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H.R.5324
Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 2000
(Introduced in the House)
Subtitle B--Direct Graduate Medical Education
SEC. 311. NOT COUNTING CERTAIN GERIATRIC RESIDENTS AGAINST GRADUATE MEDICAL EDUCATION LIMITATIONS.
For cost reporting periods beginning on or after October 1, 2000, and
before October 1, 2005, in applying the limitations regarding the total number
of full-time equivalent interns and residents in the field of allopathic or
osteopathic medicine under subsections (d)(5)(B)(v) and (h)(4)(F) of section
1886 of the Social Security Act (42 U.S.C. 1395ww) for a hospital, the
Secretary of Health and Human Services shall not take into account a maximum
of 3 interns or residents in the field of geriatric medicine to the extent the
hospital increases the number of geriatric interns or residents above the
number of such interns or residents for the hospital's most recent cost
reporting period ending before October 1, 2000.
SEC. 312. PROGRAM OF PAYMENTS TO CHILDREN'S HOSPITALS THAT OPERATE GRADUATE MEDICAL EDUCATION PROGRAMS.
Part A of title XI (42 U.S.C. 1301 et seq.) is amended by adding after
section 1150 the following new section:
`PROGRAM OF PAYMENTS TO CHILDREN'S HOSPITALS THAT OPERATE GRADUATE MEDICAL EDUCATION PROGRAMS
`SEC. 1150A. (a) PAYMENTS- The Secretary shall make 2 payments under this
section to each children's hospital for each of fiscal years 2002 through
2005, 1 for the direct expenses and the other for the indirect expenses
associated with operating approved graduate medical residency training
programs.
`(1) IN GENERAL- Subject to paragraph (2), the amounts payable under
this section to a children's hospital for an approved graduate medical
residency training program for a fiscal year are each of the following
amounts:
`(A) DIRECT EXPENSE AMOUNT- The amount determined under subsection (c)
for direct expenses associated with operating approved graduate medical residency training
programs.
`(B) INDIRECT EXPENSE AMOUNT- The amount determined under subsection
(d) for indirect expenses associated with the treatment of more severely
ill patients and the additional costs relating to teaching residents in
such programs.
`(A) IN GENERAL- The total of the payments made to children's
hospitals under subparagraph (A) or (B) of paragraph (1) in a fiscal year
shall not exceed the funds appropriated under paragraph (1) or (2),
respectively, of subsection (f) for such payments for that fiscal
year.
`(B) PRO RATA REDUCTIONS OF PAYMENTS FOR DIRECT EXPENSES- If the
Secretary determines that the amount of funds appropriated under
subsection (f)(1) for a fiscal year is insufficient to provide the total
amount of payments otherwise due for such periods under paragraph (1)(A),
the Secretary shall reduce the amounts so payable on a pro rata basis to
reflect such shortfall.
`(c) AMOUNT OF PAYMENT FOR DIRECT GRADUATE MEDICAL EDUCATION -
`(1) IN GENERAL- The amount determined under this subsection for
payments to a children's hospital for direct graduate expenses relating to
approved graduate medical residency training programs
for a fiscal year is equal to the product of--
`(A) the updated per resident amount for direct graduate medical education , as determined under
paragraph (2); and
`(B) the average number of full-time equivalent residents in the
hospital's graduate approved
medical residency training
programs (as determined under section 1886(h)(4)) during the fiscal
year.
`(2) UPDATED PER RESIDENT AMOUNT FOR DIRECT GRADUATE MEDICAL EDUCATION - The updated per resident
amount for direct graduate
medical education for a hospital for a
fiscal year is an amount determined as follows:
`(A) DETERMINATION OF HOSPITAL SINGLE PER RESIDENT AMOUNT- The
Secretary shall compute for each hospital operating an approved graduate medical education program (regardless of
whether or not it is a children's hospital) a single per resident amount
equal to the average (weighted by number of full-time equivalent
residents) of the primary care per resident amount and the non-primary
care per resident amount computed under section 1886(h)(2) for cost
reporting periods ending during fiscal year 1997.
`(B) DETERMINATION OF WAGE AND NON-WAGE-RELATED PROPORTION OF THE
SINGLE PER RESIDENT AMOUNT- The Secretary shall estimate the average
proportion of the single per resident amounts computed under subparagraph
(A) that is attributable to wages and wage-related costs.
`(C) STANDARDIZING PER RESIDENT AMOUNTS- The Secretary shall establish
a standardized per resident amount for each such hospital--
`(i) by dividing the single per resident amount computed under
subparagraph (A) into a wage-related portion and a non-wage-related
portion by applying the proportion determined under subparagraph
(B);
`(ii) by dividing the wage-related portion by the factor applied
under section 1886(d)(3)(E) for discharges occurring during fiscal year
1999 for the hospital's area; and
`(iii) by adding the non-wage-related portion to the amount computed
under clause (ii).
`(D) DETERMINATION OF NATIONAL AVERAGE- The Secretary shall compute a
national average per resident amount equal to the average of the
standardized per resident amounts computed under subparagraph (C) for such
hospitals, with the amount for each hospital weighted by the average
number of full-time equivalent residents at such hospital.
`(E) APPLICATION TO INDIVIDUAL HOSPITALS- The Secretary shall compute
for each such hospital that is a children's hospital a per resident
amount--
`(i) by dividing the national average per resident amount computed
under subparagraph (D) into a wage-related portion and a
non-wage-related portion by applying the proportion determined under
subparagraph (B);
`(ii) by multiplying the wage-related portion by the factor
described in subparagraph (C)(ii) for the hospital's area;
and
`(iii) by adding the non-wage-related portion to the amount computed
under clause (ii).
`(F) UPDATING RATE- The Secretary shall update such per resident
amount for each such children's hospital by the estimated percentage
increase in the Consumer Price Index for all urban consumers (U.S. city
average) during the period beginning October 1997, and ending with the
midpoint of the Federal fiscal year for which payments are made.
`(d) AMOUNT OF PAYMENT FOR INDIRECT MEDICAL EDUCATION -
`(1) IN GENERAL- The amount determined under this subsection for
payments to a children's hospital for indirect expenses associated with
the
treatment of more severely ill patients and the additional costs related to
the teaching of residents for a fiscal year is equal to an amount determined
appropriate by the Secretary.
`(2) FACTORS- In determining the amount under paragraph (1), the
Secretary shall--
`(A) take into account variations in case mix and regional wage levels
among children's hospitals and the number of full-time equivalent
residents in the hospitals' approved graduate medical residency training
programs; and
`(B) assure that the aggregate of the payments for indirect expenses
associated with the treatment of more severely ill patients and the
additional costs related to the teaching of residents under this section
in a fiscal year are equal to the amount appropriated for such expenses
for the fiscal year involved under subsection (f)(2).
`(1) INTERIM PAYMENTS- The Secretary shall determine, before the
beginning of each fiscal year involved for which payments may be made for a
hospital under this section, the amounts of the payments for direct graduate medical education and indirect medical education for such fiscal year and
shall (subject to paragraph (2)) make the payments of such amounts in 26
equal interim installments during such period. Such interim payments to each
individual hospital shall be based on the number of residents reported in
the hospital's most recently filed medicare cost report prior to the
application date for the Federal fiscal year for which the interim payment
amounts are established.
`(A) IN GENERAL- Subject to subparagraph (B), the Secretary shall
withhold 25 percent from each interim installment for direct and indirect
graduate medical education paid under paragraph
(1).
`(B) REDUCTION OF WITHHOLDING- The Secretary shall reduce the percent
withheld from each installment pursuant to subparagraph (A) if the
Secretary determines that such reduced percent will provide the Secretary
with a reasonable level of assurance that most hospitals will not be
overpaid on an interim basis.
`(3) RECONCILIATION- Prior to the end of each fiscal year, the Secretary
shall determine any changes to the number of residents reported by a
hospital and shall use that number of residents to determine the final
amount payable to the hospital for the current fiscal year for both direct
expense and indirect expense amounts. Based on such determination, the
Secretary shall recoup any overpayments made or pay any balance due to the
extent possible. In the event that a hospital's interim payments were
greater than the final amount to which it is entitled, the Secretary shall
have the option of recouping that excess amount in determining the amount to
be paid in the subsequent year to that hospital. The final amount so
determined shall be considered a final intermediary determination for
purposes of applying section 1878 and shall be subject to review under that
section in the same manner as the amount of payment under section 1886(d) is
subject to review under such section.
`(f) AUTHORIZATION OF APPROPRIATIONS-
`(1) DIRECT GRADUATE MEDICAL EDUCATION -
`(A) IN GENERAL- There are appropriated, out of any money in the
Treasury not otherwise appropriated, for payments under subsection
(b)(1)(A) for each of fiscal years 2002 through 2005,
$95,000,000.
`(B) CARRYOVER OF EXCESS- The amounts appropriated under subparagraph
(A) for each fiscal year shall remain available for obligation through the
end of the subsequent fiscal year.
`(2) INDIRECT MEDICAL
EDUCATION - There are
appropriated, out of any money in the Treasury not otherwise appropriated,
for payments under subsection (b)(1)(A) for each of fiscal years 2002
through 2005, $190,000,000.
`(g) DEFINITIONS- In this section:
`(1) APPROVED GRADUATE
MEDICAL RESIDENCY TRAINING
PROGRAM- The term `approved graduate medical residency training program'
has the meaning given the term `approved medical residency training program'
in section 1886(h)(5)(A).
`(2) CHILDREN'S HOSPITAL- The term `children's hospital' means a
hospital with a medicare payment agreement and which is excluded from the
medicare inpatient prospective payment system pursuant to section
1886(d)(1)(B)(iii) and its accompanying regulations.
`(3) DIRECT GRADUATE MEDICAL EDUCATION COSTS- The term `direct
graduate medical education costs' has the meaning
given such term in section 1886(h)(5)(C).'.
SEC. 313. AUTHORITY TO INCLUDE COSTS OF TRAINING OF CLINICAL PSYCHOLOGISTS
IN PAYMENTS TO HOSPITALS.
Effective for cost reporting periods beginning on or after October 1,
1999, for purposes of payments to hospitals under the medicare program under
title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.) for costs of
approved educational activities (as defined in section 413.85 of title 42 of
the Code of Federal Regulations), such approved educational activities shall
include the clinical portion of professional educational training programs,
recognized by the Secretary, for clinical psychologists.
SEC. 314. TREATMENT OF CERTAIN NEWLY ESTABLISHED RESIDENCY PROGRAMS IN
COMPUTING MEDICARE PAYMENTS FOR THE COSTS OF MEDICAL EDUCATION .
(a) IN GENERAL- Section 1886(h)(4)(H) (42 U.S.C. 1395ww(h)(4)(H)) is
amended by adding at the end the following new clause:
`(v) TREATMENT OF CERTAIN NEWLY ESTABLISHED PROGRAMS- Any hospital
that has received payments under this subsection for a cost reporting
period ending
before January 1, 1995, and that operates an approved medical residency training program
established on or after August 5, 1997, shall be treated as meeting the
requirements for an adjustment under the rules prescribed pursuant to clause (i)
with respect to such program if--
`(I) such program received accreditation from the American Council
of Graduate Medical Education not later than
August 5, 1998;
`(II) such program was in operation (with 1 or more residents in
training) as of January 1, 2000;
`(III) such hospital is located in an area that is contiguous to a
rural area and serves individuals from such rural area;
and
`(IV) such hospital serves a medical service area with a
population that is less than 500,000.'.
(b) EFFECTIVE DATE- The amendment made by subsection (a) shall take effect
as if included in the enactment of section 4623 of BBA (111 Stat. 477).
SEC. 315. EXCEPTION TO ESTABLISHING THE NUMBER OF RESIDENTS FOR CERTAIN
HOSPITALS.
(a) AMENDMENT TO LIMITATION ON RESIDENTS FOR INDIRECT GRADUATE MEDICAL EDUCATION - Section 1886(d)(5)(B)(v)
(42 U.S.C. 1395ww(d)(5)(B)(v)) is amended--
(1) by adding the following after `December 31, 1996' and before the
period: `(except in the case where a community health center held the
accreditation for an approved medical residency training program
of a hospital during fiscal year 1997 and the hospital incurred all or
substantially all of the costs of training those residents at the community
health center, the total number of full-time equivalent interns and
residents for the hospital with respect to such training program in the
fields of allopathic and osteopathic medicine may not exceed the number of
such full-time equivalent interns and residents that trained at such
hospital and such community health center during the hospital's cost
reporting period ending on or before December 31, 1997)'.
(b) AMENDMENT TO LIMITATION ON RESIDENTS FOR DIRECT GRADUATE MEDICAL EDUCATION - Section 1886(h)(4)(F) (42
U.S.C. 1395ww(h)(4)(F)) is amended--
(1) in clause (i), by striking `Such rules' and inserting `Subject to
clause (iii), such rules'; and
(2) by adding at the end the following new clause:
`(iii) SPECIAL RULE- In the case where a community health center
held the accreditation for an approved medical residency training
program of a hospital during fiscal year 1997 and the hospital incurred
all or substantially all of the costs of training those residents at the
community health center, the total number of full-time equivalent
residents before application of weighting factors for the hospital (as
determined under this paragraph) with respect to such training program
in the fields of allopathic medicine and osteopathic medicine may not
exceed the number of such full-time equivalent residents that trained at
such hospital and such community health center during the hospital's
cost reporting period ending on or before December 31,
1997.'.
(c) DEFINITION OF COMMUNITY HEALTH CENTER- For the purposes of this
section, the term `community health center' has the meaning given the term
`health center' in section 330(a) of the Public Health Service Act (42 U.S.C.
254b(a)).
(d) EFFECTIVE DATE- The amendments made by subsections (a) and (b) shall
take effect as if included in the enactment of the Balanced Budget Act of 1997
(Public Law 105-33).
Subtitle C--Miscellaneous Provisions
SEC. 321. WAIVER OF 24-MONTH WAITING PERIOD FOR MEDICARE COVERAGE OF
INDIVIDUALS DISABLED WITH AMYOTROPHIC LATERAL SCLEROSIS (ALS).
(a) IN GENERAL- Section 226 (42 U.S.C. 426) is amended--
(1) by redesignating subsection (h) as subsection (j) and by moving such
subsection to the end of the section; and
(2) by inserting after subsection (g) the following new
subsection:
`(h) For purposes of applying this section in the case of an individual
medically determined to have amyotrophic lateral sclerosis (ALS), the
following special rules apply:
`(1) Subsection (b) shall be applied as if there were no requirement for
any entitlement to benefits, or status, for a period longer than 1
month.
`(2) The entitlement under such subsection shall begin with the first
month (rather than twenty-fifth month) of entitlement or status.
`(3) Subsection (f) shall not be applied.'.
(b) CONFORMING AMENDMENT- Section 1837 (42 U.S.C. 1395p) is amended by
adding at the end the following new subsection:
`(j) In applying this section in the case of an individual who is entitled
to benefits under part A pursuant to the operation of section 226(h), the
following special rules apply:
`(1) The initial enrollment period under subsection (d) shall begin on
the first day of the first month in which the individual satisfies the
requirement of section 1836(1).
`(2) In applying subsection (g)(1), the initial enrollment period shall
begin on the first day of the first month of entitlement to disability
insurance benefits referred to in such subsection.'.
(c) EFFECTIVE DATE- The amendments made by this section shall apply to
benefits for months beginning after the date of enactment of this Act.
TITLE IV--RURAL PROVIDER PROVISIONS
Subtitle A--Critical Access Hospitals
SEC. 401. PAYMENTS TO CRITICAL ACCESS HOSPITALS FOR CLINICAL DIAGNOSTIC
LABORATORY TESTS.
(a) PAYMENT ON COST BASIS WITHOUT BENEFICIARY COST-SHARING-
(1) IN GENERAL- Section 1833(a)(6) (42 U.S.C. 1395l(a)(6)) is amended by
inserting `(including clinical diagnostic laboratory services furnished by a
critical access hospital)' after `outpatient critical access hospital
services'.
(2) NO BENEFICIARY COST-SHARING-
(A) IN GENERAL- Section 1834(g) (42 U.S.C. 1395m(g)) is amended by
inserting `(except that in the case of clinical diagnostic laboratory
services furnished by a critical access hospital the amount of payment
shall be equal to 100 percent of the reasonable costs of the critical
access hospital in providing such services)' before the period at the
end.
(B) BBRA AMENDMENT- Section 1834(g) (42 U.S.C. 1395m(g)), as amended
by section 403(d) of BBRA (113 Stat. 1501A-371), is amended--
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