years `01 and `02 and a 10-percent upward adjustment
in the underlying hospice rates.
[[Page S8852]]
Medicare+Choice. This legislation would ensure that
appropriate payments are made to Medicare+Choice (M+C) plans.
Expenditures by Medicare for its fee-for-service providers
included in BBRA-2000 indirectly benefit M+C plans to a
significant extent. Moreover, the legislation includes an
increase in the M+C growth percentage for fiscal years `01
and `02, permitting plans to move to the 50:50 blended
payment one year earlier, and allowing plans which have
decided to withdraw to reconsider by November 2000.
Physicians. Congress understands the pressures that
physicians face to deliver high-quality care while still
complying with payment and other regulatory obligations.
BBRA-2000 provides for comprehensive studies of issues
important to physicians, including: the practice expense
component of the Resource-Based Relative Value Scale (RBRVS)
physician payment system, post-payment audits, and regulatory
burdens. BBRA-2000 would provide relief to physicians in
training, whose debt can often be crushing, by lowering the
threshold for loan deferment from $72,000 to $48,000.
Beneficiary Improvements. Senate Democrats continue to
believe that passage of a universal, affordable, voluntary,
and meaningful Medicare prescription drug benefit is the
highest priority for beneficiaries. In addition, BBRA-2000
would directly assist beneficiaries in the following ways:
Coinsurance: BBRA-2000 would lower beneficiary coinsurance
to achieve a true 20 percent beneficiary copayment for all
hospital outpatient services within 20 years.
Preventive Benefits: The bill would provide for significant
advances in preventive medicine for Medicare beneficiaries,
including waiver of deductibles and cost-sharing, glaucoma
screening, counseling for smoking cessation, and nutrition
therapy.
Immunosuppressive Drugs: The bill would remove current
restrictions on payment for immunosuppressive drugs for organ
transplant patients.
ALS: The bill would waive the 24-month waiting period for
Medicare disability coverage for individuals diagnosed with
amyotrophic lateral sclerosis (ALS).
M+C Transition: For beneficiaries who have lost
Medicare+Choice plans in their area, BBRA-2000 includes
provisions that would strengthen fee-for-service Medicare and
assist beneficiaries in the period immediately following loss
of service.
Return-to-home: The bill would allow beneficiaries to
return to the same nursing home or other appropriate site-of-
care after a hospital stay.
Other Provisions. BBRA-2000 would address other high
priority issues, including: improved payment for dialysis in
fee-for-service and M+C to assure access to quality care for
end stage renal disease (ESRD) patients; increased market
basket updates for ambulance providers in fiscal years `01
and `02; an immediate opt-in to the new ambulance fee
schedule for affected providers; and enhanced training
opportunities for geriatricians and clinical psychologists.
BBRA-2000 also includes important modifications to the
Community Nursing Organization (CNO) demonstration project,
and additional funding for the Ricky Ray Hemophilia program
Medicaid and SCHIP. The growing number of uninsured
individuals and declining enrollment in the Medicaid program
are issues which also must be addressed. To improve access to
health care for the uninsured and ensure that services
available through the Medicaid and SCHIP programs are
reaching those eligible for assistance, BBRA-2000 includes
the following provisions:
Improve eligibility and enrollment processes in SCHIP and
Medicaid.
Extend and improve the Transitional Medical Assistance
program for people who leave welfare for work.
Improve access to Medicare cost-sharing assistance for low-
income beneficiaries.
Give states grants to develop home and community based
services for beneficiaries who would otherwise be in nursing
homes.
Create a new prospective payment system (PPS) for Community
Health Centers to ensure they remain a strong, viable
component of our health care safety net.
Extend Medicaid coverage of breast and cervical cancer
treatment to women diagnosed through the federally-funded
early detection program.
____
National Immigration
Law Center,
Washington, DC, September 20, 2000.
Hon. Daniel Patrick Moynihan,
464 Senate Russell Office Building,
Washington, DC.
Dear Senator Moynihan: We strongly applaud your decision to
include important health care restorations for low-income
immigrant children and pregnant women in the Senate
Democrat's Balanced Budget Act Refinement and Access to Care
proposal. The provisions would permit federal reimbursement
to states that choose to cover lawfully present children and
pregnant women under their Medicaid and State Children's
Health Insurance Programs.
As you know, legislation passed in 1996, at a time of very
tight budgets, left the safety net for legal immigrants in
tatters. As a result, health dare coverage for low-income
lawfully present immigrant children and pregnant women has
become a state-by-state patchwork, with tragic results. In
many states, there is no coverage at all for large numbers of
these children and pregnant women.
The policy of denying federal health care to lawfully
present immigrants is unfair and unwise. It is unfair because
immigrants pay the same taxes as all others, and deserve the
same access to health care that those taxes buy. In fact,
immigrant taxes are more than sufficient to pay for the
health care needs and all other expenses associated with
immigration. The average immigrant contributes $1,800 more
each year in taxes than the government pays out for her,
including the costs of roads, infrastructure, and education,
as well as all government services.
The policy is unwise because we are counting on these
immigrant children to join with all other children in
contributing to the American dream. They cannot do so if they
are hindered in their early years because they could not
obtain health care. And it is unwise because it shifts the
responsibility for immigrant health care from the federal to
the state governments, rather than maintain a shared federal-
state responsibility.
The Balanced Budget Act Refinement and Access to Care
proposal recognizes that some of the cuts to health care
providers made in the name of balancing the budget went too
far. In this time of surpluses, as Congress considers
proposals to eliminate the excesses of those budget cuts on
behalf of health care providers, Congress should also restore
services to lawfully present immigrant children and pregnant
women who sacrificed as much as anyone under the budget
balancing legislation of the 1990's.
Sincerely,
Asian Pacific American Labor Alliance, Alliance for
Children and Families, American College Obstetricians
and Gynecologists, Center for Public Policy Priorities,
Children's Defense Fund, Coalition for Humane Immigrant
Rights of Los Angeles, Council of Great City Schools,
Families USA, Florida Immigrant Advocacy Center, Inc.,
Florida Legal Services, Inc., Hebrew Immigrant Aid
Society, Immigrant Legal Resource Center, Immigration
and Refugee Services of America, Jewish Federation of
Metro Chicago, Jewish Council for Public Affairs, March
of Dimes, Migrant Legal Action Program, National Asian
Pacific American Legal Consortium, National Association
of Public Hospitals and Health Systems, National
Council of La Raza, National Head Start Association,
National Health Law Program, National Korean American
Service & Education Consortium (NAKASEC), National
Immigration Law Center, New Jersey Immigration Policy
Network, Inc., New York Immigration Coalition,
Massachusetts Immigrant and Refugee Advocacy Coalition,
Southeast Asia Resource Action Center, Texas Appleseed,
Texas Immigrant and Refugee Coalition, and United
Jewish Communities.
____
National Association of Public
Hospitals and Health Systems,
Washington DC, September 20, 2000.
Dear Senator Moynihan: I am writing on behalf of the
National Association of Public Hospitals & Health Systems
(NAPH) to express our strong support for the ``Medicare,
Medicaid, and SCHIP Balanced Budget Further Refinement Act of
2000.'' NAPH represents more than 100 metropolitan area
safety net hospitals and health systems. As safety net
institutions, our members are essential providers of care to
uninsured and vulnerable populations whose access would
otherwise be severely limited. More than 65 percent of the
patients served by these systems are either Medicaid
recipients or Medicare beneficiaries; another 25 percent are
uninsured.
NAPH is pleased that this legislation includes a number of
provisions that will assist low-income Medicaid beneficiaries
and the providers that serve them. In particular, we are
pleased that the legislation would avert Medicaid DSH
allotment reductions after fiscal year 2000 otherwise
required by the BBA. Medicaid DSH is our nation's primary
source of support for safety net hospitals that serve the
most vulnerable Medicaid, uninsured and underinsured
patients.
NAPH has long been supportive of efforts to expand access
to health insurance coverage and is pleased that the
legislation includes a number of these provisions. In
particular, the proposed legislation would allow states the
option to provide coverage under Medicaid and/or SCHIP for
legal immigrants, which will reduce confusion regarding
eligibility in the immigrant community, allow legal
immigrants to receive more appropriate care, and improve
public health in general. The legislation also includes a
state option to provide Medicaid coverage for certain women
diagnosed with breast or cervical cancer and provides
requirements designed to simplify Medicaid eligibility. We
are grateful for your efforts to expand Medicaid and SCHIP to
ensure that all low-income Americans have access to
appropriate health coverage.
NAPH is also pleased that the legislation addresses many of
the severe payment reductions in many areas (in addition to
Medicaid DSH) imposed by the BBA on providers. In particular,
NAPH is pleased that the legislation eliminates further
Medicare DSH reductions, freezes IME adjustments, and
restores the full market basket index update to hospital PPS
rates beginning April, 2001.
We thank you for your ongoing leadership in developing
legislation to assure the maintenance of the health care
safety net and we look forward to working with you further to
develop solutions to the problems of our nation's poor and
uninsured. If you have any
[[Page S8853]]
questions about this letter, please contact Charles Luband at
(202) 624-7215.
Sincerely,
Larry S. Gage,
President.
____
Families USA, The Voice for
Health Care Consumers,
September 20, 2000.
Senator Patrick Moynihan,
464 Russell Senate Office Building,
Washington, DC.
Dear Senator Moynihan: As you introduce the Medicare,
Medicaid and SCHIP Balanced Budget Further Refinement Act of
2000, we want to support a number of provisions that will
improve low-income people's access to health care coverage.
In particular, we support the expansion of Medicaid to
certain immigrant children and pregnant women, the
improvements for Medicaid adults and children, the changes
which will ease enrollment for children who may be eligible
for Medicaid and the State Child Health Insurance Program and
the changes which will help low-income seniors who may be
eligible for the Qualified Medicare Beneficiary (QMB) Program
and the Specified Low-Income Medicare Beneficiary (SLMB)
Program receive assistance in getting help with Medicare
premiums and cost-sharing.
As you well know, despite the concerted efforts of many
people, the number of uninsured Americans has continued to
grow. Recent studies have shown that uninsured Americans are
less likely to have a usual source of care, are more likely
to delay seeking care, and are less likely to use preventive
services. In addition, uninsured Americans are four times
more likely than insured patients to require both avoidable
hospitalizations and emergency hospital care.
These provisions will help more people get access to public
health insurance programs. Please let us know if we can be of
assistance in getting these provisions enacted into law.
Sincerely,
Ronald F. Pollack,
Executive Director.
____
Association of Maternal
and Child Health Programs,
September 20, 2000.
Hon. Daniel Patrick Moynihan,
U.S. Senate,
Washington, DC.
Dear Senator Moynihan: The Association of Maternal and
Child Health Programs (AMCHP) strongly supports your efforts
to further refine the Balanced Budget Act of 1997 (BBA) and
increase access to health care. In particular, we commend
your leadership over the years in improving our nation's
fiscal health. Through this visionary leadership, the nation
now has a projected $2.2 trillion on-budget surplus over the
next 10 years. It is both appropriate and fair that a portion
of this surplus should help offset severe problems facing our
health care services.
AMCHP strongly supports efforts included in your
legislation to improve access to health care for many
uninsured people including legal immigrant children and
pregnant women. In addition, we applaud efforts to improve
eligibility and enrollment processes in SCHIP and Medicaid.
AMCHP and its members want to particularly thank you for your
support of enhanced coordination and cooperation among the
various health care programs aimed at improving maternal and
child health and for your efforts to increase the
authorization level for Title V.
The Association of Maternal and Child Health Programs is an
organization dedicated to providing leadership in assuring
the health and well being of all women of reproductive age,
children and youth, including those with special health care
needs and their families. The state directors of Title V and
related programs formed the association in 1944 to share
information and collaborate with each other and others
concerned with the health of mothers and children.
In closing, thank you for your most recent efforts on
behalf of maternal and child health through the introduction
of legislation intended to further refine the BBA and improve
access to health care.
Very truly yours,
Deborah F. Dietrich,
Director of Legislative Affairs.
____
National Association of
Community Health Centers, Inc.,
September 20, 2000.
Hon. Tom Daschle,
Democratic Leader, U.S. Senate,
Washington, DC.
Hon. Daniel Patrick Moynihan,
Ranking Member, Senate Finance Committee, Washington, DC.
Dear Senators Daschle and Moynihan: On behalf of the
National Association of Community Health Centers (NACHC), the
nationwide network of 3,000 health centers, and the more than
11 million patients they serve, I am writing to express our
extreme gratitude for your inclusion of the text of S. 1277,
the Safety Net Preservation act, in your legislation to
provide relief from the Balanced Budget Act of 1997 (BBA).
As you know, the BBA eliminated a fundamental underpinning
of America's health center safety net by phasing-out and
eventually terminating the Medicaid cost-based reimbursement
system for Federally qualified health centers. Because health
centers are required by Federal law to provide access to care
to anyone, regardless of ability to pay, centers cannot
afford to be underpaid for services provided to Medicaid
patients. In other words, without this payment system, health
centers will be forced to subsidize low Medicaid payments
with grant dollars intended to care for the uninsured--
thereby forcing them to reduce the health care services they
provide in their communities.
In an effort to protect health centers from the loss of
this system, the Safety Net Preservation Act has been
introduced in the House and Senate to ensure that health
centers receive adequate Medicaid payments. This legislation,
which has the bipartisan support of 54 members of the Senate
and 243 members of the House of Representatives, has been
endorsed by NACHC, the National Association of Rural Health
Clinics, the National Rural Health Association, the United
States Conference of Mayors, and the National Association of
Counties.
Health centers believe that this legislation is essential
to their continued survival and will ensure that they remain
a viable part of America's health care safety net. Thank you
again for your commitment to protecting health centers
through your BBA relief legislation. It is our sincerest hope
that the Safety Net Preservation Act will be included in any
BBA relief package and signed into law by the time the 106th
Congress adjourns.
Please feel free to contact me if there is anything that I
can do for you.
Sincerely,
Thomas J. Van Coverden,
President and CEO.
____
Center on Budget and
Policy Priorities,
September 20, 2000.
Hon. Daniel Patrick Moynihan,
Senate Russell Building,
Washington, DC.
Dear Senator Moynihan: We write to applaud your efforts to
help low-income families and children access much-needed
health care coverage. In particular, the Center on Budget and
Policy Priorities strongly supports provisions in your
``Medicare, Medicaid, and S-CHIP Balanced Budget Refinement
Act of 2000'' aimed at reversing a trend of declining access
to health coverage by low-income families and immigrant
children. These provisions are important because families
with children have been losing out on health care coverage as
a result of unanticipated consequences of recent federal and
state actions.
A growing body of evidence indicates that a significant
number of low-income families with children have been
inadvertently harmed by federal and state laws enacted in
recent years to promote welfare reform. Despite the best
intentions of many policymakers, disturbing numbers of
families leaving welfare for work have lost out on health
care coverage. Indeed, a recent Center analysis found that
roughly half of parents and nearly one out of three children
leaving welfare lost Medicaid and were at high risk of being
uninsured even though the vast majority of them remained
eligible for Medicaid or SCHIP. Similarly, studies indicate
that the Medicaid participation of children in legal
immigrant families has dropped in recent years. The largest
group of such children consists of those who remain eligible
for Medicaid because they are citizens of the United States.
These children were not the intended targets of immigration-
based restrictions on Medicaid coverage included in the 1996
welfare law, but they nevertheless have been adversely
affected by the confusion and fear generated by the
immigration-based restrictions on health care coverage
included in the 1996 welfare law and modified in the Balanced
Budget Act of 1997.
For these reasons, we strongly applaud the provisions in
your legislation that would undue many of the unintended
consequences on health care coverage for low-income families
of recent state and federal actions, as well as restore
health care coverage to all legal immigrant children. In
particular, we strongly support the provisions designed to
promote the simplification, coordination, and streamlining of
states' application and re-enrollment procedures; to expand
state flexibility to allow schools and other organizations
that work with families to enroll children in health care
coverage under the ``presumptive eligibility'' option; to
give states more flexibility to provide transitional Medicaid
coverage to families leaving welfare for work; and to restore
state flexibility to cover legal immigrant children and
pregnant women who arrived in the United States after August
22, 1996. In combination, these provisions would represent a
very significant step forward.
Sincerely,
Robert Greenstein,
Executive Director.
____
THE NATIONAL COUNCIL
ON THE AGING,
Washington, DC, September 20, 2000.
Hon. Daniel Patrick Moynihan,
464 Russell Senate Office Building,
Washington, DC.
Dear Senator Moynihan: On behalf of the National Council on
the Aging (NCOA)--the nation's first organization formed to
represent older Americans and those who serve them--I write
to express our sincere gratitude and support for the numerous
provisions in your Medicare Balanced Budget Act (BBA)
refinement bill that would directly help Medicare
beneficiaries.
In particular, we strongly support provisions to: (1)
clarify the Medicare home health ``homebound'' problem; (2)
improve Medicare low-income protections; (3) improve Medicare
coverage and utilization of preventive services; (4) remove
the arbitrary
[[Page S8854]]
cap on immunosuppressive drug coverage; (5) provide grants to
states for home and community-based care; and (6) accelerate
the phase-in period for reducing hospital outpatient
coinsurance.
First, under current law, in order for Medicare
beneficiaries to receive coverage for home health services
they must be ``confined to home.'' Current irrational and
inconsistent interpretations of this homebound requirement
are causing substantial harm to Medicare beneficiaries by
effectively forcing home health users to be imprisoned within
their own homes. We deeply appreciate the provision to permit
beneficiaries with Alzheimer's disease or related dementia to
receive therapeutic treatment in adult day centers without
losing home health coverage. We urge that you consider going
further by including Senator Jeffords' S. 2298, which is
endorsed by 46 national organizations and would provide
relief for all beneficiaries suffering under the homebound
problem.
Second, our current methods for protecting low-income
Medicare beneficiaries against increasing out-of-pocket costs
are simply abysmal. A shocking number of those eligible for
protection simply do not receive it. Current Medicare low-
income protections are a national embarrassment. NCOA
strongly supports provisions in your bill to: provide for
presumptive eligibility for low-income protections;
significantly improve the QI-1 program for beneficiaries with
incomes between 120% and 135% of poverty; index the asset
test to inflation, which is long overdue; and improve
outreach for Qualified Medicare Beneficiaries.
Third, NCOA strongly supports the provisions to improve
preventive care for Medicare beneficiaries. It is often
easier and less expensive to prevent disease than to cure it.
Disease prevention must be an essential component of Medicare
beneficiaries' continuum of care. Medicare, however, still
fails to cover a number of important preventive services, and
those that are covered are underutilized. We support
provisions to extend Medicare coverage to tobacco cessation
counseling, glaucoma screening and medical nutrition therapy.
The addition of these new benefits will accelerate the
critical shift in Medicare from a sickness program to a
wellness program. We also support the provision to eliminate
all coinsurance and deductibles for preventive services.
Utilization of these critical services has been surprisingly
low. By encouraging greater utilization of these services,
beneficiaries' quality of life will be greatly enhanced and
Medicare expenditures will decline over the long run.
Fourth, NCOA supports the provision to eliminate the
arbitrary and costly cap on benefits for immunosuppressive
drug coverage under Medicare. The Institute of Medicine
recently recommended eliminating the time limitation, noting
the positive economic, clinical and social implications. It
makes no sense for Medicare to pay for the more expensive
consequences of organ rejection, such as dialysis or a second
transplant, but refuse to pay for the drugs to prevent the
rejection of the initial transplanted organ beyond 44 months.
This coverage can mean the difference between life and death
for some and, for others, the difference between a transplant
recipient having to experience the pain of an organ
rejection, a return to dialysis--for kidney recipients--and
the return to a long waiting list for another organ.
Fifth, we strongly support providing grants to states for
home and community-based care and to assist in implementing
the Supreme Court's Olmstead decision. These services are
grossly underfunded, resulting in unreasonable and costly
burdens on caregivers and premature placement in
institutions. Funding for home and community-based care
promotes dignity and independence and helps keep families
together. America's long-term care crisis will only grow
worse as our population ages. The proposed grants are a good
start in addressing the serious institutional bias that
exists for persons with disabilities needing long-term
services and supports.
Sixth, we support accelerating the phase-in period for
reducing hospital outpatient coinsurance. Coinsurance for
these services now averages almost 50 percent of costs.
Although current law provides that coinsurance amounts will
remain fixed at their current dollar level until they are
reduced to 20 percent of Medicare-approved payment amounts,
the process will take up to 40 years for some services. By
comparison, the most gradual phase-in Medicare has used to
date for any payment system change is 10 years. The current
phase-in schedule is simply far too long.
NCOA commends and thanks you for your strong leadership on
these important issues for America's seniors. Please let us
know if there is anything we can do to assist you in enacting
these provisions into law this year.
Sincerely,
Howard Bedlin,
Vice President, Public Policy and Advocacy.
____
Greater New York
Hospital Association,
New York, NY, September 20, 2000.
Hon. Daniel Patrick Moynihan,
464 Russell Senate Office Building,
Washington, DC.
Dear Senator Moynihan, The Greater New York Hospital
Association (GNYHA) is extremely pleased to express its
strong and unqualified support for your bill, ``The Medicare,
Medicaid, and SCHIP Balanced Budget Refinement Act of 2000,''
co-sponsored by your colleagues, Senator Charles E. Schumer
and Senator Tom Daschle. This bill, if enacted, would greatly
improve the Medicare program for all of its beneficiaries as
well as provide critical, permanent relief for America's
hospitals, skilled nursing facilities, and home health
agencies from Medicare reductions contained in the Balanced
Budget Act of 1997 (BBA).
For beneficiaries, your legislation makes a number of
important improvements in the Medicare program including new
coverage for many critical preventive health care benefits.
In addition, you provide an option for states to provide
Medicaid and SCHIP coverage for pregnant women and children
who, because they are immigrants, have been denied health
care coverage due to the restrictions contained in the
Personal Responsibility and Work Opportunity Reconciliation
Act of 1996. The bill also simplifies the SCHIP enrollment
process and improves SCHIP and Medicaid in a variety of other
ways. GNYHA strongly supports these provisions.
Your bill also recognizes that Medicare and Medicaid
beneficiaries cannot receive quality health care services
unless the health care providers they rely upon have the
resources to provide the best care possible. To that end,
GNYHA strongly supports the following provisions.
The bill halts further Medicare reductions to teaching
hospitals by maintaining the indirect medical education (IME)
payment adjustment at 6.5 percent permanently, incorporating
the provisions of your Teaching Hospital Preservation Act (S.
2394). As you know, the BBA called for a 29 percent reduction
in Medicare payments to teaching hospitals for the indirect
costs of medical education. The BBRA postponed the cuts by
one year; however, under current law, the IME adjustment
would be reduced to 6.25 percent in FY 2001 and 5.5 percent
in FY 2002 and years thereafter. The Further Refinement Act
freezes IME adjustments at 6.5 percent, saving America's
teaching hospitals from over $2 billion in additional
Medicare cuts. The bill also provides greater flexibility to
allow hospitals to increase the number of residents training
in geriatrics and allows hospitals to be reimbursed by
Medicare for the costs of training clinical psychologists.
The bill provides a full market basket update for
prospective payment system hospitals, nursing homes, and home
health agencies for the next two years. Under the BBA,
hospitals would have received market basket minus 1.1 percent
in FY 2001 and FY 2002, and nursing homes and home health
agencies would have received market basket minus 1 percent.
The BBA reduced inflation updates so substantially that the
market basket update reductions constituted the largest
single cuts suffered by hospitals and continuing care
providers under the BBA. This bill ensures Medicare payments
will keep pace with the increased costs of caring for
Medicare beneficiaries by providing full market basket
updates.
This bill restores Medicare funding for disproportionate
share hospitals (DSH) by eliminating cuts in DSH payments,
thus strengthening the safety net DSH hospitals provide for
low-income patients.
The bill eliminates further reductions in Medicare DSH
payments to states, thus enabling states to provide critical
support for hospitals that serve a disproportionate share of
low-income and uninsured patients.
The bill creates a grant program to help hospitals obtain
advanced information systems to improve quality and
efficiency.
The bill eliminates the 15 percent reduction for home
health reimbursement rates, which under current law would
take affect in 2002.
The bill extends the ``prudent layperson'' standard to
ambulance services, so that ambulance providers are not
unfairly denied payment by HMOs for services legitimately
provided to Medicare beneficiaries.
The Medicare, Medicaid, and SCHIP Balanced Budget Further
Refinement Act of 2000 recognizes the need to improve the
Medicare program by providing much-needed coverage for
Medicare beneficiaries, the need to improve the Medicaid and
SCHIP programs for low-income Americans, and the need to
repair the damage to hospitals and continuing care providers
as a result of the BBA. Without your efforts, hospitals and
continuing care providers will continue to struggle to
provide quality care and will be forced to close down
services essential to the health care needs of their
communities.
GNYHA will work diligently with members of Congress to
ensure passage of this very important legislation. GNYHA
would like to thank you for once again providing the strong
leadership necessary to improve the health care of all New
Yorkers.
My best.
Sincerely,
Kenneth E. Raske,
President.
Mr. DASCHLE. Mr. President, I join today with Senator Moynihan and
many of our colleagues in introducing the Balanced Budget Refinement
Act of 2000 (BBRA-2000).
The Balanced Budget Act of 1997 (BBA) made some justified changes in
Medicare payment policy and contributed to our current budget
surpluses. It also included important provisions to improve seniors'
access to preventive benefits, and it created the Children's
[[Page S8855]]
Health Insurance Program. These are important accomplishments.
But some of the policies enacted in the BBA cut providers
significantly more than expected. This has created severe problems for
health care providers all over the country. Last year, we took steps to
correct these problems. But we did not go far enough.
When I met with hospital administrators in South Dakota earlier this
summer, one told me that since the cuts from the BBA were implemented,
his hospital has been just barely breaking even. Usually, that alone
would be cause for concern. But then other hospital administrators told
me they were jealous, because they are far from breaking even. In my
state, the operating margins for hospitals with 50 or fewer beds were a
relatively healthy 2 percent before the BBA. Last year, these small
hospitals--which are so vital to their communities--had negative
margins of 6 percent.
Hospitals are not the only health care providers facing this problem.
Home health agencies, nursing homes, hospices, and many other providers
are all struggling to make ends meet in the face of deeper-than-
expected cuts.
The package of payment adjustments that Senate Democrats are
introducing today will provide a much-needed boost to these providers--
totaling $80 billion over 10 years. This will ensure that Medicare
beneficiaries continue to have access to the care that we have promised
them.
The bill has many provisions, but I would like to highlight a few.
For hospitals, BBRA-2000 would restore the full inflation update. It
would also improve payments for Disproportionate Share Hospitals (DSH)
and teaching hospitals, who provide essential care for some of the
neediest patients.
Our bill repeals the 15 percent cut in home health, and delays adding
medical supplies to the home health prospective payment system (PPS).
These fixes are essential to an industry that has seen an unprecedented
drop in spending.
For skilled nursing facilities we would restore the full inflation
update, with an additional two percent increase in fiscal years 2001
and 2002. We would also delay therapy caps for two additional years so
that beneficiaries do not face an arbitrary limit on the amount of care
they can receive.
Although the cost of providing care at the end of life has risen
dramatically, the base for hospice payments has not been changed since
1989. The bill restores the full inflation update for hospice
providers, and provides a ten percent upward adjustment in hospice base
rates.
We are committed to ensuring that appropriate payments are made to
Medicare+Choice plans. BBRA-2000 increases the growth rate in payments
to these plans and allows plans to move to a 50-50 national blend one
year earlier.
The bill also improves payment for ambulance providers, medical
equipment suppliers, and dialysis facilities, who all provide important
services to Medicare beneficiaries.
We recognize the special circumstances of rural health care providers
in our bill. The rural health provisions include increasing payments
for small rural hospitals, rural home health agencies, and rural
ambulance providers.
There are other steps we need to take to improve beneficiaries'
access to care. The bill we are introducing today includes a package of
refinements to Medicare that directly help beneficiaries. For example,
the bill will build on provisions in the BBA to lower beneficiary
copayments and expand preventive benefits in Medicare.
We also provide for increased access to health care through
improvements to Medicaid and the Children's Health Insurance Program.
These include changes to the BBA, such as improving state processes for
enrolling people who are eligible for Medicaid and CHIP. We also make
changes to the health-related provisions of immigration and welfare
reform legislation that passed in 1996. For example, the bill would
extend assistance to people who leave welfare for work.
Senate Democrats continue to believe that passage of an affordable,
voluntary, meaningful Medicare prescription drug benefit is of highest
priority. This bill, the Balanced Budget Refinement Act of 2000, is the
next step in ensuring that beneficiaries have access to the care they
need.
I want to thank Senator Moynihan and his staff for their hard work
putting this bill together. They have spent the last two months
listening to health care providers, beneficiaries, community leaders,
and members of our caucus. Through that listening process they have
drafted a bill that addresses the needs of the many communities that
are struggling to deal with the impact of the Balanced Budget Act.
We know the problems providers are facing in health care. And we know
how to fix many of them. The bill we are introducing today is a
comprehensive plan to ensure the stability that health care providers
need and that beneficiaries depend on. We must take this opportunity to
act, before it is too late to save some of the providers who are so
close to closing their doors.
Mr. KENNEDY. Mr. President, it is a privilege to join Senator
Daschle, Senator Moynihan, and other colleagues in introducing the
Balanced Budget Refinement Act of 2000. This bill takes the next step
in our continued effort to restore the excessive Medicare cuts in the
Balanced Budget Act of 1997. This legislation also includes several
proposals to ease the financial burden and improve care for all
beneficiaries. It also includes important proposals to increase the
effectiveness of Medicaid and the children's Health Insurance Program,
and to improve access to care for vulnerable populations, including
legal immigrant children and pregnant women. Our goal is to pass this
legislation before the end of the year.
The cost-saving measures enacted by Congress as part of the Balanced
Budget Act of 1997 have turned out to be far deeper than the estimates
at that time, and these excessive cuts have put countless outstanding
health care institutions across the country at risk.
In Massachusetts, 25 percent of home health agencies no longer serve
Medicare patients. Forty-three nursing homes have closed in the state
since 1998, and another 20 percent are in bankruptcy. Two out of every
three hospitals in Massachusetts are losing money on patient care.
The record surpluses we currently enjoy and anticipate in the years
ahead are partly due to the savings achieved by cutting Medicare in the
BBA. Most of these savings came from policy and payment reforms,
including actual cuts in payments for various services. While some
changes were clearly justified, the overall cuts were much deeper than
intended and are too severe to sustain.
Last year, in passing the Balanced Budget Refinement Act of 1999, we
made a good start. It gave needed relief to Medicare providers. But
when we enacted that bill last year, we also knew that it was only a
down-payment, and that additional relief would be needed.
The bill we are introducing today follows through on that commitment.
It would invest $80 billion over 10 years to restore payments to
Medicare and Medicaid providers, improve benefits, and increase access
to health care under Medicaid and CHIP. It provides the funding needed
to allow these essential health professionals and institutions to do
what they do best--provide the best health care possible for elderly
and disabled Americans on Medicare. It will ensure that the nation's
health care system is able to care responsibly for today's senior
citizens, and is adequately prepared to take care of those who will be
retiring in the future.
No senior citizen should be forced to enter a hospital or a nursing
home because Medicare can't afford to pay for the services that will
keep her in her own home and in her own community.
No person with a disability should be told that occupational therapy
services are no longer available. Because legislation to balance the
budget reduced the rehabilitation services they need.
No community should be told that their number one employer and
provider of health care will be closing its doors or engaging in
massive layoffs, because Medicare can no longer pay its fair share of
health costs.
No freestanding children's hospital should wonder whether it can
continue to train providers to care for children, because of uncertain
federal support for its teaching activities.
Yet these scenes and many others are playing out in towns and cities
across the country today, in large part due to the excessive cuts
required by the Balanced Budget Act three years ago.
With the retirement of the baby boom generation, the last thing we
[[Page S8856]]
should do is jeopardize the viability and commitment of the essential
institutions that care for Medicare beneficiaries. Yet that is now
happening in cities and towns across the nation. In the vast majority
of cases, the providers who care for Medicare patients are the same
providers who care for working families and everyone else in their
community. When hospitals who serve Medicare beneficiaries are
threatened, health care for the entire community is threatened too.
This legislation is an important step to maintain excellence
throughout our health care system. I commend Senator Daschle and
Senator Moynihan for their leadership on this vital issue. It deserves
prompt consideration by the Finance Committee and the entire Senate,
and it should be enacted into law before we adjourn.
Mr. DORGAN. Mr. President, I am joining with my colleagues Senator
Moynihan, Senator Daschle, and others today to introduce the Balanced
Budget Refinement Act of 2000. This legislation seeks to address some
of the unintended consequences the Balanced Budget Act, BBA, of 1997 is
having on access to Medicare services vital to older Americans. The BBA
has had a particularly serious impact on rural health care providers,
and I am pleased that the legislation we are introducing today
acknowledges the special needs of rural America.
Like many of my colleagues, I supported the Balanced Budget Act when
it was enacted by Congress in 1997 with strong bipartisan support.
Prior to the passage of this law, Medicare was projected to be
insolvent within two years (by 2001), so it was imperative that we took
action to extend Medicare's financial health and to constrain its rate
of growth to a more sustainable level. Thanks in part to this law, we
have a flourishing economy in most parts of the country and the
Medicare trust fund is projected to be solvent until 2025.
But in some respects, the Balanced Budget Act was successful beyond
our wildest expectations in reducing Medicare program costs. The
Congressional Budget Office originally estimated that Medicare spending
would be reduced by $112 billion over five years, but instead, the
reduction in spending growth has been nearly double that amount. This
unexpected result is having real consequences for Medicare
beneficiaries and health care providers, and Congress simply must take
action to address these problems before adjourning this year.
Congress took a step in the right direction towards addressing the
problems facing Medicare providers by enacting the Balanced Budget
Refinement Act, BBRA, of 1999. Unfortunately, however, there is growing
evidence that the negative changes resulting from the BBA have not been
adequately addressed by the BBRA. Moreover, the impacts continue to
disproportionately affect rural health care providers and the quality
of care rural Medicare beneficiaries receive.
Part of the problem facing rural providers is simply demographics: My
home state of North Dakota is the second oldest in the nation, and our
overall population is shrinking. In fact, in six of North Dakota's
``frontier'' counties, there were 20 or fewer births for the entire
county for the entire year of 1997. Admissions to rural hospitals have
dropped by a drastic 60 percent in the last two decades, and those
patients who do remain tend to be older and sicker. This means that
rural hospitals tend to be disproportionately dependent upon Medicare
reimbursement, to the extent that Medicare accounts for 85 percent of
their revenue. Obviously, given this reality, changes in Medicare
reimbursement have a tremendous impact on the financial health of rural
hospitals.
Another part of the problem is that Medicare has historically
reimbursed urban health care providers at a higher rate than their
rural counterparts. Of course, some of this difference can be explained
by regional differences in the cost of health care and variations in
the health status of older Americans. But this isn't the whole
explanation. Even after adjusting for these factors, a report by health
care economists found that, for example, Medicare's per beneficiary
spending was about $8,000 in Miami, but only $3,500 in Minneapolis.
When average Medicare payments for the same procedure are compared, the
disparities in payment in different areas of the country are dramatic.
For example, Medicare pays $6,588 for the treatment of simple pneumonia
in the District of Columbia, but only $3,383 in North Dakota. In my
opinion, this difference is largely explained by a Medicare
reimbursement system that is skewed in favor of urban areas. For the
most part, the BBA further perpetuates this inequity, despite efforts
by some of us to address this concern.
There are a few areas of the Balanced Budget Act and BBRA that I
think warrant further scrutiny and action, and these areas are
addressed in the legislation being introduced today. The first is
hospital payments, particularly for outpatient services. A recent
analysis by a health policy research firm estimates that the BBA would
reduce Medicare payments to North Dakota hospitals by $163.8 million
between FY 1998 and FY2002. The BBRA passed last year restores only $16
million of those reductions. So even with BBRA refinements, North
Dakota hospitals face a loss of $147.8 million in revenues. Outpatient
services are a particularly critical component of care in many North
Dakota hospitals: 40 percent of the hospitals in my state get more than
half of their revenues from outpatient services. Senator Daschle and
Moynihan's legislation will address the problems faced by rural
hospitals by, among other things, providing a full inflation increase
in Medicare payments to all hospitals in 2001 and 2002 and holding
rural hospitals permanently harmless from the outpatient prospective
payment system.
This legislation also addresses the issue of home health
reimbursement. Nearly 70 percent of the home health agencies in my home
state are hospital-based, so the changes in home-health reimbursement
are having a domino effect on North Dakota's hospitals. I am concerned
that the Health Care Financing Administration's, HCFA, proposed rule
for the new home health Prospective Payment System, PPS, does not take
account of the smaller size of rural home health agencies and the
higher fixed costs per visit. And, HCFA did not take sufficient account
of the greater travel cost per visit in rural areas, and the higher
incidence of chronic illness in rural communities. Today's legislation
would address this concern by providing a 10 percent increase in rural
home health payments for the next two years and repealing the 15
percent cut in home health reimbursement scheduled to take place on
October 1, 2001.
This legislation also proposes other changes I think are worth
further mention, including a further delay in the arbitrary caps on the
amount of physical, speech, and occupational therapy Medicare
beneficiaries can receive, and a 10 percent increase in the base
payment rate for hospice care, which hasn't been increased in over a
decade.
Finally, while all of the provisions of this bill will together help
to ensure that Medicare beneficiaries can continue to rely on the
quality care they need and expect, this legislation includes a number
of changes that will also make Medicare an even better deal. In
particular, this bill will expand Medicare's emphasis on preventive
medicine by adding such benefits as coverage for glaucoma screening,
counseling for smoking cessation, and nutrition therapy. The bill will
also eliminate the current three-year time limit on Medicare's coverage
of immunosuppressive drugs, the expensive medicines that transplant
recipients need to keep their bodies from rejecting their new organs or
tissue.
In short, the Balanced Budget Refinement Act of 2000 addresses many
of the needs and concerns of Medicare beneficiaries and health care
providers. I hope this legislation will help lay the framework for the
enactment of bipartisan legislation to address these issues before the
106th Congress goes home.
Mr. JOHNSON. Mr. President, I am pleased to cosponsor the Balanced
Budget Refinement Act introduced today that works to correct the
inequities of Medicare reforms included in the Balanced Budget Act
(BBA) of 1997.
I would like to commend Senator Daschle for his tremendous efforts on
this issue and for his leadership with the introduction of this bill.
As well, I
[[Page S8857]]
congratulate a number of my other colleagues who have contributed
immensely to the crafting of this critically important piece of
legislation, including Senators Moynihan, Rockefeller, Conrad, Graham,
Kerrey, Robb, Baucus, Breaux and others.
By way of background, as part of the effort to balance the federal
budget, the BBA of 1997 provided for major reforms in the way Medicare
pays for medical services. The BBA made some important changes in
Medicare payment policy and contributed to our current period of budget
surpluses through significant cost savings in Medicare. These changes
were originally expected to cut Medicare spending by about $112 billion
over five years, according to the Congressional Budget Office (CBO).
However, projections showed spending falling nearly twice that much,
and as a result, unintended payment cuts to providers had deepened more
significantly than expected. In the face of these profound cuts, health
care providers began to struggle, and beneficiary access to care became
threatened, due to forced reductions in services especially in rural
parts of the country such as South Dakota. As a result, Congress
addressed some of these unintended consequences of the BBA by enacting
the Balanced Budget Refinement Act (BBRA) last year which provided $16
billion over 5 years in payments to various Medicare providers,
including; Hospital Outpatient Departments; Skilled Nursing Facilities;
Rural Health Providers; Home Health Agencies; Medicare HMOs; and
Teaching Hospitals. The impact in South Dakota indicated that
approximately 9% of Medicare funding reductions imposed by the BBA of
1997 were returned as a result of the BBRA passed last year, resulting
in approximately $15.3 million being restored to South Dakota Medicare
providers.
While this was certainly a step in the right direction, the BBRA of
1999 did not do enough as concerns from hospital and nursing home
administrators, home health facilities, rural health providers,
ambulance services and Medicare beneficiaries continued to be heard
across the country.
Not surprising, I continue to hear from many South Dakota safety net
providers about the devastating effects such reductions in Medicare
reimbursements are having throughout the health care industry in my
home state. Consumers are also feeling the pain, as many individuals
are being turned away from hospitals and nursing homes who cannot
afford to accept new patients because of the lower reimbursement rates
included in BBA of 1997. The undesirable and unintended cuts are
devastating and feared to have severe implications on the quality and
access of health care throughout our nation, including South Dakota,
unless Congress acts immediately to further correct these problems. In
South Dakota, and other rural parts of the country, hospitals and other
health care providers have an extremely high percentage of Medicare
beneficiaries making these cuts in reimbursement even more devastating.
If Congress does not act in a timely fashion many of these providers
may be forced to close their doors.
Nowhere can we see the impact of closures more evident than within
the nursing home industry. Nursing homes are experiencing closures at
record rates across the country. In South Dakota, just last month we
endured our first nursing home closure in Parker, South Dakota. Not
only was this devastating for residents and workers, but the domino
economic impact that goes hand in hand with such a facility closure is
enormous for small communities to absorb.
As well, one does not have to look far in my home state of South
Dakota to see the impact many other health care providers and
facilities are experiencing. Furthermore, the consequences are being
felt across the board, from larger health systems in South Dakota
communities such as Sioux Falls, Rapid City and Aberdeen, to medium
centers in Brookings, Watertown, Pierre and Yankton, to the smaller
rural facilities in places like Martin, Edgemont, Gregory, Miller, Hot
Springs and Redfield, just to name a few. The situation is arduous for
many of these facilities, who often carry the immense task of being the
sole health care provider in the entire county. By way of example,
Gregory Healthcare Center is a 26 bed rural hospital serving
approximately 9,000 people. Not surprising, Gregory is the only local
provider to offer a range of services including surgery, obstetrics,
and various therapies, and also operates the only home health agency in
the area. The facility in Gregory was forced to cut back its' home
health services as a result of the BBA Medicare reductions. Many
individuals once benefiting from specialized medication oversight and
condition management services through Gregory's home health agency were
now at home performing these services on their own, resulting in some
cases to unnecessary hospitalizations. The situation in Gregory is by
far not an isolated situation and facilities nationwide are being
forced to cut services just to survive. Whether it be Gregory, South
Dakota, or one of far too many other facilities in this country with
similar issues, these are direct examples of the intense real life
situations that facilities, providers and beneficiaries are
experiencing every day as a result of inadequate BBA adjustments,
payment updates and beneficiary protections.
Therefore, I stand in strong support of the BBRA legislation being
introduced today which will address problems facing vital health care
services. I look forward to working with my colleagues on passage of
the BBRA of 2000 which develops a creative, cost-effective approach to
address the unintended, long-term consequences of the BBA. The proposed
budget surplus provides Congress the unique opportunity to address many
of the deficiencies in our nation's health care system. We need to
address the valid concerns of teaching hospitals, skilled nursing
facilities, home health providers, rural and community hospitals, and
other health care providers who require relief from the consequences of
the BBA.
______
Mr. DOMENICI:
S. 3078. A bill to amend the Reclamation Wastewater and Groundwater
Study and Facilities Act to authorize the Secretary of the Interior to
participate in the Santa Fe Regional Water Management and River
Restoration Project; to the Committee on Energy and Natural Resources.
reclamation wastewater and groundwater study and facilities act
Mr. DOMENICI. Mr. President, I am pleased today to be introducing a
bill authorizing the next logical step in the City of Santa Fe's
Regional Water Management and River Restoration Strategy. This bill
allows the Secretary of Interior to participate in the design, planning
and construction of the Santa Fe, New Mexico, regional water management
and river restoration project, consisting of the diversion and reuse of
water, the conversion of irrigation uses from potable water to
reclaimed water, and the use of reclaimed water to restore Santa Fe
River flows.
Limited water resources in the Santa Fe region and increased demands
threaten the sustainability of surface and groundwater supplies. The
Regional Water Management and River Restoration Strategy is a
comprehensive, collaborative plan to responsibly and sustainability
address the region's water supply needs. The full program goals are to
return flow to the river, protect riparian habitat and the traditional,
cultural and religious uses of the water.
The Santa Fe area has been working overtime to determine how best to
improve its water supply. I have been proud to help fund its efforts.
The FY99 Energy and Water Appropriations Act provided $450,000 and the
FY 2000 Energy and Water Appropriations Act included $750,000 to
support the Santa Fe Regional Water Management and River Restoration
initiative to address long-term water supplies in the greater Santa Fe
area. That funding allowed the Bureau of Reclamation to continue and
complete environmental studies required under the National
Environmental Policy Act for the comprehensive plan to improve Santa
Fe's regional water supplies through a reuse program and restoration of
the Santa Fe River watershed.
I was also pleased to gain approval for $750,000 to support the
project in the Senate FY01 VA/HUD bill to assist in the planning,
coordination and development of restoration projects for the Santa Fe
River under a comprehensive, watershed-based implementation
[[Page S8858]]
program. The funding, provided through EPA's Environmental Programs and
Management program, would help the WMRRS reuse treated effluent to
augment streamflow, recharge the regional aquifer, and enhance the
riparian habitat and recreational uses within the Santa Fe River
corridor.
The Santa Fe Water Management and River Restoration Strategy is a
cooperative partnership among Santa Fe County, the city of Santa Fe,
and the San Ildefonso Pueblo. The city of Espanola, the Eldorado Water
and Sanitation District, and the Northern Pueblos Tributary Water
Rights Association (representing San Ildefonso, Nambe, Pojoaque and
Tesuque pueblos) are also involved.
In June of this year, a $601,000 grant was awarded to the project
following my request in the FY 2000 Veterans' Affairs, Housing and
Urban Development and Independent Agencies (VA-HUD) Appropriations
Bill. The funding was awarded through the Department of Housing and
Urban Development's Economic Development Initiative (EDI) program.
This funding represents federal support for the effort to
rehabilitate the Santa Fe River, a project that is one aspect of an
overall initiative to address the future of water in the Santa Fe area.
Those funds will be used for urban river restoration planning, source
water protection planning, and development of a comprehensive trails
and open space plan.
This authorizing legislation takes the water management strategy to
the next phase. The plan has already been backed by a local and
regional commitment of at least $2.7 million for the multi-year
program. The sponsors of the program have requested this authorization
to provide additional financial support for this project. This
legislative authority will make the project eligible for future funding
as the project is developed, as well as federal cooperation with the
surrounding pueblos. I hope that this body can take swift action on the
worthy legislation.
______
By Mr. HATCH:
S. 3082. A bill to amend title XVIII of the Social Security Act to
improve the manner in which new medical technologies are made available
to Medicare beneficiaries under the Medicare Program, and for other
purposes; to the Committee on Finance.
Medicare Patient Access to Technology Act 20000
Mr. HATCH. Mr. President, when I first introduced this legislation
over one year ago, Medicare beneficiaries with advanced heart disease
could not gain access to ventriculaassist devices. Medicare patients
who could have benefitted from cochlear implants did not receive them.
It is now over a year later. Unfortunately, these problems still
persist. Medicare beneficiaries still have trouble gaining access to
many technologies that are covered under private plans. And while the
Omnibus Budget legislation for FY 2001 addressed the overall problem
and by addressing access concerns for Medicare beneficiaries, there is
still plenty of work that needs to be done. That is why I am
introducing the Medicare Patient Access to Technology Act 2000 today.
We must eliminate the delays and barriers to access that have arisen
in the way Medicare decides to cover, code and pay for new devices and
diagnostics. The measure I am introducing today is identical to
legislation introduced by Congressman Jim Ramstad and Congresswoman
Karen Thurman earlier this year. It seeks to build off of the success
we had last year in the Balanced Budget Refinement Act. The BBRA
represented an important first step in creating a Medicare program that
provides timely access to needed treatments.
The BBRA, which was signed into law as part of last year's omnibus
budget legislation made significant changes. We crafted special
temporary payments for new breakthrough technologies to ensure they are
provided to Medicare beneficiaries in a timely manner. We also
established payment categories that better reflect advances in clinical
practice and technology.
The Medicare Patient Access to Technology Act 2000 recognizes that
all Medicare beneficiaries, not just those in the outpatient setting,
should be able to benefit from these kinds of improvements.
The bill would require: annual updates of Medicare's payment
programs; temporary procedure codes to be issued by Medicare for new
technologies at the time of FDA review; quarterly updates of Medicare's
payment codes; external data to be used to improve the timeliness and
appropriateness of reimbursement decisions; and annual reports be made
on the timeliness of its coverage, coding and payment decisions.
There are some notable changes in this new version of the bill:
A provision to extend the issuance of temporary codes and quarterly
coding updates to inpatient, or ICD-9, codes as well as outpatient
(HCPCS) codes.
A provision to require HCFA to create open, timely procedures and
sound methods for making coding and payment decisions for new
diagnostic tests. It would also give stakeholders the ability to appeal
a coding or payment decision for a diagnostic test.
This legislation will provide assistance to Medicare beneficiaries
who currently face almost insurmountable barriers to advanced
technologies.
Without this bill, Medicare will continue to fall far short of making
the latest technologies and procedures available to beneficiaries in a
timely manner.
I will fight for enactment of this bill in an effort to make sure
that our seniors have access to the advanced treatments that can save
and improve their lives.
______
By Mr. LEAHY:
S. 3083. A bill to enhance privacy and the protection of the public
in the use of computers and the Internet, and for other purposes; to
the Committee on the Judiciary.
Enhancement of Privacy and public Safety in Cyberspace Act
Mr. LEAHY. Mr. President, at the end of July, the administration
transmitted to the Senate and the House of Representatives legislation
intended to increase privacy and security in cyberspace. Today, at the
request and on behalf of the Administration, I introduce this
legislation, the Enhancement of Privacy and Public Safety in Cyberspace
Act.
The White House Chief of Staff, John Podesta, announced the
administration's cyber-security proposal in an important speech at the
National Press Club on Monday, July 17, 2000. This is a complex area
that requires close attention to get the balance among law enforcement,
business and civil liberties interests just right. I welcome the
Administration's participation in this debate on the privacy
implications of government surveillance, which certainly deserves just
as much attention as the issue of the collection and dissemination of
personally-identifiable information by the private-sector.
The means by which law enforcement authorities may gain access to a
person's private ``effects'' is no longer limited by physical
proximity, as it was at the time the Framers crafted our Constitution's
Fourth Amendment right of the American people to be secure in their
persons, houses, papers and effects, against unreasonable searches and
seizures. New communications methods and surveillance devices have
dramatically expanded the opportunities for surreptitious law
enforcement access to private messages and records from remote
locations.
One example of these devices is the Federal Bureau of Investigation's
Carnivore software program, which screens Internet traffic and captures
information targeted by court orders. The Senate and House Judiciary
Committees have both conducted hearings on Carnivore to discuss how the
software works and whether it minimizes intrusion or maximizes the
potential for government abuse. The Attorney General is arranging for
an independent technical review of Carnivore, and I look forward to
reviewing the results.
In short, new communications technologies pose both benefits and
challenges to privacy and law enforcement. The Congress has worked
successfully in the past to mediate this tension with a combination of
stringent procedures for law enforcement access to our communications
and legal protections to maintain their privacy and confidentiality,
whether they occur in person or over the telephone, fax machine or
computer. In 1968, the Congress passed comprehensive legislation
authorizing government interception, under carefully defined
circumstances, of voice
[[Page S8859]]
communications over telephones or in person in Title III of the Omnibus
Crime Control and Safe Streets Act.
We returned to this important area in 1986, when we passed the
Electronic Communications Privacy Act (ECPA), which I was proud to
sponsor, that outlined procedures for law enforcement access to
electronic mail systems and remote data processing systems, and that
provided important privacy safeguards for computer users.
The Administration's legislation is an important contribution to the
ongoing debate over the sufficiency of our current laws in the face of
the exponential growth of computer and communications networks. In
fact, this legislation contains some proposals which I support. For
example, the bill would allow judicial review of pen register orders so
the judge is not just a rubber stamp, and would update the wiretap laws
to apply the same procedural rules to e-mail intercepts as to phone
intercepts.
Nevertheless, the merits of other provisions in this legislation
would benefit from additional scrutiny and debate. For example, the
legislation proposes elimination of the current $5,000 threshold for
large categories of federal computer crimes. This would lower the bar
for federal investigative and prosecutorial attention with the result
that lesser computer abuses could be converted into federal crimes.
Specifically, federal jurisdiction currently exists for a variety of
computer crimes if, and only if, such criminal offenses result in at
least $5,000 of aggregate damage or cause another specified injury,
such as the impairment of medical treatment, physical injury to a
person or a threat to public safety. Elimination of the $5,000
threshold would criminalize a variety of minor computer abuses,
regardless of whether any significant harm results. Our federal laws do
not need to reach each and every minor, inadvertent and harmless
hacking offense--after all, each of the 50 states has its own computer
crime laws. Rather, our federal laws need to reach those offenses for
which federal jurisdiction is appropriate. This can be accomplished, as
I have done in the Internet Security Act, S. 2430, which I introduced
earlier this year, by simply adding an appropriate definition of
``loss'' to the statute.
Prior Congresses have declined to over-federalize computer offenses
and sensibly determined that not all computer abuses warrant federal
criminal sanctions. When the computer crime law was first enacted in
1984, the House Judiciary Committee reporting the bill stated:
The Federal jurisdictional threshold is that there must be
$5,000 worth of benefit to the defendant or loss to another
in order to concentrate Federal resources on the more
substantial computer offenses that affect interstate or
foreign commerce. (H.Rep. 98-894, at p. 22, July 24, 1984).
Similarly, the Senate Judiciary Committee under the chairmanship of
Senator Thurmond, rejected suggestions in 1986 that ``the Congress
should enact as sweeping a Federal statute as possible so that no
computer crime is potentially uncovered.'' (S. Rep. 99-432, at p. 4,
September 3, 1986).
For example, if an overly-curious college sophomore checks a
professor's unattended computer to see what grade he is going to get
and accidentally deletes a file or a message, current Federal law does
not make that conduct a crime. That conduct may be cause for discipline
at the college, but not for the FBI to swoop in and investigate. Yet,
under the Administration's legislation, this unauthorized access to the
professor's computer would constitute a federal offense.
As the Congress considers changes in our current laws with a view to
updating our current privacy safeguards from unreasonable government
surveillance, I commend the administration for focusing attention on
this important issue by transmitting its legislative proposal.
I ask unanimous consent that the bill be printed in the Record.
There being no objection, the bill was ordered to be printed in the
Record, as follows:
S. 3083
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 ``Enhancement of Privacy and
Public Safety in Cyberspace Act''.
SEC. 2. COMPUTER CRIME.
(a) Fraud and Related Activity in Connection With
Computers.--
(1) Offenses.--Subsection (a) of section 1030 of title 18,
United States Code, is amended--
(A) in paragraph (3), by striking ``accesses such a
computer'' and inserting ``or in excess of authorization to
access any nonpublic computer of a department or agency of
the United States, accesses a computer''; and
(B) in paragraph (7), by striking ``, firm, association,
educational institution, financial institution, government
entity, or other legal entity,''.
(2) Attempted offenses.--Subsection (b) of that section is
amended by inserting before the period the following: ``as if
such person had committed the completed offense''.
(3) Punishment.--Subsection (c) of that section is
amended--
(A) in paragraph (1), by striking ``, or an attempt to
commit an offense punishable under this subparagraph'' each
place it appears in subparagraphs (A) and (B);
(B) in paragraph (2)--
(i) by striking subparagraph (A) and inserting the
following new subparagraph (A):
``(A) except as provided in subparagraphs (B) and (C) of
this subparagraph, a fine under this title or imprisonment
for not more than one year, or both, in the case of an
offense under subsection (a)(2), (a)(3), (a)(5), or (a)(6) of
this section which does not occur after a conviction for
another offense under this section;'';
(ii) in subparagraph (B), by adding ``and'' at the end; and
(iii) by striking subparagraph (C) and inserting the
following new subparagraph (C):
``(C) a fine under this title or imprisonment for not more
than ten years, or both, in the case of an offense under
subsection (a)(5)(A) or (a)(5)(B) if the offense caused (or,
in the case of an attempted offense, would, if completed,
have caused)--
``(i) loss to one or more persons during any one year
period (including loss resulting from a related course of
conduct affecting one or more other protected computers)
aggregating at least $5,000;
``(ii) the modification or impairment, or potential
modification or impairment, of the medical examination,
diagnosis, treatment, or care of one or more individuals;
``(iii) physical injury to any individual;
``(iv) a threat to public health or safety; or
``(v) damage affecting a computer system used by or for a
government entity in furtherance of the administration of
justice, national defense, or national security;'';
(C) in paragraph (3)--
(i) by striking ``(3)(A)'' and inserting ``(3)'';
(ii) by striking ``, (a)(5)(A), (a)(5)(B),'';
(iii) by striking ``, or an attempt to commit an offense
punishable under this subparagraph;''; and
(iv) by striking subparagraph (B); and
(D) by adding at the end the following new paragraph:
``(4) a fine under this title or imprisonment for not more
than ten years, or both, in the case of an offense under
subsection (a)(2), (a)(3), (a)(4), (a)(5), (a)(6), or (a)(7)
of this section which occurs after a conviction for another
offense under this section.''.
(4) Investigative authority of united states secret
service.--Subsection (d) of that section is amended--
(A) in the first sentence, by striking ``subsections
(a)(2)(A), (a)(2)(B), (a)(3), (a)(4), (a)(5), and (a)(6)
of''; and
(B) in the second sentence, by striking ``which shall be
entered into by'' and inserting ``between''.
(5) Definitions.--Subsection (e) of that section is
amended--
(A) in paragraph (2)(B), by inserting before the semicolon
the following: ``, including a computer located outside the
United States'';
(B) in paragraph (7), by striking ``and'' at the end;
(C) in paragraph (8), by striking ``or information,'' and
all that follows through the end of the paragraph and
inserting ``or information;'';
(D) in paragraph (9), by striking the period at the end and
inserting a semicolon; and
(E) by adding at the end the following new paragraphs:
``(10) the term `conviction for another offense under this
section' includes--
``(A) an adjudication of juvenile delinquency for a
violation of this section; and
``(B) a conviction under State law for a crime punishable
by imprisonment for more than one year, an element of which
is unauthorized access, or exceeding authorized access, to a
computer;
``(11) the term `loss' means any reasonable cost to any
victim, including responding to the offense, conducting a
damage assessment, restoring any data, program, system, or
information to its condition before the offense, and any
revenue lost or costs incurred because of interruption of
service; and
``(12) the term `person' includes any individual, firm,
association, educational institution, financial institution,
corporation, company, partnership, society, government
entity, or other legal entity.''.
(6) Civil actions.--Subsection (g) of that section is
amended to read as follows:
``(g) Any person who suffers damage or loss by reason of a
violation of this section may maintain a civil action against
the violator to obtain compensatory damages and injunctive or
other equitable relief. An action
[[Page S8860]]
under this subsection for a violation of subsection (a)(5)
may be brought only if the conduct involves one or more of
the factors set forth in subsection (c)(2)(C). No action may
be brought under this subsection unless such action is begun
within 2 years of the date of the act complained of or the
date of the discovery of the damage.''.
(7) Forfeiture.--That section is further amended--
(A) by redesignating subsection (h) as subsection (j); and
(B) by inserting after subsection (g), as amended by
paragraph (6) of this subsection, the following new
subsections (h) and (i):
``(h)(1) The court, in imposing sentence on any person
convicted of a violation of this section, shall order, in
addition to any other sentence imposed and irrespective of
any provision of State law, that such person forfeit to the
United States--
``(A) such person's interest in any property, whether real
or personal, that was used or intended to be used to commit
or to facilitate the commission of such violation; and
``(B) any property, whether real or personal, constituting
or derived from, any proceeds that such person obtained,
whether directly or indirectly, as a result of such
violation.
``(2) The criminal forfeiture of property under this
subsection, any seizure and disposition thereof, and any
administrative or judicial proceeding in relation thereto,
shall be governed by the provisions of section 413 of the
Comprehensive Drug Abuse Prevention and Control Act of 1970
(21 U.S.C. 853), except subsection (d) of that section.
``(i)(1) The following shall be subject to forfeiture to
the United States, and no property right shall exist in them:
``(A) Any property, whether real or personal, used or
intended to be used to commit or to facilitate the commission
of any violation of this section.
``(B) Any property, whether real or personal, which
constitutes or is derived from proceeds traceable to any
violation of this section.
``(2) The provisions of chapter 46 of this title relating
to civil forfeiture shall apply to any seizure or civil
forfeiture under this subsection.''.
(b) Amendments to Sentencing Guidelines.--Pursuant to its
authority under section 994(p) of title 28, United States
Code, the United States Sentencing Commission shall amend the
sentencing guidelines to ensure any individual convicted of a
violation of paragraph (4) or a felony violation of paragraph
(5)(A), but not a felony violation of paragraph (5)(B) or
(5)(C), of section 1030(a) of title 18, United States Code,
is imprisoned for not less than 6 months.
(c) Communications Matters.--
(1) In general.--Section 223(a)(1) of the Communications
Act of 1934 (47 U.S.C. 223(a)(1)) is amended--
(A) in subparagraphs (C) and (E), by inserting ``or
interactive computer service'' after ``telecommunications
device'';
(B) in subparagraph (D), by striking ``or'' at the end; and
(C) by adding after subparagraph (E) the following new
subparagraph:
``(F) with the intent to cause the unavailability of a
telecommunications device or interactive computer service, or
to cause damage to a protected computer (as those terms are
defined in section 1030 of title 18, United States Code),
causes or attempts to cause one or more other persons to
initiate communication with such telecommunications device,
interactive computer service, or protected computer; or''.
(2) Conforming amendment.--The section heading of that
section is amended by striking ``TELEPHONE CALLS'' and
inserting ``COMMUNICATIONS''.
SEC. 3. INTERCEPTION OF WIRE, ORAL, AND ELECTRONIC
COMMUNICATIONS.
(a) Definitions.--Section 2510 of title 18, United States
Code, is amended--
(1) in paragraph (1), by striking ``electronic storage''
and inserting ``interim storage'';
(2) in paragraph (10), by striking ``section 153(h) of
title 47 of the United States Code'' and inserting ``section
3(10) of the Communications Act of 1934 (47 U.S.C.
153(10))'';
(3) in paragraph (14)--
(A) by striking ``of electronic'' and inserting ``of wire
or electronic''; and
(B) by striking ``electronic storage'' and inserting
``interim storage''; and
(4) in paragraph (17)--
(A) by striking `` `electronic storage' '' and inserting ``
`interim storage' ''; and
(B) in subparagraph (A), by inserting ``by an electronic
communication service'' after ``intermediate storage''.
(b) Prohibition on Interception and Disclosure of
Communications.--Section 2511 of that title is amended--
(1) in subsection (2)--
(A) in paragraph (a)(i), by striking ``on officer'' and
inserting ``an officer'';
(B) in paragraph (f)--
(i) by inserting ``or 206'' after ``chapter 121''; and
(ii) by striking ``wire and oral'' and inserting ``wire,
oral, and electronic''; and
(C) in paragraph (g), by striking clause (i) and inserting
the following new clause (i):
``(i) to intercept or access a wire or electronic
communication (other than a radio communication) made through
an electronic communications system that is configured so
that such communication is readily accessible to the general
public;''; and
(2) in subsection (4)--
(A) in paragraph (a), by striking ``in paragraph (b) of
this subsection or'';
(B) by striking paragraph (b); and
(C) by redesignating paragraph (c) as paragraph (b).
(c) Prohibition on Use of Evidence of Intercepted
Communications.--Section 2515 of that title is amended--
(1) by striking ``Whenever any wire or oral communication''
and inserting ``(a) Except as provided in subsection (b),
whenever any wire, oral, or electronic communication''; and
(2) by adding at the end the following new subsection:
``(b) Subsection (a) shall not apply to the disclosure,
before a grand jury or in a criminal trial, hearing, or other
criminal proceeding, of the contents of a communication, or
evidence derived therefrom, against a person alleged to have
intercepted, used, or disclosed the communication in
violation of this chapter, or participated in such
violation.''.
(d) Authorization for Interception of Communications.--
Section 2516 of that title is amended--
(1) in subsection (1)--
(A) by striking ``wire or oral'' in the matter preceding
paragraph (a) and inserting ``wire, oral, or electronic'';
(B) in paragraph (b), by inserting ``threat,'' after
``robbery,'';
(C) by striking the first paragraph (p) and inserting the
following new paragraph (p):
``(p) a felony violation of section 1030 of this title
(relating to computer fraud and abuse), a felony violation of
section 223 of the Communications Act of 1934 (47 U.S.C. 223)
(relating to abusive communications in interstate or foreign
commerce), or a violation of section 1362 of this title
(relating to destruction of government communications
facilities); or''; and
(D) by redesignating the second paragraph (p) as paragraph
(q); and
(2) in subsection (3), by striking ``electronic
communications'' and inserting ``one-way pager
communications''.
(e) Authorization for Disclosure or Use of Intercepted
Communications.--Section 2517 of that title is amended in
subsections (1) and (2) by inserting ``or under the
circumstances described in section 2515(b) of this title''
after ``by any means authorized by this chapter''.
(f) Procedure for Interception.--Section 2518 of that title
is amended--
(1) in subsection (7), by striking ``subsection (d)'' and
inserting ``subsection (8)(d)''; and
(2) in subsection (10)--
(A) in paragraph (a)--
(i) in the matter preceding subparagraph (i), by striking
``wire or oral'' and inserting ``wire, oral, or electronic'';
and
(ii) in the flush matter following subparagraph (iii)--
(I) by striking ``intercepted wire or oral communication''
and inserting ``intercepted communication''; and
(II) by adding at the end the following new sentence: ``No
suppression may be ordered under this paragraph under the
circumstances described in section 2515(b) of this title.'';
and
(B) by striking paragraph (c).
(g) Civil Damages.--Section 2520(c)(2) of that title is
amended--
(1) in the matter preceding subparagraph (A)--
(A) by striking ``court may'' and inserting ``court
shall''; and
(B) by striking ``greater'' and inserting ``greatest'';
(2) in subparagraph (A), by striking ``or'' at the end;
(3) in subparagraph (B), by striking ``whichever is the
greater of $100 a day for each day of violation or $10,000.''
and inserting ``$500 a day for each day of violation; or'';
and
(4) by adding at the end the following new subparagraph:
``(C) statutory damages of $10,000.''.
(h) Conforming and Clerical Amendments.--
(1) Conforming amendment.--The section heading of section
2515 of that title is amended to read as follows:
``Sec. 2515. Prohibition on use as evidence of intercepted
wire, oral, or electronic communications''.
(2) Clerical amendment.--The table of sections at the
beginning of chapter 119 of that title is amended by striking
the item relating to section 2515 and inserting the following
new item:
``2515. Prohibition on use as evidence of intercepted wire, oral, or
electronic communications.''.
SEC. 4. ELECTRONIC COMMUNICATIONS PRIVACY.
(a) Unlawful Access to Stored Communications.--Section 2701
of title 18, United States Code, is amended--
(1) in subsection (a) by striking ``electronic storage''
and inserting ``interim storage'';
(2) in subsection (b)--
(A) in paragraph (1)--
(i) by striking ``purposes of'' in the matter preceding
subparagraph (A) and inserting ``a tortious or illegal
purpose,'';
(ii) in subparagraph (A) by striking ``one year'' and
inserting ``five years''; and
(iii) in subparagraph (B) by striking ``two years'' and
inserting ``ten years''; and
(B) by striking paragraph (2) and inserting the following
new paragraph (2):
``(2) in any other case--
``(A) a fine under this title or imprisonment for not more
than one year, or both, in the case of a first offense under
this subparagraph; and
[[Page S8861]]
``(B) a fine under this title or imprisonment for not more
than five years, or both, for any subsequent offense under
this subparagraph.''.
(b) Disclosure of Contents.--Section 2702 of that title is
amended--
(1) in subsection (a)--
(A) in paragraph (1)--
(i) by striking ``person or entity providing an'' and
inserting ``provider of'';
(ii) by striking ``electronic storage'' and inserting
``interim storage''; and
(iii) by striking ``and'' at the end;
(B) in paragraph (2)--
(i) by striking ``person or entity providing'' and
inserting ``provider of''; and
(ii) striking the period at the end and inserting ``;
and''; and
(C) by adding at the end the following new paragraph:
``(3) a provider of remote computing service or electronic
communication service to the public shall not knowingly
divulge a record or other information pertaining to a
subscriber to or customer of such service (not including the
contents of communications covered by paragraph (1) or (2) of
this subsection) to any governmental entity.'';
(2) in subsection (b)--
(A) in the subsection caption, by inserting ``for
Disclosure of Communications'' after ``Exceptions'';
(B) in the matter preceding paragraph (1), by striking
``person or entity'' and inserting ``provider described in
subsection (a)'';
(C) in paragraph (6)--
(i) in subparagraph (A)(ii), by striking ``or'' at the end;
(ii) in subparagraph (B), by striking the period at the end
and inserting ``; or''; and
(iii) by adding at the end the following new subparagraph:
``(C) if the provider reasonably believes that an emergency
involving immediate danger of death or serious physical
injury to any person justifies disclosure of the
information.''; and
(3) by adding at the end the following new subsection:
``(c) Exceptions for Disclosure of Customer Records.--A
provider described in subsection (a) may divulge a record or
other information pertaining to a subscriber to or customer
of such service (not including the contents of communications
covered by paragraph (1) or (2) of subsection (a))--
``(1) as otherwise authorized in section 2703 of this
title;
``(2) with the lawful consent of the customer or
subscriber;
``(3) as may be necessarily incident to the rendition of
the service or to the protection of the rights or property of
the provider of that service;
``(4) to a governmental entity, if the provider reasonably
believes that an emergency involving immediate danger of
death or serious physical injury to any person justifies
disclosure of the information; or
``(5) to any person other than a governmental entity if not
otherwise prohibited by law.''.
(c) Requirements for Governmental Access.--Section 2703 of
that title is amended--
(1) in subsection (a), by striking ``electronic storage''
each place it appears and inserting ``interim storage'';
(2) in subsection (b)(1)(B), by striking clause (i) and
inserting the following new clause (i):
``(i) uses a Federal or State grand jury or trial subpoena,
or a subpoena or equivalent process authorized by a Federal
or State statute; or'';
(3) in subsection (c)--
(A) by redesignating paragraph (2) as paragraph (3);
(B) by redesignating subparagraph (C) of paragraph (1) as
paragraph (2);
(C) in paragraph (2), as so redesignated--
(i) by striking ``an administrative subpoena authorized by
a Federal or State statute or a Federal or State grand jury
or trial subpoena'' and inserting ``a Federal or State grand
jury or trial subpoena, or a subpoena or equivalent process
authorized by a Federal or State statute,''; and
(ii) by striking ``subparagraph (B).'' and inserting
``paragraph (1).''; and
(D) in paragraph (1)--
(i) by striking ``(A) Except as provided in subparagraph
(B),'' and inserting ``A governmental entity may require'';
(ii) by striking ``may disclose'' and inserting ``to
disclose'';
(iii) by striking ``to any person other than a governmental
entity.'';
(iv) by striking ``(B) A provider of'' through ``to a
governmental entity'';
(v) by redesignating clauses (i) through (iv) as
subparagraphs (A) through (D);
(vi) by striking ``or'' at the end of subparagraph (C), as
so redesignated;
(vii) by striking the period at the end of subparagraph
(D), as so redesignated, and inserting ``; or''; and
(viii) by adding after subparagraph (D), as so
redesignated, the following new subparagraph:
``(E) seeks information pursuant to paragraph (2).''; and
(4) in subsection (d)--
(A) by striking ``subsection (c)'' and inserting
``subsection (c)(1)''; and
(B) by striking ``section 3127(2)(A)'' and inserting
``section 3127(2)''.
(d) Delayed Notice.--Section 2705(a) of that title is
amended--
(1) in paragraph (1)(B), by striking ``an administrative
subpoena authorized by a Federal or State statute or a
Federal or State grand jury subpoena'' and inserting ``a
Federal or State grand jury or trial subpoena, or a subpoena
or equivalent process authorized by a Federal or State
statute,''; and
(2) in paragraph (4), by striking ``by the court'' and all
that follows through the end of the paragraph and inserting
``, upon application, if the court determines that there is
reason to believe that notification of the existence of the
court order or subpoena may have an adverse result described
in paragraph (2) of this subsection.''.
(e) Civil Action.--Section 2707(e)(1) of that title is
amended by inserting ``a request of a governmental entity
under section 2703(f) of this title,'' after ``subpoena,''.
(f) Conforming and Clerical Amendments.--
(1) Conforming amendments.--(A) The section heading of
section 2702 of that title is amended to read as follows:
``Sec. 2702. Voluntary disclosure of customer communications
or records''.
(B) The section heading of section 2703 of that title is
amended to read as follows:
``Sec. 2703. Required disclosure of customer communications
or records''.
(2) Clerical amendment.--The table of sections at the
beginning of chapter 121 of that title is amended by striking
the items relating to sections 2702 and 2703 and inserting
the following new items:
``2702. Voluntary disclosure of customer communications or records.''.
``2703. Required disclosure of customer communications or records.''.
SEC. 5. PEN REGISTERS AND TRAP AND TRACE DEVICES.
(a) General Prohibition on Use.--Section 3121(c) of title
18, United States Code, is amended--
(1) by inserting ``or trap and trace device'' after ``pen
register'';
(2) by inserting ``, routing, addressing,'' after
``dialing''; and
(3) by striking ``call processing'' and inserting ``the
processing and transmitting of wire and electronic
communications''.
(b) Application for Order.--Section 3122(b)(2) of that
title is amended by striking ``certification by the
applicant'' and inserting ``statement of facts showing''.
(c) Issuance of Order.--Section 3123 of that title is
amended--
(1) by striking subsection (a) and inserting the following
new subsection (a):
``(a) In General.--(1) Upon an application made under
section 3122(a)(1) of this title, the court shall enter an ex
parte order authorizing the installation and use of a pen
register or a trap and trace device if the court finds, based
on facts contained in the application, that the information
likely to be obtained by such installation and use is
relevant to an ongoing criminal investigation. Such order
shall, upon service of such order, apply to any entity
providing wire or electronic communication service in the
United States whose assistance may facilitate the execution
of the order.
``(2) Upon an application made under section 3122(a)(2) of
this title, the court shall enter an ex parte order
authorizing the installation and use of a pen register or a
trap and trace device within the jurisdiction of the court if
the court finds, based on facts contained in the application,
that the information likely to be obtained by such
installation and use is relevant to an ongoing criminal
investigation.'';
(2) in subsection (b)(1)--
(A) in subparagraph (A)--
(i) by inserting ``or other facility'' after ``line''; and
(ii) by inserting ``or applied'' after ``attached''; and
(B) in subparagraph (C)--
(i) by striking ``the number'' and inserting ``the
attributes of the communications to which the order applies,
such as the number or other identifier,'';
(ii) by striking ``physical'';
(iii) by inserting ``or other facility'' after ``line'';
(iv) by inserting ``or applied'' after ``attached''; and
(v) by inserting ``authorized under subsection (a)(2) of
this section'' after ``device'' the second place it appears;
and
(4) in subsection (d)(2)--
(A) by inserting ``or other facility'' after ``line'';
(B) by inserting ``or applied'' after ``attached''; and
(C) by striking ``has been ordered by the court'' and
inserting ``is obligated by the order''.
(d) Emergency Installation.--Section 3125(a)(1) of that
title is amended--
(1) in subparagraph (A), by striking ``or'' at the end;
(2) in subparagraph (B), by striking the comma at the end
and inserting a semicolon; and
(3) by adding at the end the following new subparagraphs:
``(C) an immediate threat to a national security interest;
or
``(D) an ongoing attack on the integrity or availability of
a protected computer punishable pursuant to section
1030(c)(2)(C) of this title,''.
(e) Definitions.--Section 3127 of that title is amended--
(1) in paragraph (2), by striking subparagraph (A) and
inserting the following new subparagraph (A):
``(A) any district court of the United States (including a
magistrate judge of such a court) or United States Court of
Appeals having jurisdiction over the offense being
investigated; or'';
[[Page S8862]]
(2) in paragraph (3)--
(A) by striking ``electronic or other impulses which
identify the numbers dialed or otherwise transmitted on the
telephone line to which such device is attached'' and
inserting ``dialing, routing, addressing, and signaling
information transmitted by an instrument or facility from
which a wire or electronic communication is transmitted'';
and
(B) by inserting ``or process'' after ``device'' each place
it appears;
(3) in paragraph (4)--
(A) by inserting ``or process'' after ``a device''; and
(B) by striking ``of an instrument or device from which a
wire or electronic communication was transmitted'' and
inserting ``or other dialing, routing, addressing, and
signaling information relevant to identifying the source of a
wire or electronic communication'';
(4) in paragraph (5), by striking ``and'' at the end;
(5) in paragraph (6), by striking the period at the end and
inserting ``; and''; and
(6) by adding at the end the following new paragraph:
``(7) the term `protected computer' has the meaning given
that term in section 1030(e) of this title.''.
SEC. 6. JUVENILE MATTERS.
Section 5032 of title 18, United States Code, is amended in
the first undesignated paragraph by inserting after ``section
924(b), (g), or (h) of this title,'' the following: ``or is a
violation of section 1030(a)(1), section 1030(a)(2)(B),
section 1030(a)(3), or a felony violation of section
1030(a)(5) where such felony violation of section 1030(a)(5)
is eligible for punishment under section 1030(c)(2)(C)(ii)
through (v) of this title,''.
SEC. 7. PROTECTION OF CABLE SERVICE SUBSCRIBER PRIVACY.
Section 631 of the Communications Act of 1934 (47 U.S.C.
551) is amended--
(1) in subsection (c)(2)--
(A) in subparagraph (B), by striking ``or'' at the end;
(B) in subparagraph (C), by striking the period at the end
and inserting ``; or''; and
(C) by adding at the end the following new subparagraph:
``(D) required under chapter 119, 121, or 206 of title 18,
United States Code, except that disclosure under this
subparagraph shall not include records revealing customer
cable television viewing activity.''; and
(2) in subsection (h), by striking ``A governmental
entity'' and inserting ``Except as provided in subsection
(c)(2)(D), a governmental entity''.
______
Mr. HATCH:
S. 3084. A bill to amend title XVIII of the Social Security Act to
provide for State accreditation of diabetes self-management training
programs under the Medicare Program; to the Committee on Finance.
state accreditation of diabetes self-management training programs under
the medicare program
Mr. HATCH. Mr. President, today, I am introducing legislation that
will allow all state diabetes education programs to be reimbursed by
the Medicare program. Currently, state diabetes education programs that
only have state certification are not able to receive Medicare
reimbursement for the fine work that they do as far as educating
diabetics in the communities. As a result, these individuals have less
access to the education that they need to control their diabetes.
This issue was brought to my attention by the Program Director of the
Utah Diabetes Control Program. There are 32 diabetes education programs
in Utah that are either Utah certified or recognized by the American
Diabetes Association. Eighteen of those programs have only state
certification and seven of those are located in rural communities of
Utah, including Moab, Price, Roosevelt, Gunnison, Payson, and Tooele.
Without this legislation, these 18 programs cannot be reimbursed by
Medicare unless they are certified by the American Diabetes
Association. In Utah, our state certification program exceeds national
standards. In addition to submitting an application and documentation
that the education programs meet the national standards, Utah Diabetes
Control Program staff conduct site visits with all applying programs.
The staff also collects data through annual reports to assess continued
quality and outcomes.
One of the biggest concerns that has been brought to my attention by
the Utah Department of Health is that the American Diabetes Association
charges $850 for state programs to apply for ADA certification. The
smaller state diabetes education programs have indicated that the ADA
fee is cost-prohibitive for them, especially in the more rural areas.
On the other hand, state certification is free to all applicants.
I understand that this problem not only exists in Utah, but across
the country. I believe that this matter needs to be addressed by
Congress so that all Medicare beneficiaries, regardless of where they
live, will have access to diabetes education programs.
______
By Mr. JEFFORDS (for himself, Mr. Kennedy, Mr. Cleland, and Mrs.
Murray):
S. 3085. A bill to provide assistance to mobilize and support United
States communities in carrying out youth development programs that
assure that all youth have access to programs and services that build
the competencies and character development needed to fully prepare the
youth to become adults and effective citizens; to the Committee on
Health, Education, Labor, and Pensions.
the younger americans act
Mr. JEFFORDS. Mr. President, I rise today to introduce the Younger
American's Act with Senators Kennedy, Cleland, and Murray. This
legislation embraces the belief that youth are not only our nation's
most valuable resource, they also are our most important
responsibility. The needs of youth must be moved to a higher priority
on our nation's agenda.
It is not enough that government responds to youth when they get into
trouble with drugs, teen pregnancy, and violence. We need to strengthen
the positive rather than simply respond to the negative. Positive youth
development, the framework for the Younger American's Act, is not just
about preventing bad things from happening, but giving a nudge to help
good things happen. And we know that it works.
Evaluations of Big Brothers/Big Sisters, Boys and Girls Clubs, and
other youth development programs have demonstrated significant
increases in parental involvement, youth participation in constructive
education, social and recreation activities, enrollment in post-
secondary education, and community involvement. Just as important,
youth actively participating in youth development programs show
decreased rates of school failure and absenteeism, teen pregnancy,
delinquency, substance abuse, and violent behavior.
We also know that risk taking behavior increases with age. One third
of the high school juniors and seniors participate in two or more
health risk behaviors. That is why it is important to build a youth
development infrastructure that engages youth as they enter pre-
adolescence and keeps them engaged throughout their teen years. The
Younger American's Act is targeted to youth aged ten to nineteen. This
encompasses both the critical middle-school years, as well as the
increasingly risky high school years.
The Younger American's Act is about framing a national policy on
youth. Up until now, government has responded to kids after they have
gotten into trouble. We must take a new tack. Instead of just treating
problems, we have to promote healthy development. We have to remember
that just because a kid stays out of trouble, it doesn't mean that he
or she is ready to handle the responsibilities of adulthood. Research
has shown that kids want direction, they want close bonds with parents
and other adult mentors. And I believe we owe them that. Ideally, this
comes from strong families, but communities and government can help.
In order to keep kids engaged in positive activities, youth must be
viewed as resources; as active participants in finding solutions to
their own problems. Parents also must be part of those solutions. This
legislation requires that youth and parents be part of the decision-
making process on the federal and local levels.
The United States does not have a cohesive federal policy on youth.
Creating an Office on National Youth Policy within the White House not
only raises the priority of youth on the federal agenda, but provides
an opportunity to more effectively coordinate existing federal youth
programs to increase their impact on the lives of young Americans. The
efforts of the Office of National Youth Policy in advocating for the
needs of youth, and the Department of Health and Human Service in
implementing the Younger American's Act will be helped by the Council
on National Youth Policy. This Council, comprised of youth, parents,
[[Page S8863]]
experts in youth development, and representatives from the business
community, will help ensure that this initiative continually responds
to the changing needs of youth and their communities. It will bring a
``real world'' perspective to the efforts of the Office and HHS.
The Younger American's Act provides communities with the funding
necessary to adequately ensure that youth have access to five core
resources:
Ongoing relationships with caring adults;
Safe places with structured activities in which to grow and learn;
Services that promote healthy lifestyles, including those designed to
improve physical and mental health;
Opportunities to acquire marketable skills and competencies; and
Opportunities for community service and civic participation.
Block grant funds will be used to expand existing resources, create
new ones where none existed before, overcome barriers to accessing
those resources, and fill gaps to create a cohesive network for youth.
The funds will be funneled through states, based on an allocation
formula that equally weighs population and poverty measures, to
communities where the primary decisions regarding the use of the funds
will take place. Thirty percent of the local funds are set aside for to
address the needs of youth who are particularly vulnerable, such as
those who are in out-of home placements, abused or neglected, living in
high poverty areas, or living in rural areas where there are usually
fewer resources. Dividing the state into regions, or ``planning and
mobilization areas,'' ensures that funds will be equitably distributed
throughout a state. Empowering community boards, comprised of youth,
parents, and other members of the community, to supervise decisions
regarding the use of the block grant funds ensures that the programs,
services, and activities supported by the Act will be responsive to
local needs.
Accountability is integral to any effective federal program. The
Younger American's Act provides the Department of Health and Human
Services with the responsibility and funding to conduct research and
evaluate the effectiveness of funded initiatives. States and the
Department are charged with monitoring the use of funds by grantees,
and empowered to withhold or reduce funds if problems arise.
The Younger Americans Act will help kids gain the skills and
experience they need to successfully navigate the rough waters of
adolescence. My twenty-first century community learning centers
initiative supports the efforts of schools to operate after-school
programs that emphasize academic enrichment. It's time to get the rest
of the community involved. It's time to give the same level of support
to the thousands of youth development and youth-serving organizations
that struggle to keep their doors open every day.
I remember a young man, Brad Luck, who testified before the H.E.L.P.
Committee several years ago. As a 14-year-old, Brad embarked on a two-
year mission to open a teen center in his home town of Essex Junction,
Vermont. He formed a student board of directors, sought 501(c)(3)
status and gave over 25 community presentations to convince the town to
back the program. Demonstrating the tenacity of youth, he then spear-
headed a successful drive to raise $30,000 in 30 days to fund the
start-up of the center. Today, the center is thriving in its town-
donated space. This is an example of the type of community asset
building supported by the Younger Americans Act. The Younger Americans
Act is about an investment in our youth, our communities, and our
future. I want to thank America's Promise, the United Way, and the
National Collaboration for Youth for their work in providing the
original framework for the legislation. I am proud and excited to be
part of this important initiative.
I ask unanimous consent that a summary of the legislation be printed
in the Record.
There being no objection, the summary was ordered to be printed in
the Record, as follows:
Younger Americans Act--Summary
The Younger Americans Act provides a framework for a
cohesive national policy on youth. Loosely based on the Older
Americans Act, this legislation is an opportunity to better
coordinate the services, activities and programs that help
our young people make a successful transition from childhood
to adulthood. The bill includes a block grant program to
support local communities in their efforts to strengthen the
resources that are available to youth. But perhaps most
importantly, The Younger Americans Act is about forging
partnerships between parents, youth, government, and youth
serving organizations.
The Younger Americans Act begins with a statement of
national youth policy that youth need to have access five
core resources:
Ongoing relationships with caring adults;
Safe places with structured activities;
Services that promote healthy lifestyles, including those
designed to improve physical and mental health;
Opportunities to acquire marketable skills and
competencies; and
Opportunities for community service and civic
participation.
Reflecting the high priority which youth need to occupy on
the national agenda, the legislation establishes an Office of
National Youth Policy within the White House. This office
will serve as an effective advocate for youth within the
federal government and assist in resolving administrative and
programmatic conflicts between federal programs that are
barriers to parents, youth, communities, and service
providers in accessing the full array of core resources for
youth. Funds for this Office are authorized for $500,000 a
year.
The Younger Americans Act creates a Council on National
Youth Policy to advise the President, the Director of the
Office of National Youth Policy and the Department of Health
and Human Services on the developmental needs of youth, youth
participation, and federal youth policies. The membership of
the Council ensures that youth are active participants in the
finding solutions to many of their own problems. The Council
is authorized to conduct public forums for discussion and
serve as an information conduit between policy makers, youth,
and others involved in the provision of youth services. It is
authorized for $250,000 per year.
The Younger Americans Act creates a formula-based state
block grant to support community-based youth development
programs, activities and services. Ninety-seven percent of
the funds will be distributed to states, Native American
tribes and organizations, and outlying territories. The
Department of Health and Human Services is authorized to use
the remainder of the funds to conduct demonstration program
for youth populations that are particularly vulnerable. Funds
are distributed to states based on the population of youth
aged 10-19, and the number of children and youth receiving
free- or reduced priced lunches. There is a small state
minimum of .4 percent.
To implement the block grant, states are required to divide
the state into geographical regions called planning and
mobilization areas. States are encouraged to utilize existing
state administrative or programmatic regions. States may use
up to 4 percent of the funds for program review, monitoring,
and technical assistance; and no more than 3 percent of
the funds to address the needs of particularly vulnerable
youth populations, including youth in out-of-home
residential settings, such as foster care, communities
with high concentrations of poverty, rural areas, and
youth that have been abused or neglected. The remaining 93
percent of the funds allotted to the states must be
equitably distributed among the planning and mobilization
areas, based on the same population and school lunch
program participation formula used for the distribution of
the federal funds.
An ``area agency for youth'' will be designated to
administer the funds, under the direction of a community
board. States are encouraged to build on existing community
resources and systems. After assessing the available assets
for youth, as well as gaps in and barriers to services in the
community, a plan to address the needs of local youth in the
five core resources is developed for each region of the
state. At least 30 percent of the funds provided to the area
agency for youth must be used to address the needs of the
most vulnerable youth populations in the region. As part of
the planning process, area agencies for youth and community
boards must identify measures of program effectiveness upon
which future progress will be evaluated.
Funds are distributed, on a competitive basis, to
community-based youth serving organizations and agencies in
such a manner as to build a cohesive network of programs,
services and activities for local youth. Provisions in the
legislation ensure the participation of youth and their
families in decisions about how best to meet the needs of
local youth. There is a state or local match requirement of
20 percent for the first two years, increasing to 50 percent
by the fifth and subsequent years. The match can meet through
cash or in-kind contributions, fairly evaluated. The
legislation contains an illustrative list of youth
development activities, programs and services that may
receive funds from the Younger American's Act. That list
includes a broad variety of effective youth development
activities such as youth mentoring, community youth centers
and clubs, character development, non-school hours programs,
sports and recreation activities, academic and cultural
enrichment, workforce preparation, community service, and
referrals to health and mental health services. The block
grant is authorized for $500 million the first year, ramping
[[Page S8864]]
up to $2 billion in the fifth year of the legislation, for a
total of $5.75 billion over five years.
Although research has demonstrated the effectiveness of
positive youth development programs, accountability and
evaluation must be part of any significant investment of
federal funds. The legislation requires the Department of
Health and Human Service to conduct extensive research and
evaluation of the programs, services and activities funded
under the Act. The Department also has responsibility for
funding professional development activities for youth workers
and other training and education initiatives to increase the
capacity of local boards, agencies and organizations to
implement the block grant. These efforts are authorized for
$7 million per year.
Mr. KENNEDY. Mr. President, I commend Senator Jeffords for his
leadership on this important legislation and it is a privilege to join
him as a cosponsor on this legislation. I also commend the thirty-four
youth organizations that comprise the National Collaboration for Youth
and the more than 200 young people who have worked on this bill. They
have been skillful and tireless in their efforts to focus on the need
for a positive national strategy for youth.
Our goal in introducing the Younger Americans Act is to establish a
national policy for youth which focuses on young people, not as
problems, but as problem solvers. The Younger Americans Act is intended
to create a local and nation-wide collaborative movement to provide
programs that offer greater support for youth in the years of
adolescence. This bill, modeled on the very successful Older Americans
Act of 1965, will help youths between the ages of 10 and 19. It will
provide assistance to communities for youths development programs that
assure that all youth have access to the skills and character
development needed to become good citizens.
In other successful bipartisan measures over the years, such as Head
Start, child care, and the 21st century learning communities, we have
created a support system for parents of preschool and younger school-
age children. These programs reduce the risk that children will grow up
to become juvenile delinquents by giving them a healthy and safe start.
It's time to do the same thing for adolescents.
Americans overwhelmingly believe that government should invest in
initiatives like this. Many studies detail the effectiveness of youth
development programs. Beginning with the Carnegie Corporation Report in
1992, ``A Matter of Time--Risk and Opportunity in the Nonschool
Hours,'' a series of studies have shown repeatedly that youth
development programs at the community level produce powerful and
positive results.
In this report this last March, ``Community Counts: How Youth
Organizations Matter for Youth Development,'' Milbrey McLaughlin,
professor of education at Stanford University, calls for communities to
rethink how they design and deliver services for youths, particularly
during non-school hours. The report confirms that community involvement
is essential in creating and supporting effective programs that meet
the needs of today's youth.
Effective community-based youth development programs build on five
core resources that all youths need to be successful. These same core
resources are the basis for the Younger Americans Act. Youths need
ongoing relationships with caring adults, safe places with structured
activities, access to services that promote healthy lifestyles,
opportunities to acquire marketable skills, and opportunities for
community service and community participation.
The Younger Americans Act will establish a way for communities to
give thought and planning on the issues at the local level, and to
involve both youths and parents in the process. The Act will provide
$5.76 billion over the next five years for communities to conduct youth
development programs that recognize the primary role of the family,
promote the involvement of youth, coordinate services in the community,
and eliminate barriers which prevent youth from obtaining the guidance
and support they need to become successful adults. The Act also creates
a national youth policy office and a national youth council to advise
the President and Congress and help focus the country more effectively
on the needs of young people.
Too often, the focus on youth has emphasized their problems, not
their successes and their potential. This emphasis has sent a negative
message to youth that needs to be reversed. We need to deal with
negative behaviors, but we also need a broader strategy that provides a
positive approach to youth. The Younger Americans Act will accomplish
this goal in three ways, by focusing national attention on the
strengths and contributions of youths, by providing funds to develop
positive and cooperative youth development programs at the state and
community levels, and by promoting the involvement of parents and
youths in developing positive programs that strengthen families.
The time of adolescence is a complex transitional period of growth
and change. We know what works. The challenge we face is to provide the
resources to implement positive and practical programs effectively.
Investing in youth in ways like that will pay enormous dividends for
communities and our country. I urge all members of Congress to join in
supporting this important legislation.
____________________