[Congressional Record (Bound Edition), Volume 149 (2003), Part 12]
[Senate]
[Pages 15714-15724]
[From the U.S. Government Publishing Office, www.gpo.gov]




                           TEXT OF AMENDMENTS

  SA 975. Mr. ROCKEFELLER (for himself, Ms. Mikulski, and Mrs. Clinton)

[[Page 15715]]

proposed an amendment to the bill S. 1, to amend title XVIII of the 
Social Security Act to make improvements in the medicare program, to 
provide prescription drug coverage under the medicare program, and for 
other purposes; as follows:
       On page 10, lines 12 and 13, strike ``(other than a dual 
     eligible individual, as defined in section 1860D-
     19(a)(4)(E))''.
       On page 21, strike lines 22 through 25, and insert ``title 
     XIX through a waiver under 1115 where covered outpatient 
     drugs are the sole medical assistance benefit.''
       On page 107, line 3, strike ``30 percent'' and insert 
     ``27.5 percent''.
       On page 116, line 10, insert ``and'' after the semi-colon.
       On page 116, line 12, strike ``; and'' and insert a period.
       On page 116, strike lines 13 through 17.
       On page 116, line 24, insert ``and'' after the semi-colon.
       On page 117, line 2, strike ``; and'' and insert a period.
       On page 117, strike lines 3 through 7.
       On page 117, line 13, insert ``and'' after the semicolon.
       On page 117, line 17, strike ``; and'' and insert a period.
       On page 117, strike lines 18 through 23.
       On page 118, line 6, insert ``and'' after the semicolon.
       On page 118, in line 13, insert ``or'' after the semi-
     colon.
       On page 118, line 14, strike ``; or'' and insert a period.
       On page 118, strike line 15.
       Beginning on page 118, strike line 16 and all that follows 
     through page 119, line 9.
       On page 119, line 10, strike ``(F)'' and insert ``(E)''.
       On page 119, line 15, strike ``(G)'' and insert ``(F)''.
       On page 119, line 19, strike ``(C), (D), or (E)'' and 
     insert ``(C), or (D)''.
       On page 120, line 3, strike ``(H)'' and insert ``(G)''.
       On page 120, lines 5 and 6, strike ``who is a dual eligible 
     individual or an individual''.
       Beginning on page 121, line 24, strike ``dual eligible'' 
     and all that follows through ``and'' on page 122, line 1.
       On page 146, line 6, insert before the period ``and to the 
     design, development, acquisition or installation of improved 
     data systems necessary to track prescription drug spending 
     for purposes of implementing section 1935(c)''.
       Beginning on page 146, strike line 23 and all that follows 
     through page 149, line 21, and insert the following:
       ``(c) Federal Assumption of Medicaid Prescription Drug 
     Costs for Dually Eligible Beneficiaries.--
       ``(1) In general.--For purpose of section 1903(a)(1) for a 
     State for a calendar quarter in a year (beginning with 2006) 
     the amount computed under this subsection is equal to the 
     product of the following:
       ``(A) Standard prescription drug coverage under medicare.--
     With respect to individuals who are residents of the State, 
     who are entitled to, or enrolled for, benefits under part A 
     of title XVIII, or are enrolled under part B of title XVIII 
     and are receiving medical assistance under subparagraph 
     (A)(i), (A)(ii), or (C) of section 1902(a)(10) (or as the 
     result of the application of section 1902(f)) that includes 
     covered outpatient drugs (as defined for purposes of section 
     1927) under the State plan under this title (including such a 
     plan operated under a waiver under section 1115)--
       ``(i) the total amounts attributable to such individuals in 
     the quarter under section 1860D-19 (relating to premium and 
     cost-sharing subsidies for low-income medicare 
     beneficiaries); and
       ``(ii) the actuarial value of standard prescription drug 
     coverage (as determined under section 1860D-6(f)) provided to 
     such individuals in the quarter.
       ``(B) State matching rate.--A proportion computed by 
     subtracting from 100 percent the Federal medical assistance 
     percentage (as defined in section 1905(b)) applicable to the 
     State and the quarter.
       ``(C) Phase-out proportion.--Subject to subparagraph (D), 
     the phase-out proportion for a quarter in--
       ``(i) 2006 is 95 percent;
       ``(ii) 2007 is 90 percent;
       ``(iii) 2008 is 85 percent;
       ``(iv) 2009 is 80 percent;
       ``(v) 2010 is 75 percent; or
       ``(vi) 2011, 2012 and 2013 is 70 percent.
       ``(d) Medicaid as Secondary Payor.--In the case of an 
     individual who is entitled to a Medicare Prescription Drug 
     plan under part D or drug coverage under a MedicareAdvantage 
     plan, and medical assistance including covered outpatient 
     drugs under this title, medical assistance shall continue to 
     be provided under this title for covered outpatient drugs to 
     the extent payment is not made under the Medicare 
     Prescription Drug plan or a MedicareAdvantage plan.
       Beginning on page 152, strike line 3 and all that follows 
     through page 153, line 15, and insert the following:
       ``(f) Definition.--For purposes of this section, the term 
     `subsidy-eligible individual' has the meaning given that term 
     in subparagraph (D) of section 1860D-19(a)(4).''.
       (C) Conforming amendments.--
       (1) Section 1903(a)(1) (42 U.S.C. 1396a(a)(1)) is amended 
     by inserting before the semicolon the following: ``, reduced 
     by the amount computed under section 1935(c)(1) for the State 
     and the quarter''.
       (2) Section 1108(f) (42 U.S.C. 1308(f)) is amended by 
     inserting ``and section 1935(e)(1)(B)'' after ``Subject to 
     subsection (g)''.
       Beginning on page 157, strike line 21 and all that follows 
     through page 158, line 4.
       On page 173, beginning on line 15, strike ``that is not'' 
     and all that follows through ``includes'' on line 18 on that 
     page, and insert ``that includes but is limited solely to''.
       On page 190, in line 18, strike ``and''.
       On page 190, between lines 18 and 19, insert the following:
       ``(B) is not a dual eligible beneficiary as defined under 
     section 1807(i)(1)(B); and''.
       On page 190, line 19, strike ``(B)'' and insert ``(C)''.
                                 ______
                                 
  SA 976. Mr. ROCKEFELLER (for himself, Mr. Carper, Mr. Graham of 
Florida, Ms. Mikulski, Mrs. Clinton, and Mr. Dodd) proposed an 
amendment to the bill S. 1, to amend title XVIII of the Social Security 
Act to make improvements in the medicare program, to provide 
prescription drug coverage under the medicare program, and for other 
purposes; as follows:

       On page 51, strike lines 15 through 25 and insert the 
     following:
       ``(ii) such costs shall be treated as incurred without 
     regard to whether the individual or another person, including 
     a State program or other third-party coverage, has paid for 
     such costs.
                                 ______
                                 
  SA 977. Mr. DAYTON submitted an amendment intended to be proposed by 
him to the bill S. 1, to amend title XVIII of the Social Security Act 
to make improvements in the medicare program, to provide prescription 
drug coverage under the medicare program, and for other purposes; as 
follows:

       On page 134, strike line 9 and insert the following:
     under paragraph (1).
       ``(d) Implementation of Part D.--Notwithstanding section 
     1860D-1(a)(4) or any other provision of this part or part C, 
     the Secretary shall implement, and make benefits available 
     under, this part on January 1, 2004. The Secretary shall 
     carry out this part until the Administrator is appointed and 
     able to carry out this part. The Secretary shall not 
     implement sections 1807 and 1807A.
                                 ______
                                 
  SA 978. Mr. JEFFORDS (for himself, Mr. Kerry, Mr. Reid, Mr. Durbin, 
and Mr. Lautenberg) submitted an amendment intended to be proposed by 
him to the bill S. 14, to enhance the energy security of the United 
States, and for other purposes; which was ordered to lie on the table; 
as follows:

       On page 467, after line 16, add the following:

                Subtitle I--Renewable Portfolio Standard

     SEC. 192. RENEWABLE PORTFOLIO STANDARD.

       Title VI of the Public Utility Regulatory Policies Act of 
     1978 (16 U.S.C. 2601 et seq.) is amended by adding at the end 
     the following:

     ``SEC. 606. FEDERAL RENEWABLE PORTFOLIO STANDARD.

       ``(a) Renewable Energy Requirements.--
       ``(1) In general.--For each calendar year beginning in 
     Calendar year 2006, each retail electric supplier shall 
     submit to the Secretary, not later than April 30 of each 
     year, renewable energy credits in an amount equal to the 
     required annual percentage of the retail electric supplier's 
     total amount of kilowatt-hours of non-hydropower (excluding 
     incremental hydropower) electricity sold to retail consumers 
     during the previous calendar year.
       ``(2) Carryover.--A renewable energy credit for any year 
     that is not used to satisfy the minimum requirement for that 
     year may be carried over for use within the next two years.
       ``(b) Required Annual Percentage.--Of the total amount of 
     non-hydropower (excluding incremental hydropower) electricity 
     sold by each retail electric supplier during a calendar year, 
     the amount generated by renewable energy sources shall be not 
     less than the percentage specified below:

          


                     Percentage of Renewable Energy


          
        Calendar years:                                      Each year:
2006-2009.............................................................5
2010-2014............................................................10
2015-2019............................................................15
2020 and subsequent years............................................20

       ``(c) Submission of Renewable Energy Credits.--
       ``(1) In general.--To meet the requirements under 
     subsection (a), a retail electric supplier shall submit to 
     the Secretary either--
       ``(A) renewable energy credits issued to the retail 
     electric supplier under subsection (e);
       ``(B) renewable energy credits obtained by purchase or 
     exchange under subsection (f);

[[Page 15716]]

       ``(C) renewable energy credits purchased from the United 
     States under subsection (g); or
       ``(D) any combination of credits under subsections (e), (f) 
     or (g).
       ``(2) Prohibition on double counting.--A credit may be 
     counted toward compliance with subsection (a) only once.
       ``(d) Renewable Energy Credit Program.--The Secretary shall 
     establish, not later than 1 year after the date of enactment 
     of this Act, a program to issue, monitor the sale or exchange 
     of, and track, renewable energy credits.
       ``(e) Issuance of Renewable Energy Credits.--
       ``(1) In general.--Under the program established in 
     subsection (d), an entity that generates electric energy 
     through the use of a renewable energy resource may apply to 
     the Secretary for the issuance of renewable energy credits.
       ``(2) Application.--An application for the issuance of 
     renewable energy credits shall indicate--
       ``(A) the type of renewable energy resource used to produce 
     the electric energy;
       ``(B) the State in which the electric energy was produced; 
     and
       ``(C) any other information the Secretary determines 
     appropriate.
       ``(3) Credit value.--Except as provided in subparagraph 
     (4), the Secretary shall issue to an entity applying under 
     this subsection one renewable energy credit for each 
     kilowatt-hour of renewable energy generated in any State from 
     the date of enactment of this Act and in each subsequent 
     calendar year.
       ``(4) Credit value for distributed generation.--The 
     Secretary shall issue three renewable energy credits for each 
     kilowatt-hour of distributed generation.
       ``(5) Vesting.--A renewable energy credit will vest with 
     the owner of the system or facility that generates the 
     renewable energy unless such owner explicitly transfers the 
     credit.
       ``(6) Credit eligibility.--To be eligible for a renewable 
     energy credit, the unit of electricity generated through the 
     use of a renewable energy resource shall be sold for retail 
     consumption or used by the generator. If both a renewable 
     energy resource and a non-renewable energy resource are used 
     to generate the electric energy, the Secretary shall issue 
     renewable energy credits based on the proportion of the 
     renewable energy resource used.
       ``(7) Identifying credits.--The Secretary shall identify 
     renewable energy credits by the type and date of generation.
       ``(8) Sale under purpa contract.--When a generator sells 
     electric energy generated through the use of a renewable 
     energy resource to a retail electric supplier under a 
     contract subject to section 210 of the Public Utilities 
     Regulatory Policies Act of 1978 (16 U.S.C. 824a-3), the 
     retail electric supplier is treated as the generator of the 
     electric energy for the purposes of this Act for the duration 
     of the contract.
       ``(f) Sale or Exchange of Renewable Energy Credits.--A 
     renewable energy credit may be sold or exchanged by the 
     entity issued the renewable energy credit or by any other 
     entity that acquires the renewable energy credit. Credits may 
     be sold or exchanged in any manner not in conflict with 
     existing law, including on the spot market or by contractual 
     arrangements of any duration.
       ``(g) Purchase From the United States.--The Secretary shall 
     offer renewable energy credits for sale at the lesser of 
     three cents per kilowatt-hour or 110 percent of the average 
     market value of credits for the applicable compliance period. 
     On January 1 of each year following calendar year 2006, the 
     Secretary shall adjust for inflation the price charged per 
     credit for such calendar year.
       ``(h) State Programs.--Nothing in this section shall 
     preclude any State from requiring additional renewable energy 
     generation in the State under any renewable energy program 
     conducted by the State.
       ``(i) Consumer Allocation.--The rates charged to classes of 
     consumers by a retail electric supplier shall reflect a 
     proportional percentage of the cost of generating or 
     acquiring the required annual percentage of renewable energy 
     under subsection (a). A retail electric supplier shall not 
     represent to any customer or prospective customer that any 
     product contains more than the percentage of eligible 
     resources if the additional amount of eligible resources is 
     being used to satisfy the renewable generation requirement 
     under subsection (a).
       ``(j) Enforcement.--A retail electric supplier that does 
     not submit renewable energy credits as required under 
     subsection (a) shall be liable for the payment of a civil 
     penalty. That penalty shall be calculated on the basis of the 
     number of renewable energy credits not submitted, multiplied 
     by the lesser of 4.5 cents or 300 percent of the average 
     market value of credits for the compliance period.
       ``(k) Information Collection.--The Secretary may collect 
     the information necessary to verify and audit--
       ``(1) the annual electric energy generation and renewable 
     energy generation of any entity applying for renewable energy 
     credits under this section;
       ``(2) the validity of renewable energy credits submitted by 
     a retail electric supplier to the Secretary; and
       ``(3) the quantity of electricity sales of all retail 
     electric suppliers.
       ``(l) Voluntary Participation.--The Secretary may issue a 
     renewable energy credit pursuant to subsection (e) to any 
     entity not subject to the requirements of this Act only if 
     the entity applying for such credit meets the terms and 
     conditions of this Act to the same extent as entities subject 
     to this Act.
       ``(m) State Renewable Energy Grant Program.
       ``(1) Distribution to states.--The Secretary shall 
     distribute amounts received from sales under subsection (g) 
     and from amounts received under subsection (j) to States to 
     be used for the purposes of this section.
       ``(2) Regional equity program.--
       ``(A) Establishment of program.--Within one year from the 
     date of enactment of this Act, the Secretary shall establish 
     a program to promote renewable energy production and use 
     consistent with the purposes of this section.
       ``(B) Eligibility.--The Secretary shall make funds 
     available under this section to State energy agencies for 
     grant programs for--
       ``(i) renewable energy research and development;
       ``(ii) loan guarantees to encourage construction of 
     renewable energy facilities;
       ``(iii) consumer rebate or other programs to offset costs 
     of small residential or small commercial renewable energy 
     systems including solar hot water; or
       ``(iv) promoting distributed generation.
       ``(3) Allocation preferences.--In allocating funds under 
     the program, the Secretary shall give preference to
       ``(A) States in regions which have a disproportionately 
     small share of economically sustainable renewable energy 
     generation capacity; and
       ``(B) State grant programs most likely to stimulate or 
     enhance innovative renewable energy technologies.
       ``(n) Definitions.--In this section:
       ``(1) Biomass.--
       ``(A) In general.--The term ``biomass'' means--
       ``(i) organic material from a plant that is planted for the 
     purpose of being used to produce energy;
       ``(ii) nonhazardous, cellulosic or agricultural waste 
     material that is segregated from other waste materials and is 
     derived from-- ``(I) a forest-related resource, including--
       ``(aa) mill and harvesting residue;
       ``(bb) precommercial thinnings;
       ``(cc) slash; and
       ``(dd) brush;
       ``(II) agricultural resources, including--
       ``(aa) orchard tree crops;
       ``(bb) vineyards;
       ``(cc) grains;
       ``(dd) legumes;
       ``(ee) sugar; and
       ``(ff) other crop by-products or residues; or
       ``(III) miscellaneous waste such as--
       ``(aa) waste pallet;
       ``(bb) crate; and
       ``(cc) landscape or right-of-way tree trimmings;
       ``(iii) animal waste that is converted to a fuel rather 
     than directly combusted, the residue of which is converted to 
     a biological fertilizer, oil, or activated carbon.
       ``(B) Exclusions.--The term `biomass' shall not include--
       ``(i) municipal solid waste that is incinerated;
       ``(ii) recyclable post-consumer waste paper;
       ``(iii) painted, treated, or pressurized wood;
       ``(iv) wood contaminated with plastics or metals; or
       ``(v) tires.
       ``(2) Distributed generation.--The term `distributed 
     generation' means reduced electricity consumption from the 
     electric grid due to use by a customer of renewable energy 
     generated at a customer site.
       ``(3) Incremental hydropower.--The term `incremental 
     hydropower' means additional generation achieved from 
     increased efficiency after January 1, 2003, at a 
     hydroelectric dam that was placed in service before January 
     1, 2003.
       ``(4) Landfill gas.--The term `landfill gas' means gas 
     generated from the decomposition of household solid waste, 
     commercial solid waste, and industrial solid waste disposed 
     of in a municipal solid waste landfill unit (as those terms 
     are defined in regulations promulgated under subtitle D of 
     the Solid Waste Disposal Act (42 U.S.C. 6941 et seq.)).
       ``(5) Renewable energy.--The term `renewable energy' means 
     electricity generated from
       ``(A) a renewable energy source; or
       ``(B) hydrogen that is produced from a renewable energy 
     source.
       ``(5) Renewable energy source.--The term `renewable energy 
     source' means--
       ``(A) wind;
       ``(B) ocean waves;
       ``(C) biomass;
       ``(D) solar;
       ``(E) landfill gas;
       ``(F) incremental hydropower; or
       ``(G) geothermal.
       ``(6) Retail electric supplier.--The term `retail electric 
     supplier' means a person or entity that sells retail 
     electricity to consumers, and which sold not less than 
     500,000 megawatt-hours of electric energy to consumers for 
     purposes other than resale during the preceding calendar 
     year.

[[Page 15717]]

       ``(7) Secretary.--The term `Secretary' means the Secretary 
     of Energy.
                                 ______
                                 
  SA 979. Mr. AKAKA (for himself, Mr. Sarbanes, and Ms. Mikulski) 
proposed an amendment to the bill S. 1, to amend title XVIII of the 
Social Security Act to make improvements in the medicare program, to 
provide prescription drug coverage under the medicare program, and for 
other purposes; as follows:

       At the appropriate place, insert the following:

     SEC.  . NEGOTIATIONS BY THE OFFICE OF PERSONNEL MANAGEMENT.

       The Office of Personnel Management may not negotiate a 
     prescription drug benefit for any health benefits plan under 
     chapter 89 of title 5, United States Code, that would provide 
     a prescription drug benefit to a medicare eligible enrollee 
     in that plan that is of lesser actuarial value, based on 2003 
     constant dollars, than the prescription drug benefit 
     available to a medicare eligible enrollee of such plan on the 
     date of enactment of this Act.
                                 ______
                                 
  SA 980. Mr. AKAKA proposed an amendment to the bill S. 1, to amend 
title XVIII of the Social Security Act to make improvements in the 
medicare program, to provide prescription drug coverage under the 
medicare program, and for other purposes; as follows:

       On page 636, line 16, insert ``and citizens of the Freely 
     Associated States, which include the Federated States of 
     Micronesia, the Republic of the Marshall Islands, and the 
     Republic of Palau, lawfully residing in the United States'' 
     after ``Act''.
                                 ______
                                 
  SA 981. Mr. PRYOR proposed an amendment to the bill S. 1, to amend 
title XVIII of the Social Security Act to make improvements in the 
medicare program, to provide prescription drug coverage under the 
medicare program, and for other purposes; as follows:

       At the appropriate place, add the following:

     SEC. __. EQUAL ACCESS TO COMPETITIVE GLOBAL PRESCRIPTION 
                   MEDICINE PRICES FOR AMERICAN PURCHASERS.

       (a) Definition of Covered Product.--In this section, the 
     term ``covered product'' has the meaning given the term in 
     section 804 of the Federal Food, Drug, and Cosmetic Act (21 
     U.S.C. 384).
       (b) Prohibition.--It shall be unlawful for the manufacturer 
     of a covered product or any other person that sells a covered 
     product to refuse to sell to any wholesaler or retailer (or 
     other purchaser representing a group of wholesalers or 
     retailers) of covered products in the United States on terms 
     (including such terms as prompt payment, cash payment, volume 
     purchase, single-site delivery, the use of formularies by 
     purchasers, and any other term that effectively reduces the 
     cost to the manufacturer of supplying the drug) that are not 
     substantially the same as the most favorable (to the 
     purchaser) terms on which the person has sold or has agreed 
     to sell the covered product to any purchaser in Canada.
       (c) Enforcement.--The Secretary of Health and Human 
     Services, or any wholesaler or retailer in the United States 
     aggrieved by a violation of subsection (b), may bring a civil 
     action in United States district court against a person that 
     violates subsection (b) for an order--
       (1) enjoining the violation; and
       (2) awarding damages in the amount that is equal to 3 times 
     the amount of the value of the difference between--
       (A) the terms on which the person sold a covered product to 
     the wholesaler or retailer; and
       (B) the terms on which the person sold the covered product 
     to a person in Canada.
       (d) Effectiveness of Section.--This section takes effect on 
     the date that is 2 years after the date of enactment of this 
     Act, except that this section shall not be in effect during 
     any period after that date in which there is in effect a 
     final regulation promulgated by the Secretary of Health and 
     Human Services permitting the importation or reimportation of 
     prescription drugs under section 804 of the Federal Food, 
     Drug, and Cosmetic Act (21 U.S.C. 384).
                                 ______
                                 
  SA 982. Mr. LAUTENBERG submitted an amendment intended to be proposed 
by him to the bill S. 1, to amend title XVIII of the Social Security 
Act to make improvements in the medicare program, to provide 
prescription drug coverage under the medicare program, and for other 
purposes; which was ordered to lie on the table; as follows:

       At the end of title I, insert the following:

     SEC. __. IMPLEMENTATION OF TITLE.

       Notwithstanding any other provision of this Act, the 
     amendments made by this title shall be implemented and 
     administered so that prescription drug coverage is first 
     provided under part D of title XVIII beginning on July 1, 
     2004.
                                 ______
                                 
  SA 983. Mr. SPECTER submitted an amendment intended to be proposed by 
him to the bill S. 1, to amend title XVIII of the Social Security Act 
to make improvements in the medicare program, to provide prescription 
drug coverage under the medicare program, and for other purposes; which 
was ordered to lie on the table; as follows:

       On page 676, after line 22, insert the following:

     SEC. __. PROVISION OF INFORMATION ON ADVANCE DIRECTIVES.

       Section 1804(c) of the Social Security Act (42 U.S.C. 
     1395b-2(c)) is amended--
       (1) by redesignating paragraphs (1) through (4) as 
     subparagraphs (A) through (D), respectively;
       (2) in the matter preceding subparagraph (A), as so 
     redesignated, by striking ``The notice'' and inserting ``(1) 
     The notice''; and
       (3) by adding at the end the following:
       ``(2)(A) The Secretary shall annually provide each medicare 
     beneficiary with information concerning advance directives. 
     Such information shall be provided by the Secretary as part 
     of the Medicare and You handbook that is provided to each 
     such beneficiary. Such handbook shall include a separate 
     section on advanced directives and specific details on living 
     wills and the durable power of attorney for health care. The 
     Secretary shall ensure that the introductory letter that 
     accompanies such handbook contain a statement concerning the 
     inclusion of such information.
       ``(B) In this section:
       ``(i) The term `advance directive' has the meaning given 
     such term in section 1866(f)(3).
       ``(ii) The term `medicare beneficiary' means an individual 
     who is entitled to, or enrolled for, benefits under part A or 
     enrolled under part B, of this title.''.
                                 ______
                                 
  SA 984. Mr. BINGAMAN proposed an amendment to the bill S. 1, to amend 
title XVIII of the Social Security Act to make improvements in the 
medicare program, to provide prescription drug coverage under the 
medicare program, and for other purposes; as follows:

       At the end of subtitle C of title II, add the following:

     SEC. __. CARVING OUT DSH PAYMENTS FROM PAYMENTS TO 
                   MEDICARE+CHOICE AND MEDICAREADVANTAGE 
                   ORGANIZATIONS AND PAYING THE AMOUNTS DIRECTLY 
                   TO DSH HOSPITALS ENROLLING MEDICARE+CHOICE AND 
                   MEDICAREADVANTAGE ENROLLEES.

       (a) Removal of DSH Payments From Calculation of Adjusted 
     Average Per Capita Cost.--
       (1) Under medicare+choice.--Section 1853(c)(3) (42 U.S.C. 
     1395w-23(c)(3) and as amended by section 203) is amended--
       (A) in subparagraph (A), by striking ``subparagraph (B)'' 
     and inserting ``subparagraphs (B) and (E)'',
       (B) by adding at the end the following new subparagraph:
       ``(E) Removal of payments attributable to disproportionate 
     share payments from calculation of adjusted average per 
     capita cost.--For each year (beginning with 2004), the area-
     specific Medicare+Choice capitation rate under subparagraph 
     (A)(ii) shall be adjusted to exclude from such rate the 
     portion of such rate that the Secretary estimates is 
     attributable to additional payment amounts described in 
     section 1886(d)(5)(F) (treating hospitals reimbursed under 
     section 1814(b)(3) as if such hospitals were reimbursed under 
     section 1886).''.
       (2) Under medicareadvantage.--Section 1853(a)(5) (as 
     amended by section 203) is amended by adding at the end the 
     following new subparagraph:
       ``(C) Removal of payments attributable to disproportionate 
     share payments from calculation of adjusted average per 
     capita cost.--For each year (beginning with 2004), the area-
     specific Medicare+Choice capitation rate under subparagraph 
     (A)(ii) shall be adjusted to exclude from such rate the 
     portion of such rate that the Secretary estimates is 
     attributable to additional payment amounts described in 
     section 1886(d)(5)(F) (treating hospitals reimbursed under 
     section 1814(b)(3) as if such hospitals were reimbursed under 
     section 1886).''.
       (3) Effective dates.--The amendments made--
       (A) by paragraph (1) shall apply to plan years beginning on 
     and after January 1, 2004 and shall continue to apply to plan 
     years beginning on and after January 1, 2006; and
       (B) by paragraph (2) shall apply to plan years beginning on 
     and after January 1, 2006.
       (b) Additional DSH Payments for Managed Care Enrollees.--
     Section 1886(d)(5)(F) ((42 U.S.C. 1395ww(d)(5)(F)) is 
     amended--
       (1) in clause (ii), by striking ``clause (ix)'' and 
     inserting ``clauses (ix) and (xvi)''; and
       (2) by adding at the end the following new clause:
       ``(xvi)(I) For portions of cost reporting periods occurring 
     on or after January 1, 2004, the Secretary shall provide for 
     an additional payment amount for each applicable discharge of 
     any subsection (d) hospital that is a disproportionate share 
     hospital (as described in clause (i)).

[[Page 15718]]

       ``(II) For purposes of this clause the term `applicable 
     discharge' means the discharge of any individual who is 
     enrolled under a risk-sharing contract with a eligible 
     organization under section 1876 and who is entitled to 
     benefits under part A and any individual who is enrolled with 
     a Medicare+Choice organization or a MedicareAdvantage 
     organization under part C.
       ``(III) The amount of the payment under this clause with 
     respect to any applicable discharge shall be equal to the 
     estimated average per discharge amount that would otherwise 
     have been paid under this subparagraph if the individuals had 
     not been enrolled as described in subclause (II).
       ``(IV) The Secretary shall establish rules for paying an 
     additional amount for any hospital reimbursed under a 
     reimbursement system authorized under 1814(b)(3) if such 
     hospital would qualify as a disproportionate share hospital 
     under clause (i) were it not so reimbursed. Such payment 
     shall be determined in the same manner as the amount of 
     payment is determined under this clause for disproportionate 
     share hospitals.''.
                                 ______
                                 
  SA 985. Mr. BAUCUS (for Mr. Edwards (for himself and Mr. Harkin)) 
proposed an amendment to the bill S. 1, to amend title XVIII of the 
Social Security Act to make improvements in the medicare program, to 
provide prescription drug coverage under the medicare program, and for 
other purposes; as follows:

       At the end, add the following:

       TITLE __--DIRECT-TO-CONSUMER PRESCRIPTION DRUG ADVERTISING

     SEC. __01. HEAD-TO-HEAD TESTING AND DIRECT-TO-CONSUMER 
                   ADVERTISING.

       (a) New Drug Application.--Section 505 of the Federal Food, 
     Drug, and Cosmetic Act (21 U.S.C. 355) is amended--
       (1) in subparagraph (A) of the second sentence of 
     subsection (b)(1), by inserting before the semicolon at the 
     end the following ``(including whether the drug is safe and 
     effective for use in comparison with other drugs available 
     for substantially the same indications for use prescribed, 
     recommended, or suggested in the labeling proposed for the 
     drug)''; and
       (2) in subsection (d)(5)--
       (A) by inserting ``(A)'' after ``will''; and
       (B) by inserting after ``thereof'' the following: ``or (B) 
     offer a benefit with respect to safety, effectiveness, or 
     cost (including effectiveness with respect to a sub 
     population or condition) that is greater than the benefit 
     offered by other drugs available for substantially the same 
     indications for use prescribed, recommended, or suggested in 
     the labeling proposed for the drug''.
       (b) Misbranding.--Section 502(n)(3) of the Federal Food, 
     Drug, and Cosmetic Act (21 U.S.C. 352(n)(3)) is amended by 
     inserting after ``effectiveness'' the following: ``(including 
     effectiveness in comparison to other drugs for substantially 
     the same condition or conditions)''.
       (c) Regulations.--
       (1) In general.--Not later than 180 days after the date of 
     enactment of this Act, the Secretary of Health and Human 
     Services shall promulgate amended regulations governing 
     prescription drug advertisements.
       (2) Contents.--In addition to any other requirements, the 
     regulations under paragraph (1) shall require that--
       (A) any advertisement present a fair balance, comparable in 
     depth and detail, between--
       (B) any advertisement present a fair balance, comparable in 
     depth, between--
       (i)aural and visual presentations relating to effectiveness 
     of the drug; and
       (ii) aural and visual presentations relating to side 
     effects and contraindications, provided that, nothing in this 
     section shall require explicit images or sounds depicting 
     side effects and contraindication;
       (i) information relating to effectiveness of the drug 
     (including effectiveness in comparison to similar drugs for 
     substantially the same condition or conditions); and
       (ii) information relating to side effects and 
     contraindications;
       (C) prohibit false or misleading advertising that would 
     encourage a consumer to take the prescription drug for a use 
     other than a use for which the prescription drug is approved 
     under section 505 of the Federal Food, Drug, and Cosmetic Act 
     (21 U.S.C. 355); and
       (D) require that any prescription drug that is the subject 
     of a direct-to-consumer advertisement include in the package 
     in which the prescription drug is sold to consumers a 
     medication guide explaining the benefits and risks of use of 
     the prescription drug in terms designed to be understandable 
     to the general public.

     SEC. __02. CIVIL PENALTY.

       Section 303 of the Federal Food, Drug, and Cosmetic Act (21 
     U.S.C. 333) is amended by adding at the end the following:
       ``(h) Direct-to-Consumer Prescription Drug Advertising.--
       ``(1) In general.--A person that commits a violation of 
     section 301 involving the misbranding of a prescription drug 
     (within the meaning of section 502(n)) in a direct-to-
     consumer advertisement shall be assessed a civil penalty if--
       ``(A) the Secretary provides the person written notice of 
     the violation; and
       ``(B) the person fails to correct or cease the 
     advertisement so as to eliminate the violation not later than 
     180 days after the date of the notice.
       ``(2) Amount.--The amount of a civil penalty under 
     paragraph (1)--
       ``(A) shall not exceed $500,000 in the case of an 
     individual and $5,000,000 in the case of any other person; 
     and
       ``(B) shall not exceed $10,000,000 for all such violations 
     adjudicated in a single proceeding.
       ``(3) Procedure.--Paragraphs (3) through (5) of subsection 
     (g) apply with respect to a civil penalty under paragraph (1) 
     of this subsection to the same extent and in the same manner 
     as those paragraphs apply with respect to a civil penalty 
     under paragraph (1) or (2) of subsection (g).''.

     SEC. __03. REPORTS.

       The Secretary of Health and Human Services shall annually 
     submit to the Committee on Health, Education, Labor, and 
     Pensions of the Senate and the Committee on Energy and 
     Commerce of the House of Representatives a report that, for 
     the most recent 1-year period for which data are available--
       (1) provides the total number of direct-to-consumer 
     prescription drug advertisements made by television, radio, 
     the Internet, written publication, or other media;
       (2) identifies, for each such advertisement--
       (A) the dates on which, the times at which, and the markets 
     in which the advertisement was made; and
       (B) the type of advertisement (reminder, help-seeking, or 
     product-claim); and
       (3)(A) identifies the advertisements that violated or 
     appeared to violate section 502(n) of the Federal Food, Drug, 
     and Cosmetic Act (21 U.S.C. 352(n)); and
       (B) describes the actions taken by the Secretary in 
     response to the violations.

     SEC. __04. REVIEW OF DIRECT-TO-CONSUMER DRUG ADVERTISEMENTS.

       (a) In General.--The Secretary of Health and Human Services 
     shall expedite, to the maximum extent practicable, reviews of 
     the legality of direct-to-consumer drug advertisements.
       (b) Policy.--The Secretary of Health and Human Services 
     shall not adopt or follow any policy that would have the 
     purpose or effect of delaying reviews of the legality of 
     direct-to-consumer drug advertisements except--
       (1) as a result of notice-and-comment rulemaking; or
       (2) as the Secretary determines to be necessary to protect 
     public health and safety.
                                 ______
                                 
  SA 986. Mr. BAUCUS (for Mr. Lautenberg (for himself, Mr. Reed, Mrs. 
Clinton, and Mr. Corzine)) proposed an amendment to the bill S. 1, to 
amend title XVIII of the Social Security Act to make improvements in 
the medicare program, to provide prescription drug coverage under the 
medicare program, and for other purposes; as follows:

       At the end of title I, insert the following:

     SEC. __. IMPLEMENTATION OF TITLE.

       Notwithstanding any other provision of this Act, the 
     amendments made by this title shall be implemented and 
     administered so that prescription drug coverage is first 
     provided under part D of title XVIII beginning on July 1, 
     2004.
                                 ______
                                 
  SA 987. Mrs. HUTCHISON (for herself, Mr. Kennedy, Mr. Durbin, Mr. 
Kerry, Mr. Talent, Mr. Reed, Mrs. Murray, Mr. Specter, Mrs. Feinstein, 
Mr. Corzine, Mr. Biden, Mr. Bond, and Mr. Schumer) submitted an 
amendment intended to be proposed by her to the bill S. 1, to amend 
title XVIII of the Social Security Act to make improvements in the 
medicare program, to provide prescription drug coverage under the 
medicare program, and for other purposes; which was ordered to lie on 
the table; as follows:

       At the end of subtitle A of title IV, add the following:

     SEC. __. FREEZING INDIRECT MEDICAL EDUCATION (IME) ADJUSTMENT 
                   PERCENTAGE AT 6.5 PERCENT.

       (a) In General.--Section 1886(d)(5)(B)(ii) (42 U.S.C. 
     1395ww(d)(5)(B)(ii)) is amended--
       (1) in subclause (VI), by striking ``and'' at the end; and
       (2) by striking subclause (VII) and inserting the following 
     new subclauses:
       ``(VII) during fiscal year 2003, ``c'' is equal to 1.35; 
     and
       ``(VIII) on or after October 1, 2003, `c' is equal to 
     1.6.''.
       (b) 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 striking ``1999 or'' and inserting ``1999,''; and
       (2) by inserting ``, or the Prescription Drug and Medicare 
     Improvement Act of 2003'' after ``2000''.jennifer
                                 ______
                                 
  SA 988. Mr. THOMAS (for himself and Mrs. Lincoln) submitted an 
amendment intended to be proposed by him to the bill S. 1, to amend 
title XVIII of

[[Page 15719]]

the Social Security Act to make improvements in the medicare program, 
to provide prescription drug coverage under the medicare program, and 
for other purposes; which was ordered to lie on the table; as follows:

       At the end of subtitle B of title IV, add the following:

     SEC. __. COVERAGE OF MARRIAGE AND FAMILY THERAPIST SERVICES 
                   AND MENTAL HEALTH COUNSELOR SERVICES UNDER PART 
                   B OF THE MEDICARE PROGRAM.

       (a) Coverage of Services.--
       (1) In general.--Section 1861(s)(2) (42 U.S.C. 1395x(s)(2)) 
     is amended--
       (A) in subparagraph (U), by striking ``and'' after the 
     semicolon at the end;
       (B) in subparagraph (V)(iii), by inserting ``and'' after 
     the semicolon at the end; and
       (C) by adding at the end the following new subparagraph:
       ``(W) marriage and family therapist services (as defined in 
     subsection (ww)(1)) and mental health counselor services (as 
     defined in subsection (ww)(3));''.
       (2) Definitions.--Section 1861 (42 U.S.C. 1395x) is amended 
     by adding at the end the following new subsection:

     ``Marriage and Family Therapist Services; Marriage and Family 
  Therapist; Mental Health Counselor Services; Mental Health Counselor

       ``(ww)(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) in the case of an individual performing services in a 
     State that provides for licensure or certification of 
     marriage and family therapists, is licensed or certified as a 
     marriage and family therapist in such State.
       ``(3) The term `mental health counselor services' means 
     services performed by a mental health counselor (as defined 
     in paragraph (4)) for the diagnosis and treatment of mental 
     illnesses which the mental health counselor is legally 
     authorized to perform under State law (or the State 
     regulatory mechanism provided by the State law) of the State 
     in which such services are performed, as would otherwise be 
     covered if furnished by a physician or as 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.
       ``(4) The term `mental health counselor' means an 
     individual who--
       ``(A) possesses a master's or doctor's degree in mental 
     health counseling or a related field;
       ``(B) after obtaining such a degree has performed at least 
     2 years of supervised mental health counselor practice; and
       ``(C) in the case of an individual performing services in a 
     State that provides for licensure or certification of mental 
     health counselors or professional counselors, is licensed or 
     certified as a mental health counselor or professional 
     counselor in such State.''.
       (3) Provision for payment under part b.--Section 
     1832(a)(2)(B) (42 U.S.C. 1395k(a)(2)(B)) is amended by adding 
     at the end the following new clause:
       ``(v) marriage and family therapist services and mental 
     health counselor services;''.
       (4) Amount of payment.--Section 1833(a)(1) (42 U.S.C. 
     1395l(a)(1)) is amended--
       (A) by striking ``and (U)'' and inserting ``(U)''; and
       (B) by inserting before the semicolon at the end the 
     following: ``, and (V) with respect to marriage and family 
     therapist services and mental health counselor services under 
     section 1861(s)(2)(W), the amounts paid shall be 80 percent 
     of the lesser of the actual charge for the services or 75 
     percent of the amount determined for payment of a 
     psychologist under subparagraph (L)''.
       (5) Exclusion of marriage and family therapist services and 
     mental health counselor services from skilled nursing 
     facility prospective payment system.--Section 
     1888(e)(2)(A)(ii) (42 U.S.C. 1395yy(e)(2)(A)(ii)), as amended 
     in section 301(a), is amended by inserting ``marriage and 
     family therapist services (as defined in subsection (ww)(1)), 
     mental health counselor services (as defined in section 
     1861(ww)(3)),'' after ``qualified psychologist services,''.
       (6) Inclusion of marriage and family therapists and mental 
     health counselors as practitioners for assignment of 
     claims.--Section 1842(b)(18)(C) (42 U.S.C. 1395u(b)(18)(C)) 
     is amended by adding at the end the following new clauses:
       ``(vii) A marriage and family therapist (as defined in 
     section 1861(ww)(2)).
       ``(viii) A mental health counselor (as defined in section 
     1861(ww)(4)).''.
       (b) Coverage of Certain Mental Health Services Provided in 
     Certain Settings.--
       (1) Rural health clinics and federally qualified health 
     centers.--Section 1861(aa)(1)(B) (42 U.S.C. 1395x(aa)(1)(B)) 
     is amended by striking ``or by a clinical social worker (as 
     defined in subsection (hh)(1)),'' and inserting ``, by a 
     clinical social worker (as defined in subsection (hh)(1)), by 
     a marriage and family therapist (as defined in subsection 
     (ww)(2)), or by a mental health counselor (as defined in 
     subsection (ww)(4)),''.
       (2) Hospice programs.--Section 1861(dd)(2)(B)(i)(III) (42 
     U.S.C. 1395x(dd)(2)(B)(i)(III)) is amended by inserting ``or 
     a marriage and family therapist (as defined in subsection 
     (ww)(2))'' after ``social worker''.
       (c) Authorization of Marriage and Family Therapists To 
     Develop Discharge Plans for Post-Hospital Services.--Section 
     1861(ee)(2)(G) (42 U.S.C. 1395x(ee)(2)(G)) is amended by 
     inserting ``marriage and family therapist (as defined in 
     subsection (ww)(2)),'' after ``social worker,''.
       (d) Effective Date.--The amendments made by this section 
     shall apply with respect to services furnished on or after 
     January 1, 2004.
                                 ______
                                 
  SA 989. Ms. COLLINS submitted an amendment intended to be proposed by 
her to the bill S. 1, to amend title XVIII of the Social Security Act 
to make improvements in the medicare program, to provide prescription 
drug coverage under the medicare program, and for other purposes; which 
was ordered to lie on the table; as follows:

       At the appropriate place in subtitle C of title IV, insert 
     the following:

     SEC. __. INCREASE IN MEDICARE PAYMENT FOR CERTAIN HOME HEALTH 
                   SERVICES.

       (a) In General.--Section 1895 of the Social Security Act 
     (42 U.S.C. 1395fff) is amended by adding at the end the 
     following:
       ``(f) Increase in Payment for Services Furnished in a Rural 
     Area.--
       ``(1) In general.--In the case of home health services 
     furnished in a rural area (as defined in section 
     1886(d)(2)(D)) on or after October 1, 2003 and before October 
     1, 2006, the Secretary shall increase the payment amount 
     otherwise made under this section for such services by 10 
     percent.
       ``(2) Waiver of budget neutrality.--The Secretary shall not 
     reduce the standard prospective payment amount (or amounts) 
     under this section applicable to home health services 
     furnished during any period to offset the increase in 
     payments resulting from the application of paragraph (1).''.
       (b) Payment Adjustment.--Section 1895(b)(5) of the Social 
     Security Act (42 U.S. C. 1395fff(b)(5)) is amended by adding 
     at the end the following:``Notwithstanding this paragraph, 
     the total amount of the additional payments or payment 
     adjustments made under this paragraph may not exceed, with 
     respect to fiscal year 2004, 3 percent, and, with respect to 
     fiscal years 2005 and 2006, 4 percent, of the total payments 
     projected or estimated to be made based on the prospective 
     payment system under this subsection in the year involved.''.
       (c) Effective Date.--The amendments made by this section 
     shall apply to services furnished on or after October 1, 
     2003.
                                 ______
                                 
  SA 990. Mrs. MURRAY proposed an amendment to the bill S. 1, to amend 
title XVIII of the Social Security Act to make improvements in the 
medicare program, to provide prescription drug coverage under the 
medicare program, and for other purposes; as follows:

       At the end of subtitle A of title II, add the following:

     SEC. __. IMPROVEMENTS IN MEDICAREADVANTAGE BENCHMARK 
                   DETERMINATIONS.

       (a) Revision of National Average Used in Calculation of 
     Blend.--Section 1853(c)(4)(B)(i)(II) (42 U.S.C. 1395w-
     23(c)(4)(B)(i)(II)), as amended by section 203, is amended by 
     inserting ``who are enrolled in a MedicareAdvantage plan'' 
     after ``the average number of medicare beneficiaries''.
       (b) Change in Budget Neutrality.--Section 1853(c) (42 
     U.S.C. 1395w-23(c)), as amended by section 203, is amended--
       (1) in paragraph (1)(A)--
       (A) in clause (ii), by striking the comma at the end and 
     inserting a period; and
       (B) by striking the flush matter following clause (ii); and
       (2) by striking paragraph (5).
       (c) Inclusion of Costs of DOD and VA Military Facility 
     Services to Medicare-eligible Beneficiaries in Calculation of 
     MedicareAdvantage Payment Rates.--
       (1) For purposes of calculating medicare+choice payment 
     rates.--Section 1853(c)(3) (42 U.S.C. 1395w-23(c)(3)), as 
     amended by section 203, is amended--
       (A) in subparagraph (A), by striking ``subparagraph (B)'' 
     and inserting ``subparagraphs (B) and (E)''; and

[[Page 15720]]

       (B) by adding at the end the following new subparagraph:
       ``(E) Inclusion of costs of dod and va military facility 
     services to medicare-eligible beneficiaries.--In determining 
     the area-specific Medicare+Choice capitation rate under 
     subparagraph (A) for a year (beginning with 2006), the annual 
     per capita rate of payment for 1997 determined under section 
     1876(a)(1)(C) shall be adjusted to include in the rate the 
     Secretary's estimate, on a per capita basis, of the amount of 
     additional payments that would have been made in the area 
     involved under this title if individuals entitled to benefits 
     under this title had not received services from facilities of 
     the Department of Defense or the Department of Veterans 
     Affairs.''.
       (2) For purposes of calculating local fee-for-service 
     rates.--Section 1853(d)(5) (42 U.S.C. 1395w-23(d)(5)), as 
     amended by section 203, is amended--
       (A) in subparagraph (A), by striking ``subparagraph (B)'' 
     and inserting ``subparagraphs (B) and (C)''; and
       (B) by adding at the end the following new subparagraph:
       ``(C) Inclusion of costs of dod and va military facility 
     services to medicare-eligible beneficiaries.--In determining 
     the local fee-for-service rate under subparagraph (A) for a 
     year (beginning with 2006), the annual per capita rate of 
     payment for 1997 determined under section 1876(a)(1)(C) shall 
     be adjusted to include in the rate the Secretary's estimate, 
     on a per capita basis, of the amount of additional payments 
     that would have been made in the area involved under this 
     title if individuals entitled to benefits under this title 
     had not received services from facilities of the Department 
     of Defense or the Department of Veterans Affairs.''.
       (d) Effective Date.--The amendments made by this section 
     shall apply with respect to plan years beginning on and after 
     January 1, 2006.
                                 ______
                                 
  SA 991. Mr. HARKIN proposed an amendment to the bill S. 1, to amend 
title XVIII of the Social Security Act to make improvements in the 
medicare program, to provide prescription drug coverage under the 
medicare program, and for other purposes; as follows:

     At the appropriate place, insert the following:

               TITLE __--MEDICAID DEMONSTRATION PROJECTS

     SEC. __01. SHORT TITLE.

       This title may be cited as the ``Money Follows the Person 
     Act of 2003''.

     SEC. __02. FINDINGS.

       Congress makes the following findings:
       (1) In his budget for fiscal year 2004, President George W. 
     Bush proposes a ``Money Follows the Person'' rebalancing 
     initiative under the medicaid program to help States 
     rebalance their long-term services support systems more 
     evenly between institutional and community-based services.
       (2) The President, by proposing this initiative, and 
     Congress, recognize that States have not fully developed the 
     systems needed to create a more equitable balance between 
     institutional and community-based services spending under the 
     medicaid program.
       (3) While a few States have been successful at achieving 
     this balance, nationally, approximately 70 percent of the 
     medicaid funding spent for long-term services is devoted to 
     nursing facilities and intermediate care facilities for the 
     mentally retarded. Only 30 percent of such funding is spent 
     for community-based services.
       (4) As a result, there are often long waiting lists for 
     community-based services and supports.
       (5) In the Americans with Disabilities Act of 1990, 
     Congress found that individuals with disabilities continue to 
     encounter various forms of discrimination, including 
     segregation, and that discrimination persists in such 
     critical areas as institutionalization.
       (6) In 1999, the Supreme Court held in Olmstead v. LC (527 
     U.S. 581 (1999)) that needless institutionalization is 
     discrimination under the Americans with Disabilities Act of 
     1990, noting that institutional placement of people who can 
     be served in the community ``perpetuates unwarranted 
     assumptions that persons so isolated are unworthy of 
     participating in community life.'' (Id. at 600). The Court 
     further found that ``confinement in an institution severely 
     diminishes the everyday life activities of individuals, 
     including family relations, social contacts, work options, 
     economic independence, educational advancement, and cultural 
     enrichment.'' (Id. at 601).
       (7) Additional resources would be helpful for assisting 
     States in rebalancing their long-term services support system 
     and complying with the Olmstead decision.

     SEC. __03. AUTHORITY TO CONDUCT MEDICAID DEMONSTRATION 
                   PROJECTS.

       (a) Definitions.--In this section:
       (1) Community-based services and supports.--The term 
     ``community-based services and supports'' means, with respect 
     to a State, any items or services that are an allowable 
     expenditure for medical assistance under the State medicaid 
     program, or under a waiver of such program and that the State 
     determines would allow an individual to live in the 
     community.
       (2) Individual's representative; representative.--The terms 
     ``individual's representative'' and ``representative'' mean a 
     parent, family member, guardian, advocate, or authorized 
     representative of an individual.
       (3) Medicaid long-term care facility.--The term ``medicaid 
     long-term care facility'' means a hospital, nursing facility, 
     or intermediate care facility for the mentally retarded, as 
     such terms are defined for purposes of the medicaid program.
       (4) Medicaid program.--The term ``medicaid program'' means 
     the State medical assistance program established under title 
     XIX of the Social Security Act (42 U.S.C. 1396 et seq.).
       (5) Secretary.--The term ``Secretary'' means the Secretary 
     of Health and Human Services.
       (6) State.--The term ``State'' has the meaning given such 
     term for purposes of the medicaid program.
       (b) State Application.--A State may apply to the Secretary 
     for approval to conduct a demonstration project under which 
     the State shall provide community-based services and supports 
     to individuals--
       (1) who are eligible for medical assistance under the 
     medicaid program;
       (2) who are residing in a medicaid long-term care facility 
     and who have resided in such facility for at least 90 days; 
     and
       (3) with respect to whom there has been a determination 
     that but for the provision of community-based services and 
     supports, the individuals would continue to require the level 
     of care provided in a medicaid long-term care facility.
       (c) Requirements.--A State is not eligible to conduct a 
     demonstration project under this section unless the State 
     certifies the following:
       (1) With respect to any individual provided community-based 
     services and supports under the demonstration project, the 
     State shall continue to provide community-based services and 
     supports to the individual under the medicaid program (and at 
     the State's Federal medical assistance percentage (as defined 
     in section 1905(b) of the Social Security Act) reimbursement 
     rate), for as long as the individual remains eligible for 
     medical assistance under the State medicaid program and 
     continues to require such services and supports, beginning 
     with the month that begins after the 12-month period in which 
     the individual is provided such services and supports under 
     the demonstration project.
       (2) The State shall allow an individual participating in 
     the demonstration project (or, as appropriate, the 
     individual's representative) to choose the setting in which 
     the individual desires to receives the community-based 
     services and supports provided under the project.
       (3) The State shall identify and educate individuals 
     residing in a medicaid long-term care facility who are 
     eligible to participate in the demonstration project (and, as 
     appropriate the individual's representative) about the 
     opportunity for the individual to receive community-based 
     services and supports under the demonstration project.
       (4) The State shall ensure that each individual identified 
     in accordance with paragraph (3) (and, as appropriate, the 
     individual's representative), has the opportunity, 
     information, and tools to make an informed choice regarding 
     whether to transition to the community through participation 
     in the demonstration project or to remain in the medicaid 
     long-term care facility.
       (5) The State shall maintain an adequate quality 
     improvement system so that individuals participating in the 
     demonstration project receive adequate services and supports.
       (6) The State shall conduct a process for public 
     participation in the design and development of the 
     demonstration project and such process shall include the 
     participation of individuals with disabilities, elderly 
     individuals, or individuals with chronic conditions who are 
     part of the target populations to be served by the 
     demonstration project, and the representatives of such 
     individuals.
       (7) The Federal funds paid to a State pursuant to this 
     section shall only supplement, and shall not supplant, the 
     level of State funds expended for providing community-based 
     services and supports for individuals under the State 
     medicaid program as of the date the State application to 
     conduct a demonstration project under this section is 
     approved.
       (d) Approval of Demonstration Projects.--
       (1) In general.--Subject to paragraph (2), the Secretary 
     shall conduct a competitive application process with respect 
     to applications submitted under subsection (b) (taking into 
     consideration the preferences provided under paragraph (2)) 
     that meet the requirements of subsection (c). In determining 
     whether to approve such an application, the Secretary may 
     waive the requirement of--
       (A) section 1902(a)(1) of the Social Security Act (42 
     U.S.C. 1396a(a)(1)) to allow for sub-State demonstrations;
       (B) section 1902(a)(10)(B) of such Act (42 U.S.C. 
     1396a(a)(10)(B)) with respect to comparability; and
       (C) section 1902(a)(10)(C)(i)(III) of such Act (42 U.S.C. 
     1396a(a)(10)(C)(i)(III)) with respect to income and resource 
     limitations.

[[Page 15721]]

       (2) Preference for certain applications.--In approving 
     applications to conduct demonstration projects under this 
     section, the Secretary shall give preference to approving 
     applications that indicate that the State shall do the 
     following:
       (A) Design and implement enduring improvements in 
     community-based long-term services support systems within the 
     State to enable individuals with disabilities to live and 
     participate in community life, particularly with respect to 
     those practices that will ensure the successful transition of 
     such individuals from medicaid long-term care facilities into 
     the community.
       (B) Design and implement a long-term services support 
     system in the State that prevents individuals from entering 
     medicaid long-term care facilities in order to gain access to 
     community-based services and supports.
       (C) Engage in systemic reform activities within the State 
     to rebalance expenditures for long-term services under the 
     State medicaid program through administrative actions that 
     reduce reliance on institutional forms of service and build 
     up more community capacity.
       (D) Address the needs of populations that have been 
     underserved with respect to the availability of community 
     services or involve individuals or entities that have not 
     previously participated in the efforts of the State to 
     increase access to community-based services.
       (E) Actively engage in collaboration between public housing 
     agencies, the State medicaid agency, independent living 
     centers, and other agencies and entities in order to 
     coordinate strategies for obtaining community integrated 
     housing and supportive services for an individual who 
     participates in the demonstration project, both with respect 
     to the period during which such individual participates in 
     the project and after the individual's participation in the 
     project concludes, in order to enable the individual to 
     continue to reside in the community.
       (F) Develop and implement policies and procedures that 
     allow the State medicaid agency to administratively transfer 
     or integrate funds from the State budget accounts that are 
     obligated for expenditures for medicaid long-term care 
     facilities to other accounts for obligation for the provision 
     of community-based services and supports (including accounts 
     related to the provision of such services under a waiver 
     approved under section 1915 of the Social Security Act (42 
     U.S.C. 1396n)) when an individual transitions from residing 
     in such a facility to residing in the community.
       (e) Payments to States.--
       (1) In general.--The Secretary shall pay to each State with 
     a demonstration project approved under this section an amount 
     for each quarter occurring during the period described in 
     paragraph (2) equal to 100 percent of the State's 
     expenditures in the quarter for providing community-based 
     services and supports to individuals participating in the 
     demonstration project.
       (2) Period described.--The period described in this 
     paragraph is the 12-month period that begins on the date on 
     which an individual first receives community-based services 
     and supports under the demonstration project in a setting 
     that is not a medicaid long-term care facility and is 
     selected by the individual.
       (f) Reports.--
       (1) In general.--Each State conducting a demonstration 
     project under this section shall submit a report to the 
     Secretary that, in addition to such other requirements as the 
     Secretary may require, includes information regarding--
       (A) the types of community-based services and supports 
     provided under the demonstration project;
       (B) the number of individuals served under the project;
       (C) the expenditures for, and savings resulting from, 
     conducting the project; and
       (D) to the extent applicable, the changes in State's long-
     term services system developed in accordance with the 
     provisions of subsection (d)(2).
       (2) Uniform data format.--In requiring information under 
     this subsection, the Secretary shall develop a uniform data 
     format to be used by States in the collection and submission 
     of data in the State report required under paragraph (1).
       (g) Evaluations.--The Secretary shall use an amount, not to 
     exceed one-half of 1 percent of the amount appropriated under 
     subsection (h) for each fiscal year, to provide, directly or 
     through contract--
       (1) for the evaluation of the demonstration projects 
     conducted under this section;
       (2) technical assistance to States concerning the 
     development or implementation of such projects; and
       (3) for the collection of the data described in subsection 
     (f)(1).
       (h) Funding.--There is appropriated to carry out this 
     section, $350,000,000 for each of fiscal years 2004 through 
     2008. Funds appropriated under the preceding sentence for a 
     fiscal year shall remain available until expended, but not 
     later than September 30, 2008.

     SEC. __04. MEDICARE SECONDARY PAYOR (MSP) PROVISIONS.

       (a) Technical Amendment Concerning Secretary's Authority To 
     Make Conditional Payment When Certain Primary Plans Do Not 
     Pay Promptly.--
       (1) In general.--Section 1862(b)(2) (42 U.S.C. 1395y(b)(2)) 
     is amended--
       (A) in subparagraph (A)(ii), by striking ``promptly (as 
     determined in accordance with regulations)'';
       (B) in subparagraph (B)--
       (i) by redesignating clauses (i) through (iii) as clauses 
     (ii) through (iv), respectively; and
       (ii) by inserting before clause (ii), as so redesignated, 
     the following new clause:
       ``(i) Authority to make conditional payment.--The Secretary 
     may make payment under this title with respect to an item or 
     service if a primary plan described in subparagraph (A)(ii) 
     has not made or cannot reasonably be expected to make payment 
     with respect to such item or service promptly (as determined 
     in accordance with regulations). Any such payment by the 
     Secretary shall be conditioned on reimbursement to the 
     appropriate Trust Fund in accordance with the succeeding 
     provisions of this subsection.''.
       (2) Effective date.--The amendments made by paragraph (1) 
     shall be effective as if included in the enactment of title 
     III of the Medicare and Medicaid Budget Reconciliation 
     Amendments of 1984 (Public Law 98-369).
       (b) Clarifying Amendments to Conditional Payment 
     Provisions.--Section 1862(b)(2) (42 U.S.C. 1395y(b)(2)) is 
     further amended--
       (1) in subparagraph (A), in the matter following clause 
     (ii), by inserting the following sentence at the end: ``An 
     entity that engages in a business, trade, or profession shall 
     be deemed to have a self-insured plan if it carries its own 
     risk (whether by a failure to obtain insurance, or otherwise) 
     in whole or in part.'';
       (2) in subparagraph (B)(ii), as redesignated by subsection 
     (a)(2)(B)--
       (A) by striking the first sentence and inserting the 
     following: ``A primary plan, and an entity that receives 
     payment from a primary plan, shall reimburse the appropriate 
     Trust Fund for any payment made by the Secretary under this 
     title with respect to an item or service if it is 
     demonstrated that such primary plan has or had a 
     responsibility to make payment with respect to such item or 
     service. A primary plan's responsibility for such payment may 
     be demonstrated by a judgment, a payment conditioned upon the 
     recipient's compromise, waiver, or release (whether or not 
     there is a determination or admission of liability) of 
     payment for items or services included in a claim against the 
     primary plan or the primary plan's insured, or by other 
     means.''; and
       (B) in the final sentence, by striking ``on the date such 
     notice or other information is received'' and inserting ``on 
     the date notice of, or information related to, a primary 
     plan's responsibility for such payment or other information 
     is received''; and
       (3) in subparagraph (B)(iii), as redesignated by subsection 
     (a)(2)(B), by striking the first sentence and inserting the 
     following: ``In order to recover payment made under this 
     title for an item or service, the United States may bring an 
     action against any or all entities that are or were required 
     or responsible (directly, as an insurer or self-insurer, as a 
     third-party administrator, as an employer that sponsors or 
     contributes to a group health plan, or large group health 
     plan, or otherwise) to make payment with respect to the same 
     item or service (or any portion thereof) under a primary 
     plan. The United States may, in accordance with paragraph 
     (3)(A) collect double damages against any such entity. In 
     addition, the United States may recover under this clause 
     from any entity that has received payment from a primary plan 
     or from the proceeds of a primary plan's payment to any 
     entity.''.
       (c) Clerical Amendments.--Section 1862(b) (42 U.S.C. 
     1395y(b)) is amended--
       (1) in paragraph (1)(A), by moving the indentation of 
     clauses (ii) through (v) 2 ems to the left; and
       (2) in paragraph (3)(A), by striking ``such'' before 
     ``paragraphs''.
                                 ______
                                 
  SA 992. Mr. BAUCUS (for Ms. Stabenow (for herself and Ms. Snowe)) 
proposed an amendment to the bill S. 1, to amend title XVIII of the 
Social Security Act to make improvements in the medicare program, to 
provide prescription drug coverage under the medicare program, and for 
other purposes; as follows:

       On page 158, between lines 4 and 5, insert the following:
       (f) Clarification of State Authority Relating to Medicaid 
     Drug Rebate Agreements.--Section 1927 (42 U.S.C. 1396r-8) is 
     amended by adding at the end the following:
       ``(l) Rule of Construction.--Nothing in this section shall 
     be construed as prohibiting a State from--
       ``(1) directly entering into rebate agreements (on the 
     State's own initiative or under a section 1115 waiver 
     approved by the Secretary before, on, or after the date of 
     enactment of this subsection) that are similar to a rebate 
     agreement described in subsection

[[Page 15722]]

     (b) with a manufacturer for purposes of ensuring the 
     affordability of outpatient prescription drugs in order to 
     provide access to such drugs by residents of a State who are 
     not otherwise eligible for medical assistance under this 
     title; or
       ``(2) making prior authorization (that satisfies the 
     requirements of subsection (d) and that does not violate any 
     requirements of this title that are designed to ensure access 
     to medically necessary prescribed drugs for individuals 
     enrolled in the State program under this title) a condition 
     of not participating in such a similar rebate agreement.''.
                                 ______
                                 
  SA 993. Mr. BAUCUS (for Mr. Dorgan) proposed an amendment to the bill 
S. 1, to amend title XVIII of the Social Security Act to make 
improvements in the medicare program, to provide prescription drug 
coverage under the medicare program, and for other purposes; as 
follows:

       At the appropriate place in title IV, insert the following:

     SEC. __. COVERAGE OF CARDIOVASCULAR SCREENING TESTS.

       (a) Coverage.--Section 1861(s)(2) of the Social Security 
     Act (42 U.S.C. 1395x(s)(2)) is amended--
       (1) in subparagraph (U), by striking ``and'' at the end;
       (2) in subparagraph (V)(iii), by inserting ``and'' at the 
     end; and
       (3) by adding at the end the following new subparagraph:
       ``(W) cardiovascular screening tests (as defined in 
     subsection (ww)(1));''.
       (b) Services Described.--Section 1861 of the Social 
     Security Act (42 U.S.C. 1395x) is amended by adding at the 
     end the following new subsection:

                    ``Cardiovascular Screening Tests

       ``(ww)(1) The term `cardiovascular screening tests' means 
     the following diagnostic tests for the early detection of 
     cardiovascular disease:
       ``(A) Tests for the determination of cholesterol levels.
       ``(B) Tests for the determination of lipid levels of the 
     blood.
       ``(C) Such other tests for cardiovascular disease as the 
     Secretary may approve.
       ``(2)(A) Subject to subparagraph (B), the Secretary shall 
     establish standards, in consultation with appropriate 
     organizations, regarding the frequency and type of 
     cardiovascular screening tests.
       ``(B) With respect to the frequency of cardiovascular 
     screening tests approved by the Secretary under subparagraph 
     (A), in no case may the frequency of such tests be more often 
     than once every 2 years.''.
       (c) Frequency.--Section 1862(a)(1) of the Social Security 
     Act (42 U.S.C. 1395y(a)(1)) is amended--
       (1) by striking ``and'' at the end of subparagraph (H);
       (2) by striking the semicolon at the end of subparagraph 
     (I) and inserting ``, and''; and
       (3) by adding at the end the following new subparagraph:
       ``(J) in the case of a cardiovascular screening test (as 
     defined in section 1861(ww)(1)), which is performed more 
     frequently than is covered under section 1861(ww)(2).''.
       (d) Effective Date.--The amendments made by this section 
     shall apply to tests furnished on or after January 1, 2004.
                                 ______
                                 
  SA 994. Mr. DURBIN (for himself, Mr. Corzine, Mr. Harkin, Mrs. Boxer, 
Ms. Stabenow, Mr. Dayton, and Mr. Byrd) proposed an amendment to the 
bill S. 1, to amend title XVIII of the Social Security Act to make 
improvements in the medicare program, to provide prescription drug 
coverage under the medicare program, and for other purposes; as 
follows:

       Beginning on page 48, strike line 13 through page 50, line 
     2 and insert the following:
       ``(1) No deductible.--
       ``(A) In general.--The coverage provides for benefits 
     without the application of a deductible.
       ``(B) Application.--Notwithstanding the succeeding 
     provisions of this part, the Administrator shall not apply 
     section 1860D-19(a)(3)(A)(ii).
       ``(2) Limits on cost-sharing.--
       ``(A) In general.--The coverage has cost-sharing (for costs 
     up to the annual out-of-pocket limit under paragraph (4)) 
     that is equal to 30 percent or that is actuarially consistent 
     (using processes established under subsection (f)) with an 
     average expected payment of 30 percent of such costs.
       ``(B) Application.--Notwithstanding the succeeding 
     provisions of this part, the Administrator shall not apply 
     subsection (d)(1)(C) and paragraphs (1)(D), (2)(D), and 
     (3)(A)(iv) of section 1860D-19(a).
       On page 50, line 15, strike ``$3,700'' and insert 
     ``$1,500''.
       On page 51, strike lines 15 through 25 and insert the 
     following:
       ``(ii) such costs shall be treated as incurred without 
     regard to whether the individual or another person, including 
     a State program or other third-party coverage, has paid for 
     such costs.
       Beginning on page 77, strike line 10 and all that follows 
     through page 84, line 7, and insert the following:
       ``(e) Medicare Operated Plan Option.--
       ``(1) Access.--The Administrator shall establish and 
     operate a national plan to provide any eligible beneficiary 
     enrolled under this part (and not, except for an MSA plan or 
     a private fee-for-service plan that does not provide 
     qualified prescription drug coverage, enrolled in a 
     MedicareAdvantage plan) electing such plan with standard 
     prescription drug coverage. Under such plan, the 
     Administrator shall negotiate with pharmaceutical 
     manufacturers with respect to the purchase price of covered 
     drugs and shall encourage the use of more affordable 
     therapeutic equivalents to the extent such practices do not 
     override medical necessity as determined by the prescribing 
     physician. To the extent practicable and consistent with the 
     previous sentence, the Administrator shall implement 
     strategies similar to those used by other Federal purchasers 
     of prescription drugs, and other strategies, to reduce the 
     purchase cost of covered drugs. Eligible beneficiaries 
     enrolled under this part shall have the option of enrolling 
     in such plan or in a Medicare Prescription Drug plan or a 
     MedicareAdvantage plan available in the area in which the 
     beneficiary resides.
       ``(2) Monthly beneficiary obligation for enrollment.--
       ``(A) In general.--In the case of an eligible beneficiary 
     enrolled in the plan operated by the Administrator under 
     paragraph (1), the monthly beneficiary obligation of such 
     beneficiary for such enrollment shall be--
       ``(i) for months in the first year of implementation, $35; 
     and
       ``(ii) for months in a subsequent year, the lesser of--

       ``(I) the amount determined under this paragraph for months 
     in the previous year, increased by the annual percentage 
     increase described in section 1860D-6(c)(5) for the year 
     involved; or
       ``(II) in the case of months in years prior to 2014, the 
     specified amount.

       ``(B) Specified amount.--For purposes of this paragraph, 
     the term `specified amount' means--
       ``(i) for months in the second year of implementation, $37;
       ``(ii) for months in the third year of implementation, $40;
       ``(iii) for months in the fourth year of implementation, 
     $43;
       ``(iv) for months in the fifth year of implementation, $46;
       ``(v) for months in the sixth year of implementation, $51;
       ``(vi) for months in the seventh year of implementation, 
     $54; and
       ``(vii) for months in the eighth year of implementation, 
     $59.
       ``(3) No affect on access requirements.--The plan operated 
     by the Administrator under paragraph (1) shall be in addition 
     to the plans required under subsection (d)(1).
       ``(4) Requirement to prevent increased costs.--If the 
     Administrator determines that Federal payments made with 
     respect to eligible beneficiaries enrolled in the plan 
     operated by the Administrator under paragraph (1) exceed on 
     average the Federal payments made with respect to eligible 
     beneficiaries enrolled in a Medicare Prescription Drug plan 
     or a MedicareAdvantage plan (with respect to qualified 
     prescription drug coverage), the Administrator shall adjust 
     the requirements or payments under such a contract to 
     eliminate such excess.
       ``(f) Two-Year Contracts.--A contract approved under this 
     section for a Medicare Prescription Drug plan shall be for a 
     2-year period.
       ``(g) Implementation of Part D.--Notwithstanding any other 
     provision of this part or part C, the Secretary shall 
     implement, and make benefits available under, this part as 
     soon as practicable after the date of enactment of the 
     Prescription Drug and Medicare Improvement Act of 2003, but 
     in no case later than January 1, 2006. The Secretary shall 
     carry out this part until the Administrator is appointed and 
     able to carry out this part.
       On page 134, strike line 9 and insert the following:
     under paragraph (1).
       ``(d) Special Rules for State Pharmaceutical Assistance 
     Programs.--
       ``(1) In general.--Notwithstanding any other provision of 
     this part, in the case of the sponsor of a State 
     pharmaceutical assistance program that seeks to offer a 
     Medicare Prescription Drug plan under this part, the 
     following special rules apply:
       ``(A) Waiver of licensure.--Section 1860D-7(a)(1) shall not 
     apply.
       ``(B) Permitting limitation on enrollment.--The sponsor may 
     restrict eligibility to enroll in the plan to those low-
     income individuals who qualify (or meet the standards for 
     qualification) for the State pharmaceutical assistance 
     program.
       ``(C) Other requirements.--The Administrator may waive such 
     other requirements of this part as the Administrator finds 
     appropriate to promote the role of State pharmaceutical 
     assistance programs under this part.
       ``(2) Definition.--For purposes of this part, the term 
     `State pharmaceutical assistance program' means a program, in 
     operation as of the date of enactment of this title, that is 
     sponsored or underwritten by a State, that was established 
     pursuant to a waiver under

[[Page 15723]]

     section 1115 or otherwise, and that provides financial 
     assistance with out-of-pocket expenses with respect to 
     covered outpatient drugs for individuals in the State who 
     meet income-related qualifications specified under such 
     program.
       ``(3) Construction.--Nothing in this subsection shall 
     affect the provisions of subsection (b).''.
       At the end of title VI, add the following:

     SEC. __. NEED FOR RENEWAL.

       (a) In General.--Notwithstanding any other provision of 
     law, the provisions of, and amendments made by, this Act 
     shall remain in effect but shall be superseded by the 
     Director of the Office of Management and Budget on the date 
     that the total of the increased Federal expenditures by 
     reason of such amendments and provisions has reached 
     $400,000,000,000.
       (b) Application.--Any provision of law amended or effected 
     by this Act shall be applied and administered after the date 
     described in subsection (a) as if the provisions of, and 
     amendments made by, this Act had never been enacted.
       (c) Notification.--The Director of the Office of Management 
     and Budget shall notify Congress 6 months prior to the date 
     that the provisions of, and amendments made by, this Act will 
     be superseded pursuant to subsection (a).
                                 ______
                                 
  SA 995. Mr. REED submitted an amendment intended to be proposed by 
him to the bill S. 1, to amend title XVIII of the Social Security Act 
to make improvements in the medicare program, to provide prescription 
drug coverage under the medicare program, and for other purposes; which 
was ordered to lie on the table; as follows:

       At the end of subtitle B of title IV, add the following:

     SEC. __. ELIMINATION OF LIMITATION ON WORK GEOGRAPHIC 
                   ADJUSTMENT UNDER THE PHYSICIAN FEE SCHEDULE.

       Section 1848(e)(1)(A)(iii) (42 U.S.C. 1395w-
     4(e)(1)(A)(iii)) is amended by inserting ``(or, for purposes 
     of payment for services furnished on or after January 1, 
     2005, and before January 1, 2008, 100 percent)'' after ``\1/
     4\''.
                                 ______
                                 
  SA 996. Mr. REED submitted an amendment intended to be proposed by 
him to the bill S. 1, to amend title XVIII of the Social Security Act 
to make improvements in the medicare program, to provide prescription 
drug coverage under the medicare program, and for other purposes; which 
was ordered to lie on the table; as follows:

       In section 445(a) of the bill, strike paragraph (6) and 
     insert the following:
       ``(6) an evaluation of the appropriateness of extending 
     such adjustment or making such adjustment permanent;
       ``(7) an evaluation of the adjustment of the work 
     geographic practice cost index required under section 
     1848(e)(1)(A)(iii) of the Social Security Act (42 U.S.C. 
     1395w-4(e)(1)(A)(iii)) to reflect \1/4\ of the area cost 
     difference in physician work;
       ``(8) an evaluation of the effect of the adjustment 
     described in paragraph (7) on physician location and 
     retention in higher than average cost-of-living areas, taking 
     into account difference in recruitment costs and retention 
     rates for physicians, including specialists; and
       ``(9) an evaluation of the appropriateness of the \1/4\ 
     adjustment for the work geographic practice cost index.''.
                                 ______
                                 
  SA 997. Mr. REED submitted an amendment intended to be proposed by 
him to the bill S. 1, to amend title XVIII of the Social Security Act 
to make improvements in the medicare program, to provide prescription 
drug coverage under the medicare program, and for other purposes; which 
was ordered to lie on the table; as follows:

       On page 401, between lines 4 and 5, insert the following:
       ``(C) Education and outreach campaign.--
       ``(i) Program requirements.--

       ``(I) In general.--The Office of Beneficiary Assistance, in 
     collaboration with the Administrator of the Center for 
     Medicare & Medicaid Services, shall conduct education and 
     outreach programs that are designed to inform hard to reach 
     populations, minority populations, and rural and frontier 
     populations, about the medicare program, and particularly 
     about the medicare fee-for-service program under parts A and 
     B, and the prescription drug benefit established under part D 
     and the plan options under that part, including the low-
     income subsidies provided under section 1860D-19.
       ``(II) Dissemination.--Programs conducted under clause (i) 
     shall produce and disseminate information in major languages, 
     and shall conduct other outreach activities, including 
     mailings and low-income subsidy enrollment assistance, in 
     coordination with other appropriate Federal and State 
     agencies.
       ``(III) Sites.--Outreach and enrollment assistance 
     activities shall be conducted under such programs at sites 
     that provide, determine eligibility for, or enroll, low-
     income individuals under other Federal, State, or local 
     assistance programs, including such sites operated under 
     Federal, State, or local low-income housing, energy, 
     nutrition, health, and social services programs.
       ``(IV) Costs.--The Administrator of the Center for Medicare 
     Choices shall reimburse other Federal, State, and local 
     agencies for the expenses such agencies incur that are 
     attributable to providing coordination with the education and 
     outreach programs conducted under this subparagraph. The 
     Secretary shall determine the appropriate administrative 
     expenses that are to be allocated between the Center for 
     Medicare Choices and the Centers for Medicare & Medicaid 
     Services as a result of the collaboration required under this 
     clause.

       ``(ii) Model form.--

       ``(I) In general.--The Office of Beneficiary Assistance, in 
     coordination and cooperation with the Administrator of the 
     Center for Medicare & Medicaid Services, shall devise a model 
     application form for the premium and cost-sharing subsidies 
     established under section 1860D-19 and shall make such form 
     available for use by the States.
       ``(II) Requirements.--The model form devised under 
     subclause (I) shall be as simple as possible, shall be 
     designed so that the form is capable of being completed 
     without a face-to-face interview and of being filed 
     electronically, and shall apply for multiyear periods, with 
     beneficiaries required to report any disqualifying increases 
     in income or assets to the Administrator of the Center for 
     Medicare Choices.

                                 ______
                                 
  SA 998. Mr. DODD submitted an amendment intended to be proposed by 
him to the bill S. 1, to amend title XVIII of the Social Security Act 
to make improvements in the medicare program, to provide prescription 
drug coverage under the medicare program, and for other purposes; which 
was ordered to lie on the table; as follows:

       On page 129, strike lines 3 through 20, and insert the 
     following:
       ``(2) Amount of payment.--The amount of the payment under 
     paragraph (1) shall be an amount equal to the monthly 
     national average premium for the year (determined under 
     section 1860D-15), as adjusted using the risk adjusters that 
     apply to the standard prescription drug coverage published 
     under section 1860D-11.
                                 ______
                                 
  SA 999. Mrs. CLINTON submitted an amendment intended to be proposed 
by her to the bill S. 1, to amend title XVIII of the Social Security 
Act to make improvements in the medicare program, to provide 
prescription drug coverage under the medicare program, and for other 
purposes; which was ordered to lie on the table; as follows:

       On page 389, between lines 6 and 7, insert the following:

     SEC. __. PRIORITY AREA QUALITY INDICATORS.

       (a) In General.--The Director of the Agency for Healthcare 
     Research and Quality, in consultation with the Quality 
     Interagency Coordination Task Force, the Institute of 
     Medicine, the Joint Commission on Accreditation of Healthcare 
     Organizations, the National Committee for Quality Assurance, 
     the American Health Quality Association, the National Quality 
     Forum, and other individuals and organizations determined 
     appropriate by the Secretary of Health and Human Services, 
     shall assemble, evaluate, and, where necessary, develop or 
     update quality indicators for each of the 20 priority areas 
     for improvement in health care quality as identified by the 
     Institute of Medicine in their report entitled ``Priority 
     Areas for National Action'' in 2003, in order to assist 
     medicare beneficiaries in making informed choices about 
     health plans. The selection of appropriate quality indicators 
     under this subsection shall include the evaluation criteria 
     formulated by clinical professionals, consumers, data 
     collection experts.
       (b) Risk Adjustment.--In developing the quality indicators 
     under subsection (a), the Director of the Agency for 
     Healthcare Research and Quality shall ensure that adequate 
     risk adjustment is provided for.
       (c) Best Practices.--In carrying out this section, the 
     Director of the Agency for Healthcare Research and Quality 
     shall--
       (1) assess data concerning appropriate clinical treatments 
     based on the best scientific evidence available;
       (2) determine areas in which there is insufficient evidence 
     to determine best practices; and
       (3) compare existing quality indicators to best clinical 
     practices, validate appropriate indicators, and report on 
     areas where additional research is needed before indicators 
     can be developed.
       (d) Report.--Not later than 1 year after the date of 
     enactment of this Act, and annually thereafter, the Director 
     of the Agency for Healthcare Research and Quality shall--
       (1) submit to the Director of the National Institutes of 
     Health a report concerning areas of clinical care requiring 
     farther research necessary to establish effective clinical 
     treatments that will serve as a basis for quality indicators; 
     and

[[Page 15724]]

       (2) submit to Congress a report on the state of quality 
     measurement for priority areas that links data to the report 
     submitted under paragraph (1) for the year involved.
       (e) Authorization of Appropriations.--There are authorized 
     to be appropriated to carry out this section $12,000,000 for 
     fiscal year 2004, and $8,000,000 for each of fiscal years 
     2005 through 2009.

     SEC. __. STANDARDIZED QUALITY INDICATORS FOR FEDERAL 
                   AGENCIES.

       (a) In General.--In addition to other activities to be 
     carried out by the Quality Interagency Coordination Taskforce 
     (as established by executive order on March 13, 1998), such 
     Taskforce shall standardize indicators of health care quality 
     that are used in all Federal agencies, as appropriate.
       (b) Consultation.--In carrying out subsection (a), the 
     Quality Interagency Coordination Taskforce shall consult with 
     a public-private consensus organization (such as the National 
     Quality Forum) to enhance the likelihood of the simultaneous 
     application of the standardized indicators under subsection 
     (a) in the private sector.
       (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 to Congress a 
     report on the progress made by the Quality Interagency 
     Coordination Taskforce to standardizing quality indicators 
     throughout the Federal Government.

     SEC. __. DEMONSTRATION PROGRAM FOR COMMUNITY HEALTH CARE 
                   QUALITY DATA REPORTING.

       (a) In General.--The Secretary of Health and Human 
     Services, acting through the Director of the Centers for 
     Disease Control and Prevention and the Director of the Agency 
     for Healthcare Quality and Research, shall award not to 
     exceed 20 grants to eligible communities for the 
     establishment of demonstration programs for the reporting of 
     health care quality information at the community level.
       (b) Quality Indicators.--
       (1) In general.--For purposes of reporting information 
     under the demonstration programs under this section, 
     indicators of health care quality may include the indicators 
     developed for the 20 priority areas as identified by the 
     Institute of Medicine in the report entitled ``Priority Areas 
     for National Action'', 2003, or other indicators determined 
     appropriate by the Secretary of Health and Human Services.
       (2) Type of data.--All quality indicators with respect to 
     which reporting will be carried out under the demonstration 
     program shall be reported by race, ethnicity, gender, and 
     age.
       (c) Eligibility.--The Secretary of Health and Human 
     Services shall award grants to communities under this section 
     based on competitive proposals and criteria to be determined 
     jointly by the Director of the Centers for Disease Control 
     and Prevention and the Director of the Agency for Healthcare 
     Research and Quality. Such criteria may include a 
     demonstrated ability of the community to collect data on 
     quality indicators and a demonstrated ability to effectively 
     transmit community-level health status results to relevant 
     stakeholders.
       (d) Technical Advisory Committee.--The Secretary of Health 
     and Human Services shall establish a technical advisory 
     committee to assist grantees in data collection, data 
     analysis, and report dissemination.
       (e) Report.--Not later than 1 year after the date of 
     enactment of this Act, and annually thereafter, the Director 
     of the Centers for Disease Control and Prevention and the 
     Director of the Agency for Healthcare Research and Quality 
     shall--
       (1) submit to the Congress a report on the results of the 
     demonstration programs under this section; and
       (2) make such reports publicly available, including by 
     posting the reports on the Internet.
       (f) Evaluation.--The Secretary of Health and Human Services 
     shall, upon awarding grants under subsection (a), enter into 
     a contract for the evaluation of demonstration programs under 
     this section. Such evaluation shall compare the effectiveness 
     of such demonstration programs in collecting and reporting 
     required data, and on the effectiveness of distributing 
     information to key stakeholders in a timely fashion. Such 
     evaluations shall provide for a report on best practices.
       (g) Authorization of Appropriations.--There are authorized 
     to be appropriated to carry out this section $25,000,000 for 
     fiscal year 2004, and such sums as may be necessary for each 
     fiscal year thereafter.
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  SA 1000. Mrs. CLINTON submitted an amendment intended to be proposed 
by her to the bill S. 1, to amend title XVIII of the Social Security 
Act to make improvements in the medicare program, to provide 
prescription drug coverage under the medicare program, and for other 
purposes; which was ordered to lie on the table; as follows:

       At the end of title VI, add the following:

     SEC. __. STUDY ON EFFECTIVENESS OF CERTAIN PRESCRIPTION 
                   DRUGS.

       (a) In General.--
       (1) Research by nih.--The Director of the National 
     Institutes of Health, in coordination with the Director of 
     the Agency for Healthcare Research and Quality and the 
     Commissioner of Food and Drugs, shall conduct research, which 
     may include clinical research, to develop valid scientific 
     evidence regarding the comparative effectiveness and, where 
     appropriate, comparative safety of covered prescription drugs 
     relative to other drugs and treatments for the same disease 
     or condition.
       (2) Analysis by ahrq.--
       (A) In general.--The Director of the Agency for Healthcare 
     Research and Quality, taking into consideration the research 
     and data from the National Institutes of Health and the Food 
     and Drug Administration, shall use evidence-based practice 
     centers to synthesize available data or conduct other 
     analyses of the comparative effectiveness and, where 
     appropriate, comparative safety of covered prescription drugs 
     relative to other drugs and treatments for the same disease 
     or condition.
       (B) Safety.--In any analysis of comparative effectiveness 
     under this subparagraph, the Director of the Agency for 
     Healthcare Research and Quality shall include a discussion of 
     available information on relative safety.
       (3) Standards.--The Director of the Agency for Healthcare 
     Research and Quality, in consultation with the Commissioner 
     of Food and Drugs, the Director of the National Institutes of 
     Health, and with input from stakeholders, shall develop 
     standards for the design and conduct of studies under this 
     subsection.
       (b) Covered Prescription Drugs.--For purposes of this 
     section, the term ``covered prescription drugs'' means 
     prescription drugs that, as determined by the Director of the 
     Agency for Healthcare Research and Quality in consultation 
     with the Administrator of the Centers for Medicare & Medicaid 
     Services, account for high levels of expenditures, high 
     levels of use, or high levels of risk to individuals in 
     federally funded health programs, including Medicare and 
     Medicaid.
       (c) Dissemination.--
       (1) Annual report.--Each year the Secretary shall prepare a 
     report on the results of the research, studies, and analyses 
     conducted by the National Institutes of Health and the Agency 
     for Healthcare Research and Quality, and the Food and Drug 
     Administration under this section and submit the report to 
     the following:
       (A) Congress.
       (B) The Secretary of Defense.
       (C) The Secretary of Veterans Affairs.
       (D) The Administrator of the Centers for Medicare & 
     Medicaid Services.
       (E) The Director of the Indian Health Service.
       (F) The Director of the National Institutes of Health.
       (G) The Director of the Office of Personnel Management.
       (H) The Commissioner of Food and Drugs.
       (2) Reports for practitioners.--As soon as possible, but 
     not later than a year after the completion of any study 
     pursuant to subsection (a)(2), the Director of the Agency for 
     Healthcare Research and Quality shall--
       (A) prepare a report on the results of such study for the 
     purpose of informing health care practitioners; and
       (B) transmit the report to the Director of the National 
     Institutes of Health.
       (3) FDA drug information.--The Commissioner of Food and 
     Drugs shall--
       (A) review all data and information from studies and 
     analyses conducted or prepared under this section; and
       (B) develop appropriate summaries of such information for 
     inclusion in adequate directions for use under section 
     502(f)(1) of the Federal Food, Drug, and Cosmetic Act and in 
     summaries relating to side effects, contraindications, and 
     effectiveness under section 502(n) of that Act.
       (4) NIH internet site.--The Director of the National 
     Institutes of Health shall publish on the Institutes' 
     Internet site and through other means that will facilitate 
     access by practitioners, each report prepared under this 
     subsection by the Director of the Agency for Healthcare 
     Research and Quality.
       (d) Evidence.--In carrying out this section, the Director 
     of the National Institutes of Health and the Agency for 
     Healthcare Research and Quality shall consider only 
     methodologically sound studies, giving preference to studies 
     for which the Directors have access to sufficient underlying 
     data and analysis to address any significant concerns about 
     methodology or the reliability of data.
       (e) Authorizations of Appropriations.--There are authorized 
     to be appropriated to carry out this section, $75,000,000 for 
     fiscal year 2004, and such sums as may be necessary for each 
     fiscal year thereafter.

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