[Congressional Record Volume 149, Number 150 (Thursday, October 23, 2003)]
[Senate]
[Pages S13138-S13139]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. BINGAMAN (for himself, Mr. Inouye, Mr. Daschle, Mrs. 
        Murray, Mr. Dayton, Mr. Johnson, Ms. Cantwell, and Ms. 
        Stabenow):
  S. 1779. A bill to amend title XVIII of the Social Security Act to 
provide for fairness in the provision of medicare services for Indians; 
to the Committee on Finance.
  Mr. BINGAMAN. Mr. President, I am introducing today the Medicare 
Indian Health Fairness Act of 2003 with Senators Inouye, Daschle, 
Murray, Dayton, Johnson, Cantwell, and Stabenow. This legislation would 
take a number of steps to improve the delivery of health care to Native 
Amerians through Medicare and the Indian Health Service, IHS, system.
  First and foremost, Indian Health Service and tribal hospitals and 
clinics, which provide health care to American Indians on or near 
reservations and to Alaska Natives, are currently unable to bill for 
all Medicare Part B services. In effect, the Indian Health Service is 
subsidizing the Medicare program because those services, which would 
otherwise be paid for by Medicare, are instead paid for by IHS, which 
is horribly underfunded.
  In 2000, IHS hospitals and clinics were made eligible to bill 
Medicare for certain Part B services for the first time, including 
services delivered by physicians and certain other practitioners, but 
those services were limited and denied payment for Part B items and 
services, such as the following: Durable medical equipment--this 
includes such items as wheelchairs, as well as blood testing strips and 
blood monitors for diabetes patients, which is a severe problem among 
Native Americans; home and some institutional dialysis supplies and 
equipment--since the prevalence of diabetes in American Indians--Alaska 
Natives is three times the rate in the general U.S. population, Indian 
people experience a high rate of renal disease, including end state 
renal disease; cancer screening; pap smears; glaucoma screening; clinic 
or hospital-based ambulance services; prosthetic devices; covered 
vaccines, including hepatitis B, pneumococcal and influenza 
chemotherapy drugs; and clinical laboratory services.
  This legislation would simply make these Indian health facilities and 
providers eligible for payment for all Part B Medicare-covered items 
and services to the same extent that any other provider would be 
eligible for payment.
  Furthermore, the bill assures that Native Americans should have the 
same access to Medicare services as any other American. If IHS 
providers are unable to bill for such Medicare services, IHS budget 
shortfalls may result in rationing and delays in treatment. For some, 
it means going out of the IHS system to get prompt service, as other 
providers are able to bill the Medicare program. Native Americans and 
IHS providers should not be subject to such barriers to care and 
payment. Nor should they be subject to such complexity, as they are 
only prohibited from billing and receiving payment for certain Part B 
services.

  There is absolutely no policy rationale for limiting the payment to 
IHS, tribal hospitals and clinics to only certain Medicare Part B 
services. I urge the Senate to end this unfortunate disparity.
  Fortunately, identical language has been included in S. 1, the 
Medicare prescription drug bull that passed the Senate earlier this 
month. I offered an amendment with Senator Daschle, amendment No. 973, 
on the Senate floor and was pleased that it was accepted by Chairman 
Grassley and Ranking Member Baucus accepted it as part of the manager's 
amendment prior to final passage of the bill.
  In addition to that important provision, the ``Medicare Indian Health 
Fairness Act'' includes another provision that was adopted as part of 
S. 1 as a Bingaman amendment during the Finance Committee mark-up. This 
provision requires Medicare providers to charge no more than Medicare 
rates for inpatient hospital services provided to Indians who are 
eligible for contract health services from the Indian Health Service, 
tribally operated health programs, and urban Indian organizations.
  This allows IHS to maximize its purchase of contract health services, 
just as is done by the Department of Veterans Affairs and the 
Department of Defense. Since the contract health services, CHS, account 
is chronically underfunded, IHS and the tribes seriously ration and 
often exhaust those funds before the end of the fiscal year. In fiscal 
year 2001 alone, the Indian Health Service had insufficient funding to 
provide services for over 100,000 cases that met its medical priority 
criteria and denied 22,000 other cases of medically necessary care 
which did not meet IHS medical priorities. Therefore, this section of 
the bill would enable IHS and tribes to achieve greater economy for the 
provision of contract health services.
  The Department of Health and Human Services Office of Inspector 
General's Cost-Saver Handbook has annually made this recommendation. As 
per its 2003 Red Book or cost-saver handbook reads:

       As a federal purchaser of inpatient health care from the 
     private sector, IHS should receive rates commensurate with 
     those received by other federal agencies that engage in 
     similar purchases [such as the VA and DOD].

  The Inspector General adds:

       If the favorable Medicare rates were legislatively 
     required, the dollars saved could be applied to the backlog 
     of patient services that cannot be accommodated in the 
     Contract Health Services program.

  And last, the legislation includes a section intended to bring a 
measure of consistency, rationality and efficiency to the Medicare 
payment rate for all clinics in the Indian Health Service-supported 
health care system. This language creates a uniform payment methodology 
that would be available to all IHS and tribal clinics and corrects the 
current situation where payment rates differ widely--based not on the 
nature of the services a clinic provides, but on whether the facility 
is operated by the IHS or operated by a tribe, and whether the clinic 
is considered provider-based or free-standing. Since all clinics 
provide primary patient care and arrange for secondary, tertiary and 
specialty care on a referral basis, there is no rational reason for the 
wide disparity in the Medicare payment methodologies for these 
facilities.
  The legislation would give all Indian clinics the ability to collect 
reimbursement from the same IHS-CMS all-inclusive rate. Application of 
the same

[[Page S13139]]

all-inclusive rate to all clinics would have the added value of being 
efficient and economical to use at the clinic level and would apply the 
same payment method in Medicare, by which IHS-funded clinics are 
reimbursed, as they receive in Medicaid.
  This section of the bill was the only one not included in S. 1, but 
the rationale for it makes it an important component of this bill and 
something we hope to see passed into law as well.
  Although these provisions address a diversity of problems IHS 
providers and clinics have with respect to the Medicare program, they 
are critical and we should pass all of these provisions either as part 
of a conference agreement on S. 1, as part of the ``Indian Health Care 
Improvement Act,'' or on their merits through passage of this 
freestanding bill.
  I would like to thank Senators Inouye, Daschle, Murray, Dayton, 
Johnson, Cantwell, and Stabenow for being original cosponsors of this 
important legislation. I ask for unanimous consent that the 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. 1779

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

     SECTION 1. SHORT TITLE.

       This Act may be cited as the ``Medicare Indian Health 
     Fairness Act of 2003''.

     SEC. 2. AUTHORIZATION OF REIMBURSEMENT FOR ALL MEDICARE PART 
                   B SERVICES FURNISHED BY CERTAIN INDIAN 
                   HOSPITALS AND CLINICS.

       (a) In General.--Section 1880(e) of the Social Security Act 
     (42 U.S.C. 1395qq(e)) is amended--
       (1) in paragraph (1)(A), by striking ``for services 
     described in paragraph (2)'' and inserting ``for all items 
     and services for which payment may be made under such part'';
       (2) by striking paragraph (2); and
       (3) by redesignating paragraph (3) as paragraph (2).
       (b) Effective Date.--The amendments made by this section 
     shall apply to items and services furnished on or after the 
     first day of the sixth month beginning after the date of 
     enactment of this Act.

     SEC. 3. LIMITATION ON CHARGES FOR INPATIENT HOSPITAL CONTRACT 
                   HEALTH SERVICES PROVIDED TO INDIANS BY MEDICARE 
                   PARTICIPATING HOSPITALS.

       (a) In General.--Section 1866(a)(1) of the Social Security 
     Act (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 and 
     inserting ``, and''; and
       (3) by adding at the end the following new subparagraph:
       ``(T) in the case of hospitals which furnish inpatient 
     hospital services for which payment may be made under this 
     title, to be a participating provider of medical care--
       ``(i) under the contract health services program funded by 
     the Indian Health Service and operated by the Indian Health 
     Service, an Indian tribe, or tribal organization (as those 
     terms are defined in section 4 of the Indian Health Care 
     Improvement Act), with respect to items and services that are 
     covered under such program and furnished to an individual 
     eligible for such items and services under such program; and
       ``(ii) under a program funded by the Indian Health Service 
     and operated by an urban Indian organization with respect to 
     the purchase of items and services for an eligible urban 
     Indian (as those terms are defined in such section 4), in 
     accordance with regulations promulgated by the Secretary 
     regarding admission practices, payment methodology, and rates 
     of payment (including the acceptance of no more than such 
     payment rate as payment in full for such items and 
     services).''.
       (b) Effective Date.--The amendments made by this section 
     shall apply as of a date specified by the Secretary of Health 
     and Human Services (but in no case later than 6 months after 
     the date of enactment of this Act) to medicare participation 
     agreements in effect (or entered into) on or after such date.

     SEC. 4. EQUAL PAYMENTS FOR CLINICS IN THE INDIAN HEALTH 
                   SERVICE SUPPORTED HEALTH CARE SYSTEM.

       (a) In General.--Section 1880 of the Social Security Act 
     (42 U.S.C. 1395qq) is amended--
       (1) by redesignating subsection (f) as subsection (g); and
       (2) by inserting after subsection (e) the following new 
     subsection:
       ``(f) Notwithstanding any other provision of law, for 
     purposes of determining the rate of reimbursement for items 
     and services under this title, any outpatient or ambulatory 
     care clinic (whether freestanding or provider-based) operated 
     by the Indian Health Service, an Indian tribe, a tribal 
     organization, or an urban Indian organization (as those terms 
     are defined in section 4 of the Indian Health Care 
     Improvement Act), shall, upon the election of such clinic, be 
     reimbursed on the same basis as if such clinic were a 
     hospital outpatient department of the Indian Health 
     Service.''.
       (b) Effective Date.--The amendments made by this section 
     shall apply to items and services furnished on or after the 
     first day of the sixth month beginning after the date of 
     enactment of this Act.
                                 ______