[House Report 106-1019]
[From the U.S. Government Publishing Office]
106th Congress Rept. 106-1019
HOUSE OF REPRESENTATIVES
2d Session Part 1
======================================================================
BENEFICIARY IMPROVEMENT AND PROTECTION ACT OF 2000
_______
October 30, 2000.--Ordered to be printed
_______
Mr. Bliley, from the Committee on Commerce, submitted the following
R E P O R T
[To accompany H.R. 5291]
[Including cost estimate of the Congressional Budget Office]
The Committee on Commerce, to whom was referred the bill
(H.R. 5291) to amend titles XVIII, XIX, and XXI of the Social
Security Act to make additional corrections and refinements in
the Medicare, Medicaid, and State children's health insurance
programs, as revised by the Balanced Budget Act of 1997, having
considered the same, report favorably thereon with an amendment
and recommend that the bill as amended do pass.
CONTENTS
Page
Amendment........................................................ 2
Purpose and Summary.............................................. 29
Background and Need for Legislation.............................. 29
Hearings......................................................... 30
Committee Consideration.......................................... 30
Committee Votes.................................................. 30
Committee Oversight Findings..................................... 31
Committee on Government Reform Oversight Findings................ 31
New Budget Authority, Entitlement Authority, and Tax Expenditures 31
Committee Cost Estimate.......................................... 32
Congressional Budget Office Estimate............................. 32
Federal Mandates Statement....................................... 34
Advisory Committee Statement..................................... 34
Constitutional Authority Statement............................... 34
Applicability to Legislative Branch.............................. 34
Section-by-Section Analysis of the Legislation................... 34
Changes in Existing Law Made by the Bill, as Reported............ 67
Amendment
The amendment is as follows:
Strike all after the enacting clause and insert the
following:
SECTION 1. SHORT TITLE; AMENDMENTS TO SOCIAL SECURITY ACT; REFERENCES
TO OTHER ACTS; TABLE OF CONTENTS.
(a) Short Title.--This Act may be cited as the ``Beneficiary
Improvement and Protection Act of 2000''.
(b) Amendments to Social Security Act.--Except as otherwise
specifically provided, whenever in this Act an amendment is expressed
in terms of an amendment to or repeal of a section or other provision,
the reference shall be considered to be made to that section or other
provision of the Social Security Act.
(c) References to Other Acts.--In this Act:
(1) Balanced budget act of 1997.--The term ``BBA'' means the
Balanced Budget Act of 1997 (Public Law 105-33).
(2) Medicare, medicaid, and schip balanced budget refinement
act of 1999.--The term ``BBRA'' means the Medicare, Medicaid,
and SCHIP Balanced Budget Refinement Act of 1999, as enacted
into law by section 1000(a)(6) of Public Law 106-113 (Appendix
F).
(d) Table of Contents.--The table of contents of this Act is as
follows:
Sec. 1. Short title; amendments to Social Security Act; references to
other Acts; table of contents.
TITLE I--BENEFICIARY IMPROVEMENTS
Sec. 101. Improving availability of QMB/SLMB application forms.
Sec. 102. Study on limitation on State payment for medicare cost-
sharing affecting access to services for qualified medicare
beneficiaries.
Sec. 103. Election of periodic colonoscopy.
Sec. 104. Waiver of 24-month waiting period for medicare coverage of
individuals disabled with amyotrophic lateral sclerosis (ALS).
Sec. 105. Elimination of time limitation on medicare benefits for
immunosuppressive drugs.
Sec. 106. Preservation of coverage of drugs and biologicals under part
B of the medicare program.
Sec. 107. Demonstration of medicare coverage of medical nutrition
therapy services.
TITLE II--OTHER MEDICARE PART B PROVISIONS
Subtitle A--Access to Technology
Sec. 201. Annual reports on national coverage determinations.
Sec. 202. National limitation amount equal to 100 percent of national
median for new clinical laboratory test technologies; fee schedule for
new clinical laboratory tests.
Sec. 203. Clarifying process and standards for determining eligibility
of devices for pass-through payments under hospital outpatient PPS.
Sec. 204. Access to new technologies applied to screening mammography
to enhance breast cancer detection.
Subtitle B--Provisions Relating to Physicians Services
Sec. 211. GAO study of gastrointestinal endoscopic services furnished
in physicians offices and hospital outpatient department services.
Sec. 212. Treatment of certain physician pathology services.
Sec. 213. Physician group practice demonstration.
Sec. 214. Designation of separate category for interventional pain
management physicians.
Sec. 215. Evaluation of enrollment procedures for medical groups that
retain independent contractor physicians.
Subtitle C--Other Services
Sec. 221. 3-year moratorium on SNF part B consolidated billing
requirements.
Sec. 222. Ambulatory surgical centers.
Sec. 223. 1-year extension of moratorium on therapy caps.
Sec. 224. Revision of medicare reimbursement for telehealth services.
Sec. 225. Payment for ambulance services.
Sec. 226. Contrast enhanced diagnostic procedures under hospital
prospective payment system.
Sec. 227. 10-Year phased-in increase from 55 percent to 80 percent in
the proportion of hospital bad debt recognized.
Sec. 228. State accreditation of diabetes self-management training
programs.
Sec. 229. Update in renal dialysis composite rate.
TITLE III--MEDICARE PART A AND B PROVISIONS
Sec. 301. Home health services.
Sec. 302. Advisory opinions.
Sec. 303. Hospital geographic reclassification for labor costs for
other PPS systems.
Sec. 304. Reclassification of a metropolitan statistical area for
purposes of reimbursement under the medicare program.
Sec. 305. Making the medicare dependent, small rural hospital program
permanent.
Sec. 306. Option to base eligibility on discharges during any of the 3
most recent audited cost reporting periods.
Sec. 307. Identification and reduction of medical errors by peer review
organizations.
Sec. 308. GAO report on impact of the emergency medical treatment and
active labor act (EMTALA) on hospital emergency departments.
TITLE IV--MEDICARE+CHOICE PROGRAM STABILIZATION AND IMPROVEMENTS
Subtitle A--Payment Reforms
Sec. 401. Increasing minimum payment amount.
Sec. 402. 3 percent minimum percentage update in 2001.
Sec. 403. 10-year phase in of risk adjustment based on data from
substantially all settings.
Sec. 404. Transition to revised Medicare+Choice payment rates.
Subtitle B--Administrative Reforms
Sec. 411. Effectiveness of elections and changes of elections.
Sec. 412. Medicare+Choice program compatibility with employer or union
group health plans.
Sec. 413. Uniform premium and benefits.
TITLE V--MEDICAID
Sec. 501. DSH payments.
Sec. 502. New prospective payment system for Federally-qualified health
centers and rural health clinics.
Sec. 503. Optional coverage of legal immigrants under the medicaid
program.
Sec. 504. Additional entities qualified to determine medicaid
presumptive eligibility for low-income children.
Sec. 505. Improving welfare-to-work transition.
Sec. 506. Medicaid county-organized health systems.
Sec. 507. Medicaid recognition for services of physician assistants.
TITLE VI--STATE CHILDREN'S HEALTH INSURANCE PROGRAM
Sec. 601. Special rule for availability and redistribution of unused
fiscal year 1998 and 1999 SCHIP allotments.
Sec. 602. Optional coverage of certain legal immigrants under SCHIP.
TITLE VII--EXTENSION OF SPECIAL DIABETES GRANT PROGRAMS
Sec. 701. Extension of juvenile and Indian diabetes grant programs.
TITLE I--BENEFICIARY IMPROVEMENTS
SEC. 101. IMPROVING AVAILABILITY OF QMB/SLMB APPLICATION FORMS.
(a) Through Local Social Security Offices.--
(1) In general.--Section 1804 (42 U.S.C. 1395b-2) is amended
by adding at the end the following new subsection:
``(d) Availability of Application Forms for Medical Assistance for
Medicare Cost-Sharing.--The Secretary shall make available to the
Commissioner of Social Security appropriate forms for applying for
medical assistance for medicare cost-sharing under a State plan under
title XIX. Such Commissioner, through local offices of the Social
Security Administration shall--
``(1) notify applicants and beneficiaries who present at a
local office orally of the availability of such forms and make
such forms available to such individuals upon request; and
``(2) provide assistance to such individuals in completing
such forms and, upon request, in submitting such forms to the
appropriate State agency.''.
(2) Conforming amendment.--Section 1902(a)(8) (42 U.S.C.
1396a(a)(8)) is amended by inserting before the semicolon at
the end the following: ``and provide application forms for
medical assistance for medicare cost-sharing under the plan to
the Secretary in order to make them available through Federal
offices under section 1804(d) within the State''.
(b) Streamlining Application Process.--
(1) Requirement.--Section 1902(a)(8) (42 U.S.C. 1396a(a)(8))
is amended by striking ``, and that'' and inserting ``permit
individuals to apply for and obtain medical assistance for
medicare cost-sharing using the simplified uniform application
form developed under section 1905(p)(5), make available such
forms to such individuals, permit such individuals to apply for
such assistance by mail (and, at the State option, by telephone
or other electronic means) and not require them to apply in
person, and provide that''.
(2) Simplified application form.--Section 1905(p) (42 U.S.C.
1396d(p)) is amended by adding at the end the following new
paragraph:
``(5)(A) The Secretary shall develop a simplified application form
for use by individuals (including both qualified medicare beneficiaries
and specified low-income medicare beneficiaries) in applying for
medical assistance for medicare cost-sharing under this title. Such
form shall be easily readable by applicants and uniform nationally.
``(B) In developing such form, the Secretary shall consult with
beneficiary groups and the States.
``(C) The Secretary shall make such application forms available--
``(i) to the Commissioner of Social Security for distribution
through local social security offices;
``(ii) at such other sites at the Secretary determines
appropriate; and
``(iii) to persons upon request.''.
(c) Effective Dates.--
(1) The amendments made by subsection (a) take effect on
January 1, 2004.
(2) Effective date.--The amendments made by subsection (b)
take effect 1 year after the date of the enactment of this Act,
regardless of whether regulations have been promulgated to
carry out such amendments by such date. Secretary of Health and
Human Services shall develop the uniform application form under
the amendment made by subsection (b)(2) by not later than 9
months after the date of the enactment of this Act.
SEC. 102. STUDY ON LIMITATION ON STATE PAYMENT FOR MEDICARE COST-
SHARING AFFECTING ACCESS TO SERVICES FOR QUALIFIED
MEDICARE BENEFICIARIES.
(a) In General.--The Secretary of Health and Human Services shall
conduct a study to determine if access to certain services (including
mental health services) for qualified medicare beneficiaries has been
affected by limitations on a State's payment for medicare cost-sharing
for such beneficiaries under section 1902(n) of the Social Security Act
(42 U.S.C. 1396a(n)). As part of such study, the Secretary shall
analyze the effect of such payment limitation on providers who serve a
disproportionate share of such beneficiaries.
(b) Report.--Not later than 1 year after the date of the enactment of
this Act the Secretary shall submit to Congress a report on the study
under subsection (a). The report shall include recommendations
regarding any changes that should be made to the State payment limits
under section 1902(n) for qualified medicare beneficiaries to ensure
appropriate access to services.
SEC. 103. ELECTION OF PERIODIC COLONOSCOPY.
(a) Coverage.--Section 1861(pp)(1)(C) (42 U.S.C. 1395x(pp)(1)(C)) is
amended by inserting ``and in the case of an individual making the
election described in section 1834(d)(4)'' after ``high risk for
colorectal cancer''.
(b) Election.--Section 1834(d) (42 U.S.C. 1395m(d)) is amended--
(1) in paragraph (2)(E)--
(A) by striking ``or'' at the end of clause (i);
(B) by striking the period at the end of clause (ii)
and inserting ``; or''; and
(C) by adding at the end the following new clause:
``(iii) if the procedure is performed within
119 months after a screening colonoscopy under
paragraph (4).'';
(2) in paragraph (3)(A), by inserting ``and for individuals
making the election described in paragraph (4)'' after
``1861(pp)(2))'';
(3) in paragraph (3)(E), by adding at the end the following:
``No payment may be made under this part for a colorectal
cancer screening test consisting of a screening colonoscopy for
individuals making the election described in paragraph (4) if
the procedure is performed within the 119 months after a
previous screening colonoscopy or within 47 months after a
screening flexible sigmoidoscopy.''; and
(4) by adding at the end the following new paragraph:
``(4) Election of screening colonoscopy for individuals not
at high risk of colorectal cancer instead of screening
sigmoidoscopy.--An individual who is not at high risk of
colorectal cancer may elect to receive a screening colonoscopy
instead of a screening sigmoidoscopy.''.
(c) Effective Date.--The amendments made by this section take effect
on January 1, 2001.
SEC. 104. WAIVER OF 24-MONTH WAITING PERIOD FOR MEDICARE COVERAGE OF
INDIVIDUALS DISABLED WITH AMYOTROPHIC LATERAL
SCLEROSIS (ALS).
(a) In General.--Section 226 (42 U.S.C. 426) is amended--
(1) by redesignating subsection (h) as subsection (j) and by
moving such subsection to the end of the section, and
(2) by inserting after subsection (g) the following new
subsection:
``(h) For purposes of applying this section in the case of an
individual medically determined to have amyotrophic lateral sclerosis
(ALS), the following special rules apply:
``(1) Subsection (b) shall be applied as if there were no
requirement for any entitlement to benefits, or status, for a
period longer than 1 month.
``(2) The entitlement under such subsection shall begin with
the first month (rather than twenty-fifth month) of entitlement
or status.
``(3) Subsection (f) shall not be applied.''.
(b) Conforming Amendment.--Section 1837 (42 U.S.C. 1395p) is amended
by adding at the end the following new subsection:
``(j) In applying this section in the case of an individual who is
entitled to benefits under part A pursuant to the operation of section
226(h), the following special rules apply:
``(1) The initial enrollment period under subsection (d)
shall begin on the first day of the first month in which the
individual satisfies the requirement of section 1836(1).
``(2) In applying subsection (g)(1), the initial enrollment
period shall begin on the first day of the first month of
entitlement to disability insurance benefits referred to in
such subsection.''.
(c) Effective Date.--The amendments made by this section apply to
benefits for months beginning after the date of the enactment of this
Act.
SEC. 105. ELIMINATION OF TIME LIMITATION ON MEDICARE BENEFITS FOR
IMMUNOSUPPRESSIVE DRUGS.
(a) In General.--Section 1861(s)(2)(J) (42 U.S.C. 1395x(s)(2)(J)) is
amended by striking ``, but only'' and all that follows up to the
semicolon at the end.
(b) Effective Date.--The amendment made by subsection (a) shall apply
to drugs furnished on or after the date of the enactment of this Act.
SEC. 106. PRESERVATION OF COVERAGE OF DRUGS AND BIOLOGICALS UNDER PART
B OF THE MEDICARE PROGRAM.
(a) In General.--Section 1861(s)(2) (42 U.S.C. 1395x(s)(2)) is
amended, in each of subparagraphs (A) and (B), by striking ``(including
drugs and biologicals which cannot, as determined in accordance with
regulations, be self-administered)'' and inserting ``(including drugs
and biologicals which are not usually self-administered by the
patient)''.
(b) Effective Date.--The amendment made by subsection (a) applies to
drugs and biologicals administered on or after October 1, 2000.
SEC. 107. DEMONSTRATION OF MEDICARE COVERAGE OF MEDICAL NUTRITION
THERAPY SERVICES.
(a) In General.--The Secretary of Health and Human Services shall
conduct a demonstration project (in this section referred to as the
``project'') to examine the cost-effectiveness of providing medical
nutrition therapy services under the medicare program and the financial
impact of providing such services under the program.
(b) Scope of Services.--
(1) Time period and locations.--The project shall be
conducted--
(A) during a period of 5 fiscal years; and
(B) in the 5 States which have the highest proportion
of the population who are 65 years of age or older.
(2) Funding.--The total amount of the payments that may be
made under this section shall not exceed $60,000,000 for each
of the 5 fiscal years of the project. Funding for the project
shall be made from the Federal Supplementary Medical Insurance
Trust Fund established under section 1841 of the Social
Security Act (42 U.S.C. 1395t).
(c) Coverage as Medicare Part B Services.--
(1) In general.--Subject to the succeeding provisions of this
subsection, medical nutrition therapy services furnished under
the project shall be considered to be services covered under
part B of title XVIII of the Social Security Act.
(2) Payment.--Payment for such services shall be made at a
rate of 80 percent of the lesser of the actual charge for the
services or 85 percent of the amount determined under the fee
schedule established under section 1848(b) of the Social
Security Act (42 U.S.C. 1395w-4(b)) for the same services if
furnished by a physician.
(3) Application of limits on billing.--The provisions of
section 1842(b)(18) of the Social Security Act (42 U.S.C.
1395u(b)(18)) shall apply to a registered dietitian or
nutrition professional furnishing services under the project in
the same manner as they to a practitioner described in
subparagraph (C) of such section furnishing services under
title XVIII of such Act.
(d) Reports.--The Secretary shall submit to the Committee on Ways and
Means and the Committee on Commerce of the House of Representatives and
the Committee on Finance of the Senate interim reports on the project
and a final report on the project within 6 months after the conclusion
of the project. The final report shall include an evaluation of the
impact of the use of medical nutrition therapy services on medicare
beneficiaries and on the medicare program, including any impact on
reducing costs under the program and improving the health of
beneficiaries.
(e) Definitions.--For purposes of this section:
(1) Medical nutrition therapy services.--The term ``medical
nutrition therapy services'' means nutritional diagnostic,
therapy, and counseling services for the purpose of disease
management which are furnished by a registered dietitian or
nutrition professional (as defined in paragraph (2)) pursuant
to a referral by a physician (as defined in section 1861(r)(1)
of the Social Security Act, 42 U.S.C. 1395x(r)(1)).
(2) Registered dietitian or nutrition professional.--
(A) In general.--Subject to subparagraph (B), the
term ``registered dietitian or nutrition professional''
means an individual who--
(i) holds a baccalaureate or higher degree
granted by a regionally accredited college or
university in the United States (or an
equivalent foreign degree) with completion of
the academic requirements of a program in
nutrition or dietetics, as accredited by an
appropriate national accreditation organization
recognized by the Secretary for this purpose;
(ii) has completed at least 900 hours of
supervised dietetics practice under the
supervision of a registered dietitian or
nutrition professional; and
(iii)(I) is licensed or certified as a
dietitian or nutrition professional by the
State in which the services are performed, or
(II) in the case of an individual in a State
which does not provide for such licensure or
certification, meets such other criteria as the
Secretary establishes.
(B) Exception.--Clauses (i) and (ii) of subparagraph
(A) shall not apply in the case of an individual who as
of the date of the enactment of this Act is licensed or
certified as a dietitian or nutrition professional by
the State in which medical nutrition therapy services
are performed.
(3) Secretary.--The term ``Secretary'' means Secretary of
Health and Human Services.
TITLE II--OTHER MEDICARE PART B PROVISIONS
Subtitle A--Access to Technology
SEC. 201. ANNUAL REPORTS ON NATIONAL COVERAGE DETERMINATIONS.
(a) Annual Reports.--Not later than December 1 of each year,
beginning in 2001, the Secretary of Health and Human Services shall
submit to Congress a report that sets forth a detailed compilation of
the actual time periods that were necessary to complete and fully
implement any national coverage determinations that were made in the
previous fiscal year for items, services, or medical devices not
previously covered as a benefit under title XVIII of the Social
Security Act (42 U.S.C. 1395 et seq.), including, with respect to each
new item, service, or medical device, a statement of the time taken by
the Secretary to make the necessary coverage, coding, and payment
determinations, including the time taken to complete each significant
step in the process of making such determinations.
(b) Publication of Reports on the Internet.--The Secretary of Health
and Human Services shall publish each report submitted under subsection
(a) on the medicare Internet site of the Department of Health and Human
Services.
SEC. 202. NATIONAL LIMITATION AMOUNT EQUAL TO 100 PERCENT OF NATIONAL
MEDIAN FOR NEW CLINICAL LABORATORY TEST
TECHNOLOGIES; FEE SCHEDULE FOR NEW CLINICAL
LABORATORY TESTS.
(a) In General.--Section 1833(h)(4)(B)(viii) (42 U.S.C.
1395l(h)(4)(B)(viii)) is amended by inserting before the period the
following: ``(or 100 percent of such median in the case of a clinical
diagnostic laboratory test performed on or after January 1, 2001, that
the Secretary determines is a new test for which no limitation amount
has previously been established under this subparagraph)''.
(b) Fee Schedule for New Clinical Lab Tests.--
(1) Establishment of fee schedule for new tests.--Section
1833(h)(1) (42 U.S.C. 1395l(h)(1)) is amended--
(A) in subparagraph (B), by striking ``In'' and
inserting ``Except for tests described in subparagraph
(E), in''; and
(B) by inserting at the end the following new
subparagraph:
``(E) In the case of a clinical diagnostic laboratory test which is
described by a new code in the Health Care Financing Administration
Common Procedure Coding System (commonly referred to as `HCPCS'), for
which the Secretary is not able to crosswalk with a similar test with
an established schedule amount, the Secretary shall establish for
purposes of subparagraph (A) a single fee schedule amount for all areas
in the following manner:
``(i) By not later than December 1 of each year, beginning
with 2001, the Secretary shall cause to have published in the
Federal Register (which may include publication on an interim
final rule basis with a comment period) an interim fee schedule
amount for each such new test which shall apply for such new
tests furnished during the following year.
``(ii) The interim fee schedule amount for each such new test
shall be subject to a comment period of 60 days. The Secretary
shall review comments and data received and make appropriate
adjustments to the fee schedule for each test applicable
beginning with the following calendar year.
``(iii) For years beginning with 2002, the Secretary shall
also cause to have published in the Federal Register by not
later than December 1 of the year prior to its application, the
adjustments to the interim fee schedule amount described in
clause (ii) for each such new test for which an interim fee
schedule amount was established for a year, including
adjustments to such fee schedule amounts in response to
comments.''.
(2) Conforming amendment to update provision.--Section
1833(h)(2)(A) (42 U.S.C. 1395l(h)(2)(A)) is amended by striking
``July 1, 1984,'' and inserting the following: ``July 1, 1984.
The fee schedules established under the previous sentence and
paragraph (1)(E)(3) shall be''.
SEC. 203. CLARIFYING PROCESS AND STANDARDS FOR DETERMINING ELIGIBILITY
OF DEVICES FOR PASS-THROUGH PAYMENTS UNDER HOSPITAL
OUTPATIENT PPS.
(a) In General.--Section 1833(t)(6) (42 U.S.C. 1395l(t)(6)) is
amended--
(1) by redesignating subparagraphs (C) and (D) as
subparagraphs (D) and (E), respectively; and
(2) by striking subparagraph (B) and inserting the following:
``(B) Use of categories in determining eligibility of
a device for pass-through payments.--The Secretary
shall determine whether a medical device meets the
requirements of subparagraph (A)(iv) as follows:
``(i) Establishment of categories.--The
Secretary shall establish categories of medical
devices based on type of medical device as
follows:
``(I) In general.--The Secretary
shall establish criteria that will be
used for creation of categories through
rulemaking (which may include use of an
interim final rule with comment
period). Such categories shall be
established in a manner such that no
medical device is described by more
than one category. Such criteria shall
include a test of whether the average
cost of devices that would be included
in a category, as estimated by the
Secretary, is not insignificant as
described in paragraph (A)(iv)(II).
``(II) Initial categories.--The
categories to be applied as of the
category-based pass-through
implementation date specified pursuant
to subclause (V) shall be established
in a manner such that each medical
device that meets the requirements of
clause (ii) or (iv) of subparagraph (A)
as of such date is included in a such a
category. For purposes of the preceding
sentence, whether a medical device
meets the requirements of clause (ii)
or (iv) of subparagraph (A) as of such
date shall be determined without regard
to clause (ii) of this subparagraph and
on the basis of the program memoranda
issued before such date identifying
medical devices that meet such
requirements.
``(III) Adding categories.--The
Secretary shall promptly establish a
new category of medical device under
this clause for any medical device that
meets the requirements of subparagraph
(A)(iv) and for which none of the
categories in effect or that were
previously in effect (as described in
subparagraph (C)(iii)) is appropriate.
The Secretary shall only establish a
new category for a medical device that
is described by a category that was
previously in effect if the Secretary
determines, in accord with criteria
established under subclause (I) of this
clause, that the device represents a
significant advance in medical
technology that is expected to
significantly improve the treatment of
Medicare beneficiaries.
``(IV) Deleting categories.--The
Secretary shall delete a category at
the close of the period for which the
category is in effect (as described in
subparagraph (C)(iii)).
``(V) Category-based pass-through
implementation date.--For purposes of
this subparagraph and subparagraph (C),
the `category-based pass-through
implementation date' is a date
specified by the Secretary as of which
the categories established under this
clause are first used for purposes of
clause (ii)(I). Such date may not be
later than July 1, 2000.
``(ii) Requirements treated as met.--A
medical device shall be treated as meeting the
requirements of subparagraph (A)(iv) if--
``(I) the device is described by a
category established under clause (i),
and
``(II) an application under section
515 of the Federal Food, Drug, and
Cosmetic Act has been approved with
respect to the device, or the device
has been cleared for market under
section 510(k) of such Act, or the
device is exempt from the requirements
of section 510(k) of such Act pursuant
to subsection (l) or (m) of section 510
of such Act or section 520(g) of such
Act, without an additional requirement
for application or prior approval.
``(C) Limited period of payment.--
``(i) Drugs and biologicals.--The payment
under this paragraph with respect to a drug or
biological shall only apply during a period of
at least 2 years, but not more than 3 years,
that begins--
``(I) on the first date this
subsection is implemented in the case
of a drug or biological described in
clause (i), (ii), or (iii) of
subparagraph (A) and in the case of a
drug or biological described in
subparagraph (A)(iv) and for which
payment under this part is made as an
outpatient hospital service before such
first date; or
``(II) in the case of a drug or
biological described in subparagraph
(A)(iv) not described in subclause (I),
on the first date on which payment is
made under this part for the drug or
biological as an outpatient hospital
service.
``(ii) Medical devices.--Except as provided
in clause (iv), payment shall be made under
this paragraph with respect to a medical device
only if such device--
``(I) is described by a category of
medical devices established under
subparagraph (B)(i); and
``(II) is provided as part of a
service (or group of services) paid for
under this subsection and provided
during the period for which such
category is in effect (as described in
clause (iii)).
``(iii) Period for which category is in
effect.--For purposes of this subparagraph and
subparagraph (B), a category of medical devices
established under subparagraph (B)(i) shall be
in effect for a period of at least 2 years, but
not more than 3 years, that begins--
``(I) in the case of a category
established under subparagraph
(B)(i)(II), on the first date on which
payment was made under this paragraph
for any device described by such
category (including payments made
during the period before the category-
based pass-through implementation
date); and
``(II) in the case of a category
established under subparagraph
(B)(i)(III), on the first date on which
payment is made under this paragraph
for any medical device that is
described by such category.
``(iv) Payments made before category-based
pass-through implementation date.--
``(I) in the case of a medical device
provided as part of a service (or group
of services) paid for under this
subsection and provided during the
period beginning on the first date on
which the system under this subsection
is implemented and ending on (and
including) the day before the category-
based pass-through implementation date
specified pursuant to subparagraph
(B)(i)(V), payment shall be made in
accordance with the provisions of this
paragraph as in effect on the day
before the date of the enactment of
this subparagraph; and
``(II) notwithstanding subclause (I),
the Secretary shall make payments under
this paragraph during the period
beginning one month after the date of
enactment of the Beneficiary
Improvement and Protection Act of 2000
and ending on the same ending date in
subclause (I) with respect to any
medical device that is not included in
a program memorandum referred to in
subparagraph (B)(i)(II) but that is
substantially similar (other than with
respect to the restriction in
subparagraph (A)(iv)(I)) to devices
that are so included and that the
Secretary determines is likely to be
described by a initial category
established under such subparagraph.''.
(b) Conforming Amendments.--Section 1833(t) is further amended--
(1) in paragraph (6)(D) (as redesignated by subsection
(a)(1)), by striking ``subparagraph (D)(iii)'' in the matter
preceding clause (i) and inserting ``subparagraph (E)(iii)'';
(2) in paragraph (12)(E), by striking ``additional payments
(consistent with paragraph (6)(B))'' and inserting ``additional
payments, the determination and deletion of initial and new
categories (consistent with subparagraphs (B) and (C) of
paragraph (6))''; and
(3) in paragraph (6)(A), by striking ``the cost of the
device, drug, or biological'' and inserting ``the cost of the
drug or biological or the average cost of the category of
devices''.
(c) Effective Date.--The amendments made by this section shall become
effective on the date of the enactment of this Act.
SEC. 204. ACCESS TO NEW TECHNOLOGIES APPLIED TO SCREENING MAMMOGRAPHY
TO ENHANCE BREAST CANCER DETECTION.
(a) $15 Initial Increase in Payment Limit.--Section 1834(c)(3) (42
U.S.C. 1395m(c)(3)) is amended--
(1) in subparagraph (A)--
(A) by striking ``subparagraph (B)'' and inserting
``subparagraphs (B) and (D)''; and
(B) in clause (ii), by inserting ``(taking into
account, if applicable, subparagraph (D))'' after ``for
the preceding year''; and
(2) by adding at the end the following new subparagraph:
``(D) Increase in payment limit for new
technologies.--In the case of new technologies applied
to screening mammography performed beginning in 2001
and determined by the Secretary to enhance the
detection of breast cancer, the limit applied under
this paragraph for 2001 shall be increased by $15.''.
(b) Change in Revision of Limit.--Subparagraph (B) of such section is
amended--
(1) by striking ``Reduction of'' and inserting ``Revisions
to'',
(2) by inserting ``or new technologies described in paragraph
(1)(D)'' after ``1992'', and
(3) by inserting ``increase or'' before ``reduce''.
(c) Inclusion of New Technology.--Section 1861(jj) (42 U.S.C.
1395x(jj)) is amended by inserting before the period at the end the
following: ``, as well as new technology applied to such a procedure
that the Secretary determines enhances the detection of breast
cancer''.
(d) Effective Date.--The amendments made by this section apply to
mammography performed on or after January 1, 2001.
Subtitle B--Provisions Relating to Physicians Services
SEC. 211. GAO STUDY OF GASTROINTESTINAL ENDOSCOPIC SERVICES FURNISHED
IN PHYSICIANS OFFICES AND HOSPITAL OUTPATIENT
DEPARTMENT SERVICES.
(a) Study.--The Comptroller General of the United States shall
conduct a study on the appropriateness of furnishing gastrointestinal
endoscopic physicians services in physicians offices. In conducting
this study, the Comptroller General shall--
(1) review available scientific and clinical evidence about
the safety of performing procedures in physicians offices and
hospital outpatient departments;
(2) assess whether resource-based practice expense relative
values established by the Secretary of Health and Human
Services under the Medicare physician fee schedule under
section 1848 of the Social Security Act (42 U.S.C. 1395w-4) for
gastrointestinal endoscopic services furnished in physicians
offices and hospital outpatient departments create an incentive
to furnish such services in physicians offices instead of
hospital outpatient departments; and
(3) assess the implications for access to care for Medicare
beneficiaries if Medicare were not to cover gastrointestinal
endoscopic services in physicians offices.
(b) Report.--The Comptroller General shall submit a report to
Congress on such study no later than July 1, 2002 and include such
recommendations as the Comptroller General determines to be
appropriate.
SEC. 212. TREATMENT OF CERTAIN PHYSICIAN PATHOLOGY SERVICES.
(a) In General.--When an independent laboratory furnishes the
technical component of a physician pathology service to a fee-for-
service medicare beneficiary who is a patient of a grandfathered
hospital, the Secretary of Health and Human Services shall treat such
component as a service for which payment shall be made to the
laboratory under section 1848 of the Social Security Act (42 U.S.C.
1395w-4) and not as an inpatient hospital service for which payment is
made to the hospital under section 1886(d) of such Act (42 U.S.C.
1395ww(d)) or as an outpatient hospital service for which payment is
made to the hospital under section 1834(t) of such Act (42 U.S.C.
1395l(t))..
(b) Definitions.--For purposes of this section:
(1) Grandfathered hospital.--The term ``grandfathered
hospital'' means a hospital that had an arrangement with an
independent laboratory that was in effect as of July 22, 1999,
under which a laboratory furnished the technical component of
physician pathology services to fee-for-service medicare
beneficiaries who were hospital patients and submitted claims
for payment for such component to a medicare carrier (and not
to the hospital).
(2) Fee-for-service medicare beneficiary.--The term ``fee-
for-service medicare beneficiary'' means an individual who--
(A) is entitled to benefits under part A, or enrolled
under part B, of title XVIII of the Social Security Act
(42 U.S.C. 1395c et seq.); and
(B) is not enrolled in (i) a Medicare+Choice plan
under part C of such title (42 U.S.C. 1395w-21 et
seq.), (ii) a plan offered by an eligible organization
under section 1876 of such Act (42 U.S.C. 1395mm),
(iii) a program of all-inclusive care for the elderly
(PACE) under section 1898 of such Act, or (iv) a social
health maintenance organization (SHMO) demonstration
project established under section 4018(b) of the
Omnibus Budget Reconciliation Act of 1987 (Public Law
100-203).
(3) Medicare carrier.--The term ``medicare carrier'' means an
organization with a contract under section 1842 of such Act (42
U.S.C. 1395u).
(c) Effective Date.--Subsection (a) applies to services furnished
during the 2-year period beginning on January 1, 2001.
(d) GAO Report.--
(1) Study.--The Comptroller General of the United States
shall--
(A) analyze the types of hospitals that are
grandfathered under subsection (a); and
(B) study the effects of subsection (a) on hospitals,
laboratories, and medicare beneficiaries access to
physician pathology services.
(2) Report.--The Comptroller General shall submit a report to
Congress on such analysis and study no later than July 1, 2002.
The report shall include recommendations about whether the
provisions of subsection (a) should apply after the 2-year
period under subsection (c) for grandfathered hospitals for
either (or both) inpatient and outpatient hospital services and
whether such subsection should be extended to apply to other
hospitals that have similar characteristics to grandfathered
hospitals.
SEC. 213. PHYSICIAN GROUP PRACTICE DEMONSTRATION.
Title XVIII is amended by inserting after section 1866 the following
new sections:
``demonstration of application of physician volume increases to group
practices
``Sec. 1866A. (a) Demonstration Program Authorized.--
``(1) In general.--The Secretary shall conduct demonstration
projects to test and, if proven effective, expand the use of
incentives to health care groups participating in the program
under this title that--
``(A) encourage coordination of the care furnished to
individuals under the programs under parts A and B by
institutional and other providers, practitioners, and
suppliers of health care items and services;
``(B) encourage investment in administrative
structures and processes to ensure efficient service
delivery; and
``(C) reward physicians for improving health
outcomes.
``(2) Administration by contract.--Except as otherwise
specifically provided, the Secretary may administer the program
under this section in accordance with section 1866B.
``(3) Definitions.--For purposes of this section, terms have
the following meanings:
``(A) Physician.--Except as the Secretary may
otherwise provide, the term `physician' means any
individual who furnishes services which may be paid for
as physicians' services under this title.
``(B) Health care group.--The term `health care
group' means a group of physicians (as defined in
subparagraph (A)) organized at least in part for the
purpose of providing physicians' services under this
title. As the Secretary finds appropriate, a health
care group may include a hospital and any other
individual or entity furnishing items or services for
which payment may be made under this title that is
affiliated with the health care group under an
arrangement structured so that such individual or
entity participates in a demonstration under this
section and will share in any bonus earned under
subsection (d).
``(b) Eligibility Criteria.--
``(1) In general.--The Secretary is authorized to establish
criteria for health care groups eligible to participate in a
demonstration under this section, including criteria relating
to numbers of health care professionals in, and of patients
served by, the group, scope of services provided, and quality
of care.
``(2) Payment method.--A health care group participating in
the demonstration under this section shall agree with respect
to services furnished to beneficiaries within the scope of the
demonstration (as determined under subsection (c))--
``(A) to be paid on a fee-for-service basis; and
``(B) that payment with respect to all such services
furnished by members of the health care group to such
beneficiaries shall (where determined appropriate by
the Secretary) be made to a single entity.
``(3) Data reporting.--A health care group participating in a
demonstration under this section shall report to the Secretary
such data, at such times and in such format as the Secretary
require, for purposes of monitoring and evaluation of the
demonstration under this section.
``(c) Patients Within Scope of Demonstration.--
``(1) In general.--The Secretary shall specify, in accordance
with this subsection, the criteria for identifying those
patients of a health care group who shall be considered within
the scope of the demonstration under this section for purposes
of application of subsection (d) and for assessment of the
effectiveness of the group in achieving the objectives of this
section.
``(2) Other criteria.--The Secretary may establish additional
criteria for inclusion of beneficiaries within a demonstration
under this section, which may include frequency of contact with
physicians in the group or other factors or criteria that the
Secretary finds to be appropriate.
``(3) Notice requirements.--In the case of each beneficiary
determined to be within the scope of a demonstration under this
section with respect to a specific health care group, the
Secretary shall ensure that such beneficiary is notified of the
incentives, and of any waivers of coverage or payment rules,
applicable to such group under such demonstration.
``(d) Incentives.--
``(1) Performance target.--The Secretary shall establish for
each health care group participating in a demonstration under
this section--
``(A) a base expenditure amount, equal to the average
total payments under parts A and B for patients served
by the health care group on a fee-for-service basis in
a base period determined by the Secretary; and
``(B) an annual per capita expenditure target for
patients determined to be within the scope of the
demonstration, reflecting the base expenditure amount
adjusted for risk and expected growth rates.
``(2) Incentive bonus.--The Secretary shall pay to each
participating health care group (subject to paragraph (4)) a
bonus for each year under the demonstration equal to a portion
of the Medicare savings realized for such year relative to the
performance target.
``(3) Additional bonus for process and outcome
improvements.--At such time as the Secretary has established
appropriate criteria based on evidence the Secretary determines
to be sufficient, the Secretary shall also pay to a
participating health care group (subject to paragraph (4)) an
additional bonus for a year, equal to such portion as the
Secretary may designate of the saving to the program under this
title resulting from process improvements made by and patient
outcome improvements attributable to activities of the group.
``(4) Limitation.--The Secretary shall limit bonus payments
under this section as necessary to ensure that the aggregate
expenditures under this title (inclusive of bonus payments)
with respect to patients within the scope of the demonstration
do not exceed the amount which the Secretary estimates would be
expended if the demonstration projects under this section were
not implemented.
``provisions for administration of demonstration program
``Sec. 1866B. (a) General Administrative Authority.--
``(1) Beneficiary eligibility.--Except as otherwise provided
by the Secretary, an individual shall only be eligible to
receive benefits under the program under section 1866A (in this
section referred to as the `demonstration program') if such
individual--
``(A) is enrolled in under the program under part B
and entitled to benefits under part A; and
``(B) is not enrolled in a Medicare+Choice plan under
part C, an eligible organization under a contract under
section 1876 (or a similar organization operating under
a demonstration project authority), an organization
with an agreement under section 1833(a)(1)(A), or a
PACE program under section 1894.
``(2) Secretary's discretion as to scope of program.--The
Secretary may limit the implementation of the demonstration
program to--
``(A) a geographic area (or areas) that the Secretary
designates for purposes of the program, based upon such
criteria as the Secretary finds appropriate;
``(B) a subgroup (or subgroups) of beneficiaries or
individuals and entities furnishing items or services
(otherwise eligible to participate in the program),
selected on the basis of the number of such
participants that the Secretary finds consistent with
the effective and efficient implementation of the
program;
``(C) an element (or elements) of the program that
the Secretary determines to be suitable for
implementation; or
``(D) any combination of any of the limits described
in subparagraphs (A) through (C).
``(3) Voluntary receipt of items and services.--Items and
services shall be furnished to an individual under the
demonstration program only at the individual's election.
``(4) Agreements.--The Secretary is authorized to enter into
agreements with individuals and entities to furnish health care
items and services to beneficiaries under the demonstration
program.
``(5) Program standards and criteria.--The Secretary shall
establish performance standards for the demonstration program
including, as applicable, standards for quality of health care
items and services, cost-effectiveness, beneficiary
satisfaction, and such other factors as the Secretary finds
appropriate. The eligibility of individuals or entities for the
initial award, continuation, and renewal of agreements to
provide health care items and services under the program shall
be conditioned, at a minimum, on performance that meets or
exceeds such standards.
``(6) Administrative review of decisions affecting
individuals and entities furnishing services.--An individual or
entity furnishing services under the demonstration program
shall be entitled to a review by the program administrator (or,
if the Secretary has not contracted with a program
administrator, by the Secretary) of a decision not to enter
into, or to terminate, or not to renew, an agreement with the
entity to provide health care items or services under the
program.
``(7) Secretary's review of marketing materials.--An
agreement with an individual or entity furnishing services
under the demonstration program shall require the individual or
entity to guarantee that it will not distribute materials
marketing items or services under the program without the
Secretary's prior review and approval;
``(8) Payment in full.--
``(A) In general.--Except as provided in subparagraph
(B), an individual or entity receiving payment from the
Secretary under a contract or agreement under the
demonstration program shall agree to accept such
payment as payment in full, and such payment shall be
in lieu of any payments to which the individual or
entity would otherwise be entitled under this title.
``(B) Collection of deductibles and coinsurance.--
Such individual or entity may collect any applicable
deductible or coinsurance amount from a beneficiary.
``(b) Contracts for Program Administration.--
``(1) In general.--The Secretary may administer the
demonstration program through a contract with a program
administrator in accordance with the provisions of this
subsection.
``(2) Scope of program administrator contracts.--The
Secretary may enter into such contracts for a limited
geographic area, or on a regional or national basis.
``(3) Eligible contractors.--The Secretary may contract for
the administration of the program with--
``(A) an entity that, under a contract under section
1816 or 1842, determines the amount of and makes
payments for health care items and services furnished
under this title; or
``(B) any other entity with substantial experience in
managing the type of program concerned.
``(4) Contract award, duration, and renewal.--
``(A) In general.--A contract under this subsection
shall be for an initial term of up to three years,
renewable for additional terms of up to three years.
``(B) Noncompetitive award and renewal for entities
administering part a or part b payments.--The Secretary
may enter or renew a contract under this subsection
with an entity described in paragraph (3)(A) without
regard to the requirements of section 5 of title 41,
United States Code.
``(5) Applicability of federal acquisition regulation.--The
Federal Acquisition Regulation shall apply to program
administration contracts under this subsection.
``(6) Performance standards.--The Secretary shall establish
performance standards for the program administrator including,
as applicable, standards for the quality and cost-effectiveness
of the program administered, and such other factors as the
Secretary finds appropriate. The eligibility of entities for
the initial award, continuation, and renewal of program
administration contracts shall be conditioned, at a minimum, on
performance that meets or exceeds such standards.
``(7) Functions of program administrator.--A program
administrator shall perform any or all of the following
functions, as specified by the Secretary:
``(A) Agreements with entities furnishing health care
items and services.--Determine the qualifications of
entities seeking to enter or renew agreements to
provide services under the program, and as appropriate
enter or renew (or refuse to enter or renew) such
agreements on behalf of the Secretary.
``(B) Establishment of payment rates.--Negotiate or
otherwise establish, subject to the Secretary's
approval, payment rates for covered health care items
and services.
``(C) Payment of claims or fees.--Administer payments
for health care items or services furnished under the
program.
``(D) Payment of bonuses.--Using such guidelines as
the Secretary shall establish, and subject to the
approval of the Secretary, make bonus payments as
described in subsection (c)(2)(A)(ii) to entities
furnishing items or services for which payment may be
made under the program.
``(E) Oversight.--Monitor the compliance of
individuals and entities with agreements under the
program with the conditions of participation.
``(F) Administrative review.--Conduct reviews of
adverse determinations specified in subsection (a)(6).
``(G) Review of marketing materials.--Conduct a
review of marketing materials proposed by an entity
furnishing services under the program.
``(H) Additional functions.--Perform such other
functions as the Secretary may specify.
``(8) Limitation of liability.--The provisions of section
1157(b) shall apply with respect to activities of contractors
and their officers, employees, and agents under a contract
under this subsection.
``(9) Information sharing.--Notwithstanding section 1106 and
section 552a of title 5, United States Code, the Secretary is
authorized to disclose to an entity with a program
administration contract under this subsection such information
(including medical information) on individuals receiving health
care items and services under the program as the entity may
require to carry out its responsibilities under the contract.
``(c) Rules Applicable to Both Program Agreements and Program
Administration Contracts.--
``(1) Records, reports, and audits.--The Secretary is
authorized to require entities with agreements to provide
health care items or services under the demonstration program,
and entities with program administration contracts under
subsection (b), to maintain adequate records, to afford the
Secretary access to such records (including for audit
purposes), and to furnish such reports and other materials
(including audited financial statements and performance data)
as the Secretary may require for purposes of implementation,
oversight, and evaluation of the program and of individuals'
and entities' effectiveness in performance of such agreements
or contracts.
``(2) Bonuses.--Notwithstanding any other provision of law,
but subject to subparagraph (B)(ii), the Secretary may make
bonus payments under the program from the Federal Health
Insurance Trust Fund and the Federal Supplementary Medical
Insurance Trust Fund in amounts that do not exceed the amounts
authorized under the program in accordance with the following:
``(A) Payments to program administrators.--The
Secretary may make bonus payments under the program to
program administrators.
``(B) Payments to entities furnishing services.--
``(i) In general.--Subject to clause (ii),
the Secretary may make bonus payments to
individuals or entities furnishing items or
services for which payment may be made under
the program, or may authorize the program
administrator to make such bonus payments in
accordance with such guidelines as the
Secretary shall establish and subject to the
Secretary's approval.
``(ii) Limitations.--The Secretary may
condition such payments on the achievement of
such standards related to efficiency,
improvement in processes or outcomes of care,
or such other factors as the Secretary
determines to be appropriate.
``(3) Antidiscrimination limitation.--The Secretary shall not
enter into an agreement with an entity to provide health care
items or services under the program, or with an entity to
administer the program, unless such entity guarantees that it
will not deny, limit, or condition the coverage or provision of
benefits under the program, for individuals eligible to be
enrolled under such program, based on any health status-related
factor described in section 2702(a)(1) of the Public Health
Service Act.
``(d) Limitations on Judicial Review.--The following actions and
determinations with respect to the demonstration program shall not be
subject to review by a judicial or administrative tribunal:
``(1) Limiting the implementation of the program under
subsection (a)(2).
``(2) Establishment of program participation standards under
subsection (a)(5) or the denial or termination of, or refusal
to renew, an agreement with an entity to provide health care
items and services under the program.
``(3) Establishment of program administration contract
performance standards under subsection (b)(6), the refusal to
renew a program administration contract, or the noncompetitive
award or renewal of a program administration contract under
subsection (b)(4)(B).
``(5) Establishment of payment rates, through negotiation or
otherwise, under a program agreement or a program
administration contract.
``(6) A determination with respect to the program (where
specifically authorized by the program authority or by
subsection (c)(2))--
``(A) as to whether cost savings have been achieved,
and the amount of savings; or
``(B) as to whether, to whom, and in what amounts
bonuses will be paid.
``(e) Application Limited to Parts A and B.--None of the provisions
of this section or of the demonstration program shall apply to the
programs under part C.
``(f) Reports to Congress.--Not later than two years after the date
of enactment of this section, and biennially thereafter for six years,
the Secretary shall report to the Congress on the use of authorities
under the demonstration program. Each report shall address the impact
of the use of those authorities on expenditures, access, and quality
under the programs under this title.''.
SEC. 214. DESIGNATION OF SEPARATE CATEGORY FOR INTERVENTIONAL PAIN
MANAGEMENT PHYSICIANS.
With respect to services furnished on or after January 1, 2002, the
Secretary of Health and Human Services shall provide for the
designation under section 1848(c)(3)(A) of the Social Security Act (42
U.S.C. 1395w-4(c)(3)(A)) of interventional pain management physicians
as a separate category of physician specialists.
SEC. 215. EVALUATION OF ENROLLMENT PROCEDURES FOR MEDICAL GROUPS THAT
RETAIN INDEPENDENT CONTRACTOR PHYSICIANS.
(a) In General.--The Secretary of Health and Human Services shall
conduct an evaluation of the current medicare enrollment process for
medical groups that retain independent contractor physicians with
particular emphasis on hospital-based physicians, such as emergency
department staffing groups. In conducting the evaluation, the Secretary
shall--
(1) review the increase of individual medicare provider
numbers issued and the possible medicare program integrity
vulnerabilities of the current process;
(2) assess how program integrity could be enhanced by the
enrollment of groups that retain independent contractor
hospital-based physicians; and
(3) develop suggested procedures for the enrollment of these
groups.
(b) Report.--Not later than 1 year after the date of the enactment of
this Act, the Secretary shall submit to Congress a report on the
evaluation conducted under subsection (a).
Subtitle C--Other Services
SEC. 221. 3-YEAR MORATORIUM ON SNF PART B CONSOLIDATED BILLING
REQUIREMENTS.
(a) Moratorium in Application of Consolidated Billing to SNF
Residents in Non-covered Stays.--Section 1842(b)(6)(E) (42 U.S.C.
1395u(b)(6)(E)) is amended by inserting ``(on or after October 1,
2003)'' after ``furnished to an individual''.
(b) Moratorium in Provider Agreement Provision.--Section
1866(a)(1)(H)(ii)(I) (42 U.S.C. 1395cc(a)(1)(H)(ii)(I) is amended by
inserting ``in the case of a resident who is in a stay covered under
part A, and for services furnished on or after October 1, 2003, in the
case of a resident who is not in a stay covered under such part''
before the comma.
(c) Moratorium in Requirement for SNF Billing of Part B Services.--
Section 1862(a)(18) (42 U.S.C. 1395y(a)(18)) is amended to read as
follows:
``(18) which are covered skilled nursing facility services
described in section 1888(e)(2)(A)(i) and which are furnished
to an individual who is a resident--
``(A) of a skilled nursing facility in the case of a
resident who is in a stay covered under part A; or
``(B) of a skilled nursing facility or of a part of a
facility that includes a skilled nursing facility (as
determined under regulations) for services furnished on
or after October 1, 2003, in the case of a resident who
is not in a stay covered under such part,
by an entity other than the skilled nursing facility, unless
the services are furnished under arrangements (as defined in
section 1861(w)(1)) with the entity made by the skilled nursing
facility;''.
(d) Effective Date.--The amendments made by subsections (a), (b) and
(c) are effective as if included in the enactment of BBA.
(e) Report.--Not later than October 1, 2002, the Comptroller General
of the United States shall submit to Congress a report that includes an
analysis and recommendations on--
(1) alternatives, if any, to consolidated billing for part B
items and services described in section 1842(b)(6) of the
Social Security Act (42 U.S.C. 1395u(b)(6)) to ensure
accountability by skilled nursing facilities and accuracy in
claims submitted for all services and items provided to skilled
nursing facility residents under part B of the medicare
program;
(2) the costs expected to be incurred by skilled nursing
facilities under such alternative approaches, compared with the
costs associated with the implementation of consolidated
billing; and
(3) the costs incurred by the medicare program in
implementing such alternative approaches and their effect on
utilization review, compared with the costs and effect on
utilization review expected with consolidated billing.
SEC. 222. AMBULATORY SURGICAL CENTERS.
(a) Delay in Implementation of Prospective Payment System.--The
Secretary of Health and Human Services may not implement a revised
prospective payment system for services of ambulatory surgical
facilities under section 1833(i) of the Social Security Act (42 U.S.C.
1395l(i)) before January 1, 2002.
(b) Extending Phase-In to 4 Years.--Section 226 of the BBRA is
amended by striking paragraphs (1) and (2) and inserting the following:
``(1) in the first year of its implementation, only a
proportion (specified by the Secretary and not to exceed \1/4\)
of the payment for such services shall be made in accordance
with such system and the remainder shall be made in accordance
with current regulations; and
``(2) in each of the following 2 years a proportion
(specified by the Secretary and not to exceed \1/2\, and \3/4\,
respectively) of the payment for such services shall be made
under such system and the remainder shall be made in accordance
with current regulations.''.
(c) Deadline for Use of 1999 or Later Cost Surveys.--Section 226 of
BBRA is amended by adding at the end the following:
``By not later than January 1, 2003, the Secretary shall incorporate
data from a 1999 Medicare cost survey or a subsequent cost survey for
purposes of implementing or revising such system.''.
SEC. 223. 1-YEAR EXTENSION OF MORATORIUM ON THERAPY CAPS.
(a) In General.--Section 1833(g)(4) (42 U.S.C. 1395l(g)), as added by
section 221(a) of BBRA, is amended by striking ``and 2001'' and
inserting ``, 2001, and 2002''.
(b) Conforming Amendment To Continue Focused Medical Reviews of
Claims during Moratorium Period.--Section 221(a)(2) of BBRA is amended
by striking ``(under the amendment made by paragraph (1)(B))''.
SEC. 224. REVISION OF MEDICARE REIMBURSEMENT FOR TELEHEALTH SERVICES.
The text of section 4206 of the Balanced Budget Act of 1997 (42
U.S.C. 1395l note) is amended to read as follows:
``(a) Telehealth Services Reimbursed.--
``(1) In general.--Not later than April 1, 2001, the
Secretary of Health and Human Services shall make payments from
the Federal Supplementary Medical Insurance Trust Fund in
accordance with the methodology described in subsection (b) for
services for which payment may be made under part B of title
XVIII of the Social Security Act (42 U.S.C. 1395j et seq.) that
are furnished via a telecommunications system by a physician or
practitioner to an eligible telehealth beneficiary.
``(2) Use of store-and-forward technologies.--For purposes of
paragraph (1), in the case of any Federal telemedicine
demonstration program in Alaska or Hawaii, the term
`telecommunications system' includes store-and-forward
technologies that provide for the asynchronous transmission of
health care information in single or multimedia formats.
``(b) Methodology for Determining Amount of Payments.--
``(1) In general.--The Secretary shall make payment under
this section as follows:
``(A) Subject to subparagraph (B), with respect to a
physician or practitioner located at a distant site
that furnishes a service to an eligible medicare
beneficiary under subsection (a), an amount equal to
the amount that such physician or practitioner would
have been paid had the service been furnished without
the use of a telecommunications system.
``(B) With respect to an originating site, a facility
fee equal to--
``(i) for 2001 (beginning with April 1, 2001)
and 2002, $20; and
``(ii) for a subsequent year, the facility
fee under this subsection for the previous year
increased by the percentage increase in the MEI
(as defined in section 1842(i)(3)) for such
subsequent year.
``(2) Application of part b coinsurance and deductible.--Any
payment made under this section shall be subject to the
coinsurance and deductible requirements under subsections
(a)(1) and (b) of section 1833 of the Social Security Act (42
U.S.C. 1395l).
``(3) Application of nonparticipating physician payment
differential and balance billing limits.--The payment
differential of section 1848(a)(3) of such Act (42 U.S.C.
1395w-4(a)(3)) shall apply to services furnished by non-
participating physicians. The provisions of section 1848(g) of
such Act (42 U.S.C. 1395w-4(g)) and section 1842(b)(18) of such
Act (42 U.S.C. 1395u(b)(18)) shall apply. Payment for such
service shall be increased annually by the update factor for
physicians' services determined under section 1848(d) of such
Act (42 U.S.C. 1395w-4(d)).
``(c) Telepresenter Not Required.--Nothing in this section shall be
construed as requiring an eligible telehealth beneficiary to be
presented by a physician or practitioner at the originating site for
the furnishing of a service via a telecommunications system, unless it
is medically necessary as determined by the physician or practitioner
at the distant site.
``(d) Coverage of Additional Services.--
``(1) Study and report on additional services.--
``(A) Study.--The Secretary of Health and Human
Services shall conduct a study to identify services in
addition to those described in subsection (a)(1) that
are appropriate for payment under this section.
``(B) Report.--Not later than 2 years after the date
of enactment of this Act, the Secretary shall submit to
Congress a report on the study conducted under
subparagraph (A) together with such recommendations for
legislation that the Secretary determines are
appropriate.
``(2) In general.--The Secretary shall provide for payment
under this section for services identified in paragraph (1).
``(e) Construction Relating to Home Health Services.--
``(1) In general.--Nothing in this section or in section 1895
of the Social Security Act (42 U.S.C. 1395fff) shall be
construed as preventing a home health agency furnishing a home
health unit of service for which payment is made under the
prospective payment system established in such section from
furnishing the service via a telecommunications system.
``(2) Limitation.--The Secretary shall not consider a home
health service provided in the manner described in paragraph
(1) to be a home health visit for purposes of--
``(A) determining the amount of payment to be made
under such prospective payment system; or
``(B) any requirement relating to the certification
of a physician required under section 1814(a)(2)(C) or
section 1835(a)(2)(A) of such Act (42 U.S.C.
1395f(a)(2)(C), 1395n(a)(2)(A)).
``(3) Construction.--Nothing in this section shall be
construed as waiving the requirement for a physician
certification under section 1814(a)(2)(C) or section
1835(a)(2)(A) of such Act (42 U.S.C. 1395f(a)(2)(C),
1395n(a)(2)(A)) for the payment for home health services,
whether or not furnished via a telecommunications system.
``(f) Coverage of Items and Services.--
``(1) In general.--Subject to paragraph (2), payment for
items and services provided pursuant to subsection (a) shall
include payment for professional consultations, office visits,
office psychiatry services, including any service identified as
of July 1, 2000, by HCPCS codes 99241-99275, 99201-99215,
90804-90809, and 90862, and any additional item or service
specified by the Secretary.
``(2) Yearly update.--The Secretary shall provide a process
that provides, on at least an annual basis, for the review and
revision of services (and HCPCS codes) to those specified in
paragraph (1) for authorized payment under subsection (a).
``(g) Definitions.--In this section:
``(1) Eligible telehealth beneficiary.--The term `eligible
telehealth beneficiary' means an individual enrolled under part
B of title XVIII of the Social Security Act (42 U.S.C. 1395j et
seq.) that receives a service originating--
``(A) in an area that is designated as a health
professional shortage area under section 332(a)(1)(A)
of the Public Health Service Act (42 U.S.C.
254e(a)(1)(A));
``(B) in a county that is not included in a
Metropolitan Statistical Area;
``(C) effective January 1, 2002, in an inner-city
area that is medically underserved (as defined in
section 330(b)(3) of the Public Health Service Act (42
U.S.C. 254b(b)(3))); or
``(D) in a service which originated in a facility
which participates in a Federal telemedicine
demonstration project.
``(2) Physician.--The term `physician' has the meaning given
that term in section 1861(r) of the Social Security Act (42
U.S.C. 1395x(r))
``(3) Practitioner.--The term `practitioner' means a
practitioner described in section 1842(b)(18)(C) of the Social
Security Act (42 U.S.C. 1395u(b)(18)(C)).
``(4) Distant site.--The term `distant site' means the site
at which the physician or practitioner is located at the time
the service is provided via a telecommunications system.
``(5) Originating site.--
``(A) In general.--The term `originating site' means
any site described in subparagraph (B) at which the
eligible telehealth beneficiary is located at the time
the service is furnished via a telecommunications
system.
``(B) Sites described.--The sites described in this
subparagraph are as follows:
``(i) On or after April 1, 2001--
``(I) the office of a physician or a
practitioner,
``(II) a critical access hospital (as
defined in section 1861(mm)(1) of the
Social Security Act (42 U.S.C.
1395x(mm)(1))),
``(III) a rural health clinic (as
defined in section 1861(aa)(2) of such
Act (42 U.S.C. 1395x(aa)(2))), and
``(IV) a Federally qualified health
center (as defined in section
1861(aa)(4) of such Act (42 U.S.C.
1395x(aa)(4))).
``(ii) On or after January 1, 2002--
``(I) a hospital (as defined in
section 1861(e) of such Act (42 U.S.C.
1395x(e))),
``(II) a skilled nursing facility (as
defined in section 1861(j) of such Act
(42 U.S.C. 1395x(j))),
``(III) a comprehensive outpatient
rehabilitation facility (as defined in
section 1861(cc)(2) of such Act (42
U.S.C. 1395x(cc)(2))),
``(IV) a renal dialysis facility
(described in section 1881(b)(1) of
such Act (42 U.S.C. 1395rr(b)(1))),
``(V) an ambulatory surgical center
(described in section 1833(i)(1)(A) of
such Act (42 U.S.C. 1395l(i)(1)(A))),
``(VI) a hospital or skilled nursing
facility of the Indian Health Service
(under section 1880 of such Act (42
U.S.C. 1395qq)), and
``(VII) a community mental health
center (as defined in section
1861(ff)(3)(B) of such Act (42 U.S.C.
1395x(ff)(3)(B))).
``(6) Federal supplementary medical insurance trust fund.--
The term `Federal Supplementary Medical Insurance Trust Fund'
means the trust fund established under section 1841 of the
Social Security Act (42 U.S.C. 1395t).''.
SEC. 225. PAYMENT FOR AMBULANCE SERVICES.
(a) Eliminating BBA Reduction.--Section 1834(l)(3) (42 U.S.C.
1395m(l)(3)) is amended, in subparagraphs (A) and (B), by striking
``reduced in the case of 2001 and 2002 by 1.0 percentage points'' both
places it appears.
(b) Mileage Payments.--Section 1834(l)(2)(E) (42 U.S.C.
1395m(l)(2)(E)) is amended by inserting before the period at the end
the following: ``, except that such phase-in shall provide for full
payment of any national mileage rate beginning with the effective date
of the fee schedule for ambulance services provided by suppliers in any
State where payment for such services did not include a separate amount
for all mileage prior to the implementation of the fee schedule''.
(c) GAO Study on Costs of Ambulance Services.--
(1) Study.--The Comptroller General of the United States
shall conduct a study of the costs of providing ambulance
services covered under the medicare program under title XVIII
of the Social Security Act across the range of service levels
for which such services are provided.
(2) Report.--Not later than 18 months after the date of the
enactment of this Act, the Comptroller General shall submit a
report to the Secretary of Health and Human Services and
Congress on the study conducted under paragraph (1). Such
report shall include recommendations for any changes in
methodology or payment levels necessary to fairly compensate
suppliers of ambulance services and to ensure the access of
medicare beneficiaries to such services under the medicare
program.
SEC. 226. CONTRAST ENHANCED DIAGNOSTIC PROCEDURES UNDER HOSPITAL
PROSPECTIVE PAYMENT SYSTEM.
(a) Separate Classification.--Section 1833(t)(2) (42 U.S.C.
1395l(t)(2)) is amended--
(1) by striking ``and'' at the end of subparagraph (E);
(2) by striking the period at the end of subparagraph (F) and
inserting ``; and''; and
(3) by inserting after subparagraph (F) the following new
subparagraph:
``(G) the Secretary shall create additional groups of
covered OPD services that classify separately those
procedures that utilize contrast media from those that
do not.''.
(b) Conforming Amendment.--Section 1861(t)(1) (42 U.S.C. 1395x(t)(1))
is amended by inserting ``(including contrast agents)'' after ``only
such drugs''.
(c) Effective Date.--The amendments made by this section shall be
effective as if included in the enactment of BBA.
SEC. 227. 10-YEAR PHASED IN INCREASE FROM 55 PERCENT TO 80 PERCENT IN
THE PROPORTION OF HOSPITAL BAD DEBT RECOGNIZED.
Section 1861(v)(1)(T) (42 U.S.C. 1395x(v)(1)(T)) is amended--
(1) by striking ``and'' at the end of clause (ii);
(2) in clause (iii) by striking ``a subsequent fiscal year''
and inserting ``fiscal year 2000'' and by striking the period
at the end and inserting a semicolon; and
(3) by adding at the end the following new clauses:
``(iv) for cost reporting periods beginning during fiscal
year 2001 and each subsequent fiscal year (before fiscal year
2011), by the percent specified in clause (iii) or this clause
for the preceding fiscal year reduced by 2.5 percentage points,
of such amount otherwise allowable; and
``(v) for cost reporting periods beginning during fiscal year
2011 or a subsequent fiscal year, by 20 percent of such amount
otherwise allowable.''.
SEC. 228. STATE ACCREDITATION OF DIABETES SELF-MANAGEMENT TRAINING
PROGRAMS.
Section 1861(qq)(2) (42 U.S.C. 1395x(qq)(2)) is amended--
(1) in the matter preceding subparagraph (A) by striking
``paragraph (1)--'' and inserting ``paragraph (1):'';
(2) in subparagraph (A)--
(A) by striking ``a `certified provider' '' and
inserting ``A `certified provider' ''; and
(B) by striking ``; and'' and inserting a period; and
(3) in subparagraph (B)--
(A) by striking ``a physician, or such other
individual'' and inserting ``(i) A physician, or such
other individual'';
(B) by inserting ``(I)'' before ``meets applicable
standards'';
(C) by inserting ``(II)'' before ``is recognized'';
(D) by inserting ``, or by a program described in
clause (ii),'' after ``recognized by an organization
that represents individuals (including individuals
under this title) with diabetes''; and
(E) by adding at the end the following:
``(ii) Notwithstanding any reference to `a national
accreditation body' in section 1865(b), for purposes of clause
(i), a program described in this clause is a program operated
by a State for the purposes of accrediting diabetes self-
management training programs, if the Secretary determines that
such State program has established quality standards that meet
or exceed the standards established by the Secretary under
clause (i) or the standards originally established by the
National Diabetes Advisory Board and subsequently revised as
described in clause (i).''.
SEC. 229. UPDATE IN RENAL DIALYSIS COMPOSITE RATE.
(a) In General.--The last sentence of section 1881(b)(7) (42 U.S.C.
1395rr(b)(7)) is amended by striking ``2001, by 1.2 percent'' and
inserting ``2001, by 2.4 percent''.
(b) Report on Literature Review.--The Secretary of Health and Human
Services shall conduct a literature review of studies on the impact of
oral self-administered prescription non-calcium phosphate binding drugs
in reducing the incidence of hospitalization under the medicare program
for medicare beneficiaries with end stage renal disease. Not later than
6 months after the date of the enactment of this Act, the Secretary
shall transmit to the Committees on Commerce and Ways and Means of the
House of Representatives and the Committee on Finance of the Senate a
summary of the literature review conducted under this subsection.
TITLE III--MEDICARE PART A AND B PROVISIONS
SEC. 301. HOME HEALTH SERVICES.
(a) 1-Year Delay in 15 Percent Reduction in Payment Rates Under the
Medicare Prospective Payment System for Home Health Services.--Section
1895(b)(3)(A)(i) (42 U.S.C. 1395fff(b)(3)(A)(i)) is amended--
(1) by redesignating subparagraph (II) as subparagraph (III);
(2) in subparagraph (III), as redesignated, by striking
``described in subclause (I)'' and inserting ``described in
subclause (II)''; and
(3) by inserting after subclause (I) the following new
subclause:
``(II) For the 12-month period
beginning after the period described in
subclause (I), such amount (or amounts)
shall be equal to the amount (or
amounts) determined under subclause
(I), updated under subparagraph (B).''.
(b) Treatment of Branch Offices.--
(1) In general.--Notwithstanding any other provision of law,
in determining for purposes of title XVIII of the Social
Security Act whether an office of a home health agency
constitutes a branch office or a separate home health agency,
neither the time nor distance between a parent office of the
home health agency and a branch office shall be the sole
determinant of a home health agency's branch office status.
(2) Consideration of forms of technology in definition of
supervision.--The Secretary of Health and Human Services shall
include forms of technology in determining what constitutes
``supervision'' for purposes of determining a home heath
agency's branch office status under paragraph (1).
(c) Clarification of the Definition of Homebound.--
(1) In general.--The last sentence of sections 1814(a) and
1835(a) (42 U.S.C. 1395f(a); 1395n(a)) are each amended by
striking the period and inserting ``, including participating
in an adult day care program licensed or certified by a State,
or accredited, to furnish adult day care services in the State
for the purposes of therapeutic treatment for Alzheimer's
disease or a related dementia.''.
(2) Effective date.--The amendments made by paragraph (1)
apply to items and services provided on or after October 1,
2001.
(d) 1-Year Delay in Report.--Section 302(c) of the BBRA is amended by
striking ``six months'' and inserting ``18 months''.
SEC. 302. ADVISORY OPINIONS.
(a) Making Permanent Existing Advisory Opinion Authority.--Section
1128D(b)(6) (42 U.S.C. 1320a-7d(b)(6)) is amended by striking ``and
before the date which is 4 years after such date of enactment''.
(b) Nondisclosure of Requests and Supporting Materials.--
(1) In general.--Section 1128D(b) (42 U.S.C. 1320a-7d(b)) is
amended by adding at the end the following new paragraph:
``(7) Nondisclosure of requests and supporting materials.--A
request for an advisory opinion under this subsection and any
supporting written materials submitted by the party requesting
the opinion shall not be subject to disclosure under section
552 of title 5, United States Code.''.
(2) Effective date.--The amendment made by paragraph (1)
applies to requests made before, on, or after the date of the
enactment of this Act.
SEC. 303. HOSPITAL GEOGRAPHIC RECLASSIFICATION FOR LABOR ---COSTS FOR
OTHER PPS SYSTEMS.
(a) Hospital Geographic Reclassification for Labor Costs Applicable
to Other PPS Systems.--
(1) In general.--Notwithstanding the geographic adjustment
factor otherwise established under title XVIII of the Social
Security Act for items and services paid under a prospective
payment system described in paragraph (2), in the case of a
hospital with an application that has been approved by the
Medicare Geographic Classification Review Board under section
1886(d)(10)(C) of such Act (42 U.S.C. 1395ww(d)(10)(C)) to
change the hospital's geographic classification for a fiscal
year for purposes of the factor used to adjust the prospective
payment rate for area differences in hospital wage levels that
applies to such hospital under section 1886(d)(3)(E) of such
Act, the Secretary shall substitute such change in the
hospital's geographic adjustment that would otherwise be
applied to an entity or department of the hospital that is
provider based to account for variations in costs which are
attributable to wages and wage-related costs for items and
services paid under the prospective payment systems described
in paragraph (2).
(2) Prospective payment systems covered.--For -purposes of
this section, items and services furnished under the following
prospective payment systems are covered:
(A) SNF prospective payment system.--The prospective
payment system for covered skilled nursing facility
services under section 1888(e) of the Social Security
Act (42 U.S.C. 1395yy(e)).
(B) Home health services prospective payment
system.--The prospective payment system for home health
services under section 1895(b) of such Act (42 U.S.C.
1395fff(b)).
(C) Inpatient rehabilitation hospital services.--The
prospective payment system for inpatient rehabilitation
services under section 1888(j) of such Act (42 U.S.C.
1395ww(j)).
(D) Inpatient long-term care hospital services.--The
prospective payment system for inpatient hospital
services of long-term care hospitals under section 123
of the BBRA.
(E) Inpatient psychiatric hospital services.--The
prospective payment system for inpatient hospital
services of psychiatric hospitals and units under
section 124 of the BBRA.
(b) Effective Date.--Subsection (a) applies to fiscal years beginning
with fiscal year 2002.
SEC. 304. RECLASSIFICATION OF A METROPOLITAN STATISTICAL AREA FOR
PURPOSES OF REIMBURSEMENT UNDER THE MEDICARE
PROGRAM.
Notwithstanding any other provision of law, effective for discharges
occurring and services furnished during fiscal year 2001 and subsequent
fiscal years, for purposes of making payments under title XVIII of the
Social Security Act (42 U.S.C. 1395 et seq.) to hospitals in the
Mansfield, Ohio Metropolitan Statistical Area, such Metropolitan
Statistical Area is deemed to be located in the Cleveland-Loraine-
Elyria, Ohio Metropolitan Statistical Area. The reclassification made
under the previous sentence shall be treated as a decision of the
Medicare Geographic Classification Review Board under section
1886(d)(10) of such Act (42 U.S.C. 1395ww(d)(10)).
SEC. 305. MAKING THE MEDICARE DEPENDENT, SMALL RURAL HOSPITAL PROGRAM
PERMANENT.
(a) Payment Methodology.--Section 1886(d)(5)(G) Act (42 U.S.C.
1395ww(d)(5)(G)) is amended--
(1) in clause (i), by striking ``and before October 1,
2006,''; and
(2) in clause (ii)(II), by striking ``and before October 1,
2006,''.
(b) Conforming Amendments.--
(1) Target amount.--Section 1886(b)(3)(D) (42U.S.C.
1395ww(b)(3)(D)) is amended--
(A) in the matter preceding clause (i), by striking
``and before October 1, 2006,''; and
(B) in clause (iv), by striking ``through fiscal year
2005,'' and inserting ``or any subsequent fiscal
year,''.
(2) Permitting hospitals to decline reclassification.--
Section 13501(e)(2) of the Omnibus Budget Reconciliation Act of
1993 (42 U.S.C. 1395ww note) is amended by striking ``or fiscal
year 2000 through fiscal year 2005'' and inserting ``fiscal
year 2000, or any subsequent fiscal year''.
SEC. 306. OPTION TO BASE ELIGIBILITY ON DISCHARGES DURING ANY OF THE 3
MOST RECENT AUDITED COST REPORTING PERIODS.
(a) Option To Base Eligibility on Discharges During Any of the 3 Most
Recent Audited Cost Reporting Periods.--Section 1886(d)(5)(G)(iv)(IV)
(42 U.S.C. 1395ww(d)(5)(G)(iv)(IV)) is amended by inserting ``, or any
of the 3 most recent audited cost reporting periods,'' after ``1987''.
(b) Effective Date.--The amendments made by this section shall apply
with respect to cost reporting periods beginning on or after the date
of enactment of this Act.
SEC. 307. IDENTIFICATION AND REDUCTION OF MEDICAL ERRORS BY PEER REVIEW
ORGANIZATIONS.
(a) In General.--Section 1154(a) (42 U.S.C. 1320c-3(a)) is amended by
inserting after paragraph (11) the following new paragraph:
``(12) The organization shall assist providers,
practitioners, and Medicare+Choice organizations in identifying
and developing strategies to reduce the incidence of actual and
potential medical errors and problems related to patient safety
affecting individuals entitled to benefits under title XVIII.
For the purposes of this part and title XVIII, the functions
described in this paragraph shall be treated as a review
function.''.
(b) Effective Date.--The amendments made by this section take effect
on January 1, 2001.
SEC. 308. GAO REPORT ON IMPACT OF THE EMERGENCY MEDICAL TREATMENT AND
ACTIVE LABOR ACT (EMTALA) ON HOSPITAL EMERGENCY
DEPARTMENTS.
(a) Congressional Findings.--The Congress makes the following
findings:
(1) The Emergency Medical Treatment and Active Labor Act
(EMTALA) requires that hospitals and the emergency physicians
as well as doctors on call at hospital emergency departments
screen and stabilize patients who go to emergency departments
for treatment.
(2) Physicians who refuse to treat emergency department
patients or fail to respond to hospital emergency department
requests when on call face significant fines and are exposed to
liability under EMTALA.
(3) The Balanced Budget Act of 1997 made many changes in
hospital and physician reimbursement that appear to have had
unintended consequences that have hampered the ability of
hospitals, emergency physicians, and physicians covering
emergency department call to comply with the requirements of
EMTALA.
(4) Estimates indicate that EMTALA costs emergency department
physicians $426,000,000 per year and leads to at least
$10,000,000,000 more in uncompensated inpatient services.
(5) Emergency departments, emergency physicians, and
physicians covering emergency department call have become the
de facto providers of indigent health care in America.
(6) 27 percent of the over 4,300,000 people living in Arizona
are uninsured.
(7) Many physicians covering emergency department call in
Phoenix, Arizona, are resigning from the medical staff at
hospitals due to burdensome on-call requirements and
uncompensated care.
(8) Significant concern exists as to whether downtown Phoenix
hospitals can keep their emergency departments open.
(9) The cumulative effect of potential hospital closings and
staff resignations threatens the quality of health care in
Phoenix, Arizona.
(b) Report.--The Comptroller General of the United States shall
submit a report to the Subcommittee on Health and Environment of the
Committee on Commerce of the House of Representatives by May 1, 2001,
on the effect of the Emergency Medical Treatment and Active Labor Act
on hospitals, emergency physicians, and physicians covering emergency
department call throughout the United States, focusing on those in
Arizona (including Phoenix) and California (including Los Angeles).
(c) Report Requirements.--The report should evaluate--
(1) the extent to which hospitals, emergency physicians, and
physicians covering emergency department call provide
uncompensated services in relation to the requirements of
EMTALA;
(2) the extent to which the regulatory requirements and
enforcement of EMTALA have expanded beyond the legislation's
original intent;
(3) estimates for the total dollar amount of EMTALA-related
care uncompensated costs to emergency physicians, physicians
covering emergency department call, hospital emergency
departments;
(4) the extent to which different portions of the United
States may be experiencing different levels of uncompensated
EMTALA-related care;
(5) the extent to which EMTALA would be classified as an
unfunded mandate if it were enacted today;
(6) the extent to which States have programs to provide
financial support for such uncompensated care;
(7) possible sources of funds, including medicare hospital
bad debt accounts, that are available to hospitals to assist
with the cost of such uncompensated care; and
(8) the financial strain that illegal immigration
populations, the uninsured, and the underinsured place on
hospital emergency departments, emergency physicians, and
physicians covering emergency department call.
(d) Definition.--In this section, the terms ``Emergency Medical
Treatment and Active Labor Act'' and ``EMTALA'' mean section 1867 of
the Social Security Act (42 U.S.C. 1395dd).
TITLE IV--MEDICARE+CHOICE PROGRAM STABILIZATION AND IMPROVEMENTS
Subtitle A--Payment Reforms
SEC. 401. INCREASING MINIMUM PAYMENT AMOUNT.
Section 1853(c)(1)(B)(ii) (42 U.S.C. 1395w-23(c)(1)(B)(ii)) is
amended--
(1) by striking ``(ii) For a succeeding year'' and inserting
``(ii)(I) Subject to subclause (II), for a succeeding year'';
and
(2) by adding at the end the following new subclause:
``(II) For 2001 for any area in a
Metropolitan Statistical Area with a population
of more than 250,000, $525 (and for any other
area, $475).''.
SEC. 402. 3 PERCENT MINIMUM PERCENTAGE UPDATE FOR 2001.
Section 1853(c)(1)(C)(ii) (42 U.S.C. 1395w-23(c)(1)(C)(ii)) is
amended by inserting ``(or 103 percent in the case of 2001)'' after
``102 percent''.
SEC. 403. 10-YEAR PHASE IN OF RISK ADJUSTMENT BASED ON DATA FROM ALL
SETTINGS.
Section 1853(a)(3)(C)(ii) (42 U.S.C. 1395w-23(c)(1)(C)(ii)) is
amended--
(1) by striking ``and'' at the end of subclause (I);
(2) by striking the period at the end of subclause (II) and
inserting a semicolon; and
(3) by adding after and below subclause (II) the following:
``and, beginning in 2004, insofar as such risk
adjustment is based on data from substantially
all settings, the methodology shall be phased
in equal increments over a 10-year period,
beginning with 2004 or (if later) the first
year in which such data are used.''.
SEC. 404. TRANSITION TO REVISED MEDICARE+CHOICE PAYMENT RATES.
(a) Announcement of Revised Medicare+Choice Payment Rates.--Within 2
weeks after the date of the enactment of this Act, the Secretary of
Health and Human Services shall determine, and shall announce (in a
manner intended to provide notice to interested parties)
Medicare+Choice capitation rates under section 1853 of the Social
Security Act (42 U.S.C. 1395w-23) for 2001, revised in accordance with
the provisions of this Act.
(b) Reentry into Program Permitted for Medicare+Choice Programs in
2000.--A Medicare+Choice organization that provided notice to the
Secretary of Health and Human Services as of July 3, 2000, that it was
terminating its contract under part C of title XVIII of the Social
Security Act or was reducing the service area of a Medicare+Choice plan
offered under such part shall be permitted to continue participation
under such part, or to maintain the service area of such plan, for 2001
if it provides the Secretary with the information described in section
1854(a)(1) of the Social Security Act (42 U.S.C. 1395w-24(a)(1)) within
four weeks after the date of the enactment of this Act.
(c) Revised Submission of Proposed Premiums and Related
Information.--If--
(1) a Medicare+Choice organization provided notice to the
Secretary of Health and Human Services as of July 3, 2000, that
it was renewing its contract under part C of title XVIII of the
Social Security Act for all or part of the service area or
areas served under its current contract, and
(2) any part of the service area or areas addressed in such
notice includes a county for which the Medicare+Choice
capitation rate under section 1853(c) of such Act (42 U.S.C.
1395w-23(c)) for 2001, as determined under subsection (a), is
higher than the rate previously determined for such year,
such organization shall revise its submission of the information
described in section 1854(a)(1) of the Social Security Act (42 U.S.C.
1395w-24(a)(1)), and shall submit such revised information to the
Secretary, within four weeks after the date of the enactment of this
Act.
Subtitle B--Administrative Reforms
SEC. 411. EFFECTIVENESS OF ELECTIONS AND CHANGES OF ELECTIONS.
(a) In General.--Section 1851(f)(2) (42 U.S.C. 1395w-21(f)(2)) is
amended by striking ``made,'' and all that follows and inserting
``made.''.
(b) Effective Date.--The amendment made by subsection (a) applies
with respect to years beginning on or after on January 1, 2001.
SEC. 412. MEDICARE+CHOICE PROGRAM COMPATIBILITY WITH EMPLOYER OR UNION
GROUP HEALTH PLANS.
(a) In General.--Section 1857 (42 U.S.C. 1395w-27) is amended by
adding at the end the following new subsection:
``(i) M+C Program Compatibility With Employer or Union Group Health
Plans.--To facilitate the offering of Medicare+Choice plans under
contracts between Medicare+Choice organizations and employers, labor
organizations, or the trustees of a fund established by 1 or more
employers or labor organizations (or combination thereof) to furnish
benefits to the entity's employees, former employees (or combination
thereof) or members or former members (or combination thereof) of the
labor organizations, the Secretary may waive or modify requirements
that hinder the design of, the offering of, or the enrollment in such
Medicare+Choice plans.''.
(b) Effective Date.--The amendment made by subsection (a) applies
with respect to years beginning with 2001.
SEC. 413. UNIFORM PREMIUM AND BENEFITS.
(a) In General.--Subsections (c) and (f)(1)(D) of section 1854 (42
U.S.C. 1395w-24) are each amended by inserting before the period at the
end the following: ``, except across counties as approved by the
Secretary''.
(b) Effective Date.--The amendments made by subsection (a) apply with
respect to years beginning on or after January 1, 2001.
TITLE V--MEDICAID
SEC. 501. DSH PAYMENTS.
(a) Continuation of Medicaid DSH Allotments at Fiscal Year 2000
Levels for Fiscal Year 2001.--Section 1923(f) (42 U.S.C. 1396r-4(f)),
as amended by section 601 of the Medicare, Medicaid, and SCHIP Balanced
Budget Refinement Act of 1999 (as enacted into law by section
1000(a)(6) of Public Law 106-113), is amended--
(1) in paragraph (2)--
(A) by striking ``2002'' in the heading and inserting
``2000'';
(B) in the matter preceding the table, by striking
``2002'' and inserting ``2000''; and
(C) in the table in such paragraph, by striking the
columns labeled ``FY 01'' and ``FY 02'' relating to
fiscal years 2001 and 2002; and
(2) in paragraph (3)--
(A) by striking ``2003'' in the heading and inserting
``2001''; and
(B) by striking ``2003'' and inserting ``2001''.
(b) Special Rule for Medicaid DSH Allotment for Extremely Low DSH
States.--Section 1923(f)(3) (42 U.S.C. 1396r-4(f)(3)) is amended--
(1) in subparagraph (A), by striking ``subparagraph (B)'' and
inserting ``subparagraphs (B) and (C)''; and
(2) by adding at the end the following new subparagraph:
``(C) Special rule for extremely low dsh states.--In
the case of a State in which the total expenditures
under the State plan (including Federal and State
shares) for disproportionate share hospital adjustments
under this section for fiscal year 1999, as reported to
the Administrator of the Health Care Financing
Administration as of August 31, 2000, is greater than 0
but less than 1 percent of the State's total amount of
expenditures under the State plan for medical
assistance during the fiscal year, the DSH allotment
for fiscal year 2001 shall be increased to 1 percent of
the State's total amount of expenditures under such
plan for such assistance during such fiscal year. In
subsequent fiscal years, such increased allotment is
subject to an increase for inflation as provided in
subparagraph (A).''.
(c) District of Columbia.--Effective beginning with fiscal year 2001,
the item in the table in section 1923(f) (42 U.S.C. 1396r-4(f))
relating to District of Columbia for FY 2000, is amended by striking
``32'' and inserting ``49''.
(d) Contingent Allotment for Tennessee.--Section 1923(f) (42 U.S.C.
1396r-4(f)) is amended--
(1) in paragraph (3)(A), by striking ``or this paragraph''
and inserting ``, this paragraph, or paragraph (4)''; and
(2) by adding at the end the following new paragraph:
``(4) Contingent allotment adjustment for tennessee.--If the
State-wide waiver approved under section 1115 for the State of
Tennessee with respect to requirements under this title as in
effect on the date of the enactment of this subsection is
revoked or terminated, the DSH allotment for Tennessee for
fiscal year 2001 is deemed to be equal to $286,442,437.''.
(e) Assuring Identification of Medicaid Managed Care Patients.--
(1) In general.--Section 1932 (42 U.S.C. 1396u-2) is amended
by adding at the end the following:
``(g) Identification of Patients for Purposes of Making DSH
Payments.--Each contract with a managed care entity under section
1903(m) or under section 1905(t)(3) shall require the entity either--
``(1) to report to the State information necessary to
determine the hospital services provided under the contract
(and the identity of hospitals providing such services) for
purposes of applying sections 1886(d)(5)(F) and 1923; or
``(2) to include a sponsorship code in the identification
card issued to individuals covered under this title in order
that a hospital may identify a patient as being entitled to
benefits under this title.''.
(2) Clarification of counting managed care medicaid
patients.--Section 1923 (42 U.S.C. 1396r-4) is amended--
(A) in subsection (a)(2)(D), by inserting after ``the
proportion of low-income and medicaid patients'' the
following: ``(including such patients who receive
benefits through a managed care entity)'';
(B) in subsection (b)(2), by inserting after ``a
State plan approved under this title in a period'' the
following: ``(regardless of whether they receive
benefits on a fee-for-service basis or through a
managed care entity)''; and
(C) in subsection (b)(3)(A)(i), by inserting after
``under a State plan under this title'' the following:
``(regardless of whether the services were furnished on
a fee-for-service basis or through a managed care
entity)''.
(2) Effective date.--The amendments made by paragraph (1)
apply to payments made for periods on or after January 1, 2001.
SEC. 502. NEW PROSPECTIVE PAYMENT SYSTEM FOR FEDERALLY-QUALIFIED HEALTH
CENTERS AND RURAL HEALTH CLINICS.
(a) In General.--Section 1902(a) (42 U.S.C. 1396a(a)) is amended--
(1) in paragraph (13)--
(A) in subparagraph (A), by adding ``and'' at the
end;
(B) in subparagraph (B), by striking ``and'' at the
end; and
(C) by striking subparagraph (C); and
(2) by inserting after paragraph (14) the following new
paragraph:
``(15) provide for payment for services described in clause
(B) or (C) of section 1905(a)(2) under the plan in accordance
with subsection (aa);''.
(b) New Prospective Payment System.--Section 1902 (42 U.S.C. 1396a)
is amended by adding at the end the following:
``(aa) Payment for Services Provided by Federally-Qualified Health
Centers and Rural Health Clinics.--
``(1) In general.--Beginning with fiscal year 2001 and each
succeeding fiscal year, the State plan shall provide for
payment for services described in section 1905(a)(2)(C)
furnished by a Federally-qualified health center and services
described in section 1905(a)(2)(B) furnished by a rural health
clinic in accordance with the provisions of this subsection.
The payment rate under this subsection shall not vary based
upon the site services are provided in the case of the same
center or clinic entity.
``(2) Fiscal year 2001.--Subject to paragraph (4), for
services furnished during fiscal year 2001, the State plan
shall provide for payment for such services in an amount
(calculated on a per visit basis) that is equal to 100 percent
of the average of the costs of the center or clinic of
furnishing such services during fiscal years 1999 and 2000
which are reasonable and related to the cost of furnishing such
services, or based on such other tests of reasonableness as the
Secretary prescribes in regulations under section 1833(a)(3),
or, in the case of services to which such regulations do not
apply, the same methodology used under section 1833(a)(3),
adjusted to take into account any increase or decrease in the
scope of such services furnished by the center or clinic during
fiscal year 2001.
``(3) Fiscal year 2002 and succeeding fiscal years.--Subject
to paragraph (4), for services furnished during fiscal year
2002 or a succeeding fiscal year, the State plan shall provide
for payment for such services in an amount (calculated on a per
visit basis) that is equal to the amount calculated for such
services under this subsection for the preceding fiscal year--
``(A) increased by the percentage increase in the MEI
(as defined in section 1842(i)(3)) applicable to
primary care services (as defined in section
1842(i)(4)) for that fiscal year; and
``(B) adjusted to take into account any increase or
decrease in the scope of such services furnished by the
center or clinic during that fiscal year.
``(4) Establishment of initial year payment amount for new
centers or clinics.--In any case in which an entity first
qualifies as a Federally-qualified health center or rural
health clinic after fiscal year 2000, the State plan shall
provide for payment for services described in section
1905(a)(2)(C) furnished by the center or services described in
section 1905(a)(2)(B) furnished by the clinic in the first
fiscal year in which the center or clinic so qualifies in an
amount (calculated on a per visit basis) that is equal to 100
percent of the costs of furnishing such services during such
fiscal year based on the rates established under this
subsection for the fiscal year for other such centers or
clinics located in the same or adjacent area with a similar
case load, service package, and case mix or, in the absence of
such a center or clinic, in accordance with the regulations and
methodology referred to in paragraph (2) or based on such other
tests of reasonableness as the Secretary may specify. For each
fiscal year following the fiscal year in which the entity first
qualifies as a Federally-qualified health center or rural
health clinic, the State plan shall provide for the payment
amount to be calculated in accordance with paragraph (3).
``(5) Administration in the case of managed care.--In the
case of services furnished by a Federally-qualified health
center or rural health clinic pursuant to a contract between
the center or clinic and a managed care entity (as defined in
section 1932(a)(1)(B)), the State plan shall provide for
payment to the center or clinic (at least quarterly) by the
State of a supplemental payment equal to the amount (if any) by
which the amount determined under paragraphs (2), (3), and (4)
of this subsection exceeds the amount of the payments provided
under the contract.
``(6) Alternative payment methodologies.--Notwithstanding any
other provision of this section, the State plan may provide for
payment in any fiscal year to a Federally-qualified health
center for services described in section 1905(a)(2)(C) or to a
rural health clinic for services described in section
1905(a)(2)(B) in an amount which is determined under an
alternative payment methodology that--
``(A) is agreed to by the State and the center or
clinic; and
``(B) results in payment to the center or clinic of
an amount which is at least equal to the amount
otherwise required to be paid to the center or clinic
under this section.''.
(c) Conforming Amendments.--
(1) Section 4712 of the Balanced Budget Act of 1997 (Public
Law 105-33; 111 Stat. 508) is amended by striking subsection
(c).
(2) Section 1915(b) (42 U.S.C. 1396n(b)) is amended by
striking ``1902(a)(13)(C)'' and inserting ``1902(a)(15),
1902(aa),''.
(d) GAO Study of Future Rebasing.--The Comptroller General of the
United States shall provide for a study on the need for, and how to,
rebase or refine costs for making payment under the medicaid program
for services provided by Federally-qualified health centers and rural
health clinics (as provided under the amendments made by this section).
The Comptroller General shall provide for submittal of a report on such
study to the Congress by not later than 4 years after the date of the
enactment of this Act.
(e) Effective Date.--The amendments made by this section take effect
on October 1, 2000, and apply to services furnished on or after such
date.
SEC. 503. OPTIONAL COVERAGE OF LEGAL IMMIGRANTS UNDER THE MEDICAID
PROGRAM.
(a) In General.--Section 1903(v) (42 U.S.C. 1396b(v)) is amended--
(1) in paragraph (1), by striking ``paragraph (2)'' and
inserting ``paragraphs (2) and (4)''; and
(2) by adding at the end the following new paragraph:
``(4)(A) A State may elect (in a plan amendment under this title) to
provide medical assistance under this title, notwithstanding sections
401(a), 402(b), 403, and 421 of the Personal Responsibility and Work
Opportunity Reconciliation Act of 1996, for aliens who are lawfully
residing in the United States (including battered aliens described in
section 431(c) of such Act) and who are otherwise eligible for such
assistance, within either or both of the following eligibility
categories, but only if they have lawfully resided in the United States
for 2 years:
``(i) Pregnant women.--Women during pregnancy (and during the
60-day period beginning on the last day of the pregnancy).
``(ii) Children.--Children (as defined under such plan),
including optional targeted low-income children described in
section 1905(u)(2)(B).
``(B) In the case of a State that has elected to provide medical
assistance to a category of aliens under subparagraph (A), no debt
shall accrue under an affidavit of support against any sponsor of such
an alien who has lawfully resided in the United State for 2 years on
the basis of provision of assistance to such category.''.
(b) Effective Date.--The amendments made by subsection (a) take
effect on October 1, 2000, and apply to medical assistance and child
health assistance furnished on or after such date.
SEC. 504. ADDITIONAL ENTITIES QUALIFIED TO DETERMINE MEDICAID
PRESUMPTIVE ELIGIBILITY FOR LOW-INCOME CHILDREN.
(a) In General.--Section 1920A(b)(3)(A)(i) (42 U.S.C. 1396r-
1a(b)(3)(A)(i)) is amended--
(1) by striking ``or (II)'' and inserting ``, (II)''; and
(2) by inserting ``eligibility of a child for medical
assistance under the State plan under this title, or
eligibility of a child for child health assistance under the
program funded under title XXI, (III) is an elementary school
or secondary school, as such terms are defined in section 14101
of the Elementary and Secondary Education Act of 1965 (20
U.S.C. 8801), an elementary or secondary school operated or
supported by the Bureau of Indian Affairs, a State or tribal
child support enforcement agency, a child care resource and
referral agency, an organization that is providing emergency
food and shelter under a grant under the Stewart B. McKinney
Homeless Assistance Act, or a State or tribal office or entity
involved in enrollment in the program under this title, under
part A of title IV, under title XXI, or that determines
eligibility for any assistance or benefits provided under any
program of public or assisted housing that receives Federal
funds, including the program under section 8 or any other
section of the United States Housing Act of 1937 (42 U.S.C.
1437 et seq.) or under the Native American Housing Assistance
and Self-Determination Act of 1996 (25 U.S.C. 4101 et seq.), or
(IV) any other entity the State so deems, as approved by the
Secretary'' before the semicolon.
(b) Technical Amendments.--Section 1920A (42 U.S.C. 1396r-1a) is
amended--
(1) in subsection (b)(3)(A)(i), by striking ``42 U.S.C.
9821'' and inserting ``42 U.S.C. 9831'';
(2) in subsection (b)(3)(A)(ii), by striking ``paragraph
(1)(A)'' and inserting ``paragraph (2)''; and
(3) in subsection (c)(2), in the matter preceding
subparagraph (A), by striking ``subsection (b)(1)(A)'' and
inserting ``subsection (b)(2)''.
(c) Application to Presumptive Eligibility for Pregnant Women Under
Medicaid.--Section 1920(b) (42 U.S.C. 1396r-1(b)) is amended by adding
at the end after and below paragraph (2) the following flush sentence:
``The term `qualified provider' includes a qualified entity as defined
in section 1920A(b)(3).''.
(d) Application Under Title XXI.--Section 2107(e)(1) (42 U.S.C.
1397gg(e)(1)) is amended by adding at the end the following new
subparagraph:
``(D) Section 1920A (relating to presumptive
eligibility).''.
SEC. 505. IMPROVING WELFARE-TO-WORK TRANSITION.
(a) 1 Year Extension.--Section 1925(f) (42 U.S.C. 1396r-6(f)) is
amended by striking ``2001'' and inserting ``2002''.
(b) Simplification Options.--
(1) State option to waive reporting requirements.--Section
1925(b)(2) of such Act (42 U.S.C. 1396r-6(b)(2)) is amended by
adding at the end the following new subparagraph:
``(C) State option to waive reporting requirements.--
A State may elect to waive the reporting requirements
under subparagraph (B) and, in the case of such a
waiver for purposes of notices required under
subparagraph (A), to exclude from such notices any
reference to any requirement under subparagraph (B).''.
(2) Exemption for states covering needy families up to 185
percent of poverty.--Section 1925 (42 U.S.C. 1396r-6) is
amended--
(A) in each of subsections (a)(1) and (b)(1), by
inserting ``but subject to subsection (g),'' after
``Notwithstanding any other provision of this title,'';
and
(B) by adding at the end the following new
subsection:
``(g) Exemption for State Covering Needy Families Up to 185 Percent
of Poverty.--
``(1) In general.--At State option, the provisions of this
section shall not apply to a State that uses the authority
under section 1931(b)(2)(C) to make medical assistance
available under the State plan under this title, at a minimum,
to all individuals described in section 1931(b)(1) in families
with gross incomes (determined without regard to work-related
child care expenses of such individuals) at or below 185
percent of the income official poverty line (as defined by the
Office of Management and Budget, and revised annually in
accordance with section 673(2) of the Omnibus Budget
Reconciliation Act of 1981) applicable to a family of the size
involved.
``(2) Application to other provisions of this title.--The
State plan of a State described in paragraph (1) shall be
deemed to meet the requirements of sections
1902(a)(10)(A)(i)(I) and 1902(e)(1).''.
(3) Effective date.--The amendments made by this subsection
take effect on October 1, 2000.
SEC. 506. MEDICAID COUNTY-ORGANIZED HEALTH SYSTEMS.
Section 9517(c)(3)(C) of the Comprehensive Omnibus Budget
Reconciliation Act of 1985 is amended by striking ``10 percent'' and
inserting ``14 percent''.
SEC. 507. MEDICAID RECOGNITION FOR SERVICES OF PHYSICIAN ASSISTANTS.
(a) In General.--Section 1905(a) (42 U.S.C. 1396d(a)) is amended--
(1) by redesignating paragraphs (22) through (27) as
paragraphs (23) through (28), and
(2) by inserting after paragraph (21) the following new
paragraph:
``(22) services furnished by an physician assistant (as
defined in section 1861(aa)(5)) which the assistant is legally
authorized to perform under State law and with the supervision
of a physician;''.
(b) Conforming Amendments.--(1) Section 1902(a)(10)(C)(iv) (42 U.S.C.
1396a(a)(10)(C)(iv)) is amended by striking ``(24)'' and inserting
``(25)''.
(2) Section 1929(e)(2)(A) (42 U.S.C. 1396t(e)(2)(A)) is amended by
striking ``1905(a)(23)'' and inserting ``1905(a)(24)''.
(3) Section 1917(c)(1)(C)(ii) (42 U.S.C. 1396p(c)(1)(C)(ii)) is
amended by striking ``(22), or (24)'' and inserting ``(23), or (25)''.
TITLE VI--STATE CHILDREN'S HEALTH INSURANCE PROGRAM
SEC. 601. SPECIAL RULE FOR REDISTRIBUTION AND AVAILABILITY OF UNUSED
FISCAL YEAR 1998 AND 1999 SCHIP ALLOTMENTS.
(a) Change in Rules for Redistribution and Retention of Unused SCHIP
Allotments for Fiscal Years 1998 and 1999.--Section 2104 (42 U.S.C.
1397dd) is amended by adding at the end the following new subsection:
``(g) Rule for Redistribution and Extended Availability of Fiscal
Years 1998 and 1999 Allotments.--
``(1) Amount redistributed.--
``(A) In general.--In the case of a State that
expends all of its allotment under subsection (b) or
(c) for fiscal year 1998 by the end of fiscal year
2000, or for fiscal year 1999 by the end of fiscal year
2001, the Secretary shall redistribute to the State
under subsection (f) (from the fiscal year 1998 or 1999
allotments of other States, respectively, as determined
by the application of paragraphs (2) and (3) with
respect to the respective fiscal year)) the following
amount:
``(i) State.--In the case of 1 of the 50
States or the District of Columbia, with
respect to--
``(I) the fiscal year 1998 allotment,
the amount by which the State's
expenditures under this title in fiscal
years 1998, 1999, and 2000 exceed the
State's allotment for fiscal year 1998
under subsection (b); or
``(II) the fiscal year 1999
allotment, the amount by which the
State's expenditures under this title
in fiscal years 1999, 2000, and 2001
exceed the State's allotment for fiscal
year 1999 under subsection (b).
``(ii) Territory.--In the case of a
commonwealth or territory described in
subsection (c)(3), an amount that bears the
same ratio to 1.05 percent of the total amount
described in paragraph (2)(B)(i)(I) as the
ratio of the commonwealth's or territory's
fiscal year 1998 or 1999 allotment under
subsection (c) (as the case may be) bears to
the total of all such allotments for such
fiscal year under such subsection.
``(B) Expenditure rules.--An amount redistributed to
a State under this paragraph with respect to fiscal
year 1998 or 1999--
``(i) shall not be included in the
determination of the State's allotment for any
fiscal year under this section;
``(ii) notwithstanding subsection (e), shall
remain available for expenditure by the State
through the end of fiscal year 2002; and
``(iii) shall be counted as being expended
with respect to a fiscal year allotment in
accordance with applicable regulations of the
Secretary.
``(2) Extension of availability of portion of unexpended
fiscal years 1998 and 1999 allotments.--
``(A) In general.--Notwithstanding subsection (e):
``(i) Fiscal year 1998 allotment.--Of the
amounts allotted to a State pursuant to this
section for fiscal year 1998 that were not
expended by the State by the end of fiscal year
2000, the amount specified in subparagraph (B)
for fiscal year 1998 for such State shall
remain available for expenditure by the State
through the end of fiscal year 2002.
``(ii) Fiscal year 1999 allotment.--Of the
amounts allotted to a State pursuant to this
subsection for fiscal year 1999 that were not
expended by the State by the end of fiscal year
2001, the amount specified in subparagraph (B)
for fiscal year 1999 for such State shall
remain available for expenditure by the State
through the end of fiscal year 2002.
``(B) Amount remaining available for expenditure.--
The amount specified in this subparagraph for a State
for a fiscal year is equal to--
``(i) the amount by which (I) the total
amount available for redistribution under
subsection (f) from the allotments for that
fiscal year, exceeds (II) the total amounts
redistributed under paragraph (1) for that
fiscal year; multiplied by
``(ii) the ratio of the amount of such
State's unexpended allotment for that fiscal
year to the total amount described in clause
(i)(I) for that fiscal year.
``(C) Use of up to 10 percent of retained 1998
allotments for outreach activities.--Notwithstanding
section 2105(c)(2)(A), with respect to any State
described in subparagraph (A)(i), the State may use up
to 10 percent of the amount specified in subparagraph
(B) for fiscal year 1998 for expenditures for outreach
activities approved by the Secretary.
``(3) Determination of amounts.--For purposes of calculating
the amounts described in paragraphs (1) and (2) relating to the
allotment for fiscal year 1998 or fiscal year 1999, the
Secretary shall use the amounts reported by the States not
later than November 30, 2000, or November 30, 2001,
respectively, on HCFA Form 64 or HCFA Form 21, as approved by
the Secretary.''.
(b) Effective Date.--The amendments made by this section shall take
effect as if included in the enactment of section 4901 of BBA (111
Stat. 552).
SEC. 602. OPTIONAL COVERAGE OF CERTAIN LEGAL IMMIGRANTS UNDER SCHIP.
(a) In General.--Section 2107(e)(1) (42 U.S.C. 1397gg(e)(1)), as
amended by section 504, is amended by adding at the end the following
new subparagraph:
``(E) Section 1903(v)(4) (relating to optional
coverage of categories of lawfully residing alien
children), but only if the State has elected to apply
such section to the category of children under title
XIX.''.
(b) Effective Date.--The amendment made by this section takes effect
on October 1, 2000, and applies to medical assistance and child health
assistance furnished on or after such date.
TITLE VII--EXTENSION OF SPECIAL DIABETES GRANT PROGRAMS
SEC. 701. EXTENSION OF JUVENILE AND INDIAN DIABETES GRANT PROGRAMS.
(a) Juvenile Diabetes Research Program.--Section 330B of the Public
Health Service Act (42 U.S.C. 254c-2) is amended by adding at the end
the following new subsection:
``(c) Extension of Funding.--There are hereby appropriated, from any
amounts in the Treasury not otherwise appropriated, for each of fiscal
years 2003 through 2007, $50,000,000 for grants under this section, to
remain available until expended. Nothing in this subsection shall be
construed as providing for such amounts to be derived or deducted from
appropriations made under section 2104(a) of the Social Security
Act.''.
(b) Indian Diabetes Grant Program.----Section 330C of the Public
Health Service Act (42 U.S.C. 254c-3) is amended by adding at the end
the following new subsection:
``(d) Extension of Funding.--There are hereby appropriated, from any
amounts in the Treasury not otherwise appropriated, for each of fiscal
years 2003 through 2007, $50,000,000 for grants under this section, to
remain available until expended. Nothing in this subsection shall be
construed as providing for such amounts to be derived or deducted from
appropriations made under section 2104(a) of the Social Security
Act.''.
(c) Extension of Reports on Grant Programs.--Section 4923(b) of BBA
is amended--
(1) in paragraph (1), by striking ``an interim report'' and
inserting ``interim reports'';
(2) in paragraph (1), by striking ``, 2000'' and inserting
``in each of 2000, 2002, and 2004''; and
(3) in paragraph (2), by striking ``2002'' and inserting
``2007''.
Purpose and Summary
The purpose of this legislation is to improve and protect
patient access to Federal health care programs. The savings
achieved through changes to the Medicare and Medicaid programs
enacted as part of the Balanced Budget Act of 1997 were
integral to balancing the budget. Since passage of that
legislation, the Congressional Budget Office has estimated that
the savings from the Medicare and Medicaid programs has
exceeded the original targets, and there is concern that
beneficiaries in these programs may experience difficulty in
accessing health services. This legislation seeks to address
many of these access concerns.
H. R. 5291 increases payments to providers under the
Medicare and Medicaid programs, improves the quality of
benefits for beneficiaries, and adjusts the allocation formula
under the State Children Health Insurance Program (SCHIP).
Background and Need for Legislation
In the Balanced Budget Act of 1997 (BBA '97), the Committee
made difficult decisions in how best to address the concern of
the Nation that the Medicare program was facing financial ruin,
and changes needed to be made. Moving to a prospective payment
system for hospital outpatient department services, skilled
nursing facility services and home health services were just
some of the changes the Congressional Budget Office (CBO)
projected would reduce Federal spending by $103 billion over 5
years, and create new efficiencies within the Medicare program.
CBO continues to revise their estimates of spending in the
Medicare program. Every revision they have released since
passage of BBA '97 shows that spending is less than originally
anticipated. In addition, spending in fiscal year 1999 was
actually less than it was in fiscal year 1998.
BBA '97 also made changes to reduce Federal spending in
Medicaid. Last November, Congress responded to the low spending
in Medicare and Medicaid by refining the BBA '97 and restoring
nearly $16 billion over 5 years to the Medicare, Medicaid, and
SCHIP programs.
There are concerns that those changes were not enough.
Given the record surpluses realized in recent years, and based
on testimony provided to the Committee on this issue, this
legislation responds to those concerns.
Hearings
The Subcommittee on Health and Environment held a hearing
on July 19, 2000 entitled ``BBA '97: A Look at the Current
Impact on Patients and Providers,'' which laid the foundation
for the development of H.R. 5291, the Beneficiary Improvement
and Protection Act of 2000. The Subcommittee received testimony
from: Dr. Gail Wilensky of the Medicare Payment Advisory
Commission (MedPAC) and Dr. Bill Scanlon of the General
Accounting Office on work they have done analyzing the impact
BBA '97 has had on Medicare, Medicaid and the State Children's
Health Insurance Program (SCHIP).
The Subcommittee also received testimony from patient and
provider groups who discussed the impact the changes have had
on their ability to receive or deliver quality health care.
Witnesses consisted of Dr. Rowen K. Zetterman, American College
of Gastroenterology; Ms. Marilyn Tavenner, HCA-The HealthCare
Company; Mr. Max Richtman, The National Committee to Preserve
Social Security and Medicare; Ms. Karen Coughlin, Physicians
Health Services, Inc.; Ms. Mary Lou Connolly, UCSD HomeCare;
Mr. Daniel R. Hawkins, Jr., National Association of Community
Health Centers, Inc.; and Ms. Juliet Hancock, The National
Association for the Support of Long Term Care.
Committee Consideration
On September 26, 2000 Full Committee met in open markup
session and ordered H.R. 5291 reported to the House, as
amended, by a voice vote.
Committee Votes
Clause 3(b) of rule XIII of the Rules of the House of
Representatives requires the Committee to list the record votes
on the motion to report legislation and amendments thereto.
There were no record votes taken in connection with ordering
H.R. 5291 reported. A motion by Mr. Bliley to order H.R. 5291
reported to the House, with an amendment, was agreed to by a
voice vote.
The following amendment was agreed to by a voice vote--
An amendment in the nature of a substitute by Mr.
Bilirakis, No. 1, improving beneficiary access to
Federal health care benefits through changes to the
Medicare, Medicaid and SCHIP programs.
The following amendments were withdrawn--
An amendment to the amendment in the nature of a
substitute by Mrs. Wilson, No. 1a, giving States
greater flexibility to use SCHIP funds to cover
children currently not eligible and allowing States to
expand some services.
An amendment to the amendment in the nature of a
substitute by Mr. Barton, No. 1b, requiring community
mental health centers to meet State licensing and
certification requirements as well as ensuring that
such facilities provide certain core services.
An amendment to the amendment in the nature of a
substitute by Mr. Strickland, No. 1c, allowing the
clinical training portion of clinical psychology
graduate medical education programs to be reimbursed
under Medicare.
An amendment to the amendment in the nature of a
substitute by Mr. Engel, No. 1d, prohibiting HCFA from
issuing any new regulations that would modify the upper
limits test applied to Medicaid spending for plans
approved before October 2, 2000.
An amendment to the amendment in the nature of a
substitute, by Mrs. Wilson, No. 1e, making improvements
to the Medicare+Choice program.
An amendment to the amendment in the nature of a
substitute, by Mr. Greenwood, No. 1f, placing a
moratorium on any proposed or final regulation relating
to the Medicare upper payment limit test applied to
State Medicaid spending for any approved State plan in
place as of the date of enactment and requiring the
Secretary of Health and Human Services to work with
States to develop methods to ensure that Federal
Medicaid funds are spent on Medicaid eligible services
for Medicaid eligible beneficiaries.
An amendment to the amendment in the nature of a
substitute, by Mr. Rush, No. 1g, setting the formula
for the Medicaid upper payment limits for each class of
facility in a State.
An amendment to the amendment in the nature of a
substitute, by Mr. Stearns, No. 1h, making various
changes to how the Health Care Financing Administration
audits physician payments and other issues affecting
physicians.
An amendment to the amendment in the nature of a
substitute, by Mr. Deutsch, No. 1i, providing for a
Medicare+Choice demonstration project to allow
Medicare+Choice plans to purchase home care services
from a caregiver through a home health referral agency.
Committee Oversight Findings
Pursuant to clause 3(c)(1) of rule XIII of the Rules of the
House of Representatives, the Committee held a legislative
hearing and made findings that are reflected in this report.
Committee on Government Reform Oversight Findings
Pursuant to clause 3(c)(4) of rule XIII of the Rules of the
House of Representatives, no oversight findings have been
submitted to the Committee by the Committee on Government
Reform.
New Budget Authority, Entitlement Authority, and Tax Expenditures
In compliance with clause 3(c)(2) of rule XIII of the Rules
of the House of Representatives, the Committee finds that H.R.
5291, the Beneficiary Improvement and Protection Act of 2000,
would result in new or increased budget authority, entitlement
authority, or tax expenditures or revenues consistent with the
estimate submitted by the Congressional Budget Office.
Committee Cost Estimate
The Committee adopts as its own the cost estimate prepared
by the Director of the Congressional Budget Office pursuant to
section 402 of the Congressional Budget Act of 1974.
Congressional Budget Office Estimate
Pursuant to clause 3(c)(3) of rule XIII of the Rules of the
House of Representatives, the following is the cost estimate
provided by the Congressional Budget Office pursuant to section
402 of the Congressional Budget Act of 1974:
U.S. Congress,
Congressional Budget Office,
Washington, DC, October 2, 2000.
Hon. Tom Bliley,
Chairman, Committee on Commerce,
House of Representatives, Washington, DC.
Dear Mr. Chairman: At your request, the Congressional
Budget Office has prepared the attached table showing our
preliminary estimate of the changes in direct spending that
would result from enacting H.R. 5291, the Beneficiary Health
Improvement Act, as ordered reported by the House Committee on
Commerce on September 27, 2000. This estimate is based on draft
legislative language and modifications discussed with staff.
CBO estimates that enacting the bill would increase direct
spending by $1.7 billion in 2001, $18 billion over the 2001-
2005 period, and $55 billion over the 2001-2010 period. Because
the bill would affect direct spending, pay-as-you-go procedures
would apply.
I hope this information is helpful to you. The CBO staff
contact is Tom Bradley.
Sincerely,
Steven Lieberman
(For Dan L. Crippen, Director).
Attachment.
CBO ESTIMATE OF DIRECT SPENDING IN H.R. 5291, THE BENEFICIARY HEALTH IMPROVEMENT ACT, AS ORDERED REPORTED BY THE HOUSE COMMITTEE ON COMMERCE ON
SEPTEMBER 27, 2000 (BASED ON DRAFT LEGISLATIVE LANGUAGE AND MODIFICATIONS DISCUSSED WITH STAFF)
--------------------------------------------------------------------------------------------------------------------------------------------------------
Outlays by fiscal year in billions of dollars--
-----------------------------------------------------------------------------------------------------------
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2001-05 2001-10
--------------------------------------------------------------------------------------------------------------------------------------------------------
Title I: Beneficiary Improvements........... 0.3 0.4 0.5 0.7 0.9 1.2 1.3 1.5 1.7 2.0 2.8 10.4
Title II: Other Medicare Part B Provisions.. 0.2 0.5 0.4 0.4 0.6 0.7 0.8 1.0 1.2 1.3 2.1 7.1
Title III: Medicare Part A and B Provisions. 0.1 0.7 0.3 0.1 0.2 0.2 0.2 0.3 0.3 0.3 1.3 2.6
Title IV: Medicare+Choice Program 0.8 1.0 1.2 1.5 1.8 1.5 2.2 2.5 2.8 3.2 6.2 18.4
Stabilization and Improvements.............
Interaction: effect of fee-for-service 0 0.3 0.3 0.3 0.5 0.6 0.8 1.0 1.2 1.5 1.4 6.5
provisions on Medicare+Choice payments.....
-----------------------------------------------------------------------------------------------------------
Subtotal, Gross Medicare Spending..... 1.3 2.9 2.7 3.1 3.9 4.1 5.3 6.2 7.2 8.4 13.9 45.1
Part B Premiums............................. -0.2. -0.4 -0.3 -0.4 -0.5 -0.5 -0.7 -0.8 -0.9 -1.1 -1.7 -5.8
-----------------------------------------------------------------------------------------------------------
Subtotal, Net Medicare Spending....... 1.2 2.5 2.3 2.7 3.4 3.6 4.6 5.4 6.3 7.3 12.1 39.3
Title V: Medicaid........................... 0.5 1.3 1.3 1.2 1.3 1.5 1.5 1.6 1.8 1.8 5.7 13.9
Interaction: effect of Medicare provisions (\1\) (\1\) (\1\) (\1\) 0.1 0.2 0.2 0.2 0.2 0.3 (\1\) 1.2
on federal Medicaid spending...............
-----------------------------------------------------------------------------------------------------------
Subtotal, federal Medicaid............ 0.5 1.2 1.2 1.3 1.4 1.6 1.8 1.9 2.0 2.1 5.7 15.1
Title VI: State Children's Health Insurance (\1\) (\1\) (\1\) (\1\) (\1\) 0.1 (\1\) 0.1 0.1 (\1\) 0.2 0.3
Program....................................
Title VII: Extension of Special Diabetes 0 0 (\1\) 0.1 0.1 0.1 0.1 0.1 (\1\) (\1\) 0.2 0.5
Grant Programs.............................
-----------------------------------------------------------------------------------------------------------
Total, Changes in Direct Spending..... 1.7 3.8 3.6 4.0 5.0 5.2 6.5 7.4 8.4 9.4 18.2 55.2
--------------------------------------------------------------------------------------------------------------------------------------------------------
\1\ Costs or savings less than $50 million.
Federal Mandates Statement
The estimate of Federal mandates prepared by the Director
of the Congressional Budget Office pursuant to section 423 of
the Unfunded Mandates Reform Act was not timely submitted to
the Committee. The Committee will forward such estimate to the
House when it is submitted to the Committee.
Advisory Committee Statement
No advisory committees within the meaning of section 5(b)
of the Federal Advisory Committee Act were created by this
legislation.
Constitutional Authority Statement
Pursuant to clause 3(d)(1) of rule XIII of the Rules of the
House of Representatives, the Committee finds that the
Constitutional authority for this legislation is provided in
Article I, section 8, clause 3, which grants Congress the power
to regulate commerce with foreign nations, among the several
States, and with the Indian tribes.
Applicability to Legislative Branch
The Committee finds that the legislation does not relate to
the terms and conditions of employment or access to public
services or accommodations within the meaning of section
102(b)(3) of the Congressional Accountability Act.
Section-by-Section Analysis of the Legislation
TITLE I--BENEFICIARY IMPROVEMENTS
Section 101. Improving availability of QMB/SLMB application forms
Under current law, State Medicaid programs are required to
pay Medicare premiums and cost-sharing charges for Qualified
Medicare Beneficiaries (QMBs). These are persons whose incomes
are below 100% of the poverty line and whose resources are
below $4,000 for an individual and $6,000 for a couple. State
Medicaid programs are also required to pay Part B premiums for
Specified Low-Income Medicare Beneficiaries (SLMBs). These are
persons otherwise meeting the QMB criteria except that their
income is above the QMB level. The SLMB level is 120% of
poverty. Currently, Medicare beneficiaries must apply for QMB/
SLMB benefits at their local welfare/Medicaid office.
This section requires the Secretary of HHS to consult with
States and beneficiary groups within nine months of enactment
to develop a simplified application form for use in applying
for assistance under the QMB/SLMB programs. The form would be
easily readable and uniform nationally. Beginning one year
after enactment, the Secretary would make the application forms
available to the Social Security Administrator for distribution
through local Social Security offices as well as to other new
and existing sites as the Secretary determined appropriate.
Forms would be available to individuals upon request.
Individuals would be permitted to apply for assistance through
QMB/SLMB programs using this simplified application form and
would not be required to apply in person for such assistance.
Beginning on January 1, 2004, individuals could go to local
Social Security Offices to receive information about the QMB/
SLMB programs. These offices would notify persons who present
themselves of the availability of QMB/SLMB application forms,
make forms available on request, assist individuals in filling
out forms, and upon request, submit them to the appropriate
State agency for processing.
The provision providing for the availability of
applications in Social Security offices would be effective
January 1, 2004. The provision requiring the streamlined
application form and process would take effect 1 year after the
date of enactment, regardless of whether regulations had been
issued. The Secretary would be required to develop the
application form not later than 9 months after enactment.
Section 102. Study on limitation on State payment for Medicare cost-
sharing affecting access to services for qualified Medicare
beneficiaries
Under current law, State Medicaid programs are required to
pay Medicare premiums and cost-sharing charges for QMBs.
Medicaid's payment rates are frequently below those applicable
under Medicare. In the 1997 BBA, Congress specified that a
State Medicaid program would not be required to pay any cost-
sharing amounts for QMBs to the extent such payment would
result in a total payment for the service in excess of the
Medicaid level.
The provision requires the Secretary of HHS to conduct a
study to determine whether access to certain services
(including mental health services) has been affected by the
payment limitation. The Secretary is required to submit a
report on the study to Congress within one year of enactment.
The report must include any recommendations for change in
payment limits to assure appropriate access to services.
This section is effective upon enactment.
Section 103. Election of periodic colonoscopy
BBA '97 authorized coverage of, and established frequency
limits for, colorectal cancer screening tests. A covered test
is any of the following procedures furnished for the purpose of
early detection of colorectal cancer: (1) screening fecal-
occult blood test (for persons over 50, no more than annually);
(2) screening flexible sigmoidoscopy (for persons over 50, no
more than one every 4 years); (3) screening colonoscopy for
high-risk individuals (limited to one every 2 years); and (4)
other procedures as the Secretary finds appropriate for the
purpose of early detection of colorectal cancer. The Secretary
was required to publish, within 90 days of enactment, a
determination on the coverage of screening barium enema. Under
the regulation, barium enemas, as an alternative to either a
screening flexible sigmoidoscopy or a screening colonoscopy,
are covered in accordance with the same screening parameters
established for those tests.
The provision permits an individual who is not at high risk
to elect to receive a screening colonoscopy instead of a
screening sigmoidoscopy. Payments could not be made for such
procedures if performed within 10 years of a previous screening
colonoscopy or within 4 years of a screening flexible
sigmoidoscopy. This change comports with the new American
Cancer Society guidelines which now include this option for
average risk individuals. Further, the New England Journal of
Medicine recently reported that flexible sigmoidoscopies are
likely to miss diseased growths as much as one-third of the
time, so allowing beneficiaries the option of the more thorough
colonoscopy provides a more effective benefit.
This section is effective January 1, 2001.
Section 104. Waiver of 24-month waiting period for Medicare coverage of
individuals disabled with amyotrophic lateral sclerosis (ALS)
Currently, Medicare covers, after a 24-month waiting
period, people under age 65 who are either receiving monthly
Social Security benefits on the basis of disability or
receiving payments as disabled Railroad Retirement System
annuitants. Coverage begins with the 25th month of entitlement
for disability cash benefits.
The provision waives the 24-month waiting period for an
individual medically determined to have amyotrophic lateral
sclerosis (ALS). ALS often progresses at a rate that would make
Medicare coverage ineffective for this population if
individuals were forced to wait 24 months. This provision would
ensure individuals with ALS would be able to access medical
treatment through Medicare immediately.
The waiver of the waiting period applies to benefits for
months beginning after the date of enactment.
Section 105. Elimination of time limitation on Medicare benefits for
immunosuppresive drugs
Under current law, Medicare will pay for drugs used in
immunosuppressive therapy during the first 36 months following
a Medicare-covered organ transplant. The Balanced Budget
Refinement Act of 1999 (BBRA '99) provided for a temporary
extension of the current 36-month limit on immunosuppressive
drugs for Medicare beneficiaries otherwise exhausting their
coverage in 2000-2004. In each calendar year, there is to be an
extension specified by the Secretary (as the number of months
or partial months), applicable to persons who exhaust their
benefits in that calendar year. The increase for persons
exhausting their benefits in 2000 is 8 months. The minimum
increase for persons exhausting their benefits in 2001 is 8
months. Total expenditures over the 5-year period are limited
to $150 million. The Secretary, in making the specification of
the number of additional months for 2002-2004 is required to
make the computation so that expenditures do not exceed this
limit.
The provision eliminates the time limitation on coverage of
immunosuppressive drugs for Medicare beneficiaries and allows
for all Medicare beneficiaries to receive coverage for drugs to
prevent rejection of the donor organ following a Medicare-
covered organ transplant.
This provision applies to drugs furnished on or after
enactment.
Section 106. Preservation of coverage of drugs and biologicals under
Part B of the Medicare program
Medicare law defines covered ``medical and other health
services'' for purposes of coverage under Medicare Part B.
Included in the definition are ``services and supplies
(including drugs and biologicals which cannot, as determined in
accordance with regulations, be self- administered) furnished
as incident to a physician's professional service * * *.'' The
Medicare Carrier's Manual states that whether a drug or
biological is of a type which cannot be self-administered is
based on the usual method of administration of the form of that
drug or biological as furnished by the physician.
Individual Medicare carriers apply different policies when
considering whether a drug or biological can or can not be
self- administered. Some carriers base the determination on the
typical means of administration while others assess the
individual patient's ability to administer the drug. On August
13, 1997, the Health Care Financing Administration (HCFA)
issued a memorandum to Medicare carriers which was intended to
clarify program policy. The memorandum stated that the
inability to self-administer was to be based on the typical
means of administration of the drug, not on the individual
patient's ability to administer the drug.
As a result of this memorandum, certain patients, for
example patients with multiple sclerosis, no longer had
Medicare coverage for certain drugs. However, implementation of
this policy directive was halted for FY2000 by a provision in
the Consolidated Appropriations Act (P.L. 106-113). The
provision prohibits the use of any funds to carry out the
August 13, 1997 transmittal or to promulgate any regulation or
other transmittal or policy directive that has the effect of
imposing (or clarifying the imposition of) a restriction on the
coverage of injectable drugs beyond those applied on the day
before issuance of the transmittal. HCFA issued a Program
Memorandum in April 2000 which suspended application of the
August 13, 1997 memorandum. It noted that each carrier or
intermediary must establish its own policies individually and
can not establish model policies as a group.
This section clarifies that carriers are to reimburse for
self- injectable drugs according to pre-August 1997 policy.
This section replaces the current phrase in section 1861(s)(2)
relating to certain drugs and biologicals administered incident
to a physician's professional service. The new language
requires coverage of ``drugs and biologicals which are not
usually self-administered by the patient.'' The Committee
intends that in determining whether a drug or biological is
usually self-administered by the patient, HCFA should only
consider whether a majority of Medicare patients with the
disease or condition actually administer the drug to
themselves. In carrying out this intent, HCFA should assume, as
it did for many years, that Medicare patients do not usually
self-administer injections or infusions to themselves, while
oral medications usually are self-administered. HCFA should
also continue to take into account the circumstances under
which the drug or biological is being administered and continue
to cover products that are administered in emergencies, for
example, during which self-administered is not the usual method
of administration.
The Committee anticipates that HCFA will instruct its
contractors not to rely on this section to exclude a drug or
biological without making an explicit finding supported by
evidence that it is usually administered to themselves by a
majority of Medicare patients who use it for the condition to
which the exclusion relates.
This section applies to drugs and biologicals administered
on or after October 1, 2000.
Section 107. Demonstration of Medicare coverage of medical nutrition
therapy
BBA `97 required the Secretary of HHS to request that the
National Academy of Sciences analyze the expansion or
modification of preventive and other benefits provided to
Medicare beneficiaries. The Secretary was required to submit a
report to Congress on specific findings related to several
benefit categories. One category included in the required study
was ``nutrition therapy services, including parenteral and
enteral nutrition and including the provision of such services
by a registered dietitian.'' The Academy's Committee on
Nutrition Services for Medicare Beneficiaries, Food and
Nutrition Board, transmitted a report on nutrition therapy
early this year.
The report contained several key recommendations. The
Committee recommended that nutrition therapy, upon referral
from a physician, should be a reimbursable Medicare benefit. It
noted that current evidence suggests that nutrition therapy is
effective as part of a comprehensive approach to the management
and treatment of many conditions affecting the Medicare
population including dyslipidemia, hypertension, heart failure,
diabetes, and kidney failure. The Committee also noted that the
registered dietician is currently the single identifiable group
of health care professionals with standardized education,
clinical training, continuing education, and national
credentialing requirements necessary to be directly reimbursed
as a provider of nutrition therapy.
The provision establishes a demonstration program for
Medicare coverage of medical nutrition therapy services for
beneficiaries in the five States with the highest proportion of
population who are 65 years of age or older.
Under the demonstration program, medical nutrition therapy
services are defined as nutritional diagnostic, therapy and
counseling services for the purpose of disease management which
are furnished by a registered dietician or nutrition
professional, pursuant to a referral by a physician. The term
registered dietician or nutrition professional means an
individual who (1) has completed a baccalaureate or higher
degree with completion of academic requirements of a program in
nutrition or dietetics; (2) has completed at least 900 hours of
supervised dietetics practice under the supervision of a
registered dietitian or nutrition professional; and, (3) is
either licensed or certified as a dietician or nutrition
professional by the State in which the services are performed,
or, in a State which does not provide for such licensure or
certification, meets criteria established by the Secretary.
Persons licensed or certified as dieticians or nutrition
specialists on the date of enactment would not be required to
meet the training requirements under 1 and 2.
Under the demonstration, the provision specifies that the
amount paid for medical nutrition therapy services would equal
80% of the lesser of the actual charge for the service or 85%
of the amount that would be paid under the physician fee
schedule if such services were provided by a physician.
Assignment would be required for all claims. The Secretary is
required to submit to Congress interim reports on the
demonstration project and a final report within six months of
the conclusion of the project.
This section applies to services furnished on or after
January 1, 2002.
TITLE II--OTHER MEDICARE PART B PROVISIONS
Subtitle A--Access to Technology
Section 201. Annual reports on national coverage determinations
The Medicare statute specifies the broad service categories
paid for under the program; these include inpatient and
outpatient hospital services, physicians services, and other
types of medical care. In general, the law does not specify the
types of medical treatments, procedures, or technologies
covered. However, the law does specifically exclude coverage
for any items or services which ``are not reasonable and
necessary for the diagnosis or treatment of illness or injury
or to improve the functioning of a malformed body member.''
HCFA has generally interpreted the statute to preclude payment
for services that have not been proven safe and effective by
acceptable clinical evidence or that have not been generally
accepted in the medical community. Experimental items are
generally excluded.
Coverage decisions are made at both the national level by
the Health Care Financing Administration and at the local level
by Medicare intermediaries and carriers. Currently the majority
of determinations are made at the local level. HCFA is
currently in the process of revising the process for making
national coverage determinations.
The provision requires the Secretary of HHS to annually
submit to the Congress a report about national coverage
decisions. The report sets forth a detailed compilation of the
actual time periods that were necessary to complete and fully
implement any national coverage determinations that were made
the previous fiscal year for items, services, or medical
devices not previously covered under Medicare. The report is to
include (for each such item, device, or service) a statement of
the time taken by the Secretary to make the necessary coverage,
coding, and payment determinations, including the time taken to
complete each significant step in the process of making such
determinations. The report will be due by December 1 of each
year (beginning in 2001). The report would be published on the
Medicare Internet site.
This section is made effective upon enactment.
Section 202. National limitation amount equal to 100 percent of
national median for new clinical laboratory test technologies;
fee schedule for new clinical laboratory tests
Medicare currently pays for clinical laboratory services on
the basis of areawide fee schedules. The law sets a cap on the
payment amount for a test. BBA '97 froze the fee schedule for
the 1998-2002 period. It also lowered the cap from 76% of the
median to 74% of the median of all fee schedules for the test.
Under this section, the national limitation amount is set
at 100% of the median in the case of a test, performed after
January 1, 2001, that the Secretary determined was a new test
for which no limitation amount had been previously established.
The Secretary also is required to establish a national
uniform fee schedule amount for new tests which are unique and
unable to be crosswalked with existing tests. By December 1 of
each year (beginning in 2001), the Secretary is to publish in
the Federal Register an interim fee schedule amount for each
new test which would apply for the following year. The interim
fee schedule amount for each test is subject to a 60 day
comment period. The Secretary would review the comments and
make appropriate adjustments. By December 1 of each year
(beginning in 2002), the Secretary must publish in the Federal
Register a fee schedule amount for each such new test for which
an interim amount was established; the amount applies for the
following year.
This section is effective upon enactment.
Section 203. Clarifying process and standards for determining
eligibility of devices for pass-through payments under hospital
outpatient PPS
BBRA '99 provided that, for 2 to 3 years after the
introduction of a new device, the Secretary of HHS is required
to provide additional payments for costs of certain ``current
innovative'' devices, drugs, and biologicals, and certain
``new'' high cost devices, drugs, and biologicals used in
hospital outpatient department care. These payments are
referred to as ``pass-through payments'' because they would
pass through the hospital outpatient PPS and be paid over and
above PPS payments. ``Current'' is defined as something for
which Medicare is paying under outpatient services on the first
day of the PPS; ``new'' is defined as something for which
Medicare was not paying on an outpatient basis on December 31,
1996.
A pass-through for the cost of current innovative products
apply to (1) orphan drugs; (2) certain cancer therapy drugs,
biologicals, and brachytherapy; and (3) radiopharmaceutical
drugs and biological products.
A pass-through of costs for ``new'' medical devices, drugs,
and biologicals is required if the costs of those items is
``not insignificant'' in relation to the fee schedule amount
payable for the service.
Pass-through payments are currently made on the basis of a
product's brand-name.
This provision requires the Secretary, through public
rulemaking procedures, to establish criteria for defining
special payment categories under the hospital outpatient PPS
for new and certain current medical devices and to establish
new categories for such medical devices. These payments are
designated as ``category-based pass-through payments'' as
opposed to the current system based on brand. In general, the
payment period begins when the first such payment is made for a
device after implementation of category-based pass-through
payments.
This section is effective upon enactment.
Section 204. Access to new technologies applied to screening
mammography to enhance breast cancer detection
Medicare currently limits payment for screening mammography
to $67.81 irrespective of what type of technology is used.
This provision allows the Secretary to increase the
Medicare payment limit for screening mammographies by $15, if
the Secretary determines a new technology that enhances the
detection of breast cancer is being used.
Subtitle B--Provisions Relating to Physicians Services
Section 211. GAO study of gastrointestinal endoscopic services
furnished in physicians' offices and hospital outpatient
department services
Payments for physicians services are made on the basis of a
fee schedule which is intended to relate payments for a given
service to actual resources used. The fee schedule assigns
relative values to services; these values are the sum of three
components--a physician work component, a practice expense
component, and a malpractice expense component. Each component
is adjusted for geographic variations in costs. The adjusted
relative values are then converted into a dollar payment amount
by a conversion factor.
BBA `97 established a process for the development of new
relative values for practice expenses. The new resource-based
system is being phased-in over 4 years beginning in 1999. For
many services, there is a differential between the value
assigned to practice expenses for a service provided in a
physicians office and that assigned when the service is
provided in an institutional setting.
The provision requires the GAO to conduct a study on the
appropriateness of furnishing gastrointestinal endoscopic
services in physicians offices. The GAO is also required to
review available scientific and clinical evidence about the
safety of performing procedures in physicians offices and
hospital outpatient departments. The GAO is also required to
assess whether the assigned practice expense relative value
units assigned for these services create an incentive to
furnish services in doctors offices, rather than in hospital
outpatient departments. The GAO is further required to report
on the implications for beneficiary access if Medicare did not
cover such services in physicians offices.
The GAO is required to submit the report to Congress,
together with any recommendations, by July 1, 2002.
This section is effective upon enactment.
Section 212. Treatment of certain physician pathology services
The final rule for the Medicare physician fee schedule
issued November 2, 1999 required hospitals to bill for the
technical component of pathology services furnished to its
inpatients. Based on comments received, HCFA decided to delay
implementation of this rebundling requirement until January 1,
2001, to allow hospitals and independent laboratories
sufficient time to negotiate arrangements.
Regulations implementing the hospital outpatient
prospective payment system require hospitals to provide
directly or under arrangements all services furnished to
hospital outpatients. If a specimen (e.g., tissue, blood,
urine) is taken from a hospital outpatient, the facility or
technical component of the diagnostic test must be billed by
the hospital. Thus, independent laboratories cannot bill for
the technical component of pathology services furnished to
outpatients. On August 11, 2000, HCFA issued a program
memorandum (Transmittal No. AB-00-73) which delayed
implementation of the rebundling requirement until January 1,
2001.
The provision grandfathers hospitals that have an
arrangement with an independent lab in effect as of July 22,
1999 under which the lab was furnishing and directly billing
the carrier (not the hospital) for a 2 year period. Labs
working with these hospitals could continue direct billing for
the technical component of pathology services provided to
hospital inpatients and hospital outpatients. The provision
does not apply to services furnished to Medicare+Choice
enrollees.
The GAO will be required to analyze the types of hospitals
that are grandfathered under the provision and study the
effects of the direct billing provision on hospitals,
laboratories, and Medicare beneficiaries access to physician
pathology services. The report is due to Congress by July 1,
2002. It would include recommendations on whether the
grandfather provision should continue after the 2-year period
for either (or both) inpatient and outpatient hospital services
and whether the provision should be extended to other hospitals
with similar characteristics.
The direct billing provision would apply to services
furnished during the 2-year period beginning January 1, 2001.
The report requirement is effective on enactment.
Section 213. Physician group practice demonstration
The provision requires the Secretary to conduct
demonstration projects to test, and if proven effective, expand
the use of incentives to health care groups participating under
Medicare. These incentives include encouraging coordination of
care furnished under Medicare Parts A and B by institutional
and other providers and practitioners; encouraging investment
in administrative structures and processes encouraging
efficient service delivery; and rewarding physicians for
improving health outcomes. For purposes of the demonstration, a
health care group is a group of physicians organized, at least
in part, for the purpose of providing physicians services under
Medicare. As the Secretary finds appropriate, the group could
include a hospital or other entity that was affiliated with the
group and which would share in any bonus earned under the
demonstration.
Groups participating in the demonstration agree to be paid
on a fee-for-service basis. They also agree that payment for
all services furnished to beneficiaries would be made to a
single agency.
The Secretary specifies those patients to be considered
within the scope of the demonstration. The Secretary ensures
that each beneficiary in a demonstration program would be
notified of the incentives and of any waivers of coverage or
payment rules under the demonstration program.
The Secretary establishes for each group participating in a
demonstration, a base expenditure amount and an expenditure
target (reflecting base expenditures adjusted for risk and
expected growth rates). The Secretary pays each group a bonus
for each year equal to a portion of the savings for the year
relative to the target. In addition, at such time as the
Secretary had developed appropriate criteria, the Secretary
pays an additional bonus related to process and outcome
improvements. Total payments under demonstrations could not
exceed what the Secretary estimates would be paid in the
absence of the demonstration program.
The provision also specifies requirements for
administration of the demonstration program. These include:
limiting beneficiary eligibility to fee-for-service enrollees;
permitting the Secretary to limit the scope of the program
including limitation to a geographic area (or areas) or to
subgroup (or subgroups) of beneficiaries or entities; voluntary
receipt of services by beneficiaries; permitting the Secretary
to enter into agreements with individuals and entities;
establishment of performance standards by the Secretary;
administrative review of decisions affecting individuals and
entities furnishing services; and, Secretarial review of
marketing material. Individuals or entities receiving payment
under the program would agree to accept such payment as payment
in full, except for any deductible and coinsurance amount.
The Secretary is permitted to administer the demonstration
program through a contract with a program administrator which
could be a Medicare intermediary or carrier or other entity
with substantial experience in managing this type of program.
Contracts are for an initial term of 3 years and could be
awarded noncompetitively. The Secretary could make bonus
payments to program administrators; the Secretary could also
condition such payments on the achievement of standards related
to efficiency, improvement in processes or outcomes of care, or
other factors.
Entities with agreements to provide health services under
the demonstration and entities with program administration
contracts would be required to maintain adequate records and
furnish such reports as the Secretary may require. The
provision places certain limitations on judicial and
administrative review of certain actions and determinations
relating to the demonstration. The provision further requires
periodic reports to Congress on the use of authorities under
the demonstration program.
This section is effective upon enactment.
Section 214. Designation of separate category for interventional pain
management services
Payments for physicians services are made on the basis of a
fee schedule which is intended to relate payments for a given
service to actual resources used. The fee schedule assigns
relative values to services; these values are the sum of three
components--a physician work component, a practice expense
component, and a malpractice expense component. In making these
calculations, the Secretary is required to determine, for each
physicians service or class of services, the percentage that is
performed nationwide by physician in different specialties.
The provision specifies that for services provided on or
after January 1, 2002, the Secretary will specify
interventional pain management physicians as a separate
category of physician specialists.
This section is effective upon enactment.
Section 215. Evaluation of enrollment procedures for medical groups
that retain independent contractor physicians
Medicare generally prohibits payments for services to be
made to anyone other than the person providing a service. One
exception is if the physician or other practitioner, as a
condition of his or her employment, is required to turn over
the fee to his or her employer.
This section directs the Secretary of Health and Human
Services to evaluate the current Medicare enrollment process
for medical groups that retain independent contractor
physicians with particular emphasis on hospital-based
physicians, such as emergency department staffing groups. The
Secretary must review the increase of individual Medicare
provider numbers issued and the possible Medicare program
integrity vulnerabilities of the current process; assess how
program integrity could be enhanced by the enrollment of groups
that retain independent contractor hospital-based physicians;
and develop suggested procedures for the enrollment of these
groups.
The Secretary will submit the report to Congress one year
after the date of enactment.
This section is effective upon enactment.
Subtitle C--Other Services
Section 221. 3-year moratorium on SNF Part B consolidated billing
requirements
Under the consolidated billing requirement of BBA '97,
skilled nursing facilities (SNFs) and all nursing homes that
include a Medicare-certified SNF component must submit to
Medicare all claims for all the services provided to their
residents who are enrolled in traditional fee-for-service
Medicare. Thus, the requirement applies to claims on behalf of
beneficiaries who are long-term care residents of a nursing
home that has a SNF component as well as those who are
residents in the SNF. This requirement is referred to as
``consolidated billing.'' (The law includes a list of services
that are excluded from the consolidated billing requirement;
excluded providers may bill Medicare directly.) The
consolidated billing requirement also pertains to Medicare
covered services regardless of whether the resident does or
does not qualify for SNF care under Medicare Part A. The
requirement means that non-excluded service or care providers
who furnish covered services to SNF residents may not bill
Medicare directly, but must submit their claim to the SNF for
payment. If the item or service is covered by Medicare but is
not included in the SNF PPS, Medicare makes the payment to the
SNF, and the SNF is responsible for paying the provider.
The consolidated billing requirement went into effect in
July 1998 (implementation of the SNF PPS) for some, but not
all, SNF patients. Consolidated billing has been implemented
only for services to those SNF residents who are in a Medicare
Part A covered stay, and has not been implemented for Medicare
Part B covered services for beneficiaries who are SNF residents
whose stay is not covered under Medicare (which includes those
who are long-term care residents of the non-SNF component of
the facility). When HCFA is ready to expand implementation of
consolidated billing it will publish a notice in the Federal
Register 90 days prior to implementation.
Under this provision, implementation of consolidated
billing is delayed until October 1, 2003, for Part B-covered
services to SNF residents who are not in a SNF stay that is
covered by Medicare Part A. The Comptroller General is required
to submit a report to Congress by October 1, 2002, regarding
alternatives, if any, to consolidated billing for Part B items
and services to ensure accountability by SNFs and accuracy in
claims submitted for all services and items provided to SNF
residents under Part B.
Delay of consolidated billing is effective as if included
with enactment of BBA '97.
Section 222. Ambulatory Surgical Centers (ASCs)
Delay in Implementation of Prospective Payment System. From
the start of Medicare coverage of ASC services in 1982,
Medicare based payments to ASCs on a fee schedule. Starting
January 1, 1995, the Secretary of HHS has been required to
update ASC rates every 5 years based on a survey of the actual
audited costs incurred by a representative sample of ASCs for a
representative sample of procedures, and to increase annual
payments in the intervening years by the CPI-U. (BBA '97
modified the annual update amounts.)
On June 12, 1998, HCFA issued proposed rules which would
make major changes in Medicare payments to ASCs. The major
changes include replacing eight payment groupings with an
ambulatory payment classification (APC) system comprised of 105
payment groups; updating underlying cost data using 1994 survey
data updated to the present; and making additions to and
deletions from the list of Medicare covered ASC procedures.
Payments would range from $53 to $2,107 and would be updated by
the CPI-U annually on a calendar year basis. Final rules are
scheduled for publication in November 2000 for implementation
in April 2001. BBRA '99 delayed the implementation by requiring
a 3 year phase-in.
The Secretary would be prohibited from implementing the
changes to the APC system published on June 12, 1998 before
January 1, 2002.
This section is effective upon enactment.
Extending Phase-In to 4 Years. BBRA `99 requires that, if
the Secretary implements new ASC rates based on the 1994 data
(or any rates based on pre-1999 Medicare cost survey data),
those new rates must be phased-in by basing payments one-third
on the new rates in the first year, two-thirds in the second
year, and fully in the third year.
This provision extends the phase-in of new ASC payment
rates based on pre-1999 survey data is extended to occur over 4
years (one- fourth per year).
This section is effective upon enactment.
Deadline for Use of 1999 or Later Cost Surveys. This
provision requires the Secretary by January 1, 2003, to
incorporate data from a 1999 Medicare cost survey or a
subsequent cost survey for purposes of revising the ASC payment
system.
This section is effective upon enactment.
Section 223. One-year extension of moratorium on therapy caps
BBA `97 established annual payment limits for all
outpatient therapy services provided by non-hospital providers.
The limits applied to services provided by independent
therapists as well as to those provided by comprehensive
outpatient rehabilitation facilities (CORFs) and other
rehabilitation agencies. The limits did not apply to outpatient
services provided by hospitals.
There were two per beneficiary limits. The first was a
$1,500 per beneficiary annual cap for all outpatient physical
therapy services and speech language pathology services. The
second was a $1,500 per beneficiary annual cap for all
outpatient occupational therapy services. Beginning in 2002,
the amount would increase by the Medicare Economic Index (MEI).
BBRA '99 suspended application of the therapy limits in
2000 and 2001. (In the absence of additional legislation, the
caps would be imposed again beginning in 2002.) During this
time, the Secretary is required to conduct focused medical
reviews of therapy claims with emphasis on claims for services
provided to residents of SNFs. The Secretary is also required
to study utilization patterns in 2000 compared to those in 1998
and 1999. The study (which must be based on a statistically
significant number of claims) will look at nationwide patterns
as well as patterns by region, types of setting, and diagnosis
or condition. The Secretary is required to report the results
of this study to Congress by June 30, 2001, together with any
legislative recommendations deemed appropriate.
The provision extends the moratorium on implementation of
the therapy cap, and the focused reviews, for 1 year.
This section is effective upon enactment.
Section 224. Revision of Medicare reimbursement for telehealth services
BBA '97 provided for reimbursement from Medicare Part B for
professional consultation via telecommunications systems with
physicians and practitioners for beneficiaries residing in
rural areas.
The provision requires payments to be made no later than
April 1, 2001, in accordance with revised payment procedures,
for services that are provided on a telecommunications system
by a practitioner or provider to an eligible beneficiary.
Services covered under the provision will include payments for
professional consultations, office visits, office psychiatry
visits, including any service identified, as of July 1, 2000,
by the following HCPCS codes: 99241-99275, 99201-99215, 90804-
90809, and 90862. The Secretary must develop a process to
determine what other services would be appropriate to be
provided under telehealth and shall annually update covered
services through this process.
An eligible beneficiary would be a person residing in a
designated health professional shortage area, a county that is
not in a metropolitan statistical area (MSA), an inner city
area that is medically underserved (effective January 1, 2002),
or an area in which there is a Federal telemedicine
demonstration program. In the case of any Federal telemedicine
demonstration program in Alaska or Hawaii, the term
telecommunications system would include store-and-forward
technologies that provide for asynchronous transmission of
health care information in single or multi-media formats.
The provision requires the Secretary to make payments for
telemedicine services in an amount equal to the amount that
would have been paid to the physician or practitioner if the
service had been furnished to the beneficiary without the use
of a telecommunications system. It also eliminates the 75/25
percent fee splitting requirement.
A facility fee would be paid to the originating site. This
fee would equal $20 in 2001 and 2002, increased by the
percentage increase in the Medicare Economic Index (MEI) in
future years. Payments would be subject to beneficiary cost-
sharing, however balance billing protections apply. Beginning
April 1, 2001, an originating site would be defined as: the
physician's or practitioner's office, a critical access
hospital, rural health clinic, or Federally qualified health
center. Beginning in January 1, 2002, the definition would be
expanded to include a hospital, skilled nursing facility,
comprehensive outpatient rehabilitation facility, renal
dialysis facility, ambulatory surgical center, hospital or
skilled nursing facility of the Indian Health Service, or a
community mental health center.
The provision specifies that nothing would be construed as
requiring an eligible telehealth beneficiary to be presented by
the physician or practitioner at the originating site for the
furnishing of a service, unless it was determined medically
necessary by the physician or practitioner at the distant site.
The provision requires the Secretary to conduct a study to
identify additional services that are appropriate for
reimbursement. The report, together with recommendations, would
be transmitted to Congress within 2 years of enactment.
The provision clarifies that the telecommunications
provisions should not be construed as preventing a home health
agency from providing a service, for which payment is made
under the prospective payment system, via a telecommunications
system.
This section is effective upon enactment.
Section 225. Payment for ambulance services
Payment for ambulance services provided by freestanding
suppliers is currently based on reasonable charge screens.
Hospital or other provider-based ambulance services are paid on
a reasonable cost basis. Payment cannot exceed what would be
paid to a freestanding supplier. The reasonable costs or
charges cannot exceed costs or charges recognized in a prior
year, increased by the CPI-U minus one percentage point.
BBA '97 provided for the implementation of a fee schedule,
effective January 1, 2000. The aggregate amount of payments in
2000 could not exceed what would otherwise be paid under the
prior system. Increases in subsequent years are to equal the
CPI increase, except that there is a one percentage point
reduction in 2001 and 2002.
Implementation of the fee schedule has been delayed until
at least January 1, 2001.
The provision eliminates the 1.0 percentage point reduction
for 2001 and 2002 so that ambulance services will receive a
full update for CPI. The provision also specifies that any
phase-in of the ambulance fee schedule shall provide, in any
State in which suppliers had not been paid a separate amount
for all mileage, for full payment of the national mileage rate
beginning with the effective date of the fee schedule.
The provision requires the GAO to conduct a study of the
costs of providing ambulance services across the range of
service levels. Within 18 months of enactment, GAO is required
to report to Congress on the study. The report includes any
recommendations for changes in methodology or payment levels
necessary to fairly compensate suppliers and to ensure access
for Medicare beneficiaries.
This section is effective upon enactment.
Section 226. Contrast enhanced diagnostic procedures under hospital
prospective payment system
Currently, Medicare covers diagnostic scanning procedures
used in hospital outpatient departments, including procedures
that require injection of agents that enhance the visibility of
organs showing greater contrast among organs and organ parts.
Under the outpatient PPS, coverage of certain agents used for
contrasting is generally included in the PPS amount for the
procedure for which contrast agents are used.
The Secretary is required to create under the hospital
outpatient department PPS additional groups of covered services
that classify separately those procedures that utilize contrast
media from those that do not. The provision is retroactive to
the implementation of the hospital outpatient department PPS
(August 1, 2000). The provision also amends the definition of a
drug to include contrast agents.
This section is effective as if enacted as part of BBA '97.
Section. 227. Increase from 55 percent to 80 percent the proportion of
hospital bad debt recognized
Currently, hospitals receive compensation from Medicare for
certain portions of amounts they are unable to collect from
beneficiaries for deductibles and coinsurance (applicable to
both inpatient and outpatient department care). BBA '97
established a schedule under which the amount of a hospital's
bad debt Medicare would recognize as an allowable cost would
decline from 75% for cost reporting periods beginning in FY1998
to 55% for cost reporting periods beginning in FY2000 and
thereafter. Prior to BBA '97, hospitals received compensation
for 100% of bad debt incurred.
This provision would reinstate the ability of hospitals to
receive compensation for bad debt. The provision would phase-in
Medicare payment for up to 80% of a hospital's allowable costs
in equal increments beginning in FY 2000 over 10 years.
Section 228. State accreditation of diabetes outpatient self-management
training programs
BBA '97 authorized coverage, effective July 1, 1998, for
diabetes outpatient self-management training services. These
services are defined as including educational and training
services furnished to an individual with diabetes by a
certified provider in an outpatient setting. Certified
providers for these purposes are defined as physicians or other
individuals or entities that, in addition to providing diabetes
self-management training services, provide other items or
services reimbursed by Medicare. Providers must meet quality
standards established by the Secretary. They are deemed to meet
the Secretary's standards if they meet standards originally
established by the National Diabetes Advisory Board and
subsequently revised by organizations who participated in the
establishment of standards of the Board, or if they are
recognized by an organization representing persons with
diabetes, as meeting standards for furnishing such services.
The provision authorizes State accreditation of diabetes
self- management training programs, provided that the Secretary
determined that the State program had established quality
standards that meet or exceed the national standards or the
standards originally established by the National Diabetes
Advisory Board, and subsequently revised.
This section is effective upon enactment.
TITLE III--MEDICARE PART A AND B PROVISIONS
Section 301. Home health services
One-Year Delay in 15 Percent Reduction in Payment Rates
under the Medicare Prospective Payment System for Home Health
Services. BBA '97 required implementation of a home health care
prospective payment system and specified that the prospective
payment system (PPS) be designed so that in the first 12 months
of operation the aggregate amount of Medicare PPS payments
would equal the total payments that would have been paid under
the interim payment system had it remained in effect that year
but with a 15% across-the-board reduction in Medicare payments
to home health agencies. The home health PPS was originally
scheduled for implementation in FY 1999 but was delayed until
October 1, 2000 (FY 2001). BBRA '99 delayed the 15% reduction
until 12 months after October 1, 2000 (thus the reduction would
go into effect on October 1, 2001), but it required the
Secretary to report on the need for a 15% or other reduction 6
months after implementation of the PPS. (This report would be
due by March 1, 2001.)
The provision requires that the aggregate amount of
Medicare payments to home health agencies in the second year of
the PPS (FY2002) must equal the aggregate payments in the first
year of the PPS, updated by the Market Basket Increase minus
1.1 percentage points. The 15% reduction to aggregate PPS
amounts would be delayed until October 1, 2002.
This section is effective upon enactment.
Treatment of Branch Offices of Home Health Agencies. Prior
to BBA '97, home health agency (HHA) payments were based on the
HHA's billing location. Thus, an agency headquartered in an
urban area would be paid according to rates for urban areas,
even though that agency had provided some of its billable
visits through branch offices serving rural communities. BBA
'97 required HHAs to submit payment claims on the basis of the
location in which the service was provided. The home health PPS
payments are based on the location in which the care is
furnished.
A home health agency may have both branch offices and
subunits. Subunits must meet the same conditions of
participation as the parent home health agency. These
conditions of participation include staffing and supervision
standards. Branch offices do not have to meet the conditions of
participation independently of the home health agency, and thus
are not subject to the same staffing and supervision
requirements. For this reason, in order to ensure that branch
offices of HHAs are adequately supervised, HCFA regional
offices have established ``time and distance'' restrictions on
how far a branch office may be from an agency's main office.
Typically, these restrictions specify that a branch office may
be no farther than 60 miles or 60 minutes from the main office
for that HHA, although they vary in different areas. The branch
office must be easily accessible from the parent office in case
of an emergency as the branch office does not have the same
skilled staff on site.
Under this provision, use of time and distance as the sole
determinant of a home health agency's branch office status is
prohibited.
This section is effective upon enactment.
Consideration of Forms of Technology in Definition of
Supervision. One component of the definition of a home health
agency is that it has policies governing the services it
furnishes and provides for supervision of such services by a
physician or registered professional nurse.
This section requires the Secretary to include various
forms of technology in determining what constitutes
``supervision'' for purposes of an agency's meeting the
definition of a home health agency.
This section is effective upon enactment.
Clarification of the Definition of Homebound. To qualify
for home health care under Medicare an individual must be
homebound or ``confined to home.'' A homebound individual is
defined as one who cannot leave home without a considerable and
taxing effort and only with the aid of devices such as a
wheelchair, a walker, or through use of special transportation.
Absences from home may occur infrequently for short periods of
time for such purposes as to receive medical treatment.
Medicare law requires that a physician certify that an
individual's medical condition confines him or her to home.
Currently, some regional home health intermediaries exclude
individuals with Alzheimer's from home care if they leave the
home for medical or therapeutic treatment at an adult day care
center.
This provision clarifies that approved absences from home
include participation in an adult day care program licensed or
certified by a State to furnish such services for therapeutic
treatment for Alzheimer's disease or a related dementia. This
would not change the requirement the home health services must
be provided by a Medicare home health agency.
This provision is effective October 1, 2001.
One-Year Delay in Report. BBRA '99 required the Secretary
to submit, within 6 months of implementation of the home health
PPS, a report to Congress on the need for a 15% or other
reduction in Medicare payments to home health agencies.
This section requires the Secretary to submit a report to
Congress on the need for the 15% or other reduction no later
than 18 months after implementation of the home health PPS.
This section is effective upon enactment.
Section 302. Advisory opinions
The Health Insurance Portability and Accountability Act of
1996 (HIPAA, P.L. 104-91) required the Department of Health and
Human Services, through the Office of the Inspector General
(OIG) in consultation with the Department of Justice, to issue
advisory opinions to outside parties who request guidance on
the applicability of the anti-kickback statute, safe harbor
provisions and other OIG health care fraud and abuse sanctions.
The authority to issue this guidance expired on August 21,
2000. The OIG protects submissions of proprietary information
to the extent possible under the Freedom of Information Act
(FOIA; 5 U.S.C Sec. 552).
This section makes permanent the OIG's authority to issue
guidance. Any supporting documentation submitted as part of a
request for an advisory opinion will not be subject to FOIA.
Section 303. Hospital geographic reclassification for labor costs for
other PPS systems opinions
As part of Medicare's prospective payment system for acute
hospitals, a hospital may apply to the Medicare Geographic
Classification Review Board (MGCRB) to be reclassified to a
different area for the purposes of using its wage index, its
standardized amount, or both. Although some of Medicare's
payment systems for other provider types use the hospital wage
index, reclassification decisions made by the MGCRB only apply
to inpatient and outpatient hospital PPS payments.
Under this section, MGCRB reclassification decisions to
adjust the hospital's wage index in a fiscal year will apply to
provider-based entities or distinct part units of that
particular hospital paid under the following payment systems:
home health PPS, skilled nursing facility PPS, inpatient
rehabilitation hospital PPS, inpatient long term care hospital
PPS, inpatient psychiatric hospital PPS.
Section 304. Reclassification of a metropolitan statistical area for
the purposes of reimbursement under the Medicare program
As part of Medicare's prospective payment system for acute
hospitals, hospitals may apply to the Medicare Geographic
Classification Review Board to be reclassified to a different
area for the purposes of using its wage index, its standardized
amount, or both. Hospitals that are in or that are reclassified
to metropolitan areas (MSAs) with population of one million or
more are considered to be in large urban areas and receive
payment based on a higher standardized amount. The labor-
related amount of the standardized amount is adjusted by the
wage index value of the area the hospital is in or the area to
which the hospital has been reclassified. With respect to MGCRB
wage index reclassifications, if the wage data for the
redesignated hospitals reduces the wage index value of the area
to which the hospitals are redesignated by 1 percentage point
or less, the original wage index value for the area (exclusive
of the wage data for the redesignated hospitals) applies to the
redesignated hospitals. However, if the wage data for the
redesignated hospitals reduced the wage index value of the area
to which the hospitals are redesignated by more than 1
percentage point, the redesignated hospitals are subject to
that combined wage index value.
This provision establishes, for FY2001 and subsequently,
hospitals in the Mansfield Ohio MSA are deemed to be located in
the Cleveland-Loraine-Elyria Ohio MSA, a large urban area. The
reclassification made under the previous sentence is to be
treated as a MGCRB decision.
This section is effective beginning in fiscal year 2001.
Section 305. Making the Medicare dependent, small rural hospital
program permanent
Medicare dependent hospitals (MDHs) are small rural
hospitals that treat a relatively high proportion of Medicare
patients. MDH's special payment status was phased out as of
September 30, 1994 and then reinstated, on a modified basis by
BBA '97, starting on October 1, 1997 through October 1, 2001.
MDH classification was extended to October 1, 2006 by BBRA '99.
This provision makes the MDH program permanent. Conforming
amendments would permit hospitals to decline reclassification
by the Medicare Geographic Classification Review Board from a
rural to an urban area in order to maintain its MDH status.
This section is effective upon enactment.
Section 306. Option to base eligibility on discharges during any of the
3 most recent audited cost reporting periods
Medicare dependent hospitals are small rural hospitals that
treat a relatively high proportion of Medicare patients.
Generally, a MDH is located in a rural area, has 100 beds or
less, is not classified as a sole community hospital, and had a
least 60% of its days or discharges during FY 1987 attributable
to Medicare Part A beneficiaries.
This provision updates the MDH criteria to permit an
otherwise qualifying small rural hospital to be classified as
an MDH if at least 60% of its days or discharges were
attributable to Medicare Part A beneficiaries in any of the 3
most recently audited cost reporting periods.
This section is effective upon enactment.
Section 307. Identification and reduction of medical errors by peer
review organizations
Peer review organizations (PROs) now have certain statutory
responsibilities to work with hospitals and other providers to
improve clinical outcomes through data collection and analysis.
PROs also address certain beneficiary complaints and work to
prevent Medicare payment errors.
This provision gives PROs the authority to work with
providers, practitioner, and Medicare+Choice organizations to
identify and reduce the incidence of medical errors and
problems affecting patient safety.
This section is effective January 1, 2001.
Section 308. GAO Report on Impact of the Emergency Medical Treatment
and Active Labor Act (EMTALA) on hospital emergency departments
The Emergency Medical Treatment and Active Labor Act
(EMTALA) requires that doctors on call at hospital emergency
departments screen and stabilize patients who go to emergency
departments for treatment. Physicians who refuse to treat
emergency department patients or fail to respond to hospital
emergency department requests when on call face significant
fines and are exposed to liability under EMTALA. There are
concerns that the impact of EMTALA, as well as provisions in
the Balanced Budget Act of 1997, has led to many physicians
covering emergency department calls in Phoenix, Arizona to
resign from various hospitals' medical staffs, thus raising
concerns as to whether downtown Phoenix hospitals can keep
their emergency departments open.
This provision would require the General Accounting Office
to report to the Subcommittee on Health and Environment of the
Committee on Commerce of the House of Representatives by May 1,
2001, on the effect of EMTALA on hospitals, emergency
physicians, and physicians covering emergency department calls,
focusing on those in Arizona and California.
TITLE IV--MEDICARE+CHOICE PROGRAM STABILIZATION AND IMPROVEMENTS
Subtitle A--Payment Reforms
Section 401. Increasing minimum payment amount
Under current law, each county is subject to a floor
amount, designed to raise payments in certain counties more
quickly than would otherwise occur. The minimum payment amount
for aged Medicare+Choice (M+C) enrollees is $401.61 for 2000
and will be $415.01 for 2001. As required by law, each year
this payment amount is increased by a measure of the national
growth percentage. In 2001, payments for M+C organizations will
be set at the floor amount in about one-third of all counties.
This section sets the minimum payment amount or floor
payment for aged enrollees in a Metropolitan Statistical Area
with a population of more than 250,000 at $525 in 2001. For all
other areas, the minimum would be $475. This provision would
not apply to M+C private fee-for service plans.
Section 402. 3 Percent minimum percentage update in 2001
The minimum increase rule under current law protects
counties that would otherwise receive only a small (if any)
increase. In 1998, the minimum rate for any payment area was
102% of its 1997 AAPCC. For each subsequent year, it will be
102% of its annual M+C per capita rate for the previous year.
All plans are subject to the same minimum increase.
This section allows plans to receive a 3.0% minimum update,
rather than the 2% minimum update for 2001.
Section 403. 10-year phase in of risk adjustment based on data from all
settings
M+C payments are risk adjusted to reflect variations in the
cost of providing health care among Medicare beneficiaries. For
example, if sicker and older patients all sign up for one M+C
plan, risk adjustment is designed to compensate the plan for
their above average health expenses.
BBA '97 required the Secretary of HHS to develop a risk
adjustment mechanism that uses variations in health status as
well as demographic factors to account for variations in costs.
Beginning in January 2000, the Health Care Financing
Administration implemented a new risk adjustment mechanism
built on 15 principal inpatient diagnostic cost groups (PIP-
DCGs). Payments are adjusted based on inpatient data using the
PIP-DCG adjuster and demographic factors, so that this system
accounts for both demographic and health-status variations.
Under this mechanism, the per capita payment made to a plan for
an enrollee is adjusted if that enrollee had an inpatient stay
during the previous year. Separate demographically-based
payments are used for enrollees without a prior
hospitalization, newly eligible aged persons, newly eligible
disabled Medicare enrollees, and others without a medical
history.
BBRA '99 slowed down the implementation of the Secretary's
proposed phase-in schedule of this system, through 2002. In
2000 and 2001, 10% of payments will include risk adjustment
using the PIP-DCG method and 90% will be based solely on the
older demographic method. In 2002, up to 20% of the payments
will be adjusted under the new system, with the remainder of
the payment based on adjustments under the old method. After
2002, the splits are not set in law, although the Secretary
originally planned to: (1) base 80% of payments on the PIP-DCG
system in 2003; and (2) develop a new risk adjustment system
for 2004 and beyond that would incorporate both inpatient and
outpatient diagnoses.
This provision phases in a new risk adjustment method based
on data from substantially all settings gradually over 10
years, in one-tenth increments, starting in 2004, or, if later,
the first year in which such data are used.
Section 404. Transition to revised Medicare+Choice payment rates
Under current law, M+C organizations which choose not to
renew their contract with HCFA or to reduce their service area
must notify HCFA in writing by July 1 of the year in which the
contract would end. (For example notification was due by July
3, 2000 (because July 1 fell on a Saturday) for contracts
ending December 31, 2000.)
Under this section, within 2 weeks after the date of
enactment of the bill, the Secretary of Health and Human
Services must announce revised M+C capitation rates for 2001,
due to changes from this legislation. Plans that previously
provided notice of their intention to terminate contracts or
reduce their service area for 2001 would have 4 weeks after
enactment of this Act to rescind their notice and submit an
ACR. Further, any M+C organization that would receive higher
capitation payments as a result of this bill must submit
revised ACR information within four weeks after the date of
enactment.
Subtitle B--Administrative Reforms
Section 411. Effectiveness of elections and changes of elections
The Balanced Budget Refinement Act changed BBA '97 to
specify that any request to enroll in or disenroll from a M+C
plan made after the 10th of the month will not be effective
until the first day of the second calendar month thereafter.
This provision reverses that policy and returns to the
policy in effect with the BBA '97, allowing individuals who
enroll in an M+C plan after the 10th day of the month to
receive coverage beginning on the first day of the next
calendar month, effective January 1, 2001.
Section 412. Medicare+Choice Program compatibility with employer or
union group health plans
This section grants the Secretary authority to waive
certain rules that hinder the design of or offering of
Medicare+Choice plans to employers and labor organizations,
thereby enabling employers and their retirees to take advantage
of the Medicare+Choice program.
Over the past few years, employers have increasingly relied
on health plans that participate in Medicare to meet their
retirees' health care needs. The growing participation in
Medicare health plans among employers and retirees reflects the
attractiveness over the fee-for-service Medicare program and
traditional indemnity retiree health benefits.
Many employers have turned to Medicare+Choice as a way to
continue offering coverage to their retirees. Certain BBA rules
related to enrollment effective dates and beneficiary
information (e.g., all beneficiaries receive the same
information), among others, have made it more difficult for
employers to offer Medicare+Choice plans to their retirees.
Section 413. Uniform premium and benefit
This section allows the Secretary to waive the BBA '97 rule
that Medicare+Choice organizations offer uniform benefits and
premiums across a service area without regard to different
payment levels in the service area. BBA '97 limited plans'
ability to continue or begin serving lower-payment counties,
just the opposite of the BBA '97 goal of expanded choice.
The Balanced Budget Act of 1997 required Medicare+Choice
plans to have a uniform benefit package and premium across a
service area. The Balanced Budget Act of 1999 modified this
requirement and allowed plans to break their ACR into service
areas which could be as small as a county. Under current law,
there is no requirement that you provide the same premium and
benefit level in two different counties in your service area.
However, plans must submit a separate ACR for each segment.
This provision would allow plans to vary benefits across
counties without submitting a separate ACR for each county. We
note, however, that the Health Care Financing Administration
still has the the ability to audit and monitor these situations
to ensure that plans continue to be accountable to the Medicare
program and its beneficiaries.
This provision is effective upon enactment.
TITLE V--MEDICAID
Subtitle A--General Provisions
Section 501. DSH allotments
Continuation of Medicaid DSH Allotments at Fiscal Year 2000
Levels. Medicaid requires States to make disproportionate share
(DSH) payments to certain hospitals treating large numbers of
low-income and Medicaid patients. Within broad Federal
guidelines, States determine the formulas used to make payments
to individual hospitals and to designate which hospitals
qualify for payments. Those payments are matched by the Federal
government at the Federal medical assistance percentage (FMAP),
the same percentage that applies to most other Medicaid
payments for benefits.
Provisions were included in the Balanced Budget Act of 1997
that made graduated reductions in DSH spending over time. The
formula-based DSH allotments were replaced with specific DSH
allotments for each State for FY1998 through 2002, with some
high DSH States (above 12%) taking reductions. After 2002, each
State's allotment will be equal to its allotment for the
previous year increased by the percentage change in the
consumer price index for the previous year. Each State's DSH
payments for FY2003 and beyond are limited to no more than 12%
of spending for medical assistance for that year.
The Committee's provision stops the reduction in allotments
to the high DSH States by freezing State-specific DSH
allotments for FY2001 at the FY2000 levels, and allow these
allotments to grow for inflation. For FY2001 and beyond, each
State's DSH allotment would be equal to its allotment for the
previous year increased by the percentage change in the
consumer price index for the previous year, subject to a
ceiling equal to 12% of that State's total medical assistance
payments in that year.
Special Rule For Medicaid DSH Allotment for Extremely Low
DSH States. The Committee's provision rebases Medicaid DSH
allotments for extremely low DSH States.
In the case of a State where the total FY1999 Federal and
State DSH expenditures (as reported to HCFA on August 31, 2000)
is less than one percent of the State's total medical
assistance expenditures during that fiscal year, the DSH
allotment for FY2001 must be increased to 1 percent of the
State's total amount of expenditures under their plan for such
assistance during that fiscal year. This new allotment becomes
the State's base allotment for the purposes of applying section
501(a) in future years, and these States would be allowed to
grow at CPI-U with the rest of the States. This provision does
not apply to Hawaii and Tennessee, which do not have DSH
programs.
District of Columbia. The DSH allotment for the District of
Colombia is set at $32 million for FY2000.
For the purpose of calculating the FY2001 allotment, the
Committee's provision would increase the FY2000 DSH allotment
for the District of Columbia to $49 million. This change is
intended to compensate for a technical error in calculating the
District's 1995 DSH allotment.
Contingent Allotment for Tennessee. Some States in the past
obtained waivers of certain Medicaid provisions for a number of
purposes including requiring Medicaid beneficiaries to enroll
in managed care organizations (MCOs), or limiting MCO services
to a specific population or geographic area or to expand the
program to individuals who would not otherwise be eligible for
Medicaid. These renewable waivers are authorized under sections
1915(b), 1915(c), or 1115 of the Medicaid law. These waivers
are required to be budget neutral so oftentimes, the States
discontinued their regular DSH programs and used Federal share
DSH allotments to help offset the costs of the program
expansions.
If Tennessee's State-wide section 1115 Medicaid waiver
program is revoked or terminated, the Committee's provision
sets Tennessee's FY2001 DSH allotment equal to $286,442,437 so
that it could re-institute a regular DSH program and resume DSH
payments to hospitals.
Assuring Identification of Medicaid Managed Care Patients.
Medicaid requires States to make disproportionate share (DSH)
payments to certain hospitals treating large numbers of low-
income and Medicaid patients. Within broad Federal guidelines,
States determine the formulas used to make payments to
individual hospitals and to designate which hospitals qualify
for payments. Those payments are matched by the Federal
government at the Federal medical assistance percentage (FMAP),
the same percentage that applies to most other Medicaid
payments for benefits.
States may provide disproportionate share payments to those
hospitals whose Medicaid inpatient utilization rate is at least
one standard deviation above the mean Medicaid inpatient
utilization rate for all hospitals receiving Medicaid payments
in the State, and must provide payments to those with a low-
income utilization rate above 25 percent. The Medicaid
inpatient utilization rate is in part based on the number of
inpatient days attributable to Medicaid beneficiaries. The low-
income utilization rate includes the total revenues paid on
behalf of Medicaid beneficiaries.
The Committee's provision clarifies that Medicaid enrollees
of managed care organizations and primary care case management
organizations are to be included for the purposes of
calculating the Medicaid inpatient utilization rate and the
low-income utilization rate. With the move to managed care, the
fee-for-service number by itself is no longer an accurate
representation of Medicaid utilization. The State must include
in their MCO contracts information that allows the State to
determine which hospital services are provided to Medicaid
beneficiaries through managed care. The Committee's provision
would also requires States to include a sponsorship code for
the managed care entity on the Medicaid beneficiary's
identification card.
This section is effective January 1, 2001.
Section 502. New prospective payment system for federally-qualified
health centers and rural health clinics
Under the Balanced Budget Act of 1997, Congress repealed
the requirement that States pay Federally Qualified Health
Centers (FQHCs) based on costs incurred in providing care
(cost-based reimbursement). States now pay Federally Qualified
Health Centers and Rural Health Clinics (RHCs) a percentage of
the facilities' reasonable costs for providing services. This
percentage decreases for specified fiscal years--100% of costs
for services furnished during FY1998 and FY1999; 95% for FY2001
and FY2002; 90% for FY2003; 85% for FY2004; and cost-based
reimbursement will expire in 2005. Two special payment rules
are applicable during FY1998-FY2002. In the case of a contract
between an FQHC or RHC and a managed care organization (MCO),
the MCO must pay the FQHC or RHC at least as much as it would
pay any other provider for similar services. States are
required to make supplemental payments to the FQHCs and RHCs,
equal to the difference between the contracted amounts and the
cost-based amounts.
The Committee's provision creates a new Medicaid
prospective payment system for FQHCs and RHCs beginning in
FY2001. An average of the reasonable costs incurred in FY 1999
and 2000 will form the base for prospective payments beginning
in FY 2001 to FQHCs and RHCs. This amount will take into
account any increase or decrease in the scope of services
furnished. For entities first qualifying as FQHCs or RHCs after
2000, the per visit payments will begin in the first year that
the center or clinic attains such qualification and are to be
based on 100% of the costs incurred during that year based on
the rates established for similar centers or clinics with
similar caseloads in the same adjacent geographic area. In the
absence of such similar centers or clinics, the methodology
would be based on that used for developing rates for
established FQHCs or RHCs or a methodology established by the
Secretary.
For subsequent fiscal years, per visit payments for all
FQHCs and RHCs are equal to amounts for the preceding fiscal
year increased by the percentage increase or decrease in the
Medicare Economic Index applicable to primary care services for
that fiscal year, and adjusted for any increase in the scope of
services furnished during that fiscal year. In managed care
contracts, States must make supplemental payments to the center
or clinic equal to the difference between contracted amounts
and the prospective payment system amounts. Those payments are
to be paid on a schedule mutually agreed to by the State and
the FQHC or RHC. Alternative payment methods are permitted only
when payments are at least equal to amounts otherwise provided.
The Committee's provision also directs the Comptroller
General to provide for a study on how to rebase or refine cost
payment methods for the services of FQHCs and RHCs. The report
is due to Congress no later than 4 years after the date of
enactment.
This section is effective October 1, 2000.
Section 503. Optional coverage of legal immigrants under the Medicaid
program
For the purposes of determining alien eligibility for
Federal benefits, the law recognizes two general categories of
aliens: qualified and non-qualified aliens. Qualified aliens
include legal permanent residents, refugees, aliens paroled
into the United States for at least 1 year, aliens granted
asylum or related relief, certain abused spouses and children
and Cuban-Haitian entrants. Non-qualified aliens are other non-
citizens, including illegal aliens, aliens admitted for a
temporary purpose, such as tourists and foreign students,
short-term parolees, asylum applicants, and various classes or
aliens granted temporary permission to remain.
In general, non-qualified aliens are not eligible for
Federal medical assistance under title XIX except in the case
of medical emergency.
In addition, States are required to cover certain
categories of aliens provided they meet the State's financial
and other eligibility criteria. These groups include: (1)
veterans or persons on active military duty; (2) refugees,
asylees, and Cuban and Haitian entrants for seven years after
entry, and Amerasians for five years after entry; (3) lawful
permanent residents who can be credited with 40 quarters of
Social Security coverage; and (4) Canadian- and Mexican-born
immigrants of at least 50% North American Native heritage.
Legal immigrants who were receiving SSI (and related Medicaid)
as of August 22, 1996 continue to be eligible. In addition,
those who were here by August 22, 1996, and subsequently became
disabled are also eligible for SSI and related Medicaid.
Other lawfully residing aliens may become eligible for
Medicaid at State option subject to their State's financial and
other criteria, for example, aliens residing in the United
States before August 22, 1996. Those entering the United States
after August 22, 1996 are barred for 5 years from all but
emergency medical assistance. After 5 years, they may become
eligible for full Medicaid at State option.
Aliens entering with sponsors after December 19, 1997 are
subject to the ``deeming rule,'' under which the sponsors'
income and resources are deemed to be available to the
immigrant in determining the immigrant's financial eligibility
for benefits until the immigrant becomes a citizen or meets the
10-year work requirement or is credited with 40 quarters of
work by SSA.
The Committee's provision amends title XIX to allow States
the option of extending Medicaid coverage to pregnant women
(during pregnancy and for 60 days following birth) or children
who would not otherwise qualify under the 1996 welfare reform
law provisions pertaining to eligibility for lawfully residing
illegal immigrants. To qualify, the pregnant woman or children
must meet all other Medicaid eligibility requirements and must
have been lawfully residing in the United States for at least 2
years. States could elect to apply the new option to immigrant
pregnant women, immigrant children, or both.
In a State that elects to provide Medical assistance to
pregnant women and children under this provision, action may
not be brought under an affidavit of support against the
sponsor of such an alien on the basis of the medical care
received. In a State that elects this option, the provisions of
the law that might restrict participation in Medicaid of
immigrants who have lawfully resided in the country for at
least two years would cease to apply. Additionally, if a State
chooses to cover these immigrants, sponsors would not incur a
debt for the cost of Medicaid benefits provided to immigrants
under the election and sponsors would not be asked to repay the
value of the medical care received after the two year period
had been met. Under section 602, States electing to apply the
new option to immigrant children in Medicaid would also be
permitted to extend coverage to them in SCHIP under the same
terms.
This section is effective October 1, 2000.
Section 504. Additional entities qualified to determine Medicaid
presumptive eligibility for low-income children
Qualified Entities to Determine Presumptive Eligibility for
Low- Income Children. Currently, States have the option of
extending what is known as ``presumptive eligibility'' to two
categories of Medicaid beneficiaries--pregnant women and
children under 19 years of age. Presumptive eligibility allows
such individuals whose family income appears to be below the
State's Medicaid income standards to enroll temporarily in
Medicaid, until a final formal determination of eligibility is
made. The primary purpose of this option is to make needed
services immediately available to these specified groups.
Presumptive eligibility has been permitted for pregnant women
since 1986, and for children under 19 since 1997.
The law defines the entities permitted to make presumptive
eligibility determinations. For children, qualified entities
include Medicaid providers, or agencies authorized to determine
eligibility for Head Start programs, subsidized child care
(under the Child Care and Development Block Grant), or the
Special Supplemental Food Program for Women, Infants and
Children (WIC).
For pregnant women, a qualified entity is a provider that:
(1) is eligible to receive payments under Medicaid, and
provides services of the types delivered by outpatient
hospitals, Rural Health Clinics, Federally Qualified Health
Centers, or other clinics, and has been designated by the State
as being capable of making presumptive eligibility
determinations, and receives funds under the Consolidated
Health Centers program or the Rural Health Outreach, Network
Development and Telemedicine Grant, or the Maternal and Child
Health Services Block Grant Program, or the Health Services for
Urban Indians program; (2) participates in a program
established under the Special Supplemental Food Program for
Women, Infants and Children (WIC) or the Commodity Supplemental
Food Program; (3) participates in a State perinatal program; or
(4) is the Indian Health Service or a health program or
facility operated by the tribe or tribal organization under the
Indian Self Determination Act.
The Committee's provision adds several new entities to the
list of those qualified to make Medicaid presumptive
eligibility determinations for low-income children and pregnant
women, including (1) those authorized to determine eligibility
for children under Medicaid (title XIX) or the State Children's
Health Insurance Program (title XXI); (2) elementary or
secondary schools as defined in the Elementary and Secondary
Education Act of 1965; (3) elementary or secondary schools
operated or supported by the Bureau of Indian Affairs; (4)
State or tribal child support enforcement agencies; (5) child
care resource and referral agencies; (6) organizations
providing emergency food and shelter under a grant through the
Stewart B. McKinney Homeless Assistance Act; (7) State or
tribal offices or entities involved in enrollment under
Medicaid, the Temporary Assistance for Needy Families program
(part A of title IV), the State Children Health Insurance
Program, or that determines eligibility for assistance or
benefits provided under any program of public or assisted
housing that receives Federal funds, including the program
under Section 8 or any other section of the United States
Housing Act of 1937 or under the Native American Housing
Assistance and Self-Determination Act of 1996; or (8) any other
entity deemed by a State, as approved by the Secretary of
Health and Human Services (HHS).
The entities included in this provision are all locations
that interact with individuals who may be potentially eligible
for health insurance through Medicaid or SCHIP. These entities
may have access to the family's income information and could
cross reference State Medicaid and SCHIP income eligibility
guidelines to determine whether or not the children or pregnant
women would qualify for health insurance based on income. This
provision does not change current law that requires the State
to make the ultimate eligibility determination.
This section is effective October 1, 2000.
Application of Presumptive Eligibility Provisions to the
State Children's Health Insurance Program. States' allotments
under the State Children's Health Insurance Program (SCHIP;
title XXI of the Social Security Act) are made available to pay
only the Federal share of costs associated with separate (non-
Medicaid) SCHIP programs. The Federal share of costs associated
with Medicaid expansions under SCHIP are paid for under
Medicaid. State SCHIP allotments are reduced by the amounts
paid under Medicaid for SCHIP Medicaid expansion costs.
Medicaid's presumptive eligibility option allows States to
enroll temporarily children whose family income appears to be
below the State's applicable income standards, until a final
formal determination of eligibility is made. Benefits provided
during periods of presumptive eligibility to Medicaid children,
both those presumed to be eligible under regular Medicaid and
those presumed to be eligible under SCHIP Medicaid expansions,
are paid out of title XIX and are counted against a State's
SCHIP allotment.
There is no express provision for the treatment of
presumptive eligibility under separate (non-Medicaid) SCHIP
programs. However, the Secretary of Health and Human Services
permits States to develop an equivalent procedure for separate
(non-Medicaid) SCHIP programs. Expenditures associated with
presumptive eligibility for children who are eventually
determined to be ineligible for Medicaid (under title XIX or
under a Medicaid expansion under SCHIP) or for a separate (non-
Medicaid) SCHIP program are counted against title XXI
allotments under the health service initiatives option. Health
service initiatives, direct purchase of services to provide
child health assistance, outreach activities and other
reasonable costs to administer the program are treated as
administrative expenses. All administrative expenses are
subject to an overall limit of 10% of total program spending
per fiscal year.
The Committee's provision would clarify States' authority
to conduct presumptive eligibility, as defined in title XIX and
amended by the previous provision, under separate (non-
Medicaid) SCHIP programs.
This section is effective October 1, 2000.
Section 505. Improving welfare-to-work transition under the Medicaid
program
Eligibility for Temporary Assistance for Needy Families
(TANF) does not confer automatic Medicaid eligibility.
Nonetheless, current law preserves Medicaid entitlement for
individuals who meet the requirements for the former Aid to
Families with Dependent Children (AFDC) programs that were in
effect in States on July 16, 1996, even if they do not qualify
for assistance under TANF. This group was created to ensure
that certain low-income families do not lose their Medicaid
eligibility as a result of welfare reform. States are required
to use the eligibility determination processes that were
already in place for AFDC and Medicaid, including the same
income and resource standards and other rules formerly used to
determine if a family's income and composition made it eligible
for AFDC and Medicaid. States may modify their ``pre-reform''
AFDC income and resource standards as follows: (1) States may
lower their income eligibility standards, but not below those
used on May 1, 1988, (2) States may increase their income and
resource standards up to the percentage increase in the
Consumer Price Index (CPI), and (3) States may use less
restrictive income and resource methodologies than those in
effect on July 16, 1996.
Transitional medical assistance (TMA) under Medicaid was
created to address the concern that the loss of Medicaid for
individuals who successfully obtain employment would be a
disincentive to seeking and keeping jobs. States are required
to continue Medicaid for 6 months for families included in the
group (described above) who received Medicaid in at least 3 of
the last 6 months preceding the month in which the family lost
Medicaid coverage due to increased hours of employment,
increased earnings of the caretaker relative, or the family
member's loss of one of the time limited earned income
disregards. States must extend Medicaid coverage for an
additional 6 months for families that were covered during the
entire first 6-month period, and are earning below 185% of the
Federal poverty line. The TMA provision will sunset at the end
of fiscal year 2001.
States must adhere to certain notification requirements for
TMA. During the initial 6-month extension period, at specified
intervals, States must notify qualifying families about: (1)
their option for an additional 6 months of Medicaid coverage,
(2) the reporting requirements applicable to the initial
extension period and the additional extension period, (3)
whether premiums are required for extended assistance,
including premiums required in the first 3 months of the
additional 6-month extension, and (4) other out-of-pocket
expenses, benefits, reporting and payment procedures and any
pre- existing condition limitations, waiting periods, or other
coverage limitations imposed under any alternative coverage
options offered. During the additional 6-month extension
period, States must notify qualifying families about the
reporting requirements applicable to this period of extension
and the amount of any premium required for such extended
assistance for the final 3 months of coverage.
To qualify for TMA, families must meet certain reporting
requirements. Families receiving the initial 6 months of TMA
must report gross monthly earnings and the monthly costs of
employment-related child care for months 1 through 3 of this
period. Such reporting is a condition for eligibility for the
additional 6 months of TMA. During the second 6 months of TMA,
families must report the same financial information for months
4 through 9. Thus, families who qualify for the full 12 months
of TMA must report gross earnings and employment-related child
care costs for each of months 1 through 9.
The Committee's provision extends the sunset on the TMA
provision by one year to fiscal year 2002. It also gives States
the option to waive reporting requirements for families
qualifying for up to 12 months of TMA (and the corresponding
obligation of States to notify families of these reporting
requirements).
Individuals who are eligible for TMA are automatically
eligible for the first six months. The only requirement that
beneficiaries must meet during this period is to have a
dependent child living in the home. This provision would allow
States the option to eliminate this reporting requirement
during the first six months.
The provision gives States the option to eliminate the
reporting requirements laid out in the statute for the second
six months as well. The provision does not in any way alter the
requirement that families' incomes do not exceed 185% of
poverty. States must continue to ensure that families meet the
income requirements to continue to be eligible. The provision
in the Committee's bill would allow States the flexibility to
look to the regular eligibility redetermination rules and
procedures (rather than mandate that they follow the statutory
requirements) to ensure that families continue to meet the
requirements for eligibility. For example, the Health Care
Financing Administration recently notified States of States'
ability to do ex parte determinations using existing current
information that beneficiaries have filed for other programs to
determine and redetermine eligibility, rather than requiring
individuals to present in the State office at each interval.
This provision will give States more flexibility in managing
their programs and alleviate burden on beneficiaries as well.
Finally, the Committee's provision makes TMA an option,
rather than a requirement, for the subset of States that
already cover individuals in this group at or above 185% of
poverty. States that are already covering these individuals in
their Medicaid program and are meeting Medicaid eligibility
requirements will be deemed to have met the TMA requirements.
The Committee believes this option is in keeping with its
desire to reduce burdensome or overly prescriptive requirements
on States and beneficiaries without decreasing accountability
or access.
This section is effective October 1, 2000.
Section 506. Medicaid county-organized health systems
Health insuring organizations (HIOs) are county-sponsored
health maintenance organizations which are currently providing
care to a limited number of beneficiaries in the California
Medicaid program. Currently, five HIOs operate in seven
California counties. These entities are exempt from certain
Federal statutory requirements for Medicaid HMO contracts if
the HIOs enroll no more than 10 percent of all Medicaid
beneficiaries in these California counties (not counting
qualified Medicare beneficiaries.)
The committee's provision allows the current exemption from
Medicaid HMO contracting requirements to continue to apply as
long as no more than 14% of all Medicaid beneficiaries in these
California counties are enrolled in those HIOs.
This provision is effective upon enactment of this
legislation.
Section 507. Medicaid recognition for services of physician assistants
The Federal Medicaid statute lists services that qualify as
Medicaid benefits. Federal matching payments are available
toward the cost of items on the list, if covered by State
Medicaid programs. States are required to cover certain of
those listed items and may choose to cover other items on the
list. Congress recognized the services of physician assistants
for Medicare in the Balanced Budget Act of 1997. However, a
parallel change was not made in Medicaid. Currently, all but
three States cover the services of physician assistants under
Medicaid.
The Committee's provision includes services provided by
physician assistants as Medicaid recognized benefits as long as
the services are provided under the supervision of a physician
and are authorized under State law. The services of physician
assistants would be an optional Medicaid benefit.
This section is effective upon enactment.
TITLE VI--STATE CHILDREN'S HEALTH INSURANCE PROGRAM
Section 601. Special rule for availability and redistribution of unused
fiscal year 1998 and 1999 SCHIP allotments
Title XXI of the Social Security Act, the State Children's
Health Insurance Program, authorizes and appropriates funds for
SCHIP for FY1998 through FY2007. To receive Federal funds,
States must submit a plan describing their program to the
Health Care Financing Administration for approval. In order to
access FY1998 allotments, States must have had such approval
prior to October 1, 1999. Allotment of funds among the States
is determined by a formula set in law. This formula is based on
a combination of the number of low-income children and low-
income uninsured children in the State, and includes a cost
factor that represents the average wages in the State compared
to the national average.
SCHIP funds not drawn down from a State's Federal allotment
by the end of each fiscal year continue to be available for 2
additional fiscal years, giving each State a total of 3 years
to draw down its allotment of Federal matching funds from a
given year.
FY1998 allotments not spent by the end of FY2000 (as of
September 30, 2000) and FY1999 funds not spent by the end of
FY2001 (as of September 30, 2001) will be redistributed by a
method to be determined by the Secretary of Health and Human
Services (HHS) to States that have fully expended their
existing FY1998 or FY1999 allotments respectively and are able
to provide required matching funds. Redistributed funds not
spent by the end of the fiscal year in which they are
reallocated will officially expire and return to the Federal
Treasury.
Health service initiatives, direct purchase of services to
provide child health assistance, outreach activities and other
reasonable costs to administer the program are treated as
administrative expenses. All administrative expenses are
subject to an overall limit of 10% of total program spending
per fiscal year.
The Committee's provision establishes a new method for
distributing unspent FY1998 and FY1999 allotments to States and
territories.
For FY1998, each State (and the District of Columbia) that
uses all its SCHIP allotment would receive from the pool of
unspent 1998 funds, the amount of its expenditures in excess of
its original exhausted allotment. For FY1998, each territory
(and commonwealth) that expends all its 1998 SCHIP allotment
would receive an amount that bears the same ratio to 1.05
percent of the total amount available for redistribution
(across all States and territories) as the ratio of its
original allotment to the total FY1998 allotment for all
territories. For such States and territories, the same
redistribution methods apply with respect to FY1999 funds. The
States which have exhausted their 1998 and/or 1999 allotments
would have two years to expend the funds which they receive
through this process.
For FY1998, each State that did not use all its SCHIP
allotment would receive an amount equal to the total amount of
unspent 1998 funds, less the amounts distributed to States that
fully exhausted their original allotments (described in the
paragraph above), multiplied by the ratio of its unspent
original 1998 allotment to the total amount of unspent 1998
funds. For such States, the same redistribution methods apply
with respect to FY1999 funds. The amount of unspent FY1998 and
FY1999 funds provided to these States that had not fully spent
their allotments for these years would remain available to them
through the end of FY2002. These States may use up to 10% of
the retained FY1998 funds for outreach activities, in addition
to amounts spent under the 10% administration cap under current
law. However, the States which have already exhausted their
1998 and/or 1999 allotments will not be able use 10% of this
additional allotment for outreach.
To calculate the amounts available for redistribution in
each formula described above, the Secretary will use amounts
reported by States not later than November 30 of the relevant
fiscal year on HCFA Form 64 or HCFA Form 21, as approved by the
Secretary.
This section is effective upon enactment.
Section 602. Optional coverage of legal immigrants under SCHIP
For States choosing to provide health insurance coverage
through a Medicaid expansion under SCHIP, legal immigrant
children are subject to the same Medicaid restrictions as other
legal immigrants. States that operate a separate State (non-
Medicaid) SCHIP program must cover those legal immigrant
children who meet the Federal definition of qualified alien and
who are otherwise eligible. These include: (1) all qualified
alien children who were in the United States before August 22,
1996; (2) refugees, asylees, and certain Cuban, Haitian and
Amerasian immigrants; (3) unmarried, dependent children of
veterans and active duty service members of the Armed Forces;
and (4) qualified alien children who enter the United States on
or after August 22, 1996 as lawful permanent residents and who
are in continuous residence for 5 years--before 5 years of
continuous residence, qualified alien children are barred from
participation in SCHIP. States that operate separate State
programs also may cover battered immigrants as determined by
INS provided the qualified alien child is otherwise eligible
for the program.
In the case of qualified alien children entering with
sponsors after December 19, 1997, SCHIP coverage is subject to
the ``deeming rule,'' under which the sponsors' income and
resources are deemed to be available to the qualified alien
child in determining their eligibility for benefits until the
child becomes a citizen or meets the 10-year work requirement.
The Committee's provision adds a new State option to SCHIP
that would allow States to expand health insurance coverage to
lawfully residing alien children who are otherwise eligible for
SCHIP and who have been lawfully residing in the United States
for 2 years. In a State that elects this option, the provisions
of the 1996 welfare reform law that might restrict the
participation in SCHIP of immigrants who have lawfully resided
in the country for at least two years would cease to apply. In
addition, if a State chooses to cover these immigrants,
sponsors would not incur a debt for the cost of SCHIP benefits
provided to immigrants under the election and sponsors would
not be asked to repay the value of the medical care received
after the two year period had been met. The option to expand
coverage to this group under SCHIP would only be available to
States that have opted to expand coverage to this category of
children under their Medicaid State plan.
This section is effective October 1, 2000.
TITLE VII--EXTENSION OF SPECIAL DIABETES GRANT PROGRAMS
Section 701. Extension of juvenile and Indian diabetes grant programs
Juvenile Diabetes Research Program. The Balanced Budget Act
of 1997 amended title III of the Public Health Service Act to
create a grant program under which the Secretary could make
grants to support prevention and treatment services of, and
research relating to, type 1 diabetes in children. Congress
committed $150 million, ($30 million each year over 5 years
FY1998 through FY2002), for this program, with the funds being
transferred from title XXI of the Social Security Act (State
Children's Health Insurance Program) for these grants. This
commitment was in addition to the annual appropriations for
NIH.
The Committee's provision extends appropriated funds from
the Treasury to be made available for diabetes grants, bringing
the total to $50 million each for FY2003 and FY2007. The funds
will remain available until expended. The funds may not be
derived or deducted from the State Children's Health Insurance
Program.
This section is effective upon enactment.
Indian Diabetes Grant Program. The Balanced Budget Act of
1997 amended title III of the Public Health Service Act to
create a grant program under which the Secretary could make
grants to support prevention and treatment services of diabetes
in Indians. These grants were to purchase services provided
through one or more of the following entities: the Indian
Health Service, a tribal Indian health program, and an urban
Indian health program. Congress committed $150 million, ($30
million each year over 5 years FY1998 through FY2002), for this
program, with the funds being transferred from Title XXI of the
Social Security Act (State Children's Health Insurance Program)
for these grants.
The Committee's provision extends appropriated funds
available from the Treasury for diabetes prevention and
treatment programs for Indians, bringing the total to $50
million each for FY2003 and FY2007. The funds will remain
available until expended. The funds may not be derived or
deducted from the State Children's Health Insurance Program.
This section is effective upon enactment.
Extension of Reports on Grant Programs. The Balanced Budget
Act of 1997 required that the Secretary conduct an evaluation
of the diabetes grant programs established under this section
and report to the appropriate committees of Congress an interim
report on January 1, 2000, and a final report on January 1,
2002.
The Committee's provision extends the interim report
requirements to every two years, 2000, 2002, 2004, with a final
report due on January 1, 2007.
This section is effective upon enactment.
Changes in Existing Law Made by the Bill, as Reported
In compliance with clause 3(e) of rule XIII of the Rules of
the House of Representatives, changes in existing law made by
the bill, as reported, are shown as follows (existing law
proposed to be omitted is enclosed in black brackets, new
matter is printed in italic, existing law in which no change is
proposed is shown in roman):
SOCIAL SECURITY ACT
* * * * * * *
TITLE II--FEDERAL OLD-AGE, SURVIVORS, AND DISABILITY INSURANCE BENEFITS
* * * * * * *
entitlement to hospital insurance benefits
Sec. 226. (a) * * *
* * * * * * *
(h) For purposes of applying this section in the case of an
individual medically determined to have amyotrophic lateral
sclerosis (ALS), the following special rules apply:
(1) Subsection (b) shall be applied as if there were
no requirement for any entitlement to benefits, or
status, for a period longer than 1 month.
(2) The entitlement under such subsection shall begin
with the first month (rather than twenty-fifth month)
of entitlement or status.
(3) Subsection (f) shall not be applied.
* * * * * * *
[(h)] (j) For entitlement to hospital insurance benefits in
the case of certain uninsured individuals, see section 103 of
the Social Security Amendments of 1965.
* * * * * * *
TITLE XI--GENERAL PROVISIONS, PEER REVIEW, AND ADMINISTRATIVE
SIMPLIFICATION
* * * * * * *
guidance regarding application of health care fraud and abuse sanctions
Sec. 1128D. (a) * * *
* * * * * * *
(b) Advisory Opinions.--
(1) * * *
* * * * * * *
(6) Application of subsection.--This subsection shall
apply to requests for advisory opinions made on or
after the date which is 6 months after the date of
enactment of this section [and before the date which is
4 years after such date of enactment].
(7) Nondisclosure of requests and supporting
materials.--A request for an advisory opinion under
this subsection and any supporting written materials
submitted by the party requesting the opinion shall not
be subject to disclosure under section 552 of title 5,
United States Code.
* * * * * * *
functions of peer review organizations
Sec. 1154. (a) Any utilization and quality control peer
review organization entering into a contract with the Secretary
under this part must perform the following functions:
(1) * * *
* * * * * * *
(12) The organization shall assist providers,
practitioners, and Medicare+Choice organizations in
identifying and developing strategies to reduce the
incidence of actual and potential medical errors and
problems related to patient safety affecting
individuals entitled to benefits under title XVIII. For
the purposes of this part and title XVIII, the
functions described in this paragraph shall be treated
as a review function.
* * * * * * *
TITLE XVIII--HEALTH INSURANCE FOR THE AGED AND DISABLED
* * * * * * *
notice of medicare benefits; medicare and medigap information
Sec. 1804. (a) * * *
* * * * * * *
(d) Availability of Application Forms for Medical Assistance
for Medicare Cost-Sharing.--The Secretary shall make available
to the Commissioner of Social Security appropriate forms for
applying for medical assistance for medicare cost-sharing under
a State plan under title XIX. Such Commissioner, through local
offices of the Social Security Administration shall--
(1) notify applicants and beneficiaries who present
at a local office orally of the availability of such
forms and make such forms available to such individuals
upon request; and
(2) provide assistance to such individuals in
completing such forms and, upon request, in submitting
such forms to the appropriate State agency.
* * * * * * *
Part A--Hospital Insurance Benefits for the Aged and Disabled
* * * * * * *
CONDITIONS OF AND LIMITATIONS ON PAYMENT FOR SERVICES
Requirement of Requests and Certifications
Sec. 1814. (a) Except as provided in subsections (d) and (g)
and in section 1876, payment for services furnished an
individual may be made only to providers of services which are
eligible therefor under section 1866 and only if--
(1) * * *
* * * * * * *
To the extent provided by regulations, the certification and
recertification requirements of paragraph (2) shall be deemed
satisfied where, at a later date, a physician, nurse
practitioner, or clinical nurse specialist (as the case may be)
makes certification of the kind provided in subparagraph (A),
(B), (C), or (D) of paragraph (2) (whichever would have
applied), but only where such certification is accompanied by
such medical and other evidence as may be required by such
regulations. With respect to the physician certification
required by paragraph (2) for home health services furnished to
any individual by a home health agency (other than an agency
which is a governmental entity) and with respect to the
establishment and review of a plan for such services, the
Secretary shall prescribe regulations which shall become
effective no later than July 1, 1981, and which prohibit a
physician who has a significant ownership interest in, or a
significant financial or contractual relationship with, such
home health agency from performing such certification and from
establishing or reviewing such plan, except that such
prohibition shall not apply with respect to a home health
agency which is a sole community home health agency (as
determined by the Secretary). For purposes of the preceding
sentence, service by a physician as an uncompensated officer or
director of a home health agency shall not constitute having a
significant ownership interest in, or a significant financial
or contractual relationship with, such agency. For purposes of
paragraph (2)(C), an individual shall be considered to be
``confined to his home'' if the individual has a condition, due
to an illness or injury, that restricts the ability of the
individual to leave his or her home except with the assistance
of another individual or the aid of a supportive device (such
as crutches, a cane, a wheelchair, or a walker), or if the
individual has a condition such that leaving his or her home is
medically contraindicated. While an individual does not have to
be bedridden to be considered ``confined to his home'', the
condition of the individual should be such that there exists a
normal inability to leave home, that leaving home requires a
considerable and taxing effort by the individual, and that
absences of the individual from home are infrequent or of
relatively short duration, or are attributable to the need to
receive medical treatment[.], including participating in an
adult day care program licensed or certified by a State, or
accredited, to furnish adult day care services in the State for
the purposes of therapeutic treatment for Alzheimer's disease
or a related dementia.
* * * * * * *
Part B--Supplementary Medical Insurance Benefits for the Aged and
Disabled
* * * * * * *
PAYMENT OF BENEFITS
Sec. 1833. (a) * * *
* * * * * * *
(g)(1) * * *
* * * * * * *
(4) This subsection shall not apply to expenses incurred with
respect to services furnished during 2000 [and 2001], 2001, and
2002.
(h)(1)(A) * * *
(B) [In] Except for tests described in subparagraph (E), in
the case of clinical diagnostic laboratory tests performed by a
physician or by a laboratory (other than tests performed by a
qualified hospital laboratory (as defined in subparagraph (D))
for outpatients of such hospital), the fee schedules
established under subparagraph (A) shall be established on a
regional, statewide, or carrier service area basis (as the
Secretary may determine to be appropriate) for tests furnished
on or after July 1, 1984.
* * * * * * *
(E) In the case of a clinical diagnostic laboratory test
which is described by a new code in the Health Care Financing
Administration Common Procedure Coding System (commonly
referred to as ``HCPCS''), for which the Secretary is not able
to crosswalk with a similar test with an established schedule
amount, the Secretary shall establish for purposes of
subparagraph (A) a single fee schedule amount for all areas in
the following manner:
(i) By not later than December 1 of each year,
beginning with 2001, the Secretary shall cause to have
published in the Federal Register (which may include
publication on an interim final rule basis with a
comment period) an interim fee schedule amount for each
such new test which shall apply for such new tests
furnished during the following year.
(ii) The interim fee schedule amount for each such
new test shall be subject to a comment period of 60
days. The Secretary shall review comments and data
received and make appropriate adjustments to the fee
schedule for each test applicable beginning with the
following calendar year.
(iii) For years beginning with 2002, the Secretary
shall also cause to have published in the Federal
Register by not later than December 1 of the year prior
to its application, the adjustments to the interim fee
schedule amount described in clause (ii) for each such
new test for which an interim fee schedule amount was
established for a year, including adjustments to such
fee schedule amounts in response to comments.
(2)(A)(i) Except as provided in paragraph (4), the Secretary
shall set the fee schedules at 60 percent (or, in the case of a
test performed by a qualified hospital laboratory (as defined
in paragraph (1)(D)) for outpatients of such hospital, 62
percent) of the prevailing charge level determined pursuant to
the third and fourth sentences of section 1842(b)(3) for
similar clinical diagnostic laboratory tests for the applicable
region, State, or area for the 12-month period beginning [July
1, 1984,] July 1, 1984. The fee schedules established under the
previous sentence and paragraph (1)(E)(3) shall be adjusted
annually (to become effective on January 1 of each year) by a
percentage increase or decrease equal to the percentage
increase or decrease in the Consumer Price Index for All Urban
Consumers (United States city average), and subject to such
other adjustments as the Secretary determines are justified by
technological changes.
* * * * * * *
(4)(A) * * *
(B) For purposes of subsections (a)(1)(D)(i) and
(a)(2)(D)(i), the limitation amount for a clinical diagnostic
laboratory test performed--
(i) * * *
* * * * * * *
(viii) after December 31, 1997, is equal to 74
percent of such median (or 100 percent of such median
in the case of a clinical diagnostic laboratory test
performed on or after January 1, 2001, that the
Secretary determines is a new test for which no
limitation amount has previously been established under
this subparagraph).
* * * * * * *
(t) Prospective Payment System for Hospital Outpatient
Department Services.--
(1) * * *
* * * * * * *
(2) System requirements.--Under the payment system--
(A) * * *
* * * * * * *
(E) the Secretary shall establish, in a
budget neutral manner, outlier adjustments
under paragraph (5) and transitional pass-
through payments under paragraph (6) and other
adjustments as determined to be necessary to
ensure equitable payments, such as adjustments
for certain classes of hospitals; [and]
(F) the Secretary shall develop a method for
controlling unnecessary increases in the volume
of covered OPD services[.]; and
(G) the Secretary shall create additional
groups of covered OPD services that classify
separately those procedures that utilize
contrast media from those that do not.
* * * * * * *
(6) Transitional pass-through for additional costs of
innovative medical devices, drugs, and biologicals.--
(A) In general.--The Secretary shall provide
for an additional payment under this paragraph
for any of the following that are provided as
part of a covered OPD service (or group of
services):
(i) * * *
* * * * * * *
(iv) New medical devices, drugs, and
biologicals.--A medical device, drug,
or biological not described in clause
(i), (ii), or (iii) if--
(I) * * *
(II) [the cost of the device,
drug, or biological] the cost
of the drug or biological or
the average cost of the
category of devices is not
insignificant in relation to
the OPD fee schedule amount (as
calculated under paragraph
(3)(D)) payable for the service
(or group of services)
involved.
[(B) Limited period of payment.--The payment
under this paragraph with respect to a medical
device, drug, or biological shall only apply
during a period of at least 2 years, but not
more than 3 years, that begins--
[(i) on the first date this
subsection is implemented in the case
of a drug, biological, or device
described in clause (i), (ii), or (iii)
of subparagraph (A) and in the case of
a device, drug, or biological described
in subparagraph (A)(iv) and for which
payment under this part is made as an
outpatient hospital service before such
first date; or
[(ii) in the case of a device, drug,
or biological described in subparagraph
(A)(iv) not described in clause (i), on
the first date on which payment is made
under this part for the device, drug,
or biological as an outpatient hospital
service.]
(B) Use of categories in determining
eligibility of a device for pass-through
payments.--The Secretary shall determine
whether a medical device meets the requirements
of subparagraph (A)(iv) as follows:
(i) Establishment of categories.--The
Secretary shall establish categories of
medical devices based on type of
medical device as follows:
(I) In general.--The
Secretary shall establish
criteria that will be used for
creation of categories through
rulemaking (which may include
use of an interim final rule
with comment period). Such
categories shall be established
in a manner such that no
medical device is described by
more than one category. Such
criteria shall include a test
of whether the average cost of
devices that would be included
in a category, as estimated by
the Secretary, is not
insignificant as described in
paragraph (A)(iv)(II).
(II) Initial categories.--The
categories to be applied as of
the category-based pass-through
implementation date specified
pursuant to subclause (V) shall
be established in a manner such
that each medical device that
meets the requirements of
clause (ii) or (iv) of
subparagraph (A) as of such
date is included in a such a
category. For purposes of the
preceding sentence, whether a
medical device meets the
requirements of clause (ii) or
(iv) of subparagraph (A) as of
such date shall be determined
without regard to clause (ii)
of this subparagraph and on the
basis of the program memoranda
issued before such date
identifying medical devices
that meet such requirements.
(III) Adding categories.--The
Secretary shall promptly
establish a new category of
medical device under this
clause for any medical device
that meets the requirements of
subparagraph (A)(iv) and for
which none of the categories in
effect or that were previously
in effect (as described in
subparagraph (C)(iii)) is
appropriate. The Secretary
shall only establish a new
category for a medical device
that is described by a category
that was previously in effect
if the Secretary determines, in
accord with criteria
established under subclause (I)
of this clause, that the device
represents a significant
advance in medical technology
that is expected to
significantly improve the
treatment of Medicare
beneficiaries.
(IV) Deleting categories.--
The Secretary shall delete a
category at the close of the
period for which the category
is in effect (as described in
subparagraph (C)(iii)).
(V) Category-based pass-
through implementation date.--
For purposes of this
subparagraph and subparagraph
(C), the ``category-based pass-
through implementation date''
is a date specified by the
Secretary as of which the
categories established under
this clause are first used for
purposes of clause (ii)(I).
Such date may not be later than
July 1, 2000.
(ii) Requirements treated as met.--A
medical device shall be treated as
meeting the requirements of
subparagraph (A)(iv) if--
(I) the device is described
by a category established under
clause (i), and
(II) an application under
section 515 of the Federal
Food, Drug, and Cosmetic Act
has been approved with respect
to the device, or the device
has been cleared for market
under section 510(k) of such
Act, or the device is exempt
from the requirements of
section 510(k) of such Act
pursuant to subsection (l) or
(m) of section 510 of such Act
or section 520(g) of such Act,
without an additional
requirement for application or
prior approval.---
(C) Limited period of payment.--
(i) Drugs and biologicals.--The
payment under this paragraph with
respect to a drug or biological shall
only apply during a period of at least
2 years, but not more than 3 years,
that begins--
(I) on the first date this
subsection is implemented in
the case of a drug or
biological described in clause
(i), (ii), or (iii) of
subparagraph (A) and in the
case of a drug or biological
described in subparagraph
(A)(iv) and for which payment
under this part is made as an
outpatient hospital service
before such first date; or
(II) in the case of a drug or
biological described in
subparagraph (A)(iv) not
described in subclause (I), on
the first date on which payment
is made under this part for the
drug or biological as an
outpatient hospital service.
(ii) Medical devices.--Except as
provided in clause (iv), payment shall
be made under this paragraph with
respect to a medical device only if
such device--
(I) is described by a
category of medical devices
established under subparagraph
(B)(i); and
(II) is provided as part of a
service (or group of services)
paid for under this subsection
and provided during the period
for which such category is in
effect (as described in clause
(iii)).
(iii) Period for which category is in
effect.--For purposes of this
subparagraph and subparagraph (B), a
category of medical devices established
under subparagraph (B)(i) shall be in
effect for a period of at least 2
years, but not more than 3 years, that
begins--
(I) in the case of a category
established under subparagraph
(B)(i)(II), on the first date
on which payment was made under
this paragraph for any device
described by such category
(including payments made during
the period before the category-
based pass-through
implementation date); and
(II) in the case of a
category established under
subparagraph (B)(i)(III), on
the first date on which payment
is made under this paragraph
for any medical device that is
described by such category.
(iv) Payments made before category-
based pass-through implementation
date.--
(I) in the case of a medical
device provided as part of a
service (or group of services)
paid for under this subsection
and provided during the period
beginning on the first date on
which the system under this
subsection is implemented and
ending on (and including) the
day before the category-based
pass-through implementation
date specified pursuant to
subparagraph (B)(i)(V), payment
shall be made in accordance
with the provisions of this
paragraph as in effect on the
day before the date of the
enactment of this subparagraph;
and
(II) notwithstanding
subclause (I), the Secretary
shall make payments under this
paragraph during the period
beginning one month after the
date of enactment of the
Beneficiary Improvement and
Protection Act of 2000 and
ending on the same ending date
in subclause (I) with respect
to any medical device that is
not included in a program
memorandum referred to in
subparagraph (B)(i)(II) but
that is substantially similar
(other than with respect to the
restriction in subparagraph
(A)(iv)(I)) to devices that are
so included and that the
Secretary determines is likely
to be described by a initial
category established under such
subparagraph.
[(C)] (D) Amount of additional payment.--
Subject to [subparagraph (D)(iii)] subparagraph
(E)(iii), the amount of the payment under this
paragraph with respect to a device, drug, or
biological provided as part of a covered OPD
service is--
(i) * * *
* * * * * * *
[(D)] (E) Limit on aggregate annual
adjustment.--
(i) In general.--The total of the
additional payments made under this
paragraph for covered OPD services
furnished in a year (as estimated by
the Secretary before the beginning of
the year) may not exceed the applicable
percentage (specified in clause (ii))
of the total program payments estimated
to be made under this subsection for
all covered OPD services furnished in
that year. If this paragraph is first
applied to less than a full year, the
previous sentence shall apply only to
the portion of such year.
* * * * * * *
(12) Limitation on review.--There shall be no
administrative or judicial review under section 1869,
1878, or otherwise of--
(A) * * *
* * * * * * *
(E) the determination of the fixed multiple,
or a fixed dollar cutoff amount, the marginal
cost of care, or applicable percentage under
paragraph (5) or the determination of
insignificance of cost, the duration of the
[additional payments (consistent with paragraph
(6)(B))] additional payments, the determination
and deletion of initial and new categories
(consistent with subparagraphs (B) and (C) of
paragraph (6)), the portion of the medicare OPD
fee schedule amount associated with particular
devices, drugs, or biologicals, and the
application of any pro rata reduction under
paragraph (6).
* * * * * * *
SPECIAL PAYMENT RULES FOR PARTICULAR ITEMS AND SERVICES
Sec. 1834. (a) * * *
* * * * * * *
(c) Payments and Standards for Screening Mammography.--
(1) * * *
* * * * * * *
(3) Limit.--
(A) $55, indexed.--Except as provided by the
Secretary under [subparagraph (B)]
subparagraphs (B) and (D), the limit
established under this paragraph--
(i) * * *
(ii) for screening mammography
performed in a subsequent year is the
limit established under this paragraph
for the preceding year (taking into
account, if applicable, subparagraph
(D)) increased by the percentage
increase in the MEI for that subsequent
year.
(B) [Reduction of] Revisions to limit.--The
Secretary shall review from time to time the
appropriateness of the amount of the limit
established under this paragraph. The Secretary
may, with respect to screening mammography
performed in a year after 1992 or new
technologies described in paragraph (1)(D),
increase or reduce the amount of such limit as
it applies nationally or in any area to the
amount that the Secretary estimates is required
to assure that screening mammography of an
appropriate quality is readily and conveniently
available during the year.
* * * * * * *
(D) Increase in payment limit for new
technologies.--In the case of new technologies
applied to screening mammography performed
beginning in 2001 and determined by the
Secretary to enhance the detection of breast
cancer, the limit applied under this paragraph
for 2001 shall be increased by $15.
* * * * * * *
(d) Frequency Limits and Payment for Colorectal Cancer
Screening Tests.--
(1) * * *
* * * * * * *
(2) Screening flexible sigmoidoscopies.--
(A) * * *
* * * * * * *
(E) Frequency limit.--No payment may be made
under this part for a colorectal cancer
screening test consisting of a screening
flexible sigmoidoscopy--
(i) if the individual is under 50
years of age; [or]
(ii) if the procedure is performed
within the 47 months after a previous
screening flexible sigmoidoscopy[.]; or
(iii) if the procedure is performed
within 119 months after a screening
colonoscopy under paragraph (4).
(3) Screening colonoscopy for individuals at high
risk for colorectal cancer.--
(A) Fee schedule.--With respect to colorectal
cancer screening test consisting of a screening
colonoscopy for individuals at high risk for
colorectal cancer (as defined in section
1861(pp)(2)) and for individuals making the
election described in paragraph (4), payment
under section 1848 shall be consistent with
payment amounts under such section for similar
or related services.
* * * * * * *
(E) Frequency limit.--No payment may be made
under this part for a colorectal cancer
screening test consisting of a screening
colonoscopy for individuals at high risk for
colorectal cancer if the procedure is performed
within the 23 months after a previous screening
colonoscopy. No payment may be made under this
part for a colorectal cancer screening test
consisting of a screening colonoscopy for
individuals making the election described in
paragraph (4) if the procedure is performed
within the 119 months after a previous
screening colonoscopy or within 47 months after
a screening flexible sigmoidoscopy.
(4) Election of screening colonoscopy for individuals
not at high risk of colorectal cancer instead of
screening sigmoidoscopy.--An individual who is not at
high risk of colorectal cancer may elect to receive a
screening colonoscopy instead of a screening
sigmoidoscopy.
* * * * * * *
(l) Establishment of Fee Schedule for Ambulance Services.--
(1) * * *
(2) Considerations.--In establishing such fee
schedule, the Secretary shall--
(A) * * *
* * * * * * *
(E) phase in the application of the payment
rates under the fee schedule in an efficient
and fair manner, except that such phase-in
shall provide for full payment of any national
mileage rate beginning with the effective date
of the fee schedule for ambulance services
provided by suppliers in any State who were not
paid a separate amount for all mileage prior to
the implementation of the fee schedule.
(3) Savings.--In establishing such fee schedule, the
Secretary shall--
(A) ensure that the aggregate amount of
payments made for ambulance services under this
part during 2000 does not exceed the aggregate
amount of payments which would have been made
for such services under this part during such
year if the amendments made by section 4531(a)
of the Balanced Budget Act of 1997 continued in
effect, except that in making such
determination the Secretary shall assume an
update in such payments for 2002 equal to
percentage increase in the consumer price index
for all urban consumers (U.S. city average) for
the 12-month period ending with June of the
previous year [reduced in the case of 2001 and
2002 by 1.0 percentage points]; and
(B) set the payment amounts provided under
the fee schedule for services furnished in 2001
and each subsequent year at amounts equal to
the payment amounts under the fee schedule for
services furnished during the previous year,
increased by the percentage increase in the
consumer price index for all urban consumers
(U.S. city average) for the 12-month period
ending with June of the previous year [reduced
in the case of 2001 and 2002 by 1.0 percentage
points].
* * * * * * *
PROCEDURE FOR PAYMENT OF CLAIMS OF PROVIDERS OF SERVICES
Sec. 1835. (a) Except as provided in subsections (b), (c),
and (e), payment for services described in section 1832(a)(2)
furnished an individual may be made only to providers of
services which are eligible therefor under section 1866(a), and
only if--
(1) * * *
* * * * * * *
To the extent provided by regulations, the certification and
recertification requirements of paragraph (2) shall be deemed
satisfied where, at a later date, a physician makes a
certification of the kind provided in subparagraph (A) or (B)
of paragraph (2) (whichever would have applied), but only where
such certification is accompanied by such medical and other
evidence as may be required by such regulations. With respect
to the physician certification required by paragraph (2) for
home health services furnished to any individual by a home
health agency (other than an agency which is a governmental
entity) and with respect to the establishment and review of a
plan for such services, the Secretary shall prescribe
regulations which shall become effective no later than July 1,
1981, and which prohibit a physician who has a significant
ownership interest in, or a significant financial or
contractual relationship with, such home health agency from
performing such certification and from establishing or
reviewing such plan, except that such prohibition shall not
apply with respect to a home health agency which is a sole
community home health agency (as determined by the Secretary).
For purposes of the preceding sentence, service by a physician
as an uncompensated officer or director of a home health agency
shall not constitute having a significant ownership interest
in, or a significant financial or contractual relationship
with, such agency. For purposes of paragraph (2)(A), an
individual shall be considered to be ``confined to his home''
if the individual has a condition, due to an illness or injury,
that restricts the ability of the individual to leave his or
her home except with the assistance of another individual or
the aid of a supportive device (such as crutches, a cane, a
wheelchair, or a walker), or if the individual has a condition
such that leaving his or her home is medically contraindicated.
While an individual does not have to be bedridden to be
considered ``confined to his home'', the condition of the
individual should be such that there exists a normal inability
to leave home, that leaving home requires a considerable and
taxing effort by the individual, and that absences of the
individual from home are infrequent or of relatively short
duration, or are attributable to the need to receive medical
treatment[.], including participating in an adult day care
program licensed or certified by a State, or accredited to
furnish adult day care services in the State, to furnish adult
day care services in the State for the purposes of therapeutic
treatment for Alzheimer's disease or a related dementia.
* * * * * * *
ENROLLMENT PERIODS
Sec. 1837. (a) * * *
* * * * * * *
(j) In applying this section in the case of an individual who
is entitled to benefits under part A pursuant to the operation
of section 226(h), the following special rules apply:
(1) The initial enrollment period under subsection
(d) shall begin on the first day of the first month in
which the individual satisfies the requirement of
section 1836(1).
(2) In applying subsection (g)(1), the initial
enrollment period shall begin on the first day of the
first month of entitlement to disability insurance
benefits referred to in such subsection.
* * * * * * *
USE OF CARRIERS FOR ADMINISTRATION OF BENEFITS
Sec. 1842. (a) * * *
* * * * * * *
(b)(1) * * *
* * * * * * *
(6) No payment under this part for a service provided to any
individual shall (except as provided in section 1870) be made
to anyone other than such individual or (pursuant to an
assignment described in subparagraph (B)(ii) of paragraph (3))
the physician or other person who provided the service, except
that (A) payment may be made (i) to the employer of such
physician or other person if such physician or other person is
required as a condition of his employment to turn over his fee
for such service to his employer, or (ii) (where the service
was provided in a hospital, critical access hospital, clinic,
or other facility) to the facility in which the service was
provided if there is a contractual arrangement between such
physician or other person and such facility under which such
facility submits the bill for such service, (B) payment may be
made to an entity (i) which provides coverage of the services
under a health benefits plan, but only to the extent that
payment is not made under this part, (ii) which has paid the
person who provided the service an amount (including the amount
payable under this part) which that person has accepted as
payment in full for the service, and (iii) to which the
individual has agreed in writing that payment may be made under
this part, (C) in the case of services described in clause (i)
of section 1861(s)(2)(K), payment shall be made to either (i)
the employer of the physician assistant involved, or (ii) with
respect to a physician assistant who was the owner of a rural
health clinic (as described in section 1861(aa)(2)) for a
continuous period beginning prior to the date of the enactment
of the Balanced Budget Act of 1997 and ending on the date that
the Secretary determines such rural health clinic no longer
meets the requirements of section 1861(aa)(2), for such
services provided before January 1, 2003, payment may be made
directly to the physician assistant; (D) payment may be made to
a physician for physicians' services (and services furnished
incident to such services) furnished by a second physician to
patients of the first physician if (i) the first physician is
unavailable to provide the services; (ii) the services are
furnished pursuant to an arrangement between the two physicians
that (I) is informal and reciprocal, or (II) involves per diem
or other fee-for-time compensation for such services; (iii) the
services are not provided by the second physician over a
continuous period of more than 60 days; and (iv) the claim form
submitted to the carrier for such services includes the second
physician's unique identifier (provided under the system
established under subsection (r)) and indicates that the claim
meets the requirements of this subparagraph for payment to the
first physician, (E) in the case of an item or service (other
than services described in section 1888(e)(2)(A)(ii)) furnished
to an individual (on or after October 1, 2003) who (at the time
the item or service is furnished) is a resident of a skilled
nursing facility or of a part of a facility that includes a
skilled nursing facility (as determined under regulations),
payment shall be made to the facility (without regard to
whether or not the item or service was furnished by the
facility, by others under arrangement with them made by the
facility, under any other contracting or consulting
arrangement, or otherwise), and (F) in the case of home health
services (including medical supplies described in section
1861(m)(5), but excluding durable medical equipment to the
extent provided for in such section) furnished to an individual
who (at the time the item or service is furnished) is under a
plan of care of a home health agency, payment shall be made to
the agency (without regard to whether or not the item or
service was furnished by the agency, by others under
arrangement with them made by the agency, or when any other
contracting or consulting arrangement, or otherwise). No
payment which under the preceding sentence may be made directly
to the physician or other person providing the service involved
(pursuant to an assignment described in subparagraph (B)(ii) of
paragraph (3)) shall be made to anyone else under a
reassignment or power of attorney (except to an employer or
facility as described in clause (A) of such sentence); but
nothing in this subsection shall be construed (i) to prevent
the making of such a payment in accordance with an assignment
from the individual to whom the service was provided or a
reassignment from the physician or other person providing such
service if such assignment or reassignment is made to a
governmental agency or entity or is established by or pursuant
to the order of a court of competent jurisdiction, or (ii) to
preclude an agent of the physician or other person providing
the service from receiving any such payment if (but only if)
such agent does so pursuant to an agency agreement under which
the compensation to be paid to the agent for his services for
or in connection with the billing or collection of payments due
such physician or other person under this title is unrelated
(directly or indirectly) to the amount of such payments or the
billings therefor, and is not dependent upon the actual
collection of any such payment. For purposes of subparagraph
(C) of the first sentence of this paragraph, an employment
relationship may include any independent contractor
arrangement, and employer status shall be determined in
accordance with the law of the State in which the services
described in such clause are performed.
* * * * * * *
Part C--Medicare+Choice Program
eligibility, election, and enrollment
Sec. 1851. (a) * * *
* * * * * * *
(f) Effectiveness of Elections and Changes of Elections.--
(1) * * *
(2) During continuous open enrollment periods.--An
election or change of coverage made under subsection
(e)(2) shall take effect with the first day of the
first calendar month following the date on which the
election or change is [made, except that if such
election or change is made after the 10th day of any
calendar month, then the election or change shall not
take effect until the first day of the second calendar
month following the date on which the election or
change is made.] made.
* * * * * * *
payments to medicare+choice organizations
Sec. 1853. (a) Payments to Organizations.--
(1) * * *
* * * * * * *
(3) Establishment of risk adjustment factors.--
(A) * * *
* * * * * * *
(C) Initial implementation.--
(i) * * *
(ii) Phase-in.--Such risk adjustment
methodology shall be implemented in a
phased-in manner so that the
methodology insofar as it makes
adjustments to capitation rates for
health status applies to--
(I) 10 percent of \1/12\ of
the annual Medicare+Choice
capitation rate in 2000 and
2001; [and]
(II) not more than 20 percent
of such capitation rate in
2002[.];
and, beginning in 2004, insofar as such
risk adjustment is based on data from
substantially all settings, the
methodology shall be phased in equal
increments over a 10-year period,
beginning with 2004 or (if later) the
first year in which such data are used.
* * * * * * *
(c) Calculation of Annual Medicare+Choice Capitation Rates.--
(1) In general.--For purposes of this part, subject
to paragraphs (6)(C) and (7), each annual
Medicare+Choice capitation rate, for a Medicare+Choice
payment area for a contract year consisting of a
calendar year, is equal to the largest of the amounts
specified in the following subparagraph (A), (B), or
(C):
(A) * * *
* * * * * * *
(B) Minimum amount.--12 multiplied by the
following amount:
(i) For 1998, $367 (but not to
exceed, in the case of an area outside
the 50 States and the District of
Columbia, 150 percent of the annual per
capita rate of payment for 1997
determined under section 1876(a)(1)(C)
for the area).
[(ii) For a succeeding year] (ii)(I)
Subject to subclause (II), for a
succeeding year, the minimum amount
specified in this clause (or clause
(i)) for the preceding year increased
by the national per capita
Medicare+Choice growth percentage,
described in paragraph (6)(A) for that
succeeding year.
(II) For 2001 for any area in a
Metropolitan Statistical Area with a
population of more than 250,000, $525
(and for any other area, $475).
(C) Minimum percentage increase.--
(i) * * *
(ii) For a subsequent year, 102
percent (or 103 percent in the case of
2001) of the annual Medicare+Choice
capitation rate under this paragraph
for the area for the previous year.
* * * * * * *
premiums
Sec. 1854. (a) * * *
* * * * * * *
(c) Uniform Premium.--The Medicare+Choice monthly basic and
supplemental beneficiary premium, the Medicare+Choice monthly
MSA premium charged under subsection (b) of a Medicare+Choice
organization under this part may not vary among individuals
enrolled in the plan, except across counties as approved by the
Secretary.
* * * * * * *
(f) Requirement for Additional Benefits.--
(1) Requirement.--
(A) * * *
* * * * * * *
(D) Uniform application.--This paragraph
shall be applied uniformly for all enrollees
for a plan, except across counties as approved
by the Secretary.
* * * * * * *
contracts with medicare+choice organizations
Sec. 1857. (a) * * *
* * * * * * *
(i) M+C Program Compatibility With Employer or Union Group
Health Plans.--To facilitate the offering of Medicare+Choice
plans under contracts between Medicare+Choice organizations and
employers, labor organizations, or the trustees of a fund
established by 1 or more employers or labor organizations (or
combination thereof) to furnish benefits to the entity's
employees, former employees (or combination thereof) or members
or former members (or combination thereof) of the labor
organizations, the Secretary may waive or modify requirements
that hinder the design of, the offering of, or the enrollment
in such Medicare+Choice plans.
* * * * * * *
Part D--Miscellaneous Provisions
definitions of services, institutions, etc.
Sec. 1861. For purposes of this title--
Spell of Illness
(a) * * *
* * * * * * *
Medical and Other Health Services
(s) The term ``medical and other health services'' means any
of the following items or services:
(1) physicians' services;
(2)(A) services and supplies [(including drugs and
biologicals which cannot, as determined in accordance
with regulations, be self-administered)] (including
drugs and biologicals which are not usually self-
administered by the patient) furnished as an incident
to a physician's professional service, of kinds which
are commonly furnished in physicians' offices and are
commonly either rendered without charge or included in
the physicians' bills;
(B) hospital services [(including drugs and
biologicals which cannot, as determined in accordance
with regulations, be self-administered)] (including
drugs and biologicals which are not usually self-
administered by the patient) incident to physicians'
services rendered to outpatients and partial
hospitalization services incident to such services;
* * * * * * *
(J) prescription drugs used in immunosuppressive
therapy furnished, to an individual who receives an
organ transplant for which payment is made under this
title[, but only in the case of drugs furnished--
[(i) before 1995, within 12 months after the
date of the transplant procedure,
[(ii) during 1995, within 18 months after the
date of the transplant procedure,
[(iii) during 1996, within 24 months after
the date of the transplant procedure,
[(iv) during 1997, within 30 months after the
date of the transplant procedure, and
[(v) during any year after 1997, within 36
months after the date of the transplant
procedureplus such additional number of months
(if any) provided under section 1832(b)];
* * * * * * *
Drugs and Biologicals
(t)(1) The term ``drugs'' and the term ``biologicals'',
except for purposes of subsection (m)(5) and paragraph (2),
include only such drugs (including contrast agents) and
biologicals, respectively, as are included (or approved for
inclusion) in the United States Pharmacopoeia, the National
Formulary, or the United States Homeopathic Pharmacopoeia, or
in New Drugs or Accepted Dental Remedies (except for any drugs
and biologicals unfavorably evaluated therein), or as are
approved by the pharmacy and drug therapeutics committee (or
equivalent committee) of the medical staff of the hospital
furnishing such drugs and biologicals for use in such hospital.
* * * * * * *
Reasonable Cost
(v)(1)(A) * * *
* * * * * * *
(T) In determining such reasonable costs for hospitals, no
reduction in copayments under section 1833(t)(5)(B) shall be
treated as a bad debt and the amount of bad debts otherwise
treated as allowable costs which are attributable to the
deductibles and coinsurance amounts under this title shall be
reduced--
(i) * * *
(ii) for cost reporting periods beginning during
fiscal year 1999, by 40 percent of such amount
otherwise allowable, [and]
(iii) for cost reporting periods beginning during [a
subsequent fiscal year] fiscal year 2000, by 45 percent
of such amount otherwise allowable[.];
(iv) for cost reporting periods beginning during
fiscal year 2001 and each subsequent fiscal year
(before fiscal year 2011), by the percent specified in
clause (iii) or this clause for the preceding fiscal
year reduced by 2.5 percentage points, of such amount
otherwise allowable; and
(v) for cost reporting periods beginning during
fiscal year 2011 or a subsequent fiscal year, by 20
percent of such amount otherwise allowable.
* * * * * * *
Screening Mammography
(jj) The term ``screening mammography'' means a radiologic
procedure provided to a woman for the purpose of early
detection of breast cancer and includes a physician's
interpretation of the results of the procedure, as well as new
technology applied to such a procedure that the Secretary
determines enhances the detection of breast cancer.
* * * * * * *
Colorectal Cancer Screening Tests
(pp)(1) The term ``colorectal cancer screening test'' means
any of the following procedures furnished to an individual for
the purpose of early detection of colorectal cancer:
(A) * * *
* * * * * * *
(C) In the case of an individual at high risk for
colorectal cancer and in the case of an individual
making the election described in section 1834(d)(4),
screening colonoscopy.
* * * * * * *
Diabetes Outpatient Self-Management Training Services
(qq)(1) * * *
(2) In [paragraph (1)--] paragraph (1):
(A) [a ``certified provider''] A ``certified
provider'' is a physician, or other individual or
entity designated by the Secretary, that, in addition
to providing diabetes outpatient self-management
training services, provides other items or services for
which payment may be made under this title[; and].
(B) [a physician, or such other individual] (i) A
physician, or such other individual or entity, meets
the quality standards described in this paragraph if
the physician, or individual or entity, meets quality
standards established by the Secretary, except that the
physician or other individual or entity shall be deemed
to have met such standards if the physician or other
individual or entity (I) meets applicable standards
originally established by the National Diabetes
Advisory Board and subsequently revised by
organizations who participated in the establishment of
standards by such Board, or (II) is recognized by an
organization that represents individuals (including
individuals under this title) with diabetes, or by a
program described in clause (ii), as meeting standards
for furnishing the services.
(ii) Notwithstanding any reference to ``a national
accreditation body'' in section 1865(b), for purposes
of clause (i), a program described in this clause is a
program operated by a State for the purposes of
accrediting diabetes self-management training programs,
if the Secretary determines that such State program has
established quality standards that meet or exceed the
standards established by the Secretary under clause (i)
or the standards originally established by the National
Diabetes Advisory Board and subsequently revised as
described in clause (i).
* * * * * * *
exclusions from coverage and medicare as secondary payer
Sec. 1862. (a) Notwithstanding any other provision of this
title, no payment may be made under part A or part B for any
expenses incurred for items or services--
(1) * * *
* * * * * * *
[(18) which are covered skilled nursing facility
services described in section 1888(e)(2)(A)(i) and
which are furnished to an individual who is a resident
of a skilled nursing facility or of a part of a
facility that includes a skilled nursing facility (as
determined under regulations), by an entity other than
the skilled nursing facility, unless the services are
furnished under arrangements (as defined in section
1861(w)(1)) with the entity made by the skilled nursing
facility;]
(18) which are covered skilled nursing facility
services described in section 1888(e)(2)(A)(i) and
which are furnished to an individual who is a
resident--
(A) of a skilled nursing facility in the case
of a resident who is in a stay covered under
part A; or
(B) of a skilled nursing facility or of a
part of a facility that includes a skilled
nursing facility (as determined under
regulations) for services furnished on or after
October 1, 2003, in the case of a resident who
is not in a stay covered under such part,
by an entity other than the skilled nursing facility,
unless the services are furnished under arrangements
(as defined in section 1861(w)(1)) with the entity made
by the skilled nursing facility;
* * * * * * *
agreements with providers of services
Sec. 1866. (a)(1) Any provider of services (except a fund
designated for purposes of section 1814(g) and section 1835(e))
shall be qualified to participate under this title and shall be
eligible for payments under this title if it files with the
Secretary an agreement--
(A) * * *
* * * * * * *
(H)(i) * * *
(ii) in the case of skilled nursing facilities which
provide covered skilled nursing facility services--
(I) that are furnished to an individual who
is a resident of the skilled nursing facility
in the case of a resident who is in a stay
covered under part A, and for services
furnished on or after October 1, 2003, in the
case of a resident who is not in a stay covered
under such part, and
* * * * * * *
demonstration of application of physician volume increases to group
practices
Sec. 1866A. (a) Demonstration Program Authorized.--
(1) In general.--The Secretary shall conduct
demonstration projects to test and, if proven
effective, expand the use of incentives to health care
groups participating in the program under this title
that--
(A) encourage coordination of the care
furnished to individuals under the programs
under parts A and B by institutional and other
providers, practitioners, and suppliers of
health care items and services;
(B) encourage investment in administrative
structures and processes to ensure efficient
service delivery; and
(C) reward physicians for improving health
outcomes.
(2) Administration by contract.--Except as otherwise
specifically provided, the Secretary may administer the
program under this section in accordance with section
1866B.
(3) Definitions.--For purposes of this section, terms
have the following meanings:
(A) Physician.--Except as the Secretary may
otherwise provide, the term ``physician'' means
any individual who furnishes services which may
be paid for as physicians' services under this
title .
(B) Health care group.--The term ``health
care group'' means a group of physicians (as
defined in subparagraph (A)) organized at least
in part for the purpose of providing
physicians' services under this title. As the
Secretary finds appropriate, a health care
group may include a hospital and any other
individual or entity furnishing items or
services for which payment may be made under
this title that is affiliated with the health
care group under an arrangement structured so
that such individual or entity participates in
a demonstration under this section and will
share in any bonus earned under subsection (d).
(b) Eligibility Criteria.--
(1) In general.--The Secretary is authorized to
establish criteria for health care groups eligible to
participate in a demonstration under this section,
including criteria relating to numbers of health care
professionals in, and of patients served by, the group,
scope of services provided, and quality of care.
(2) Payment method.--A health care group
participating in the demonstration under this section
shall agree with respect to services furnished to
beneficiaries within the scope of the demonstration (as
determined under subsection (c))--
(A) to be paid on a fee-for-service basis;
and
(B) that payment with respect to all such
services furnished by members of the health
care group to such beneficiaries shall (where
determined appropriate by the Secretary) be
made to a single entity.
(3) Data reporting.--A health care group
participating in a demonstration under this section
shall report to the Secretary such data, at such times
and in such format as the Secretary require, for
purposes of monitoring and evaluation of the
demonstration under this section.
(c) Patients Within Scope of Demonstration.--
(1) In general.--The Secretary shall specify, in
accordance with this subsection, the criteria for
identifying those patients of a health care group who
shall be considered within the scope of the
demonstration under this section for purposes of
application of subsection (d) and for assessment of the
effectiveness of the group in achieving the objectives
of this section.
(2) Other criteria.--The Secretary may establish
additional criteria for inclusion of beneficiaries
within a demonstration under this section, which may
include frequency of contact with physicians in the
group or other factors or criteria that the Secretary
finds to be appropriate.
(3) Notice requirements.--In the case of each
beneficiary determined to be within the scope of a
demonstration under this section with respect to a
specific health care group, the Secretary shall ensure
that such beneficiary is notified of the incentives,
and of any waivers of coverage or payment rules,
applicable to such group under such demonstration.
(d) Incentives.--
(1) Performance target.--The Secretary shall
establish for each health care group participating in a
demonstration under this section--
(A) a base expenditure amount, equal to the
average total payments under parts A and B for
patients served by the health care group on a
fee-for-service basis in a base period
determined by the Secretary; and
(B) an annual per capita expenditure target
for patients determined to be within the scope
of the demonstration, reflecting the base
expenditure amount adjusted for risk and
expected growth rates.
(2) Incentive bonus.--The Secretary shall pay to each
participating health care group (subject to paragraph
(4)) a bonus for each year under the demonstration
equal to a portion of the Medicare savings realized for
such year relative to the performance target.
(3) Additional bonus for process and outcome
improvements.--At such time as the Secretary has
established appropriate criteria based on evidence the
Secretary determines to be sufficient, the Secretary
shall also pay to a participating health care group
(subject to paragraph (4)) an additional bonus for a
year, equal to such portion as the Secretary may
designate of the saving to the program under this title
resulting from process improvements made by and patient
outcome improvements attributable to activities of the
group.
(4) Limitation.--The Secretary shall limit bonus
payments under this section as necessary to ensure that
the aggregate expenditures under this title (inclusive
of bonus payments) with respect to patients within the
scope of the demonstration do not exceed the amount
which the Secretary estimates would be expended if the
demonstration projects under this section were not
implemented.
provisions for administration of demonstration program
Sec. 1866B. (a) General Administrative Authority.--
(1) Beneficiary eligibility.--Except as otherwise
provided by the Secretary, an individual shall only be
eligible to receive benefits under the program under
section 1866A (in this section referred to as the
``demonstration program'') if such individual--
(A) is enrolled in under the program under
part B and entitled to benefits under part A;
and
(B) is not enrolled in a Medicare+Choice plan
under part C, an eligible organization under a
contract under section 1876 (or a similar
organization operating under a demonstration
project authority), an organization with an
agreement under section 1833(a)(1)(A), or a
PACE program under section 1894.
(2) Secretary's discretion as to scope of program.--
The Secretary may limit the implementation of the
demonstration program to--
(A) a geographic area (or areas) that the
Secretary designates for purposes of the
program, based upon such criteria as the
Secretary finds appropriate;
(B) a subgroup (or subgroups) of
beneficiaries or individuals and entities
furnishing items or services (otherwise
eligible to participate in the program),
selected on the basis of the number of such
participants that the Secretary finds
consistent with the effective and efficient
implementation of the program;
(C) an element (or elements) of the program
that the Secretary determines to be suitable
for implementation; or
(D) any combination of any of the limits
described in subparagraphs (A) through (C).
(3) Voluntary receipt of items and services.--Items
and services shall be furnished to an individual under
the demonstration program only at the individual's
election.
(4) Agreements.--The Secretary is authorized to enter
into agreements with individuals and entities to
furnish health care items and services to beneficiaries
under the demonstration program.
(5) Program standards and criteria.--The Secretary
shall establish performance standards for the
demonstration program including, as applicable,
standards for quality of health care items and
services, cost-effectiveness, beneficiary satisfaction,
and such other factors as the Secretary finds
appropriate. The eligibility of individuals or entities
for the initial award, continuation, and renewal of
agreements to provide health care items and services
under the program shall be conditioned, at a minimum,
on performance that meets or exceeds such standards.
(6) Administrative review of decisions affecting
individuals and entities furnishing services.--An
individual or entity furnishing services under the
demonstration program shall be entitled to a review by
the program administrator (or, if the Secretary has not
contracted with a program administrator, by the
Secretary) of a decision not to enter into, or to
terminate, or not to renew, an agreement with the
entity to provide health care items or services under
the program.
(7) Secretary's review of marketing materials.--An
agreement with an individual or entity furnishing
services under the demonstration program shall require
the individual or entity to guarantee that it will not
distribute materials marketing items or services under
the program without the Secretary's prior review and
approval;
(8) Payment in full.--
(A) In general.--Except as provided in
subparagraph (B), an individual or entity
receiving payment from the Secretary under a
contract or agreement under the demonstration
program shall agree to accept such payment as
payment in full, and such payment shall be in
lieu of any payments to which the individual or
entity would otherwise be entitled under this
title.
(B) Collection of deductibles and
coinsurance.--Such individual or entity may
collect any applicable deductible or
coinsurance amount from a beneficiary.
(b) Contracts for Program Administration.--
(1) In general.--The Secretary may administer the
demonstration program through a contract with a program
administrator in accordance with the provisions of this
subsection.
(2) Scope of program administrator contracts.--The
Secretary may enter into such contracts for a limited
geographic area, or on a regional or national basis.
(3) Eligible contractors.--The Secretary may contract
for the administration of the program with--
(A) an entity that, under a contract under
section 1816 or 1842, determines the amount of
and makes payments for health care items and
services furnished under this title; or
(B) any other entity with substantial
experience in managing the type of program
concerned.
(4) Contract award, duration, and renewal.--
(A) In general.--A contract under this
subsection shall be for an initial term of up
to three years, renewable for additional terms
of up to three years.
(B) Noncompetitive award and renewal for
entities administering part a or part b
payments.--The Secretary may enter or renew a
contract under this subsection with an entity
described in paragraph (3)(A) without regard to
the requirements of section 5 of title 41,
United States Code.
(5) Applicability of federal acquisition
regulation.--The Federal Acquisition Regulation shall
apply to program administration contracts under this
subsection.
(6) Performance standards.--The Secretary shall
establish performance standards for the program
administrator including, as applicable, standards for
the quality and cost-effectiveness of the program
administered, and such other factors as the Secretary
finds appropriate. The eligibility of entities for the
initial award, continuation, and renewal of program
administration contracts shall be conditioned, at a
minimum, on performance that meets or exceeds such
standards.
(7) Functions of program administrator.--A program
administrator shall perform any or all of the following
functions, as specified by the Secretary:
(A) Agreements with entities furnishing
health care items and services.--Determine the
qualifications of entities seeking to enter or
renew agreements to provide services under the
program, and as appropriate enter or renew (or
refuse to enter or renew) such agreements on
behalf of the Secretary.
(B) Establishment of payment rates.--
Negotiate or otherwise establish, subject to
the Secretary's approval, payment rates for
covered health care items and services.
(C) Payment of claims or fees.--Administer
payments for health care items or services
furnished under the program.
(D) Payment of bonuses.--Using such
guidelines as the Secretary shall establish,
and subject to the approval of the Secretary,
make bonus payments as described in subsection
(c)(2)(A)(ii) to entities furnishing items or
services for which payment may be made under
the program.
(E) Oversight.--Monitor the compliance of
individuals and entities with agreements under
the program with the conditions of
participation.
(F) Administrative review.--Conduct reviews
of adverse determinations specified in
subsection (a)(6).
(G) Review of marketing materials.--Conduct a
review of marketing materials proposed by an
entity furnishing services under the program.
(H) Additional functions.--Perform such other
functions as the Secretary may specify.
(8) Limitation of liability.--The provisions of
section 1157(b) shall apply with respect to activities
of contractors and their officers, employees, and
agents under a contract under this subsection.
(9) Information sharing.--Notwithstanding section
1106 and section 552a of title 5, United States Code,
the Secretary is authorized to disclose to an entity
with a program administration contract under this
subsection such information (including medical
information) on individuals receiving health care items
and services under the program as the entity may
require to carry out its responsibilities under the
contract.
(c) Rules Applicable to Both Program Agreements and Program
Administration Contracts.--
(1) Records, reports, and audits.--The Secretary is
authorized to require entities with agreements to
provide health care items or services under the
demonstration program, and entities with program
administration contracts under subsection (b), to
maintain adequate records, to afford the Secretary
access to such records (including for audit purposes),
and to furnish such reports and other materials
(including audited financial statements and performance
data) as the Secretary may require for purposes of
implementation, oversight, and evaluation of the
program and of individuals' and entities' effectiveness
in performance of such agreements or contracts.
(2) Bonuses.--Notwithstanding any other provision of
law, but subject to subparagraph (B)(ii), the Secretary
may make bonus payments under the program from the
Federal Health Insurance Trust Fund and the Federal
Supplementary Medical Insurance Trust Fund in amounts
that do not exceed the amounts authorized under the
program in accordance with the following:
(A) Payments to program administrators.--The
Secretary may make bonus payments under the
program to program administrators.
(B) Payments to entities furnishing
services.--
(i) In general.--Subject to clause
(ii), the Secretary may make bonus
payments to individuals or entities
furnishing items or services for which
payment may be made under the program,
or may authorize the program
administrator to make such bonus
payments in accordance with such
guidelines as the Secretary shall
establish and subject to the
Secretary's approval.
(ii) Limitations.--The Secretary may
condition such payments on the
achievement of such standards related
to efficiency, improvement in processes
or outcomes of care, or such other
factors as the Secretary determines to
be appropriate.
(3) Antidiscrimination limitation.--The Secretary
shall not enter into an agreement with an entity to
provide health care items or services under the
program, or with an entity to administer the program,
unless such entity guarantees that it will not deny,
limit, or condition the coverage or provision of
benefits under the program, for individuals eligible to
be enrolled under such program, based on any health
status-related factor described in section 2702(a)(1)
of the Public Health Service Act.
(d) Limitations on Judicial Review.--The following actions
and determinations with respect to the demonstration program
shall not be subject to review by a judicial or administrative
tribunal:
(1) Limiting the implementation of the program under
subsection (a)(2).
(2) Establishment of program participation standards
under subsection (a)(5) or the denial or termination
of, or refusal to renew, an agreement with an entity to
provide health care items and services under the
program.
(3) Establishment of program administration contract
performance standards under subsection (b)(6), the
refusal to renew a program administration contract, or
the noncompetitive award or renewal of a program
administration contract under subsection (b)(4)(B).
(5) Establishment of payment rates, through
negotiation or otherwise, under a program agreement or
a program administration contract.
(6) A determination with respect to the program
(where specifically authorized by the program authority
or by subsection (c)(2))--
(A) as to whether cost savings have been
achieved, and the amount of savings; or
(B) as to whether, to whom, and in what
amounts bonuses will be paid.
(e) Application Limited to Parts A and B.--None of the
provisions of this section or of the demonstration program
shall apply to the programs under part C.
(f) Reports to Congress.--Not later than two years after the
date of enactment of this section, and biennially thereafter
for six years, the Secretary shall report to the Congress on
the use of authorities under the demonstration program. Each
report shall address the impact of the use of those authorities
on expenditures, access, and quality under the programs under
this title.
* * * * * * *
medicare coverage for end stage renal disease patients
Sec. 1881. (a) * * *
* * * * * * *
(b)(1) * * *
* * * * * * *
(7) The Secretary shall provide by regulation for a method
(or methods) for determining prospectively the amounts of
payments to be made for dialysis services furnished by
providers of services and renal dialysis facilities to
individuals in a facility and to such individuals at home. Such
method (or methods) shall provide for the prospective
determination of a rate (or rates) for each mode of care based
on a single composite weighted formula (which takes into
account the mix of patients who receive dialysis services at a
facility or at home and the relative costs of providing such
services in such settings) for hospital-based facilities and
such a single composite weighted formula for other renal
dialysis facilities, or based on such other method or
combination of methods which differentiate between hospital-
based facilities and other renal dialysis facilities and which
the Secretary determines, after detailed analysis, will more
effectively encourage the more efficient delivery of dialysis
services and will provide greater incentives for increased use
of home dialysis than through the single composite weighted
formulas. The amount of a payment made under any method other
than a method based on a single composite weighted formula may
not exceed the amount (or, in the case of continuous cycling
peritoneal dialysis, 130 percent of the amount) of the median
payment that would have been made under the formula for
hospital-based facilities. The Secretary shall provide for such
exceptions to such methods as may be warranted by unusual
circumstances (including the special circumstances of sole
facilities located in isolated, rural areas and of pediatric
facilities). Each application for such an exception shall be
deemed to be approved unless the Secretary disapproves it by
not later than 60 working days after the date the application
is filed. The Secretary may provide that such method will serve
in lieu of any target reimbursement rate that would otherwise
be established under paragraph (6). The Secretary shall reduce
the amount of each composite rate payment under this paragraph
for each treatment by 50 cents (subject to such adjustments as
may be required to reflect modes of dialysis other than
hemodialysis) and provide for payment of such amount to the
organizations (designated under subsection (c)(1)(A)) for such
organizations' necessary and proper administrative costs
incurred in carrying out the responsibilities described in
subsection (c)(2). The Secretary shall provide that amounts
paid under the previous sentence shall be distributed to the
organizations described in subsection (c)(1)(A) to ensure
equitable treatment of all such network organizations. The
Secretary in distributing any such payments to network
organizations shall take into account--
(A) * * *
* * * * * * *
The Secretary shall increase the amount of each composite rate
payment for dialysis services furnished during 2000 by 1.2
percent above such composite rate payment amounts for such
services furnished on December 31, 1999, and for such services
furnished on or after January 1, [2001, by 1.2 percent] 2000,
by 2.4 percent above such composite rate payment amounts for
such services furnished on December 31, 2000.
* * * * * * *
payment to hospitals for inpatient hospital services
Sec. 1886. (a) * * *
* * * * * * *
(b)(1) * * *
* * * * * * *
(3)(A) * * *
* * * * * * *
(D) For cost reporting periods ending on or before September
30, 1994, and for cost reporting periods beginning on or after
October 1, 1997, [and before October 1, 2006,] in the case of a
hospital that is a medicare-dependent, small rural hospital (as
defined in subsection (d)(5)(G)), the term ``target amount''
means--
(i) * * *
* * * * * * *
(iv) with respect to discharges occurring during
fiscal year 1998 [through fiscal year 2005,] or any
subsequent fiscal year, the target amount for the
preceding year increased by the applicable percentage
increase under subparagraph (B)(iv).
* * * * * * *
(d)(1) * * *
* * * * * * *
(5)(A) * * *
* * * * * * *
(G)(i) For any cost reporting period beginning on or after
April 1, 1990, and before October 1, 1994, or discharges
occurring on or after October 1, 1997, [and before October 1,
2006,] in the case of a subsection (d) hospital which is a
medicare-dependent, small rural hospital, payment under
paragraph (1)(A) shall be equal to the sum of the amount
determined under clause (ii) and the amount determined under
paragraph (1)(A)(iii).
(ii) The amount determined under this clause is--
(I) * * *
(II) for discharges occurring during any subsequent
cost reporting period (or portion thereof) and before
October 1, 1994, or discharges occurring on or after
October 1, 1997, [and before October 1, 2006,] 50
percent of the amount by which the hospital's target
amount for the cost reporting period (as defined in
subsection (b)(3)(D)) exceeds the amount determined
under paragraph (1)(A)(iii).
* * * * * * *
(iv) The term ``medicare-dependent, small rural hospital''
means, with respect to any cost reporting period to which
clause (i) applies, any hospital--
(I) * * *
* * * * * * *
(IV) for which not less than 60 percent of its
inpatient days or discharges during the cost reporting
period beginning in fiscal year 1987, or any of the 3
most recent audited cost reporting periods, were
attributable to inpatients entitled to benefits under
part A.
* * * * * * *
prospective payment for home health services
Sec. 1895. (a) * * *
(b) System of Prospective Payment for Home Health Services.--
(1) * * *
* * * * * * *
(3) Payment basis.--
(A) Initial basis.--
(i) In general.--Under such system
the Secretary shall provide for
computation of a standard prospective
payment amount (or amounts) as follows:
(I) Such amount (or amounts)
shall initially be based on the
most current audited cost
report data available to the
Secretary and shall be computed
in a manner so that the total
amounts payable under the
system for the 12-month period
beginning on the date the
Secretary implements the system
shall be equal to the total
amount that would have been
made if the system had not been
in effect.
(II) For the 12-month period
beginning after the period
described in subclause (I),
such amount (or amounts) shall
be equal to the amount (or
amounts) determined under
subclause (I), updated under
subparagraph (B).
[(II)] (III) For periods
beginning after the period
described in subclause [(I)]
(II), such amount (or amounts)
shall be equal to the amount
(or amounts) that would have
been determined under subclause
(I) that would have been made
for fiscal year 2001 if the
system had not been in effect
and if section
1861(v)(1)(L)(ix) had not been
enacted but if the reduction in
limits described in clause (ii)
had been in effect, updated
under subparagraph (B).
* * * * * * *
TITLE XIX--GRANTS TO STATES FOR MEDICAL ASSISTANCE PROGRAMS
* * * * * * *
STATE PLANS FOR MEDICAL ASSISTANCE
Sec. 1902. (a) A State plan for medical assistance must--
(1) * * *
* * * * * * *
(8) provide that all individuals wishing to make
application for medical assistance under the plan shall
have opportunity to do so[, and that] permit
individuals to apply for and obtain medical assistance
for medicare cost-sharing using the simplified uniform
application form developed under section 1905(p)(5),
make available such forms to such individuals, permit
such individuals to apply for such assistance by mail
(and, at the State option, by telephone or other
electronic means) and not require them to apply in
person, and provide that such assistance shall be
furnished with reasonable promptness to all eligible
individuals and provide application forms for medical
assistance for medicare cost-sharing under the plan to
the Secretary in order to make them available through
Federal offices under section 1804(d) within the State;
* * * * * * *
(10) provide--
(A) * * *
* * * * * * *
(C) that if medical assistance is included
for any group of individuals described in
section 1905(a) who are not described in
subparagraph (A) or (E), then--
(i) * * *
* * * * * * *
(iv) if such medical assistance
includes services in institutions for
mental diseases or in an intermediate
care facility for the mentally retarded
(or both) for any such group, it also
must include for all groups covered at
least the care and services listed in
paragraphs (1) through (5) and (17) of
section 1905(a) or the care and
services listed in any 7 of the
paragraphs numbered (1) through [(24)]
(25) of such section;
* * * * * * *
(13) provide--
(A) for a public process for determination of
rates of payment under the plan for hospital
services, nursing facility services, and
services of intermediate care facilities for
the mentally retarded under which--
(i) * * *
* * * * * * *
(iv) in the case of hospitals, such
rates take into account (in a manner
consistent with section 1923) the
situation of hospitals which serve a
disproportionate number of low-income
patients with special needs; and
(B) for payment for hospice care in amounts
no lower than the amounts, using the same
methodology, used under part A of title XVIII
and for payment of amounts under section
1905(o)(3); except that in the case of hospice
care which is furnished to an individual who is
a resident of a nursing facility or
intermediate care facility for the mentally
retarded, and who would be eligible under the
plan for nursing facility services or services
in an intermediate care facility for the
mentally retarded if he had not elected to
receive hospice care, there shall be paid an
additional amount, to take into account the
room and board furnished by the facility, equal
to at least 95 percent of the rate that would
have been paid by the State under the plan for
facility services in that facility for that
individual; [and]
[(C)(i) for payment for services described in
clause (B) or (C) of section 1905(a)(2) under
the plan, of 100 percent (or 95 percent for
services furnished during fiscal year 2000,
fiscal year 2001, or fiscal year 2002, 90
percent for services furnished during fiscal
year 2003, or 85 percent for services furnished
during fiscal year 2004) of costs which are
reasonable and related to the cost of
furnishing such services or based on such other
tests of reasonableness, as the Secretary
prescribes in regulations under section
1833(a)(3), or, in the case of services to
which those regulations do not apply, on the
same methodology used under section 1833(a)(3)
and (ii) in carrying out clause (i) in the case
of services furnished by a Federally-qualified
health center or a rural health clinic pursuant
to a contract between the center and an
organization under section 1903(m), for payment
to the center or clinic at least quarterly by
the State of a supplemental payment equal to
the amount (if any) by which the amount
determined under clause (i) exceeds the amount
of the payments provided under such contract;]
* * * * * * *
(15) provide for payment for services described in
clause (B) or (C) of section 1905(a)(2) under the plan
in accordance with subsection (aa);
* * * * * * *
(aa) Payment for Services Provided by Federally-Qualified
Health Centers and Rural Health Clinics.--
(1) In general.--Beginning with fiscal year 2001 and
each succeeding fiscal year, the State plan shall
provide for payment for services described in section
1905(a)(2)(C) furnished by a Federally-qualified health
center and services described in section 1905(a)(2)(B)
furnished by a rural health clinic in accordance with
the provisions of this subsection. The payment rate
under this subsection shall not vary based upon the
site services are provided in the case of the same
center or clinic entity.
(2) Fiscal year 2001.--Subject to paragraph (4), for
services furnished during fiscal year 2001, the State
plan shall provide for payment for such services in an
amount (calculated on a per visit basis) that is equal
to 100 percent of the average of the costs of the
center or clinic of furnishing such services during
fiscal years 1999 and 2000 which are reasonable and
related to the cost of furnishing such services, or
based on such other tests of reasonableness as the
Secretary prescribes in regulations under section
1833(a)(3), or, in the case of services to which such
regulations do not apply, the same methodology used
under section 1833(a)(3), adjusted to take into account
any increase or decrease in the scope of such services
furnished by the center or clinic during fiscal year
2001.
(3) Fiscal year 2002 and succeeding fiscal years.--
Subject to paragraph (4), for services furnished during
fiscal year 2002 or a succeeding fiscal year, the State
plan shall provide for payment for such services in an
amount (calculated on a per visit basis) that is equal
to the amount calculated for such services under this
subsection for the preceding fiscal year--
(A) increased by the percentage increase in
the MEI (as defined in section 1842(i)(3))
applicable to primary care services (as defined
in section 1842(i)(4)) for that fiscal year;
and
(B) adjusted to take into account any
increase or decrease in the scope of such
services furnished by the center or clinic
during that fiscal year.
(4) Establishment of initial year payment amount for
new centers or clinics.--In any case in which an entity
first qualifies as a Federally-qualified health center
or rural health clinic after fiscal year 2000, the
State plan shall provide for payment for services
described in section 1905(a)(2)(C) furnished by the
center or services described in section 1905(a)(2)(B)
furnished by the clinic in the first fiscal year in
which the center or clinic so qualifies in an amount
(calculated on a per visit basis) that is equal to 100
percent of the costs of furnishing such services during
such fiscal year based on the rates established under
this subsection for the fiscal year for other such
centers or clinics located in the same or adjacent area
with a similar case load, service package, and case mix
or, in the absence of such a center or clinic, in
accordance with the regulations and methodology
referred to in paragraph (2) or based on such other
tests of reasonableness as the Secretary may specify.
For each fiscal year following the fiscal year in which
the entity first qualifies as a Federally-qualified
health center or rural health clinic, the State plan
shall provide for the payment amount to be calculated
in accordance with paragraph (3).
(5) Administration in the case of managed care.--In
the case of services furnished by a Federally-qualified
health center or rural health clinic pursuant to a
contract between the center or clinic and a managed
care entity (as defined in section 1932(a)(1)(B)), the
State plan shall provide for payment to the center or
clinic (at least quarterly) by the State of a
supplemental payment equal to the amount (if any) by
which the amount determined under paragraphs (2), (3),
and (4) of this subsection exceeds the amount of the
payments provided under the contract.
(6) Alternative payment methodologies.--
Notwithstanding any other provision of this section,
the State plan may provide for payment in any fiscal
year to a Federally-qualified health center for
services described in section 1905(a)(2)(C) or to a
rural health clinic for services described in section
1905(a)(2)(B) in an amount which is determined under an
alternative payment methodology that--
(A) is agreed to by the State and the center
or clinic; and
(B) results in payment to the center or
clinic of an amount which is at least equal to
the amount otherwise required to be paid to the
center or clinic under this section.
* * * * * * *
PAYMENT TO STATES
Sec. 1903. (a) * * *
* * * * * * *
(v)(1) Notwithstanding the preceding provisions of this
section, except as provided in [paragraph (2)] paragraphs (2)
and (4), no payment may be made to a State under this section
for medical assistance furnished to an alien who is not
lawfully admitted for permanent residence or otherwise
permanently residing in the United States under color of law.
* * * * * * *
(4)(A) A State may elect (in a plan amendment under this
title) to provide medical assistance under this title,
notwithstanding sections 401(a), 402(b), 403, and 421 of the
Personal Responsibility and Work Opportunity Reconciliation Act
of 1996, for aliens who are lawfully residing in the United
States (including battered aliens described in section 431(c)
of such Act) and who are otherwise eligible for such
assistance, within either or both of the following eligibility
categories, but only if they have lawfully resided in the
United States for 2 years:
(i) Pregnant women.--Women during pregnancy (and
during the 60-day period beginning on the last day of
the pregnancy).
(ii) Children.--Children (as defined under such
plan), including optional targeted low-income children
described in section 1905(u)(2)(B).
(B) In the case of a State that has elected to provide
medical assistance to a category of aliens under subparagraph
(A), no debt shall accrue under an affidavit of support against
any sponsor of such an alien who has lawfully resided in the
United States for 2 years on the basis of provision of
assistance to such category.
* * * * * * *
DEFINITIONS
Sec. 1905. For purposes of this title--
(a) The term ``medical assistance'' means payment of part or
all of the cost of the following care and services (if provided
in or after the third month before the month in which the
recipient makes application for assistance or, in the case of
medicare cost-sharing with respect to a qualified medicare
beneficiary described in subsection (p)(1), if provided after
the month in which the individual becomes such a beneficiary)
for individuals, and, with respect to physicians' or dentists'
services, at the option of the State, to individuals (other
than individuals with respect to whom there is being paid, or
who are eligible, or would be eligible if they were not in a
medical institution, to have paid with respect to them a State
supplementary payment and are eligible for medical assistance
equal in amount, duration, and scope to the medical assistance
made available to individuals described in section
1902(a)(10)(A)) not receiving aid or assistance under any plan
of the State approved under title I, X, XIV, or XVI, or part A
of title IV, and with respect to whom supplemental security
income benefits are not being paid under title XVI, who are--
(i) * * *
* * * * * * *
but whose income and resources are insufficient to meet all of
such cost--
(1) inpatient hospital services (other than services
in an institution for mental diseases);
* * * * * * *
(22) services furnished by a physician assistant (as
defined in section 1861(aa)(5)) which the assistant is
legally authorized to perform under State law and with
the supervision of a physician;
[(22)] (23) home and community care (to the extent
allowed and as defined in section 1929) for
functionally disabled elderly individuals;
[(23)] (24) community supported living arrangements
services (to the extent allowed and as defined in
section 1930);
[(24)] (25) personal care services furnished to an
individual who is not an inpatient or resident of a
hospital, nursing facility, intermediate care facility
for the mentally retarded, or institution for mental
disease that are (A) authorized for the individual by a
physician in accordance with a plan of treatment or (at
the option of the State) otherwise authorized for the
individual in accordance with a service plan approved
by the State, (B) provided by an individual who is
qualified to provide such services and who is not a
member of the individual's family, and (C) furnished in
a home or other location;
[(25)] (26) primary care case management services (as
defined in subsection (t));
[(26)] (27) services furnished under a PACE program
under section 1934 to PACE program eligible individuals
enrolled under the program under such section; and
[(27)] (28) any other medical care, and any other
type of remedial care recognized under State law,
specified by the Secretary,
* * * * * * *
(p)(1) * * *
* * * * * * *
(5)(A) The Secretary shall develop a simplified application
form for use by individuals (including both qualified medicare
beneficiaries and specified low-income medicare beneficiaries)
in applying for medical assistance for medicare cost-sharing
under this title. Such form shall be easily readable by
applicants and uniform nationally.
(B) In developing such form, the Secretary shall consult with
beneficiary groups and the States.
(C) The Secretary shall make such application forms
available--
(i) to the Commissioner of Social Security for
distribution through local social security offices;
(ii) at such other sites at the Secretary determines
appropriate; and
(iii) to persons upon request.
* * * * * * *
PROVISIONS RESPECTING INAPPLICABILITY AND WAIVER OF CERTAIN
REQUIREMENTS OF THIS TITLE
Sec. 1915. (a) * * *
* * * * * * *
(b) The Secretary, to the extent he finds it to be cost-
effective and efficient and not inconsistent with the purposes
of this title, may waive such requirements of section 1902
(other than subsection (s)) (other than sections
[1902(a)(13)(C)] 1902(a)(15), 1902(aa), and 1902(a)(10)(A)
insofar as it requires provision of the care and services
described in section 1905(a)(2)(C)) as may be necessary for a
State--
(1) * * *
* * * * * * *
liens, adjustments and recoveries, and transfers of assets
Sec. 1917. (a) * * *
* * * * * * *
(c)(1)(A) * * *
* * * * * * *
(C)(i) * * *
* * * * * * *
(ii) The services described in this subparagraph with respect
to a noninstitutionalized individual are services (not
including any services described in clause (i)) that are
described in paragraph (7), [(22), or (24)] (23), or (25) of
section 1905(a), and, at the option of a State, other long-term
care services for which medical assistance is otherwise
available under the State plan to individuals requiring long-
term care.
* * * * * * *
PRESUMPTIVE ELIGIBILITY FOR PREGNANT WOMEN
Sec. 1920. (a) * * *
(b) For purposes of this section--
(1) * * *
* * * * * * *
(2) the term ``qualified provider'' means any
provider that--
(A) * * *
* * * * * * *
The term ``qualified provider'' includes a qualified entity as
defined in section 1920A(b)(3).
* * * * * * *
presumptive eligibility for children
Sec. 1920A. (a) * * *
(b) For purposes of this section:
(1) * * *
* * * * * * *
(3)(A) Subject to subparagraph (B), the term
``qualified entity'' means any entity that--
(i)(I) is eligible for payments under a State
plan approved under this title and provides
items and services described in subsection (a)
[or (II)], (II) is authorized to determine
eligibility of a child to participate in a Head
Start program under the Head Start Act ([42
U.S.C. 9821] 42 U.S.C. 9831 et seq.),
eligibility of a child to receive child care
services for which financial assistance is
provided under the Child Care and Development
Block Grant Act of 1990 (42 U.S.C. 9858 et
seq.), eligibility of an infant or child to
receive assistance under the special
supplemental nutrition program for women,
infants, and children (WIC) under section 17 of
the Child Nutrition Act of 1966 (42 U.S.C.
1786) eligibility of a child for medical
assistance under the State plan under this
title, or eligibility of a child for child
health assistance under the program funded
under title XXI, (III) is an elementary school
or secondary school, as such terms are defined
in section 14101 of the Elementary and
Secondary Education Act of 1965 (20 U.S.C.
8801), an elementary or secondary school
operated or supported by the Bureau of Indian
Affairs, a State or tribal child support
enforcement agency, a child care resource and
referral agency, an organization that is
providing emergency food and shelter under a
grant under the Stewart B. McKinney Homeless
Assistance Act, or a State or tribal office or
entity involved in enrollment in the program
under this title, under part A of title IV,
under title XXI, or that determines eligibility
for any assistance or benefits provided under
any program of public or assisted housing that
receives Federal funds, including the program
under section 8 or any other section of the
United States Housing Act of 1937 (42 U.S.C.
1437 et seq.) or under the Native American
Housing Assistance and Self-Determination Act
of 1996 (25 U.S.C. 4101 et seq.), or (IV) any
other entity the State so deems, as approved by
the Secretary; and
(ii) is determined by the State agency to be
capable of making determinations of the type
described in [paragraph (1)(A)] paragraph (2).
* * * * * * *
ADJUSTMENT IN PAYMENT FOR INPATIENT HOSPITAL SERVICES FURNISHED BY
DISPROPORTIONATE SHARE HOSPITALS
Sec. 1923. (a) Implementation of Requirement.--
(1) * * *
* * * * * * *
(2)(A) * * *
* * * * * * *
(D) A State plan under this title shall not be
considered to meet the requirements of section
1902(a)(13)(A)(iv) (insofar as it requires payments to
hospitals to take into account the situation of
hospitals that serve a disproportionate number of low-
income patients with special needs), as of October 1,
1998, unless the State has submitted to the Secretary
by such date a description of the methodology used by
the State to identify and to make payments to
disproportionate share hospitals, including children's
hospitals, on the basis of the proportion of low-income
and medicaid patients (including such patients who
receive benefits through a managed care entity) served
by such hospitals. The State shall provide an annual
report to the Secretary describing the disproportionate
share payments to each such disproportionate share
hospital.
* * * * * * *
(b) Hospitals Deemed Disproportionate Share.--
(1) * * *
* * * * * * *
(2) For purposes of paragraph (1)(A), the term
``medicaid inpatient utilization rate'' means, for a
hospital, a fraction (expressed as a percentage), the
numerator of which is the hospital's number of
inpatient days attributable to patients who (for such
days) were eligible for medical assistance under a
State plan approved under this title in a period
(regardless of whether they receive benefits on a fee-
for-service basis or through a managed care entity),
and the denominator of which is the total number of the
hospital's inpatient days in that period. In this
paragraph, the term ``inpatient day'' includes each day
in which an individual (including a newborn) is an
inpatient in the hospital, whether or not the
individual is in a specialized ward and whether or not
the individual remains in the hospital for lack of
suitable placement elsewhere.
(3) For purposes of paragraph (1)(B), the term ``low-
income utilization rate'' means, for a hospital, the
sum of--
(A) the fraction (expressed as a
percentage)--
(i) the numerator of which is the sum
(for a period) of (I) the total
revenues paid the hospital for patient
services under a State plan under this
title (regardless of whether the
services were furnished on a fee-for-
service basis or through a managed care
entity) and (II) the amount of the cash
subsidies for patient services received
directly from State and local
governments, and
* * * * * * *
(f) Limitation on Federal Financial Participation.--
(1) * * *
(2) State dsh allotments for fiscal years 1998
through [2002] 2000.--The DSH allotment for a State for
each fiscal year during the period beginning with
fiscal year 1998 and ending with fiscal year [2002]
2000 is determined in accordance with the following
table:
----------------------------------------------------------------------------------------------------------------
DSH Allotment (in millions of dollars)
State or District -------------------------------------------------
FY 98 FY 99 FY 00 [FY 01] [FY 02]
----------------------------------------------------------------------------------------------------------------
Alabama 293 269 248 [246] [246]
Alaska 10 10 10 [9] [9]
Arizona 81 81 81 [81] [81]
Arkansas 2 2 2 [2] [2]
California 1,085 1,068 986 [931] [877]
Colorado 93 85 79 [74] [74]
Connecticut 200 194 164 [160] [160]
Delaware 4 4 4 [4] [4]
District of Columbia 23 23 [32] 49 [32] [32]
Florida 207 203 197 [188] [160]
Georgia 253 248 241 [228] [215]
Hawaii 0 0 0 [0] [0]
Idaho 1 1 1 [1] [1]
Illinois 203 199 193 [182] [172]
Indiana 201 197 191 [181] [171]
Iowa 8 8 8 [8] [8]
Kansas 51 49 42 [36] [33]
Kentucky 137 134 130 [123] [116]
Louisiana 880 795 713 [658] [631]
Maine 103 99 84 [84] [84]
Maryland 72 70 68 [64] [61]
Massachusetts 288 282 273 [259] [244]
Michigan 249 244 237 [224] [212]
Minnesota 16 33 [33] [33]
Mississippi 143 141 136 [129] [122]
Missouri 436 423 379 [379] [379]
Montana 0.2 0.2 0.2 [0.2] [0.2]
Nebraska 5 5 5 [5] [5]
Nevada 37 37 37 [37] [37]
New Hampshire 140 136 130 [130] [130]
New Jersey 600 582 515 [515] [515]
New Mexico 5 9 [9] [9]
New York 1,512 1,482 1,436 [1,361] [1,285]
North Carolina 278 272 264 [250] [236]
North Dakota 1 1 1 [1] [1]
Ohio 382 374 363 [344] [325]
Oklahoma 16 16 16 [16] [16]
Oregon 20 20 20 [20] [20]
Pennsylvania 529 518 502 [476] [449]
Rhode Island 62 60 58 [55] [52]
South Carolina 313 303 262 [262] [262]
South Dakota 1 1 1 [1] [1]
Tennessee 0 0 0 [0] [0]
Texas 979 950 806 [765] [765]
Utah 3 3 3 [3] [3]
Vermont 18 18 18 [18] [18]
Virginia 70 68 66 [63] [59]
Washington 174 171 166 [157] [148]
West Virginia 64 63 61 [58] [54]
Wisconsin 7 7 7 [7] [7]
Wyoming 0 \3\0 0.1 [0.1] [0.1]
----------------------------------------------------------------------------------------------------------------
(3) State dsh allotments for fiscal year [2003] 2001
and thereafter.--
(A) In general.--The DSH allotment for any
State for fiscal year [2003] 2001 and each
succeeding fiscal year is equal to the DSH
allotment for the State for the preceding
fiscal year under paragraph (2) [or this
paragraph], this paragraph, or paragraph (4),
increased, subject to [subparagraph (B)]
subparagraphs (B) and (C), by the percentage
change in the consumer price index for all
urban consumers (all items; U.S. city average),
for the previous fiscal year.
* * * * * * *
(C) Special rule for extremely low dsh
states.--In the case of a State in which the
total expenditures under the State plan
(including Federal and State shares) for
disproportionate share hospital adjustments
under this section for fiscal year 1999, as
reported to the Administrator of the Health
Care Financing Administration as of August 31,
2000, is greater than 0 but less than 1 percent
of the State's total amount of expenditures
under the State plan for medical assistance
during the fiscal year, the DSH allotment for
fiscal year 2001 shall be increased to 1
percent of the State's total amount of
expenditures under such plan for such
assistance during such fiscal year. In
subsequent fiscal years, such increased
allotment is subject to an increase for
inflation as provided in subparagraph (A).
* * * * * * *
EXTENSION OF ELIGIBILITY FOR MEDICAL ASSISTANCE
Sec. 1925. (a) Initial 6-Month Extension.--
(1) Requirement.--Notwithstanding any other provision
of this title, but subject to subsection (g), each
State plan approved under this title must provide that
each family which was receiving aid pursuant to a plan
of the State approved under part A of title IV in at
least 3 of the 6 months immediately preceding the month
in which such family becomes ineligible for such aid,
because of hours of, or income from, employment of the
caretaker relative (as defined in subsection (e)) or
because of section 402(a)(8)(B)(ii)(II) (providing for
a time-limited earned income disregard), shall, subject
to paragraph (3) and without any reapplication for
benefits under the plan, remain eligible for assistance
under the plan approved under this title during the
immediately succeeding 6-month period in accordance
with this subsection.
* * * * * * *
(b) Additional 6-Month Extension.--
(1) Requirement.--Notwithstanding any other provision
of this title, but subject to subsection (g), each
State plan approved under this title shall provide that
the State shall offer to each family, which has
received assistance during the entire 6-month period
under subsection (a) and which meets the requirement of
paragraph (2)(B)(i), in the last month of the period
the option of extending coverage under this subsection
for the succeeding 6-month period, subject to paragraph
(3).
(2) Notice and reporting requirements.--
(A) * * *
* * * * * * *
(C) State option to waive reporting
requirements.--A State may elect to waive the
reporting requirements under subparagraph (B)
and, in the case of such a waiver for purposes
of notices required under subparagraph (A), to
exclude from such notices any reference to any
requirement under subparagraph (B).
* * * * * * *
(f) Sunset.--This section shall not apply with respect to
families that cease to be eligible for aid under part A of
title IV after September 30, [2001] 2002.
(g) Exemption for State Covering Needy Families Up to 185
Percent of Poverty.--
(1) In general.--At State option, the provisions of
this section shall not apply to a State that uses the
authority under section 1931(b)(2)(C) to make medical
assistance available under the State plan under this
title, at a minimum, to all individuals described in
section 1931(b)(1) in families with gross incomes
(determined without regard to work-related child care
expenses of such individuals) at or below 185 percent
of the income official poverty line (as defined by the
Office of Management and Budget, and revised annually
in accordance with section 673(2) of the Omnibus Budget
Reconciliation Act of 1981) applicable to a family of
the size involved.
(2) Application to other provisions of this title.--
The State plan of a State described in paragraph (1)
shall be deemed to meet the requirements of sections
1902(a)(10)(A)(i)(I) and 1902(e)(1).
* * * * * * *
Home and Community Care for Functionally Disabled Elderly Individuals
Sec. 1929. (a) * * *
* * * * * * *
(e) Ceiling on Payment Amounts and Maintenance of Effort.--
(1) * * *
* * * * * * *
(2) Maintenance of effort.--
(A) Annual reports.--As a condition for the
receipt of payment under section 1903(a) with
respect to medical assistance provided by a
State for home and community care (other than a
waiver under section 1915(c) and other than
home health care services described in section
1905(a)(7) and personal care services specified
under regulations under section [1905(a)(23)]
1905(a)(24)), the State shall report to the
Secretary, with respect to each Federal fiscal
year (beginning with fiscal year 1990) and in a
format developed or approved by the Secretary,
the amount of funds obligated by the State with
respect to the provision of home and community
care to the functionally disabled elderly in
that fiscal year.
* * * * * * *
provisions relating to managed care
Sec. 1932. (a) * * *
* * * * * * *
(g) Identification of Patients for Purposes of Making DSH
Payments.--Each contract with a managed care entity under
section 1903(m) or under section 1905(t)(3) shall require the
entity either--
(1) to report to the State information necessary to
determine the hospital services provided under the
contract (and the identity of hospitals providing such
services) for purposes of applying sections
1886(d)(5)(F) and 1923; or
(2) to include a sponsorship code in the
identification card issued to individuals covered under
this title in order that a hospital may identify a
patient as being entitled to benefits under this title.
* * * * * * *
TITLE XXI--STATE CHILDREN'S HEALTH INSURANCE PROGRAM
* * * * * * *
SEC. 2104. ALLOTMENTS.
(a) * * *
* * * * * * *
(g) Rule for Redistribution and Extended Availability of
Fiscal Years 1998 and 1999 Allotments.--
(1) Amount redistributed.--
(A) In general.--In the case of a State that
expends all of its allotment under subsection
(b) or (c) for fiscal year 1998 by the end of
fiscal year 2000, or for fiscal year 1999 by
the end of fiscal year 2001, the Secretary
shall redistribute to the State under
subsection (f) (from the fiscal year 1998 or
1999 allotments of other States, respectively,
as determined by the application of paragraphs
(2) and (3) with respect to the respective
fiscal year)) the following amount:
(i) State.--In the case of 1 of the
50 States or the District of Columbia,
with respect to--
(I) the fiscal year 1998
allotment, the amount by which
the State's expenditures under
this title in fiscal years
1998, 1999, and 2000 exceed the
State's allotment for fiscal
year 1998 under subsection (b);
or
(II) the fiscal year 1999
allotment, the amount by which
the State's expenditures under
this title in fiscal years
1999, 2000, and 2001 exceed the
State's allotment for fiscal
year 1999 under subsection (b).
(ii) Territory.--In the case of a
commonwealth or territory described in
subsection (c)(3), an amount that bears
the same ratio to 1.05 percent of the
total amount described in paragraph
(2)(B)(i)(I) as the ratio of the
commonwealth's or territory's fiscal
year 1998 or 1999 allotment under
subsection (c) (as the case may be)
bears to the total of all such
allotments for such fiscal year under
such subsection.
(B) Expenditure rules.--An amount
redistributed to a State under this paragraph
with respect to fiscal year 1998 or 1999--
(i) shall not be included in the
determination of the State's allotment
for any fiscal year under this section;
(ii) notwithstanding subsection (e),
shall remain available for expenditure
by the State through the end of fiscal
year 2002; and
(iii) shall be counted as being
expended with respect to a fiscal year
allotment in accordance with applicable
regulations of the Secretary.
(2) Extension of availability of portion of
unexpended fiscal years 1998 and 1999 allotments.--
(A) In general.--Notwithstanding subsection
(e):
(i) Fiscal year 1998 allotment.--Of
the amounts allotted to a State
pursuant to this section for fiscal
year 1998 that were not expended by the
State by the end of fiscal year 2000,
the amount specified in subparagraph
(B) for fiscal year 1998 for such State
shall remain available for expenditure
by the State through the end of fiscal
year 2002.
(ii) Fiscal year 1999 allotment.--Of
the amounts allotted to a State
pursuant to this subsection for fiscal
year 1999 that were not expended by the
State by the end of fiscal year 2001,
the amount specified in subparagraph
(B) for fiscal year 1999 for such State
shall remain available for expenditure
by the State through the end of fiscal
year 2002.
(B) Amount remaining available for
expenditure.--The amount specified in this
subparagraph for a State for a fiscal year is
equal to--
(i) the amount by which (I) the total
amount available for redistribution
under subsection (f) from the
allotments for that fiscal year,
exceeds (II) the total amounts
redistributed under paragraph (1) for
that fiscal year; multiplied by
(ii) the ratio of the amount of such
State's unexpended allotment for that
fiscal year to the total amount
described in clause (i)(I) for that
fiscal year.
(C) Use of up to 10 percent of retained 1998
allotments for outreach activities.--
Notwithstanding section 2105(c)(2)(A), with
respect to any State described in subparagraph
(A)(i), the State may use up to 10 percent of
the amount specified in subparagraph (B) for
fiscal year 1998 for expenditures for outreach
activities approved by the Secretary.
(3) Determination of amounts.--For purposes of
calculating the amounts described in paragraphs (1) and
(2) relating to the allotment for fiscal year 1998 or
fiscal year 1999, the Secretary shall use the amounts
reported by the States not later than November 30,
2000, or November 30, 2001, respectively, on HCFA Form
64 or HCFA Form 21, as approved by the Secretary.
* * * * * * *
SEC. 2107. STRATEGIC OBJECTIVES AND PERFORMANCE GOALS; PLAN
ADMINISTRATION.
(a) * * *
* * * * * * *
(e) Application of Certain General Provisions.--The following
sections of this Act shall apply to States under this title in
the same manner as they apply to a State under title XIX:
(1) Title xix provisions.--
(A) * * *
* * * * * * *
(D) Section 1920A (relating to presumptive
eligibility).''.
(E) Section 1903(v)(4) (relating to optional
coverage of categories of lawfully residing
alien children), but only if the State has
elected to apply such section to the category
of children under title XIX.
----------
MEDICARE, MEDICAID, AND SCHIP BALANCED BUDGET REFINEMENT ACT OF 1999
* * * * * * *
TITLE II--PROVISIONS RELATING TO PART B
* * * * * * *
Subtitle C--Other Services
SEC. 221. REVISION OF PROVISIONS RELATING TO THERAPY SERVICES.
(a) 2-Year Moratorium on Caps.--
(1) * * *
* * * * * * *
(2) Focused medical reviews of claims during
moratorium period.--During years in which paragraph (4)
of section 1833(g) of the Social Security Act (42
U.S.C. 1395l(g)) applies [(under the amendment made by
paragraph (1)(B))], the Secretary of Health and Human
Services shall conduct focused medical reviews of
claims for reimbursement for services described in
paragraph (1) or (3) of such section, with an emphasis
on such claims for services that are provided to
residents of skilled nursing facilities.
* * * * * * *
SEC. 226. PHASE-IN OF PPS FOR AMBULATORY SURGICAL CENTERS.
If the Secretary of Health and Human Services implements a
revised prospective payment system for services of ambulatory
surgical facilities under section 1833(i) of the Social
Security Act (42 U.S.C. 1395l(i)), prior to incorporating data
from the 1999 Medicare cost survey or a subsequent cost survey,
such system shall be implemented in a manner so that--
[(1) in the first year of its implementation, only a
proportion (specified by the Secretary and not to
exceed \1/3\) of the payment for such services shall be
made in accordance with such system and the remainder
shall be made in accordance with current regulations;
and
[(2) in the following year a proportion (specified by
the Secretary and not to exceed \2/3\) of the payment
for such services shall be made under such system and
the remainder shall be made in accordance with current
regulations.]
(1) in the first year of its implementation, only a
proportion (specified by the Secretary and not to
exceed \1/4\) of the payment for such services shall be
made in accordance with such system and the remainder
shall be made in accordance with current regulations;
and
(2) in each of the following 2 years a proportion
(specified by the Secretary and not to exceed \1/2\,
and \3/4\, respectively) of the payment for such
services shall be made under such system and the
remainder shall be made in accordance with current
regulations.
By not later than January 1, 2003, the Secretary shall
incorporate data from a 1999 Medicare cost survey or a
subsequent cost survey for purposes of implementing or revising
such system.
* * * * * * *
TITLE III--PROVISIONS RELATING TO PARTS A AND B
Subtitle A--Home Health Services
* * * * * * *
SEC. 302. DELAY IN APPLICATION OF 15 PERCENT REDUCTION IN PAYMENT RATES
FOR HOME HEALTH SERVICES UNTIL ONE YEAR AFTER
IMPLEMENTATION OF PROSPECTIVE PAYMENT SYSTEM.
(a) * * *
* * * * * * *
(c) Report.--Not later than the date that is [six] 18 months
after the date the Secretary of Health and Human Services
implements the prospective payment system for home health
services under section 1895 of the Social Security Act (42
U.S.C. 1395fff), the Secretary shall submit to Congress a
report analyzing the need for the 15 percent reduction under
subsection (b)(3)(A)(ii) of such section, or for any reduction,
in the computation of the base payment amounts under the
prospective payment system for home health services established
under such section.
* * * * * * *
----------
BALANCED BUDGET ACT OF 1997
* * * * * * *
TITLE IV--MEDICARE, MEDICAID, AND CHILDREN'S HEALTH PROVISIONS
* * * * * * *
Subtitle C--Rural Initiatives
* * * * * * *
SEC. 4206. MEDICARE REIMBURSEMENT FOR TELEHEALTH SERVICES.
[(a) In General.--Not later than January 1, 1999, the
Secretary of Health and Human Services shall make payments from
the Federal Supplementary Medical Insurance Trust Fund under
part B of title XVIII of the Social Security Act (42 U.S.C.
1395j et seq.) in accordance with the methodology described in
subsection (b) for professional consultation via
telecommunications systems with a physician (as defined in
section 1861(r) of such Act (42 U.S.C. 1395x(r)) or a
practitioner (described in section 1842(b)(18)(C) of such Act
(42 U.S.C. 1395u(b)(18)(C)) furnishing a service for which
payment may be made under such part to a beneficiary under the
medicare program residing in a county in a rural area (as
defined in section 1886(d)(2)(D) of such Act (42 U.S.C.
1395ww(d)(2)(D))) that is designated as a health professional
shortage area under section 332(a)(1)(A) of the Public Health
Service Act (42 U.S.C. 254e(a)(1)(A)), notwithstanding that the
individual physician or practitioner providing the professional
consultation is not at the same location as the physician or
practitioner furnishing the service to that beneficiary.
[(b) Methodology for Determining Amount of Payments.--Taking
into account the findings of the report required under section
192 of the Health Insurance Portability and Accountability Act
of 1996 (Public Law 104-191; 110 Stat. 1988), the findings of
the report required under paragraph (c), and any other findings
related to the clinical efficacy and cost-effectiveness of
telehealth applications, the Secretary shall establish a
methodology for determining the amount of payments made under
subsection (a) within the following parameters:
[(1) The payment shall shared between the referring
physician or practitioner and the consulting physician
or practitioner. The amount of such payment shall not
be greater than the current fee schedule of the
consulting physician or practitioner for the health
care services provided.
[(2) The payment shall not include any reimbursement
for any telephone line charges or any facility fees,
and a beneficiary may not be billed for any such
charges or fees.
[(3) The payment shall be made subject to the
coinsurance and deductible requirements under
subsections (a)(1) and (b) of section 1833 of the
Social Security Act (42 U.S.C. 1395l).
[(4) The payment differential of section 1848(a)(3)
of such Act (42 U.S.C. 1395w-4(a)(3)) shall apply to
services furnished by non-participating physicians. The
provisions of section 1848(g) of such Act (42 U.S.C.
1395w-4(g)) and section 1842(b)(18) of such Act (42
U.S.C. 1395u(b)(18)) shall apply. Payment for such
service shall be increased annually by the update
factor for physicians' services determined under
section 1848(d) of such Act (42 U.S.C. 1395w-4(d)).
[(c) Supplemental Report.--Not later than January 1, 1999,
the Secretary shall submit a report to Congress which shall
contain a detailed analysis of--
[(1) how telemedicine and telehealth systems are
expanding access to health care services;
[(2) the clinical efficacy and cost-effectiveness of
telemedicine and telehealth applications;
[(3) the quality of telemedicine and telehealth
services delivered; and
[(4) the reasonable cost of telecommunications
charges incurred in practicing telemedicine and
telehealth in rural, frontier, and underserved areas.
[(d) Expansion of Telehealth Services for Certain Medicare
Beneficiaries.--
[(1) In general.--Not later than January 1, 1999, the
Secretary shall submit a report to Congress that
examines the possibility of making payments from the
Federal Supplementary Medical Insurance Trust Fund
under part B of title XVIII of the Social Security Act
(42 U.S.C. 1395j et seq.) for professional consultation
via telecommunications systems with such a physician or
practitioner furnishing a service for which payment may
be made under such part to a beneficiary described in
paragraph (2), notwithstanding that the individual
physician or practitioner providing the professional
consultation is not at the same location as the
physician or practitioner furnishing the service to
that beneficiary.
[(2) Beneficiary described.--A beneficiary described
in this paragraph is a beneficiary under the medicare
program under title XVIII of the Social Security Act
(42 U.S.C. 1395 et seq.) who does not reside in a rural
area (as so defined) that is designated as a health
professional shortage area under section 332(a)(1)(A)
of the Public Health Service Act (42 U.S.C.
254e(a)(1)(A)), who is homebound or nursing homebound,
and for whom being transferred for health care services
imposes a serious hardship.
[(3) Report.--The report described in paragraph (1)
shall contain a detailed statement of the potential
costs and savings to the medicare program of making the
payments described in that paragraph using various
reimbursement schemes.]
(a) Telehealth Services Reimbursed.--
(1) In general.--Not later than April 1, 2001, the
Secretary of Health and Human Services shall make
payments from the Federal Supplementary Medical
Insurance Trust Fund in accordance with the methodology
described in subsection (b) for services for which
payment may be made under part B of title XVIII of the
Social Security Act (42 U.S.C. 1395j et seq.) that are
furnished via a telecommunications system by a
physician or practitioner to an eligible telehealth
beneficiary.
(2) Use of store-and-forward technologies.--For
purposes of paragraph (1), in the case of any Federal
telemedicine demonstration program in Alaska or Hawaii,
the term ``telecommunications system'' includes store-
and-forward technologies that provide for the
asynchronous transmission of health care information in
single or multimedia formats.
(b) Methodology for Determining Amount of Payments.--
(1) In general.--The Secretary shall make payment
under this section as follows:
(A) Subject to subparagraph (B), with respect
to a physician or practitioner located at a
distant site that furnishes a service to an
eligible medicare beneficiary under subsection
(a), an amount equal to the amount that such
physician or practitioner would have been paid
had the service been furnished without the use
of a telecommunications system.
(B) With respect to an originating site, a
facility fee equal to--
(i) for 2001 (beginning with April 1,
2001) and 2002, $20; and
(ii) for a subsequent year, the
facility fee under this subsection for
the previous year increased by the
percentage increase in the MEI (as
defined in section 1842(i)(3)) for such
subsequent year.
(2) Application of part b coinsurance and
deductible.--Any payment made under this section shall
be subject to the coinsurance and deductible
requirements under subsections (a)(1) and (b) of
section 1833 of the Social Security Act (42 U.S.C.
1395l).
(3) Application of nonparticipating physician payment
differential and balance billing limits.--The payment
differential of section 1848(a)(3) of such Act (42
U.S.C. 1395w-4(a)(3)) shall apply to services furnished
by non-participating physicians. The provisions of
section 1848(g) of such Act (42 U.S.C. 1395w-4(g)) and
section 1842(b)(18) of such Act (42 U.S.C.
1395u(b)(18)) shall apply. Payment for such service
shall be increased annually by the update factor for
physicians' services determined under section 1848(d)
of such Act (42 U.S.C. 1395w-4(d)).
(c) Telepresenter Not Required.--Nothing in this section
shall be construed as requiring an eligible telehealth
beneficiary to be presented by a physician or practitioner at
the originating site for the furnishing of a service via a
telecommunications system, unless it is medically necessary as
determined by the physician or practitioner at the distant
site.
(d) Coverage of Additional Services.--
(1) Study and report on additional services.--
(A) Study.--The Secretary of Health and Human
Services shall conduct a study to identify
services in addition to those described in
subsection (a)(1) that are appropriate for
payment under this section.
(B) Report.--Not later than 2 years after the
date of enactment of this Act, the Secretary
shall submit to Congress a report on the study
conducted under subparagraph (A) together with
such recommendations for legislation that the
Secretary determines are appropriate.
(2) In general.--The Secretary shall provide for
payment under this section for services identified in
paragraph (1).
(e) Construction Relating to Home Health Services.--
(1) In general.--Nothing in this section or in
section 1895 of the Social Security Act (42 U.S.C.
1395fff) shall be construed as preventing a home health
agency furnishing a home health unit of service for
which payment is made under the prospective payment
system established in such section from furnishing the
service via a telecommunications system.
(2) Limitation.--The Secretary shall not consider a
home health service provided in the manner described in
paragraph (1) to be a home health visit for purposes
of--
(A) determining the amount of payment to be
made under such prospective payment system; or
(B) any requirement relating to the
certification of a physician required under
section 1814(a)(2)(C) or section 1835(a)(2)(A)
of such Act (42 U.S.C. 1395f(a)(2)(C),
1395n(a)(2)(A)).
(3) Construction.--Nothing in this section shall be
construed as waiving the requirement for a physician
certification under section 1814(a)(2)(C) or section
1835(a)(2)(A) of such Act (42 U.S.C. 1395f(a)(2)(C),
1395n(a)(2)(A)) for the payment for home health
services, whether or not furnished via a
telecommunications system.
(f) Coverage of Items and Services.--
(1) In general.--Subject to paragraph (2), payment
for items and services provided pursuant to subsection
(a) shall include payment for professional
consultations, office visits, office psychiatry
services, including any service identified as of July
1, 2000, by HCPCS codes 99241-99275, 99201-99215,
90804-90809, and 90862, and any additional item or
service specified by the Secretary.
(2) Yearly update.--The Secretary shall provide a
process that provides, on at least an annual basis, for
the review and revision of services (and HCPCS codes)
to those specified in paragraph (1) for authorized
payment under subsection (a).
(g) Definitions.--In this section:
(1) Eligible telehealth beneficiary.--The term
``eligible telehealth beneficiary'' means an individual
enrolled under part B of title XVIII of the Social
Security Act (42 U.S.C. 1395j et seq.) that receives a
service originating--
(A) in an area that is designated as a health
professional shortage area under section
332(a)(1)(A) of the Public Health Service Act
(42 U.S.C. 254e(a)(1)(A));
(B) in a county that is not included in a
Metropolitan Statistical Area;
(C) effective January 1, 2002, in an inner-
city area that is medically underserved (as
defined in section 330(b)(3) of the Public
Health Service Act (42 U.S.C. 254b(b)(3))); or
(D) in a service which originated in a
facility which participates in a Federal
telemedicine demonstration project.
(2) Physician.--The term ``physician'' has the
meaning given that term in section 1861(r) of the
Social Security Act (42 U.S.C. 1395x(r))
(3) Practitioner.--The term ``practitioner'' means a
practitioner described in section 1842(b)(18)(C) of the
Social Security Act (42 U.S.C. 1395u(b)(18)(C)).
(4) Distant site.--The term ``distant site'' means
the site at which the physician or practitioner is
located at the time the service is provided via a
telecommunications system.
(5) Originating site.--
(A) In general.--The term ``originating
site'' means any site described in subparagraph
(B) at which the eligible telehealth
beneficiary is located at the time the service
is furnished via a telecommunications system.
(B) Sites described.--The sites described in
this subparagraph are as follows:
(i) On or after April 1, 2001--
(I) the office of a physician
or a practitioner,
(II) a critical access
hospital (as defined in section
1861(mm)(1) of the Social
Security Act (42 U.S.C.
1395x(mm)(1))),
(III) a rural health clinic
(as defined in section
1861(aa)(2) of such Act (42
U.S.C. 1395x(aa)(2))), and
(IV) a Federally qualified
health center (as defined in
section 1861(aa)(4) of such Act
(42 U.S.C. 1395x(aa)(4))).
(ii) On or after January 1, 2002--
(I) a hospital (as defined in
section 1861(e) of such Act (42
U.S.C. 1395x(e))),
(II) a skilled nursing
facility (as defined in section
1861(j) of such Act (42 U.S.C.
1395x(j))),
(III) a comprehensive
outpatient rehabilitation
facility (as defined in section
1861(cc)(2) of such Act (42
U.S.C. 1395x(cc)(2))),
(IV) a renal dialysis
facility (described in section
1881(b)(1) of such Act (42
U.S.C. 1395rr(b)(1))),
(V) an ambulatory surgical
center (described in section
1833(i)(1)(A) of such Act (42
U.S.C. 1395l(i)(1)(A))),
(VI) a hospital or skilled
nursing facility of the Indian
Health Service (under section
1880 of such Act (42 U.S.C.
1395qq)), and
(VII) a community mental
health center (as defined in
section 1861(ff)(3)(B) of such
Act (42 U.S.C.
1395x(ff)(3)(B))).
(6) Federal supplementary medical insurance trust
fund.--The term ``Federal Supplementary Medical
Insurance Trust Fund'' means the trust fund established
under section 1841 of the Social Security Act (42
U.S.C. 1395t).
* * * * * * *
Subtitle H--Medicaid
* * * * * * *
CHAPTER 2--FLEXIBILITY IN PAYMENT OF PROVIDERS
* * * * * * *
SEC. 4712. PAYMENT FOR CENTER AND CLINIC SERVICES.
(a) * * *
* * * * * * *
[(c) End of Transitional Payment Rules.--Effective for
services furnished on or after October 1, 2003--
[(1) subparagraph (C) of section 1902(a)(13) (42
U.S.C. 1396a(a)(13)), as so redesignated, is repealed,
and
[(2) clause (ix) of section 1903(m)(2)(A) (42 U.S.C.
1396b(m)(2)(A)) is repealed.]
* * * * * * *
Subtitle J--State Children's Health Insurance Program
* * * * * * *
CHAPTER 3--DIABETES GRANT PROGRAMS
* * * * * * *
SEC. 4923. REPORT ON DIABETES GRANT PROGRAMS.
(a) * * *
(b) Reports.--The Secretary shall submit to the appropriate
committees of Congress--
(1) [an interim report] interim reports on the
evaluation conducted under subsection (a) not later
than January 1[, 2000] in each of 2000, 2002, and 2004,
and
(2) a final report on such evaluation not later than
January 1, [2002] 2007.
* * * * * * *
----------
SECTION 13501 OF THE OMNIBUS BUDGET RECONCILIATION ACT OF 1993
SEC. 13501. PAYMENTS FOR PPS HOSPITALS.
(a) * * *
* * * * * * *
(e) Extension for Medicare-Dependent, Small Rural
Hospitals.--
(1) * * *
* * * * * * *
(2) Permitting hospitals to decline
reclassification.--If any hospital fails to qualify as
a medicare-dependent, small rural hospital under
section 1886(d)(5)(G)(i) of the Social Security Act as
a result of a decision by the Medicare Geographic
Classification Review Board under section 1886(d)(10)
of such Act to reclassify the hospital as being located
in an urban area for fiscal year 1993, fiscal year
1994, fiscal year 1998, fiscal year 1999, [or fiscal
year 2000 through fiscal year 2005] fiscal year 2000,
or any subsequent fiscal year, the Secretary of Health
and Human Services shall--
(A) * * *
* * * * * * *
----------
SECTION 9517 OF THE CONSOLIDATED OMNIBUS BUDGET RECONCILIATION ACT OF
1985
SEC. 9517. MODIFYING APPLICATION OF MEDICAID HMO PROVISIONS FOR CERTAIN
HEALTH CENTERS.
(a) * * *
* * * * * * *
(c) Health Insuring Organizations.--(1) * * *
* * * * * * *
(3)(A) Subject to subparagraph (C), in the case of up to 3
health insuring organizations which are described in
subparagraph (B), which first become operational on or after
January 1, 1986, and which are designated by the Governor, and
approved by the Legislature, of California, the amendments made
by paragraph (1) shall not apply.
* * * * * * *
(C) Subparagraph (A) shall not apply with respect to any
period for which the Secretary of Health and Human Services
determines that the number of medicaid beneficiaries enrolled
with health insuring organizations described in subparagraph
(B) exceeds [10] 14 percent of the number of such beneficiaries
in the State of California.
* * * * * * *
----------
PUBLIC HEALTH SERVICE ACT
* * * * * * *
TITLE III--GENERAL POWERS AND DUTIES OF PUBLIC HEALTH SERVICE
* * * * * * *
Part D--Primary Health Care
Subpart I--Health Centers
* * * * * * *
SEC. 330B. SPECIAL DIABETES PROGRAMS FOR TYPE I DIABETES.
(a) * * *
* * * * * * *
(c) Extension of Funding.--There are hereby appropriated,
from any amounts in the Treasury not otherwise appropriated,
for each of fiscal years 2003 through 2007, $50,000,000 for
grants under this section, to remain available until expended.
Nothing in this subsection shall be construed as providing for
such amounts to be derived or deducted from appropriations made
under section 2104(a) of the Social Security Act.
SEC. 330C. SPECIAL DIABETES PROGRAMS FOR INDIANS.
(a) * * *
* * * * * * *
(d) Extension of Funding.--There are hereby appropriated,
from any amounts in the Treasury not otherwise appropriated,
for each of fiscal years 2003 through 2007, $50,000,000 for
grants under this section, to remain available until expended.
Nothing in this subsection shall be construed as providing for
such amounts to be derived or deducted from appropriations made
under section 2104(a) of the Social Security Act.
* * * * * * *