HR 5601 IH
106th CONGRESS
2d Session
H. R. 5601
To amend titles XVIII, XIX, and XXI of the Social Security Act to
provide benefits improvements and beneficiary protections in the Medicare and
Medicaid programs and the State child health insurance program (SCHIP), as
revised by the Balanced Budget Act of 1997 and the Medicare, Medicaid, and SCHIP
Balanced Budget Refinement Act of 1999, and for other purposes.
IN THE HOUSE OF REPRESENTATIVES
October 30, 2000
Mr. RANGEL (for himself and Mr. DINGELL) introduced the following bill; which
was referred to the Committee on Ways and Means, and in addition to the
Committee on Commerce, for a period to be subsequently determined by the
Speaker, in each case for consideration of such provisions as fall within the
jurisdiction of the committee concerned
A BILL
To amend titles XVIII, XIX, and XXI of the Social Security Act to
provide benefits improvements and beneficiary protections in the Medicare and
Medicaid programs and the State child health insurance program (SCHIP), as
revised by the Balanced Budget Act of 1997 and the Medicare, Medicaid, and SCHIP
Balanced Budget Refinement Act of 1999, and for other purposes.
Be it enacted by the Senate and House of Representatives of the United
States of America in Congress assembled,
SECTION 1. SHORT TITLE; AMENDMENTS TO SOCIAL SECURITY ACT; REFERENCES TO
OTHER ACTS; TABLE OF CONTENTS.
(a) SHORT TITLE- This Act may be cited as the `Medicare, Medicaid, and
SCHIP Benefits 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; 111 Stat. 251).
(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 (Appendix F, 113 Stat. 1501A-321), as enacted
into law by section 1000(a)(6) of Public Law 106-113.
(d) TABLE OF CONTENTS- The table of contents of this Act is as follows:
Sec. 1. Short title; amendments to Social Security Act; references to
other Acts; table of contents.
TITLE I--MEDICARE BENEFICIARY IMPROVEMENTS
Subtitle A--Improved Preventive Benefits
Sec. 101. Coverage of biennial screening pap smear and pelvic
exams.
Sec. 102. Coverage of screening for glaucoma.
Sec. 103. Coverage of screening colonoscopy for average risk
individuals.
Sec. 104. Modernization of screening mammography benefit.
Sec. 105. Coverage of medical nutrition therapy services for
beneficiaries with diabetes or a renal disease.
Sec. 106. Extension of part A coverage for workers with
disabilities.
Subtitle B--Other Beneficiary Improvements
Sec. 111. Acceleration of reduction of beneficiary copayment for
hospital outpatient department services.
Sec. 112. Preservation of coverage of drugs and biologicals under part B
of the medicare program.
Sec. 113. Elimination of time limitation on medicare benefits for
immunosuppressive drugs.
Sec. 114. Imposition of billing limits on drugs.
Sec. 115. Improving availability of QMB/SLMB application forms.
Subtitle C--Demonstration Projects and Studies
Sec. 121. Demonstration project for disease management for severely
chronically ill medicare beneficiaries.
Sec. 122. Cancer prevention and treatment demonstration for ethnic and
racial minorities.
Sec. 123. Study on medicare coverage of routine thyroid screening.
Sec. 124. MedPAC study on consumer coalitions.
Sec. 125. Study on limitation on State payment for medicare cost-sharing
affecting access to services for qualified medicare beneficiaries.
Sec. 126. Waiver of 24-month waiting period for medicare coverage of
individuals disabled with amyotrophic lateral sclerosis (ALS).
Sec. 127. Studies on preventive interventions in primary care for older
Americans.
Sec. 128. MedPAC study and report on medicare coverage of cardiac and
pulmonary rehabilitation therapy services.
TITLE II--RURAL HEALTH CARE IMPROVEMENTS
Subtitle A--Critical Access Hospital Provisions
Sec. 201. Clarification of no beneficiary cost-sharing for clinical
diagnostic laboratory tests furnished by critical access hospitals.
Sec. 202. Assistance with fee schedule payment for professional services
under all-inclusive rate.
Sec. 203. Exemption of critical access hospital swing beds from SNF
PPS.
Sec. 204. Payment in critical access hospitals for emergency room
on-call physicians.
Sec. 205. Treatment of ambulance services furnished by certain critical
access hospitals.
Sec. 206. GAO study on certain eligibility requirements for critical
access hospitals.
Subtitle B--Other Rural Hospitals Provisions
Sec. 211. Equitable treatment for rural disproportionate share
hospitals.
Sec. 212. Option to base eligibility for medicare dependent, small rural
hospital program on discharges during 2 of the 3 most recently audited cost
reporting periods.
Sec. 213. Extension of option to use rebased target amounts to all sole
community hospitals.
Sec. 214. MedPAC analysis of impact of volume on per unit cost of rural
hospitals with psychiatric units.
Subtitle C--Other Rural Provisions
Sec. 221. Assistance for providers of ambulance services in rural
areas.
Sec. 222. Payment for certain physician assistant services.
Sec. 223. Revision of medicare reimbursement for telehealth
services.
Sec. 224. Expanding access to rural health clinics.
Sec. 225. MedPAC study on low-volume, isolated rural health care
providers.
TITLE III--PROVISIONS RELATING TO PART A
Subtitle A--Inpatient Hospital Services
Sec. 301. Eliminating reduction in pps hospital payment update.
Sec. 302. Additional modification in transition for indirect medical
education (IME) percentage adjustment.
Sec. 303. Decrease in reductions for disproportionate share hospital
(DSH) payments.
Sec. 304. Wage index improvements.
Sec. 305. Payment for inpatient services of rehabilitation
hospitals.
Sec. 306. Payment for inpatient services of psychiatric hospitals.
Sec. 307. Payment for inpatient services of long-term care
hospitals.
Sec. 308. Increase in base payment to Puerto Rico acute care
hospitals.
Subtitle B--Adjustments to PPS Payments for Skilled Nursing Facilities
Sec. 311. Elimination of reduction in skilled nursing facility (SNF)
market basket update in 2001.
Sec. 312. Increase in nursing component of PPS Federal rate.
Sec. 313. Application of SNF consolidated billing requirement limited to
part A covered stays.
Sec. 314. Adjustment of rehabilitation RUGs to correct anomaly in
payment rates.
Sec. 315. Establishment of process for geographic
reclassification.
Subtitle C--Hospice Care
Sec. 321. Full market basket increase for 2001 and 2002.
Sec. 322. Clarification of physician certification.
Sec. 323. MedPAC report on access to, and use of, hospice benefit.
Subtitle D--Other Provisions
Sec. 331. Relief from medicare part A late enrollment penalty for group
buy-in for State and local retirees.
Sec. 332. Hospital geographic reclassification for labor costs for other
PPS systems.
TITLE IV--PROVISIONS RELATING TO PART B
Subtitle A--Hospital Outpatient Services
Sec. 401. Revision of hospital outpatient PPS payment update.
Sec. 402. Clarifying process and standards for determining eligibility
of devices for pass-through payments under hospital outpatient PPS.
Sec. 403. Application of OPD PPS transitional corridor payments to
certain hospitals that did not submit a 1996 cost report.
Sec. 404. Application of rules for determining provider-based status for
certain entities.
Sec. 405. Treatment of children's hospitals under prospective payment
system.
Sec. 406. Inclusion of temperature monitored cryoablation in
transitional pass-through for certain medical devices, drugs, and
biologicals under OPD PPS.
Subtitle B--Provisions Relating to Physicians' Services
Sec. 411. GAO studies relating to physicians' services.
Sec. 412. Physician group practice demonstration.
Sec. 413. Study on enrollment procedures for groups that retain
independent contractor physicians.
Subtitle C--Other Services
Sec. 421. 1-year extension of moratorium on therapy caps; report on
standards for supervision of physical therapy assistants.
Sec. 422. Update in renal dialysis composite rate.
Sec. 423. Payment for ambulance services.
Sec. 424. Ambulatory surgical centers.
Sec. 425. Full update for durable medical equipment.
Sec. 426. Full update for orthotics and prosthetics.
Sec. 427. Establishment of special payment provisions and requirements
for prosthetics and certain custom fabricated orthotic items.
Sec. 428. Replacement of prosthetic devices and parts.
Sec. 429. Revised part B payment for drugs and biologicals and related
services.
Sec. 430. Contrast enhanced diagnostic procedures under hospital
prospective payment system.
Sec. 431. Qualifications for community mental health centers.
Sec. 432. Modification of medicare billing requirements for certain
Indian providers.
Sec. 433. GAO study on coverage of surgical first assisting services of
certified registered nurse first assistants.
Sec. 434. MedPAC study and report on medicare reimbursement for services
provided by certain providers.
Sec. 435. MedPAC study and report on medicare coverage of services
provided by certain nonphysician providers.
Sec. 436. GAO study and report on the costs of emergency and medical
transportation services.
Sec. 437. GAO studies and reports on medicare payments.
Sec. 438. MedPAC study on access to outpatient pain management
services.
TITLE V--PROVISIONS RELATING TO PARTS A AND B
Subtitle A--Home Health Services
Sec. 501. 2-year additional delay in application of 15 percent reduction
on payment limits for home health services.
Sec. 502. Restoration of full home health market basket update for home
health services for fiscal year 2001.
Sec. 503. Temporary two-month extension of periodic interim
payments.
Sec. 504. Use of telehealth in delivery of home health services.
Sec. 505. Study on costs to home health agencies of purchasing
nonroutine medical supplies.
Sec. 506. Treatment of branch offices; GAO study on supervision of home
health care provided in isolated rural areas.
Sec. 507. Clarification of the homebound definition under the medicare
home health benefit.
Subtitle B--Direct Graduate Medical Education
Sec. 511. Increase in floor for direct graduate medical education
payments.
Sec. 512. Change in distribution formula for Medicare+Choice-related
nursing and allied health education costs.
Subtitle C--Changes in Medicare Coverage and Appeals Process
Sec. 521. Revisions to medicare appeals process.
Sec. 522. Revisions to medicare coverage process.
Subtitle D--Improving Access to New Technologies
Sec. 531. Reimbursement improvements for new clinical laboratory tests
and durable medical equipment.
Sec. 532. Retention of HCPCS level III codes.
Sec. 533. Recognition of new medical technologies under inpatient
hospital PPS.
Subtitle E--Other Provisions
Sec. 541. Increase in reimbursement for bad debt.
Sec. 542. Treatment of certain physician pathology services under
medicare.
Sec. 543. Extension of advisory opinion authority.
Sec. 544. Change in annual MedPAC reporting.
Sec. 545. Development of patient assessment instruments.
Sec. 546. GAO report on impact of the Emergency Medical Treatment and
Active Labor Act (EMTALA) on hospital emergency departments.
Sec. 547. Application of Bloodborne Pathogen standard to certain
hospitals.
TITLE VI--PROVISIONS RELATING TO PART C (MEDICARE+CHOICE PROGRAM) AND OTHER
MEDICARE MANAGED CARE PROVISIONS
Subtitle A--Medicare+Choice Payment Reforms
Sec. 601. Increase in minimum payment amount.
Sec. 602. Increase in minimum percentage increase.
Sec. 603. 10-year phase-in of risk adjustment.
Sec. 604. Transition to revised Medicare+Choice payment rates.
Sec. 605. Revision of payment rates for ESRD patients enrolled in
Medicare+Choice plans.
Sec. 606. Permitting premium reductions as additional benefits under
Medicare+Choice plans.
Sec. 607. Full implementation of risk adjustment for congestive heart
failure enrollees for 2001.
Sec. 608. Expansion of application of Medicare+Choice new entry
bonus.
Sec. 609. Report on inclusion of certain costs of the Department of
Veterans Affairs and military facility services in calculating
Medicare+Choice payment rates.
Subtitle B--Other Medicare+Choice Reforms
Sec. 611. Payment of additional amounts for new benefits covered during
a contract term.
Sec. 612. Restriction on implementation of significant new regulatory
requirements mid-year.
Sec. 613. Timely approval of marketing material that follows model
marketing language.
Sec. 614. Avoiding duplicative regulation.
Sec. 615. Election of uniform local coverage policy for Medicare+Choice
plan covering multiple localities.
Sec. 616. Eliminating health disparities in Medicare+Choice
program.
Sec. 617. Medicare+Choice program compatibility with employer or union
group health plans.
Sec. 618. Special medigap enrollment antidiscrimination provision for
certain beneficiaries.
Sec. 619. Restoring effective date of elections and changes of elections
of Medicare+Choice plans.
Sec. 620. Permitting ESRD beneficiaries to enroll in another
Medicare+Choice plan if the plan in which they are enrolled is
terminated.
Sec. 621. Providing choice for skilled nursing facility services under
the Medicare+Choice program.
Sec. 622. Providing for accountability of Medicare+Choice plans.
Sec. 623. Civil monetary penalties for contract default by a
Medicare+Choice organization.
Subtitle C--Other Managed Care Reforms
Sec. 631. 1-year extension of social health maintenance organization
(SHMO) demonstration project.
Sec. 632. Revised terms and conditions for extension of medicare
community nursing organization (CNO) demonstration project.
Sec. 633. Extension of medicare municipal health services demonstration
projects.
Sec. 634. Service area expansion for medicare cost contracts during
transition period.
TITLE VII--MEDICAID
Sec. 702. New prospective payment system for Federally-qualified health
centers and rural health clinics.
Sec. 703. Streamlined approval of continued State-wide section 1115
medicaid waivers.
Sec. 704. Medicaid county-organized health systems.
Sec. 705. Deadline for issuance of final regulation relating to medicaid
upper payment limits.
Sec. 707. Optional coverage of legal immigrants under the medicaid
program.
Sec. 708. Additional entities qualified to determine medicaid
presumptive eligibility for low-income children.
Sec. 709. Improving welfare-to-work transition.
TITLE VIII--STATE CHILDREN'S HEALTH INSURANCE PROGRAM
Sec. 801. Special rule for redistribution and availability of unused
fiscal year 1998 and 1999 SCHIP allotments.
Sec. 802. Authority to pay medicaid expansion SCHIP costs from title XXI
appropriation.
TITLE IX--OTHER PROVISIONS
Subtitle A--PACE Program
Sec. 901. Extension of transition for current waivers.
Sec. 902. Continuing of certain operating arrangements permitted.
Sec. 903. Flexibility in exercising waiver authority.
Subtitle B--Outreach to Eligible Low-Income Medicare Beneficiaries
Sec. 911. Outreach on availability of medicare cost-sharing assistance
to eligible low-income medicare beneficiaries.
Subtitle C--Maternal and Child Health Block Grant
Sec. 921. Increase in authorization of appropriations for the maternal
and child health services block grant.
Subtitle D--Diabetes
Sec. 931. Increase in appropriations for special diabetes programs for
type I diabetes and Indians.
Sec. 932. Appropriations for Ricky Ray Hemophilia Relief Fund.
TITLE I--MEDICARE BENEFICIARY IMPROVEMENTS
Subtitle A--Improved Preventive Benefits
SEC. 101. COVERAGE OF BIENNIAL SCREENING PAP SMEAR AND PELVIC EXAMS.
(1) BIENNIAL SCREENING PAP SMEAR- Section 1861(nn)(1) (42 U.S.C.
1395x(nn)(1)) is amended by striking `3 years' and inserting `2
years'.
(2) BIENNIAL SCREENING PELVIC EXAM- Section 1861(nn)(2) (42 U.S.C.
1395x(nn)(2)) is amended by striking `3 years' and inserting `2
years'.
(b) EFFECTIVE DATE- The amendments made by subsection (a) apply to items
and services furnished on or after July 1, 2001.
SEC. 102. COVERAGE OF SCREENING FOR GLAUCOMA.
(a) COVERAGE- Section 1861(s)(2) (42 U.S.C. 1395x(s)(2)) is amended--
(1) by striking `and' at the end of subparagraph (S);
(2) by inserting `and' at the end of subparagraph (T); and
(3) by adding at the end the following:
`(U) screening for glaucoma (as defined in subsection (uu)) for
individuals determined to be at high risk for glaucoma, individuals with a
family history of glaucoma and individuals with diabetes;'.
(b) SERVICES DESCRIBED- Section 1861 (42 U.S.C. 1395x) is amended by
adding at the end the following new subsection:
`Screening for Glaucoma
`(uu) The term `screening for glaucoma' means a dilated eye examination
with an intraocular pressure measurement, and a direct ophthalmoscopy or a
slit-lamp biomicroscopic examination for the early detection of glaucoma which
is furnished by or under the direct supervision of an optometrist or
ophthalmologist who is legally authorized to furnish such services under State
law (or the State regulatory mechanism provided by State law) of the State in
which the services are furnished, as would otherwise be covered if furnished
by a physician or as an incident to a physician's professional service, if the
individual involved has not had such an examination in the preceding
year.'.
(c) CONFORMING AMENDMENT- Section 1862(a)(1)(F) (42 U.S.C. 1395y(a)(1)(F))
is amended--
(1) by striking `and,'; and
(2) by adding at the end the following: `and, in the case of screening
for glaucoma, which is performed more frequently than is provided under
section 1861(uu),'.
(d) EFFECTIVE DATE- The amendments made by this section shall apply to
services furnished on or after January 1, 2002.
SEC. 103. COVERAGE OF SCREENING COLONOSCOPY FOR AVERAGE RISK
INDIVIDUALS.
(a) IN GENERAL- Section 1861(pp) (42 U.S.C. 1395x(pp)) is amended--
(1) in paragraph (1)(C), by striking `In the case of an individual at
high risk for colorectal cancer, screening colonoscopy' and inserting
`Screening colonoscopy'; and
(2) in paragraph (2), by striking `In paragraph (1)(C), an' and
inserting `An'.
(b) FREQUENCY LIMITS FOR SCREENING COLONOSCOPY- Section 1834(d) (42 U.S.C.
1395m(d)) is amended--
(1) in paragraph (2)(E)(ii), by inserting before the period at the end
the following: `or, in the case of an individual who is not at high risk for
colorectal cancer, if the procedure is performed within the 119 months after
a previous screening colonoscopy';
(A) in the heading by striking `FOR INDIVIDUALS AT HIGH RISK FOR
COLORECTAL CANCER';
(B) in subparagraph (A), by striking `for individuals at high risk for
colorectal cancer (as defined in section 1861(pp)(2))';
(C) in subparagraph (E), by inserting before the period at the end the
following: `or for other individuals if the procedure is performed within
the 119 months after a previous screening colonoscopy or within 47 months
after a previous screening flexible sigmoidoscopy'.
(c) EFFECTIVE DATE- The amendments made by this section apply to
colorectal cancer screening services provided on or after July 1, 2001.
SEC. 104. MODERNIZATION OF SCREENING MAMMOGRAPHY BENEFIT.
(a) INCLUSION IN PHYSICIAN FEE SCHEDULE- Section 1848(j)(3) (42 U.S.C.
1395w-4(j)(3)) is amended by inserting `(13),' after `(4),'.
(b) CONFORMING AMENDMENT- Section 1834(c) (42 U.S.C. 1395m(c)) is amended
to read as follows:
`(c) PAYMENT AND STANDARDS FOR SCREENING MAMMOGRAPHY-
`(1) IN GENERAL- With respect to expenses incurred for screening
mammography (as defined in section 1861(jj)), payment may be made
only--
`(A) for screening mammography conducted consistent with the frequency
permitted under paragraph (2); and
`(B) if the screening mammography is conducted by a facility that has
a certificate (or provisional certificate) issued under section 354 of the
Public Health Service Act.
`(A) IN GENERAL- Subject to revision by the Secretary under
subparagraph (B)--
`(i) no payment may be made under this part for screening
mammography performed on a woman under 35 years of age;
`(ii) payment may be made under this part for only one screening
mammography performed on a woman over 34 years of age, but under 40
years of age; and
`(iii) in the case of a woman over 39 years of age, payment may not
be made under this part for screening mammography performed within 11
months following the month in which a previous screening mammography was
performed.
`(B) REVISION OF FREQUENCY-
`(i) REVIEW- The Secretary, in consultation with the Director of the
National Cancer Institute, shall review periodically the appropriate
frequency for performing screening mammography, based on age and such
other factors as the Secretary believes to be pertinent.
`(ii) REVISION OF FREQUENCY- The Secretary, taking into
consideration the review made under clause (i), may revise from time to
time the frequency with which screening mammography may be paid for
under this subsection.'.
(c) EFFECTIVE DATE- The amendments made by subsections (a) and (b) apply
with respect to screening mammographies furnished on or after January 1,
2002.
(d) PAYMENT FOR NEW TECHNOLOGIES-
(1) TESTS FURNISHED IN 2001-
(A) SCREENING- For a screening mammography (as defined in section
1861(jj) of the Social Security Act (42 U.S.C. 1395(jj))) furnished during
the period beginning on April 1, 2001, and ending on December 31, 2001,
that uses a new technology, payment for such screening mammography shall
be made as follows:
(i) In the case of a technology which directly takes a digital image
(without involving film) and subsequently analyzes such resulting image
with software to identify possible problem areas, in an amount equal to
150 percent of the amount of payment under section 1848 of such Act (42
U.S.C. 1395w-4) for a bilateral diagnostic mammography (under HCPCS code
76091) for such year.
(ii) In the case of a technology which allows conversion of a
standard film mammogram into a digital image and subsequently analyzes
such resulting image with software to identify possible problem areas,
in an amount equal to the limit that would otherwise be applied under
section 1834(c)(3) of such Act (42 U.S.C. 1395m(c)(3)) for 2001,
increased by $15.
(B) BILATERAL DIAGNOSTIC MAMMOGRAPHY- For a bilateral diagnostic
mammography (under HCPCS code 76091) furnished during the period beginning
on April 1, 2001, and ending on December 31, 2001, that uses a new
technology described in subparagraph (A)(i), payment for such mammography
shall be the amount of payment provided for under such
subparagraph.
The Secretary of Health and Human Services may implement the provisions
of this paragraph by program memorandum or otherwise.
(2) CONSIDERATION OF NEW HCPCS CODE FOR NEW TECHNOLOGIES AFTER 2001- The
Secretary shall determine, for such screening mammographies performed after
2001, whether the assignment of a new HCPCS code is appropriate for
screening mammography that uses a new technology. If the Secretary
determines that a new code is appropriate for such screening mammography,
the Secretary shall provide for such new code for such tests furnished after
2001.
(3) NEW TECHNOLOGY DESCRIBED- For purposes of this subsection, a new
technology with respect to a screening mammography is an advance in
technology with respect to the test or equipment that results in the
following:
(A) A significant increase or decrease in the resources used in the
test or in the manufacture of the equipment.
(B) A significant improvement in the performance of the test or
equipment.
(C) A significant advance in medical technology that is expected to
significantly improve the treatment of medicare beneficiaries.
(4) HCPCS CODE DEFINED- The term `HCPCS code' means an alphanumeric code
under the Health Care Financing Administration Common Procedure Coding
System (HCPCS).
SEC. 105. COVERAGE OF MEDICAL NUTRITION THERAPY SERVICES FOR BENEFICIARIES
WITH DIABETES OR A RENAL DISEASE.
(a) COVERAGE- Section 1861(s)(2) (42 U.S.C. 1395x(s)(2)), as amended by
section 102(a), is amended--
(1) in subparagraph (T), by striking `and' at the end;
(2) in subparagraph (U), by inserting `and' at the end; and
(3) by adding at the end the following new subparagraph:
`(V) medical nutrition therapy services (as defined in subsection
(vv)(1)) in the case of a beneficiary with diabetes or a renal disease
who--
`(i) has not received diabetes outpatient self-management training
services within a time period determined by the Secretary; and
`(ii) meets such other criteria determined by the Secretary after
consideration of protocols established by dietitian or nutrition
professional organizations;'.
(b) SERVICES DESCRIBED- Section 1861 (42 U.S.C. 1395x), as amended by
section 102(b), is amended by adding at the end the following:
`Medical Nutrition Therapy Services; Registered Dietitian or Nutrition
Professional
`(vv)(1) The term `medical nutrition therapy services' means nutritional
diagnostic, therapy, and counseling services for the purpose of disease
management which are furnished by a registered dietitian or nutrition
professional (as defined in paragraph (2)) pursuant to a referral by a
physician (as defined in subsection (r)(1)).
`(2) Subject to paragraph (3), the term `registered dietitian or nutrition
professional' means an individual who--
`(A) holds a baccalaureate or higher degree granted by a regionally
accredited college or university in the United States (or an equivalent
foreign degree) with completion of the academic requirements of a program in
nutrition or dietetics, as accredited by an appropriate national
accreditation organization recognized by the Secretary for this
purpose;
`(B) has completed at least 900 hours of supervised dietetics practice
under the supervision of a registered dietitian or nutrition professional;
and
`(C)(i) is licensed or certified as a dietitian or nutrition
professional by the State in which the services are performed; or
`(ii) in the case of an individual in a State that does not provide for
such licensure or certification, meets such other criteria as the Secretary
establishes.
`(3) Subparagraphs (A) and (B) of paragraph (2) shall not apply in the
case of an individual who, as of the date of the enactment of this subsection,
is licensed or certified as a dietitian or nutrition professional by the State
in which medical nutrition therapy services are performed.'.
(c) PAYMENT- Section 1833(a)(1) (42 U.S.C. 1395l(a)(1)) is amended--
(1) by striking `and' before `(S)'; and
(2) by inserting before the semicolon at the end the following: `, and
(T) with respect to medical nutrition therapy services (as defined in
section 1861(vv)), the amount paid shall be 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) for the same services if
furnished by a physician'.
(d) APPLICATION OF LIMITS ON BILLING- Section 1842(b)(18)(C) (42 U.S.C.
1395u(b)(18)(C)) is amended by adding at the end the following new clause:
`(vi) A registered dietitian or nutrition professional.'.
(e) EFFECTIVE DATE- The amendments made by this section apply to services
furnished on or after January 1, 2002.
(f) STUDY- Not later than July 1, 2003, the Secretary of Health and Human
Services shall submit to Congress a report that contains recommendations with
respect to the expansion to other medicare beneficiary populations of the
medical nutrition therapy services benefit (furnished under the amendments
made by this section).
SEC. 106. EXTENSION OF PART A COVERAGE FOR WORKERS WITH DISABILITIES.
(a) CONTINUATION OF COVERAGE-
(1) IN GENERAL- Section 226 (42 U.S.C. 426) is amended--
(A) in the third sentence of subsection (b), by inserting `, except as
provided in subsection (j)' after `but not in excess of 24 such months';
and
(B) by adding at the end the following:
`(j) The 24-month limitation on deemed entitlement under the third
sentence of subsection (b) shall not apply--
`(1) for months occurring during the 10-year period beginning with the
first month that begins after the date of enactment of this subsection;
and
`(2) for subsequent months, in the case of an individual who was
entitled to benefits under subsection (b) as of the last month of such
10-year period and would continue (but for such 24-month limitation) to be
so entitled.'.
(2) CONFORMING AMENDMENT- Section 1818A(a)(2)(C) (42 U.S.C.
1395i-2a(a)(2)(C)) is amended--
(A) by striking `solely'; and
(B) by inserting `or the expiration of the last month of the 10-year
period described in section 226(j)' before the semicolon.
(b) GAO REPORT- Not later than 8 years after the date of the enactment of
this section, the Comptroller General of the United States shall submit a
report to the Congress that--
(1) examines the effectiveness and cost of subsection (j) of section 226
(42 U.S.C. 426); and
(2) recommends whether such subsection (j) should continue to be applied
beyond the 10-year period described in the subsection.
(c) EFFECTIVE DATE- The amendments made by subsection (a) apply to months
beginning with the first month that begins after the date of enactment of this
section.
(d) TREATMENT OF CERTAIN INDIVIDUALS- An individual enrolled under section
1818A (42 U.S.C. 1395i2a) shall be treated with respect to premium payment
obligations under such section as though the individual had continued to be
entitled to benefits under section 226(b) for--
(1) months described in section 226(j)(1) (42 U.S.C. 426(j)(1)) (as
added by subsection (a)); and
(2) subsequent months, in the case of an individual who was so enrolled
as of the last month described in section 226(j)(2) (42 U.S.C. 426(j)(2))
(as so added).
(e) REPEAL OF PARTIAL EXTENSION PROVISION AND STUDY REQUIREMENT- Section
202 of Public Law 106-170 is repealed.
SEC. 107. 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), respectively; and
(2) by inserting after paragraph (21) the following new paragraph:
`(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;'.
(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. 1396(p)(c)(1)(C)(ii)) is amended
by striking `(22), or (24)' and inserting `(23), or (25)'.
Subtitle B--Other Beneficiary Improvements
SEC. 111. ACCELERATION OF REDUCTION OF BENEFICIARY COPAYMENT FOR HOSPITAL
OUTPATIENT DEPARTMENT SERVICES.
(a) REDUCING THE UPPER LIMIT ON BENEFICIARY COPAYMENT-
(1) IN GENERAL- Section 1833(t)(8)(C) (42 U.S.C. 1395l(t)(8)(C)) is
amended to read as follows:
`(C) LIMITATION ON COPAYMENT AMOUNT-
`(i) TO INPATIENT HOSPITAL DEDUCTIBLE AMOUNT- In no case shall the
copayment amount for a procedure performed in a year exceed the amount
of the inpatient hospital deductible established under section 1813(b)
for that year.
`(ii) TO SPECIFIED PERCENTAGE- The Secretary shall reduce the
national unadjusted copayment amount for a covered OPD service (or group
of such services) furnished in a year in a manner so that the effective
copayment rate (determined on a national unadjusted basis) for that
service in the year does not exceed the following
percentage:
`(I) For procedures performed in 2001, 60 percent.
`(II) For procedures performed in 2002 or 2003, 55
percent.
`(III) For procedures performed in 2004, 50
percent.
`(IV) For procedures performed in 2005, 45 percent.
`(V) For procedures performed in 2006 and thereafter, 40
percent.'.
(2) EFFECTIVE DATE- The amendment made by paragraph (1) applies with
respect to services furnished on or after January 1, 2001.
(b) CONSTRUCTION REGARDING LIMITING INCREASES IN COST-SHARING- Nothing in
this Act or the Social Security Act shall be construed as preventing a
hospital from waiving the amount of any coinsurance for outpatient hospital
services under the medicare program under title XVIII of the Social Security
Act that may have been increased as a result of the implementation of the
prospective payment system under section 1833(t) of the Social Security Act
(42 U.S.C. 1395l(t)).
(c) GAO STUDY OF REDUCTION IN MEDIGAP PREMIUM LEVELS RESULTING FROM
REDUCTIONS IN COINSURANCE- The Comptroller General of the United States shall
work, in concert with the National Association of Insurance Commissioners, to
evaluate the extent to which the premium levels for medicare supplemental
policies reflect the reductions in coinsurance resulting from the amendment
made by subsection (a). Not later than April 1, 2004, the Comptroller General
shall submit to Congress a report on such evaluation and the extent to which
the reductions in beneficiary coinsurance effected by such amendment have
resulted in actual savings to medicare beneficiaries.
SEC. 112. 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 the date of the enactment of this
Act.
SEC. 113. 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) CONFORMING AMENDMENTS-
(1) EXTENDED COVERAGE- Section 1832 (42 U.S.C. 1395k) is amended--
(A) by striking subsection (b); and
(B) by redesignating subsection (c) as subsection (b).
(2) PASS-THROUGH; REPORT- Section 227 of BBRA is amended by striking
subsection (d).
(c) 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. 114. IMPOSITION OF BILLING LIMITS ON DRUGS.
(a) IN GENERAL- Section 1842(o) (42 U.S.C. 1395u(o)) is amended by adding
at the end the following new paragraph:
`(3)(A) Payment for a charge for any drug or biological for which payment
may be made under this part may be made under this part only on an
assignment-related basis.
`(B) The provisions of subsection (b)(18)(B) shall apply to charges for
such drugs or biologicals in the same manner as they apply to services
furnished by a practitioner described in subsection (b)(18)(C).'.
(b) EFFECTIVE DATE- The amendment made by subsection (a) shall apply to
items furnished on or after January 1, 2001.
SEC. 115. 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.'.
(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.
Subtitle C--Demonstration Projects and Studies
SEC. 121. DEMONSTRATION PROJECT FOR DISEASE MANAGEMENT FOR SEVERELY
CHRONICALLY ILL MEDICARE BENEFICIARIES.
(a) IN GENERAL- The Secretary of Health and Human Services shall conduct a
demonstration project under this section (in this section referred to as the
`project') to demonstrate the impact on costs and health outcomes of applying
disease management to medicare beneficiaries with diagnosed, advanced-stage
congestive heart failure, diabetes, or coronary heart disease. In no case may
the number of participants in the project exceed 30,000 at any time.
(b) VOLUNTARY PARTICIPATION-
(1) ELIGIBILITY- Medicare beneficiaries are eligible to participate in
the project only if--
(A) they meet specific medical criteria demonstrating the appropriate
diagnosis and the advanced nature of their disease;
(B) their physicians approve of participation in the project;
and
(C) they are not enrolled in a Medicare+Choice plan.
(2) BENEFITS- A beneficiary who is enrolled in the project shall be
eligible--
(A) for disease management services related to their chronic health
condition; and
(B) for payment for all costs for prescription drugs without regard to
whether or not they relate to the chronic health condition, except that
the project may provide for modest cost-sharing with respect to
prescription drug coverage.
(c) CONTRACTS WITH DISEASE MANAGEMENT ORGANIZATIONS-
(1) IN GENERAL- The Secretary of Health and Human Services shall carry
out the project through contracts with up to three disease management
organizations. The Secretary shall not enter into such a contract with an
organization unless the organization demonstrates that it can produce
improved health outcomes and reduce aggregate medicare expenditures
consistent with paragraph (2).
(2) CONTRACT PROVISIONS- Under such contracts--
(A) such an organization shall be required to provide for prescription
drug coverage described in subsection (b)(2)(B);
(B) such an organization shall be paid a fee negotiated and
established by the Secretary in a manner so that (taking into account
savings in expenditures under parts A and B of the medicare program under
title XVIII of the Social Security Act) there will be a net reduction in
expenditures under the medicare program as a result of the project;
and
(C) such an organization shall guarantee, through an appropriate
arrangement with a reinsurance company or otherwise, the net reduction in
expenditures described in subparagraph (B).
(3) PAYMENTS- Payments to such organizations shall be made in
appropriate proportion from the Trust Funds established under title XVIII of
the Social Security Act.
(d) APPLICATION OF MEDIGAP PROTECTIONS TO DEMONSTRATION PROJECT ENROLLEES-
(1) Subject to paragraph (2), the provisions of section 1882(s)(3) (other than
clauses (i) through (iv) of subparagraph (B)) and 1882(s)(4) of the Social
Security Act shall apply to enrollment (and termination of enrollment) in the
demonstration project under this section, in the same manner as they apply to
enrollment (and termination of enrollment) with a Medicare+Choice organization
in a Medicare+Choice plan.
(2) In applying paragraph (1)--
(A) any reference in clause (v) or (vi) of section 1882(s)(3)(B) of such
Act to 12 months is deemed a reference to the period of the demonstration
project; and
(B) the notification required under section 1882(s)(3)(D) of such Act
shall be provided in a manner specified by the Secretary of Health and Human
Services.
(e) DURATION- The project shall last for not longer than 3 years.
(f) WAIVER- The Secretary of Health and Human Services shall waive such
provisions of title XVIII of the Social Security Act as may be necessary to
provide for payment for services under the project in accordance with
subsection (c)(3).
(g) REPORT- The Secretary of Health and Human Services shall submit to
Congress an interim report on the project not later than 2 years after the
date it is first implemented and a final report on the project not later than
6 months after the date of its completion. Such reports shall include
information on the impact of the project on costs and health outcomes and
recommendations on the cost-effectiveness of extending or expanding the
project.
SEC. 122. CANCER PREVENTION AND TREATMENT DEMONSTRATION FOR ETHNIC AND
RACIAL MINORITIES.
(1) IN GENERAL- The Secretary of Health and Human Services (in this
section referred to as the `Secretary') shall conduct demonstration projects
(in this section referred to as `demonstration projects') for the purpose of
developing models and evaluating methods that--
(A) improve the quality of items and services provided to target
individuals in order to facilitate reduced disparities in early detection
and treatment of cancer;
(B) improve clinical outcomes, satisfaction, quality of life, and
appropriate use of medicare-covered services and referral patterns among
those target individuals with cancer;
(C) eliminate disparities in the rate of preventive cancer screening
measures, such as pap smears and prostate cancer screenings, among target
individuals; and
(D) promote collaboration with community-based organizations to ensure
cultural competency of health care professionals and linguistic access for
persons with limited English proficiency.
(2) TARGET INDIVIDUAL DEFINED- In this section, the term `target
individual' means an individual of a racial and ethnic minority group, as
defined by section 1707 of the Public Health Service Act, who is entitled to
benefits under part A, and enrolled under part B, of title XVIII of the
Social Security Act.
(1) INITIAL DESIGN- Not later than 1 year after the date of the
enactment of this Act, the Secretary shall evaluate best practices in the
private sector, community programs, and academic research of methods that
reduce disparities among individuals of racial and ethnic minority groups in
the prevention and treatment of cancer and shall design the demonstration
projects based on such evaluation.
(2) NUMBER AND PROJECT AREAS- Not later than 2 years after the date of
the enactment of this Act, the Secretary shall implement at least 9
demonstration projects, including the following:
(A) 2 projects for each of the 4 major racial and ethnic minority
groups (American Indians (including Alaska Natives, Eskimos, and Aleuts);
Asian Americans and Pacific Islanders; Blacks; and Hispanics. The 2
projects must target different ethnic subpopulations.
(B) 1 project within the Pacific Islands.
(C) At least 1 project each in a rural area and inner-city
area.
(3) EXPANSION OF PROJECTS; IMPLEMENTATION OF DEMONSTRATION PROJECT
RESULTS- If the initial report under subsection (c) contains an evaluation
that demonstration projects--
(A) reduce expenditures under the medicare program under title XVIII
of the Social Security Act; or
(B) do not increase expenditures under the medicare program and reduce
racial and ethnic health disparities in the quality of health care
services provided to target individuals and increase satisfaction of
beneficiaries and health care providers;
the Secretary shall continue the existing demonstration projects and may
expand the number of demonstration projects.
(1) IN GENERAL- Not later than 2 years after the date the Secretary
implements the initial demonstration projects, and biannually thereafter,
the Secretary shall submit to Congress a report regarding the demonstration
projects.
(2) CONTENTS OF REPORT- Each report under paragraph (1) shall include
the following:
(A) A description of the demonstration projects.
(i) the cost-effectiveness of the demonstration
projects;
(ii) the quality of the health care services provided to target
individuals under the demonstration projects; and
(iii) beneficiary and health care provider satisfaction under the
demonstration projects.
(C) Any other information regarding the demonstration projects that
the Secretary determines to be appropriate.
(d) WAIVER AUTHORITY- The Secretary shall waive compliance with the
requirements of title XVIII of the Social Security Act to such extent and for
such period as the Secretary determines is necessary to conduct demonstration
projects.
(1) DEMONSTRATION PROJECTS-
(A) STATE PROJECTS- Except as provided in subparagraph (B), the
Secretary shall provide for the transfer from the Federal Hospital
Insurance Trust Fund and the Federal Supplementary Insurance Trust Fund
under title XVIII of the Social Security Act, in such proportions as the
Secretary determines to be appropriate, of such funds as are necessary for
the costs of carrying out the demonstration projects.
(B) TERRITORY PROJECTS- In the case of a demonstration project
described in subsection (b)(2)(B), amounts shall be available only as
provided in any Federal law making appropriations for the
territories.
(2) LIMITATION- In conducting demonstration projects, the Secretary
shall ensure that the aggregate payments made by the Secretary do not exceed
the sum of the amount which the Secretary would have paid under the program
for the prevention and treatment of cancer if the demonstration projects
were not implemented, plus $25,000,000.
SEC. 123. STUDY ON MEDICARE COVERAGE OF ROUTINE THYROID SCREENING.
(a) STUDY- The Secretary of Health and Human Services shall request the
National Academy of Sciences, and as appropriate in conjunction with the
United States Preventive Services Task Force, to conduct a study on the
addition of coverage of routine thyroid screening using a thyroid stimulating
hormone test as a preventive benefit provided to medicare beneficiaries under
title XVIII of the Social Security Act for some or all medicare beneficiaries.
In conducting the study, the Academy shall consider the short-term and
long-term benefits, and costs to the medicare program, of such addition.
(b) REPORT- Not later than 2 years after the date of the enactment of this
Act, the Secretary of Health and Human Services shall submit a report on the
findings of the study conducted under subsection (a) 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.
SEC. 124. MEDPAC STUDY ON CONSUMER COALITIONS.
(a) STUDY- The Medicare Payment Advisory Commission shall conduct a study
that examines the use of consumer coalitions in the marketing of
Medicare+Choice plans under the medicare program under title XVIII of the
Social Security Act. The study shall examine--
(1) the potential for increased efficiency in the medicare program
through greater beneficiary knowledge of their health care options,
decreased marketing costs of Medicare+Choice organizations, and creation of
a group market;
(2) the implications of Medicare+Choice plans and medicare supplemental
policies (under section 1882 of the Social Security Act (42 U.S.C. 1395ss))
offering medicare beneficiaries in the same geographic location different
benefits and premiums based on their affiliation with a consumer
coalition;
(3) how coalitions should be governed, how they should be accountable to
the Secretary of Health and Human Services, and how potential conflicts of
interest in the activities of consumer coalitions should be avoided;
and
(4) how such coalitions should be funded.
(b) REPORT- Not later than 1 year after the date of the enactment of this
Act, the Commission shall submit to Congress a report on the study conducted
under subsection (a). The report shall include a recommendation on whether and
how a demonstration project might be conducted for the operation of consumer
coalitions under the medicare program.
(c) CONSUMER COALITION DEFINED- For purposes of this section, the term
`consumer coalition' means a nonprofit, community-based group of organizations
that--
(1) provides information to medicare beneficiaries about their health
care options under the medicare program; and
(2) negotiates benefits and premiums for medicare beneficiaries who are
members or otherwise affiliated with the group of organizations with
Medicare+Choice organizations offering Medicare+Choice plans, issuers of
medicare supplemental policies, issuers of long-term care coverage, and
pharmacy benefit managers.
SEC. 125. 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. 126. 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. 127. STUDIES ON PREVENTIVE INTERVENTIONS IN PRIMARY CARE FOR OLDER
AMERICANS.
(a) STUDIES- The Secretary of Health and Human Services, acting through
the United States Preventive Services Task Force, shall conduct a series of
studies designed to identify preventive interventions that can be delivered in
the primary care setting and that are most valuable to older Americans.
(b) MISSION STATEMENT- The mission statement of the United States
Preventive Services Task Force is amended to include the evaluation of
services that are of particular relevance to older Americans.
(c) REPORT- Not later than 1 year after the date of the enactment of this
Act, and annually thereafter, the Secretary of Health and Human Services shall
submit to Congress a report on the conclusions of the studies conducted under
subsection (a), together with recommendations for such legislation and
administrative actions as the Secretary considers appropriate.
SEC. 128. MEDPAC STUDY AND REPORT ON MEDICARE COVERAGE OF CARDIAC AND
PULMONARY REHABILITATION THERAPY SERVICES.
(1) IN GENERAL- The Medicare Payment Advisory Commission shall conduct a
study on coverage of cardiac and pulmonary rehabilitation therapy services
under the medicare program under title XVIII of the Social Security
Act.
(2) FOCUS- In conducting the study under paragraph (1), the Commission
shall focus on the appropriate--
(A) qualifying diagnoses required for coverage of cardiac and
pulmonary rehabilitation therapy services;
(B) level of physician direct involvement and supervision in
furnishing such services; and
(C) level of reimbursement for such services.
(b) REPORT- Not later than 18 months after the date of the enactment of
this Act, the Commission shall submit to Congress a report on the study
conducted under subsection (a) together with such recommendations for
legislation and administrative action as the Commission determines
appropriate.
TITLE II--RURAL HEALTH CARE IMPROVEMENTS
Subtitle A--Critical Access Hospital Provisions
SEC. 201. CLARIFICATION OF NO BENEFICIARY COST-SHARING FOR CLINICAL
DIAGNOSTIC LABORATORY TESTS FURNISHED BY CRITICAL ACCESS HOSPITALS.
(a) PAYMENT CLARIFICATION- Section 1834(g) (42 U.S.C. 1395m(g)) is amended
by adding at the end the following new paragraph:
`(4) NO BENEFICIARY COST-SHARING FOR CLINICAL DIAGNOSTIC LABORATORY
SERVICES- No coinsurance, deductible, copayment, or other cost-sharing
otherwise applicable under this part shall apply with respect to clinical
diagnostic laboratory services furnished as an outpatient critical access
hospital service. Nothing in this title shall be construed as providing for
payment for clinical diagnostic laboratory services furnished as part of
outpatient critical access hospital services, other than on the basis
described in this subsection.'.
(b) TECHNICAL AND CONFORMING AMENDMENTS-
(1) Paragraphs (1)(D)(i) and (2)(D)(i) of section 1833(a) (42 U.S.C.
1395l(a)) are each amended by striking `or which are furnished on an
outpatient basis by a critical access hospital'.
(2) Section 403(d)(2) of BBRA (113 Stat. 1501A-371) is amended by
striking `The amendment made by subsection (a) shall apply' and inserting
`Paragraphs (1) through (3) of section 1834(g) of the Social Security Act
(as amended by paragraph (1)) apply'.
(c) EFFECTIVE DATES- The amendment made--
(1) by subsection (a) applies to services furnished on or after the date
of the enactment of BBRA;
(2) by subsection (b)(1) applies as if included in the enactment of
section 403(e)(1) of BBRA (113 Stat. 1501A-371); and
(3) by subsection (b)(2) applies as if included in the enactment of
section 403(d)(2) of BBRA (113 Stat. 1501A-371).
SEC. 202. ASSISTANCE WITH FEE SCHEDULE PAYMENT FOR PROFESSIONAL SERVICES
UNDER ALL-INCLUSIVE RATE.
(a) IN GENERAL- Section 1834(g)(2)(B) (42 U.S.C. 1395m(g)(2)(B)) is
amended by inserting `115 percent of' before `such amounts'.
(b) EFFECTIVE DATE- The amendment made by subsection (a) applies with
respect to items and services furnished on or after April 1, 2001.
SEC. 203. EXEMPTION OF CRITICAL ACCESS HOSPITAL SWING BEDS FROM SNF
PPS.
(a) IN GENERAL- Section 1888(e)(7) (42 U.S.C. 1395yy(e)(7)) is
amended--
(1) in the heading, by striking `TRANSITION FOR' and inserting
`TREATMENT OF';
(2) in subparagraph (A), by striking `IN GENERAL- The' and inserting
`TRANSITION- Subject to subparagraph (C), the';
(3) in subparagraph (A), by inserting `(other than critical access
hospitals)' after `facilities described in subparagraph (B)';
(4) in subparagraph (B), by striking `, for which payment' and all that
follows before the period; and
(5) by adding at the end the following new subparagraph:
`(C) EXEMPTION FROM PPS OF SWING-BED SERVICES FURNISHED IN CRITICAL
ACCESS HOSPITALS- The prospective payment system established under this
subsection shall not apply to services furnished by a critical access
hospital pursuant to an agreement under section 1883.'.
(b) PAYMENT ON A REASONABLE COST BASIS FOR SWING BED SERVICES FURNISHED BY
CRITICAL ACCESS HOSPITALS- Section 1883(a) (42 U.S.C. 1395tt(a)) is
amended--
(1) in paragraph (2)(A), by inserting `(other than a critical access
hospital)' after `any hospital'; and
(2) by adding at the end the following new paragraph:
`(3) Notwithstanding any other provision of this title, a critical access
hospital shall be paid for covered skilled nursing facility services furnished
under an agreement entered into under this section on the basis of the
reasonable costs of such services (as determined under section 1861(v)).'.
(c) EFFECTIVE DATE- The amendments made by this section shall apply to
cost reporting periods beginning on or after the date of the enactment of this
Act.
SEC. 204. PAYMENT IN CRITICAL ACCESS HOSPITALS FOR EMERGENCY ROOM ON-CALL
PHYSICIANS.
(a) IN GENERAL- Section 1834(g) (42 U.S.C. 1395m(g)), as amended by
section 201(a), is further amended by adding at the end the following new
paragraph:
`(5) COVERAGE OF COSTS FOR EMERGENCY ROOM ON-CALL PHYSICIANS- In
determining the reasonable costs of outpatient critical access hospital
services under paragraphs (1) and (2)(A), the Secretary shall recognize as
allowable costs, amounts (as defined by the Secretary) for reasonable
compensation and related costs for emergency room physicians who are on-call
(as defined by the Secretary) but who are not present on the premises of the
critical access hospital involved, and are not otherwise furnishing
physicians' services and are not on-call at any other provider or
facility.'.
(b) EFFECTIVE DATE- The amendment made by subsection (a) applies to cost
reporting periods beginning on or after October 1, 2001.
SEC. 205. TREATMENT OF AMBULANCE SERVICES FURNISHED BY CERTAIN CRITICAL
ACCESS HOSPITALS.
(a) IN GENERAL- Section 1834(l) (42 U.S.C. 1395m(l)) is amended by adding
at the end the following new paragraph:
`(8) SERVICES FURNISHED BY CRITICAL ACCESS HOSPITALS- Notwithstanding
any other provision of this subsection, the Secretary shall pay the
reasonable costs incurred in furnishing ambulance services if such services
are furnished--
`(A) by a critical access hospital (as defined in section
1861(mm)(1)), or
`(B) by an entity that is owned and operated by a critical access
hospital,
but only if the critical access hospital or entity is the only provider
or supplier of ambulance services that is located within a 35-mile drive of
such critical access hospital.'.
(b) CONFORMING AMENDMENT- Section 1833(a)(1)(R) (42 U.S.C. 1395l(a)(1)(R))
is amended--
(1) by striking `ambulance service,' and inserting `ambulance services,
(i)'; and
(2) by inserting before the comma at the end the following: `and (ii)
with respect to ambulance services described in section 1834(l)(8), the
amounts paid shall be the amounts determined under section 1834(g) for
outpatient critical access hospital services'.
(c) EFFECTIVE DATE- The amendments made by this section apply to services
furnished on or after the date of the enactment of this Act.
SEC. 206. GAO STUDY ON CERTAIN ELIGIBILITY REQUIREMENTS FOR CRITICAL ACCESS
HOSPITALS.
(a) STUDY- The Comptroller General of the United States shall conduct a
study on the eligibility requirements for critical access hospitals under
section 1820(c) of the Social Security Act (42 U.S.C. 1395i-4(c)) with respect
to limitations on average length of stay and number of beds in such a
hospital, including an analysis of--
(1) the feasibility of having a distinct part unit as part of a critical
access hospital for purposes of the medicare program under title XVIII of
such Act, and
(2) the effect of seasonal variations in patient admissions on critical
access hospital eligibility requirements with respect to limitations on
average annual length of stay and number of beds.
(b) REPORT- Not later than 1 year after the date of the enactment of this
Act, the Comptroller General shall submit to Congress a report on the study
conducted under subsection (a) together with recommendations regarding--
(1) whether distinct part units should be permitted as part of a
critical access hospital under the medicare program;
(2) if so permitted, the payment methodologies that should apply with
respect to services provided by such units;
(3) whether, and to what extent, such units should be included in or
excluded from the bed limits applicable to critical access hospitals under
the medicare program; and
(4) any adjustments to such eligibility requirements to account for
seasonal variations in patient admissions.
Subtitle B--Other Rural Hospitals Provisions
SEC. 211. EQUITABLE TREATMENT FOR RURAL DISPROPORTIONATE SHARE
HOSPITALS.
(a) APPLICATION OF UNIFORM THRESHOLD- Section 1886(d)(5)(F)(v) (42 U.S.C.
1395ww(d)(5)(F)(v)) is amended--
(1) in subclause (II), by inserting `(or 15 percent, for discharges
occurring on or after October 1, 2001)' after `30 percent';
(2) in subclause (III), by inserting `(or 15 percent, for discharges
occurring on or after October 1, 2001)' after `40 percent'; and
(3) in subclause (IV), by inserting `(or 15 percent, for discharges
occurring on or after October 1, 2001)' after `45 percent'.
(b) ADJUSTMENT OF PAYMENT FORMULAS-
(1) SOLE COMMUNITY HOSPITALS- Section 1886(d)(5)(F) (42 U.S.C.
1395ww(d)(5)(F)) is amended--
(A) in clause (iv)(VI), by inserting after `10 percent' the following:
`or, for discharges occurring on or after October 1, 2001, is equal to the
percent determined in accordance with clause (x)'; and
(B) by adding at the end the following new clause:
`(x) For purposes of clause (iv)(VI), in the case of a hospital for
a cost reporting period with a disproportionate patient percentage (as
defined in clause (vi)) that--
`(I) is less than 19.3, the disproportionate share adjustment
percentage is determined in accordance with the following formula:
(P-15)(.65)-2.5;
`(II) is equal to or exceeds 19.3, but is less than 30.0, such
adjustment percentage is equal to 5.25 percent; or
`(III) is equal to or exceeds 30, such adjustment percentage is
equal to 10 percent, where P is the hospital's disproportionate
patient percentage (as defined in clause (vi)).'.
(2) RURAL REFERRAL CENTERS- Such section is further amended--
(A) in clause (iv)(V), by inserting after clause (viii) the following:
or, for discharges occurring on or after October 1, 2001, is equal to the
percent determined in accordance with clause (xi); and
(B) by adding at the end the following new clause:
`(xi) For purposes of clause (iv)(V), in the case of a hospital for
a cost reporting period with a disproportionate patient percentage (as
defined in clause (vi)) that--
`(I) is less than 19.3, the disproportionate share adjustment
percentage is determined in accordance with the following formula:
(P-15)(.65)-2.5;
`(II) is equal to or exceeds 19.3, but is less than 30.0, such
adjustment percentage is equal to 5.25 percent; or
`(III) is equal to or exceeds 30, such adjustment percentage is
determined in accordance with the following formula: (P-30)(.6)-5.25,
where P is the hospital's disproportionate patient percentage (as
defined in clause (vi)).'.
(3) SMALL RURAL HOSPITALS GENERALLY- Such section is further
amended--
(A) in clause (iv)(III), by inserting after `4 percent' the following:
`or, for discharges occurring on or after October 1, 2001, is equal to the
percent determined in accordance with clause (xii)'; and
(B) by adding at the end the following new clause:
`(xii) For purposes of clause (iv)(III), in the case of a hospital
for a cost reporting period with a disproportionate patient percentage
(as defined in clause (vi)) that--
`(I) is less than 19.3, the disproportionate share adjustment
percentage is determined in accordance with the following formula:
(P-15)(.65)-2.5;
`(II) is equal to or exceeds 19.3, such adjustment percentage is
equal to 5.25 percent, where P is the hospital's disproportionate
patient percentage (as defined in clause (vi)).'.
(4) HOSPITALS THAT ARE BOTH SOLE COMMUNITY HOSPITALS AND RURAL REFERRAL
CENTERS- Such section is further amended, in clause (iv)(IV), by inserting
after clause (viii) the following: `or, for discharges occurring on or after
October 1, 2001, the greater of the percentages determined under clause (x)
or (xi)'.
(5) URBAN HOSPITALS WITH LESS THAN 100 BEDS- Such section is further
amended--
(A) in clause (iv)(II), by inserting after 5 percent the following:
`or, for discharges occurring on or after October 1, 2001, is equal to the
percent determined in accordance with clause (xiii); and
(B) by adding at the end the following new clause:
`(xiii) For purposes of clause (iv)(II), in the case of a hospital
for a cost reporting period with a disproportionate patient percentage
(as defined in clause (vi)) that--
`(I) is less than 19.3, the disproportionate share adjustment
percentage is determined in accordance with the following formula:
(P-15)(.65)-2.5;
`(II) is equal to or exceeds 19.3, such adjustment percentage is
equal to 5.25 percent; where P is the hospital's disproportionate
patient percentage (as defined in clause (vi)).'.
SEC. 212. OPTION TO BASE ELIGIBILITY FOR MEDICARE DEPENDENT, SMALL RURAL
HOSPITAL PROGRAM ON DISCHARGES DURING 2 OF THE 3 MOST RECENTLY AUDITED COST
REPORTING PERIODS.
(a) IN GENERAL- Section 1886(d)(5)(G)(iv)(IV) (42 U.S.C.
1395ww(d)(5)(G)(iv)(IV)) is amended by inserting `, or 2 of the 3 most
recently audited cost reporting periods for which the Secretary has a settled
cost report,' after `1987'.
(b) EFFECTIVE DATE- The amendment made by this section shall apply with
respect to cost reporting periods beginning on or after April 1, 2001.
SEC. 213. EXTENSION OF OPTION TO USE REBASED TARGET AMOUNTS TO ALL SOLE
COMMUNITY HOSPITALS.
(a) IN GENERAL- Section 1886(b)(3)(I)(i) (42 U.S.C. 1395ww(b)(3)(I)(i)) is
amended--
(1) in the matter preceding subclause (I), by striking `that for its
cost reporting period beginning during 1999' and all that follows through
`for such target amount' and inserting `there shall be substituted for the
amount otherwise determined under subsection (d)(5)(D)(i), if such
substitution results in a greater amount of payment under this section for
the hospital';
(2) in subclause (I), by striking `target amount otherwise applicable'
and all that follows through `target amount')' and inserting `the amount
otherwise applicable to the hospital under subsection (d)(5)(D)(i) (referred
to in this clause as the `subsection (d)(5)(D)(i) amount')'; and
(3) in each of subclauses (II) and (III), by striking `subparagraph (C)
target amount' and inserting `subsection (d)(5)(D)(i) amount'.
(b) EFFECTIVE DATE- The amendments made by this section shall take effect
as if included in the enactment of section 405 of BBRA (113 Stat.
1501A-372).
SEC. 214. MEDPAC ANALYSIS OF IMPACT OF VOLUME ON PER UNIT COST OF RURAL
HOSPITALS WITH PSYCHIATRIC UNITS.
The Medicare Payment Advisory Commission, in its study conducted pursuant
to subsection (a) of section 411 of BBRA (113 Stat. 1501A-377), shall
include--
(1) in such study an analysis of the impact of volume on the per unit
cost of rural hospitals with psychiatric units; and
(2) in its report under subsection (b) of such section a recommendation
on whether special treatment for such hospitals may be warranted.
Subtitle C--Other Rural Provisions
SEC. 221. ASSISTANCE FOR PROVIDERS OF AMBULANCE SERVICES IN RURAL
AREAS.
(a) TRANSITIONAL ASSISTANCE IN CERTAIN MILEAGE RATES- Section 1834(l) (42
U.S.C. 1395m(l)) is amended by adding at the end the following new
paragraph:
`(8) TRANSITIONAL ASSISTANCE FOR RURAL PROVIDERS- In the case of ground
ambulance services furnished on or after the date on which the Secretary
implements the fee schedule under this subsection and before January 1,
2004, for which the transportation originates in a rural area (as defined in
section 1886(d)(2)(D)) or in a rural census tract of a metropolitan
statistical area (as determined under the most recent modification of the
Goldsmith Modification, originally published in the Federal Register on
February 27, 1992 (57 Fed. Reg. 6725)), the fee schedule established under
this subsection shall provide that, with respect to the payment rate for
mileage for a trip above 17 miles, and up to 50 miles, the rate otherwise
established shall be increased by not less than 1/2 of the additional
payment per mile established for the first 17 miles of such a trip
originating in a rural area.'.
(b) GAO STUDIES ON THE COSTS OF AMBULANCE SERVICES FURNISHED IN RURAL
AREAS-
(1) STUDY- The Comptroller General of the United States shall conduct a
study on each of the matters described in paragraph (2).
(2) MATTERS DESCRIBED- The matters referred to in paragraph (1) are the
following:
(A) The cost of efficiently providing ambulance services for trips
originating in rural areas, with special emphasis on collection of cost
data from rural providers.
(B) The means by which rural areas with low population densities can
be identified for the purpose of designating areas in which the cost of
providing ambulance services would be expected to be higher than similar
services provided in more heavily populated areas because of low usage.
Such study shall also include an analysis of the additional costs of
providing ambulance services in areas designated under the previous
sentence.
(3) REPORT- Not later than June 30, 2002, the Comptroller General shall
submit to Congress a report on the results of the studies conducted under
paragraph (1) and shall include recommendations on steps that should be
taken to assure access to ambulance services in rural areas.
(c) ADJUSTMENT IN RURAL RATES- In providing for adjustments under
subparagraph (D) of section 1834(l)(2) of the Social Security Act (42 U.S.C.
1395m(l)(2)) for years beginning with 2004, the Secretary of Health and Human
Services shall take into consideration the recommendations contained in the
report under subsection (b)(2) and shall adjust the fee schedule payment rates
under such section for ambulance services provided in low density rural areas
based on the increased cost (if any) of providing such services in such
areas.
(d) EFFECTIVE DATE- The amendment made by subsection (a) applies to
services furnished on or after the date the Secretary implements the fee
schedule under section 1834(l) of the Social Security Act (42 U.S.C.
1395m(l)). In applying such amendment to services furnished on or after such
date and before January 1, 2002, the amount of the rate increase provided
under such amendment shall be equal to $1.25 per mile.
SEC. 222. PAYMENT FOR CERTAIN PHYSICIAN ASSISTANT SERVICES.
(a) PAYMENT FOR CERTAIN PHYSICIAN ASSISTANT SERVICES- Section
1842(b)(6)(C) (42 U.S.C. 1395u(b)(6)(C)) is amended--
(1) by striking `for such services provided before January 1, 2003,';
and
(2) by striking the semicolon at the end and inserting a comma.
(b) EFFECTIVE DATE- The amendments made by subsection (a) shall take
effect on the date of the enactment of this Act.
SEC. 223. REVISION OF MEDICARE REIMBURSEMENT FOR TELEHEALTH SERVICES.
(a) TIME LIMIT FOR BBA PROVISION- Section 4206(a) of BBA (42 U.S.C. 1395l
note) is amended by striking `Not later than January 1, 1999' and inserting
`For services furnished on and after January 1, 1999, and before July 1,
2001'.
(b) EXPANSION OF MEDICARE PAYMENT FOR TELEHEALTH SERVICES- Section 1834
(42 U.S.C. 1395m) is amended by adding at the end the following new
subsection:
`(m) PAYMENT FOR TELEHEALTH SERVICES-
`(1) IN GENERAL- The Secretary shall pay for telehealth services that
are furnished via a telecommunications system by a physician (as defined in
section 1861(r)) or a practitioner (described in section 1842(b)(18)(C)) to
an eligible telehealth individual enrolled under this part notwithstanding
that the individual physician or practitioner providing the telehealth
service is not at the same location as the beneficiary. For purposes of the
preceding sentence, in the case of any Federal telemedicine demonstration
program conducted 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.
`(A) DISTANT SITE- The Secretary shall pay to a physician or
practitioner located at a distant site that furnishes a telehealth service
to an eligible telehealth individual an amount equal to the amount that
such physician or practitioner would have been paid under this title had
such service been furnished without the use of a telecommunications
system.
`(B) FACILITY FEE FOR ORIGINATING SITE- With respect to a telehealth
service, subject to section 1833(a)(1)(U), there shall be paid to the
originating site a facility fee equal to--
`(i) for the period beginning on July 1, 2001, and ending on
December 31, 2001, and for 2002, $20; and
`(ii) for a subsequent year, the facility fee specified in clause
(i) or this clause for the preceding year increased by the percentage
increase in the MEI (as defined in section 1842(i)(3)) for such
subsequent year.
`(C) TELEPRESENTER NOT REQUIRED- Nothing in this subsection shall be
construed as requiring an eligible telehealth individual 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).
`(3) LIMITATION ON BENEFICIARY CHARGES-
`(A) PHYSICIAN AND PRACTITIONER- The provisions of section 1848(g) and
subparagraphs (A) and (B) of section 1842(b)(18) shall apply to a
physician or practitioner receiving payment under this subsection in the
same manner as they apply to physicians or practitioners under such
sections.
`(B) ORIGINATING SITE- The provisions of section 1842(b)(18) shall
apply to originating sites receiving a facility fee in the same manner as
they apply to practitioners under such section.
`(4) DEFINITIONS- For purposes of this subsection:
`(A) 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.
`(B) ELIGIBLE TELEHEALTH INDIVIDUAL- The term `eligible telehealth
individual' means an individual enrolled under this part who receives a
telehealth service furnished at an originating site.
`(i) IN GENERAL- The term `originating site' means only those sites
described in clause (ii) at which the eligible telehealth individual is
located at the time the service is furnished via a telecommunications
system and only if such site is located--
`(I) in an area that is designated as a rural health professional
shortage area under section 332(a)(1)(A) of the Public Health Service
Act (42 U.S.C. 254e(a)(1)(A));
`(II) in a county that is not included in a Metropolitan
Statistical Area; or
`(III) from an entity that participates in a Federal telemedicine
demonstration project that has been approved by (or receives funding
from) the Secretary of Health and Human Services as of December 31,
2000.
`(ii) SITES DESCRIBED- The sites referred to in clause (i) are the
following sites:
`(I) The office of a physician or practitioner.
`(II) A critical access hospital (as defined in section
1861(mm)(1)).
`(III) A rural health clinic (as defined in section
1861(aa)(s)).
`(IV) A Federally qualified health center (as defined in section
1861(aa)(4)).
`(V) A hospital (as defined in section 1861(e)).
`(D) PHYSICIAN- The term `physician' has the meaning given that term
in section 1861(r).
`(E) PRACTITIONER- The term `practitioner' has the meaning given
that term in section 1842(b)(18)(C).
`(i) IN GENERAL- The term `telehealth service' means professional
consultations, office visits,
and office psychiatry services (identified as of July 1, 2000, by HCPCS codes
99241-99275, 99201-99215, 90804-90809, and 90862 (and as subsequently modified
by the Secretary)), and any additional service specified by the Secretary.
`(ii) YEARLY UPDATE- The Secretary shall establish a process that
provides, on an annual basis, for the addition or deletion of services
(and HCPCS codes), as appropriate, to those specified in clause (i) for
authorized payment under paragraph (1).'.
(c) CONFORMING AMENDMENT- Section 1833(a)(1) (42 U.S.C. 1395l(1)), as
amended by section 105(c), is further amended--
(1) by striking `and (T)' and inserting `(T)'; and
(2) by inserting before the semicolon at the end the following: `, and
(U) with respect to facility fees described in section 1834(m)(2)(B), the
amounts paid shall be 80 percent of the lesser of the actual charge or the
amounts specified in such section'.
(d) STUDY AND REPORT ON ADDITIONAL COVERAGE-
(1) STUDY- The Secretary of Health and Human Services shall conduct a
study to identify--
(A) settings and sites for the provision of telehealth services that
are in addition to those permitted under section 1834(m) of the Social
Security Act, as added by subsection (b);
(B) practitioners that may be reimbursed under such section for
furnishing telehealth services that are in addition to the practitioners
that may be reimbursed for such services under such section; and
(C) geographic areas in which telehealth services may be reimbursed
that are in addition to the geographic areas where such services may be
reimbursed under such section.
(2) REPORT- Not later than 2 years after the date of the enactment of
this Act, the Secretary shall submit to Congress a report on the study
conducted under paragraph (1) together with such recommendations for
legislation that the Secretary determines are appropriate.
(e) EFFECTIVE DATE- The amendments made by subsections (b) and (c) shall
be effective for services furnished on or after July 1, 2001.
SEC. 224. EXPANDING ACCESS TO RURAL HEALTH CLINICS.
(a) IN GENERAL- The matter in section 1833(f) (42 U.S.C. 1395l(f))
preceding paragraph (1) is amended by striking `rural hospitals' and inserting
`hospitals'.
(b) EFFECTIVE DATE- The amendment made by subsection (a) shall apply to
services furnished on or after July 1, 2001.
SEC. 225. MEDPAC STUDY ON LOW-VOLUME, ISOLATED RURAL HEALTH CARE
PROVIDERS.
(a) STUDY- The Medicare Payment Advisory Commission shall conduct a study
on the effect of low patient and procedure volume on the financial status of
low-volume, isolated rural health care providers participating in the medicare
program under title XVIII of the Social Security Act.
(b) REPORT- Not later than 18 months after the date of the enactment of
this Act, the Commission shall submit to Congress a report on the study
conducted under subsection (a) indicating--
(1) whether low-volume, isolated rural health care providers are having,
or may have, significantly decreased medicare margins or other financial
difficulties resulting from any of the payment methodologies described in
subsection (c);
(2) whether the status as a low-volume, isolated rural health care
provider should be designated under the medicare program and any criteria
that should be used to qualify for such a status; and
(3) any changes in the payment methodologies described in subsection (c)
that are necessary to provide appropriate reimbursement under the medicare
program to low-volume, isolated rural health care providers (as designated
pursuant to paragraph (2)).
(c) PAYMENT METHODOLOGIES DESCRIBED- The payment methodologies described
in this subsection are the following:
(1) The prospective payment system for hospital outpatient department
services under section 1833(t) of the Social Security Act (42 U.S.C.
1395l(t)).
(2) The fee schedule for ambulance services under section 1834(l) of
such Act (42 U.S.C. 1395m(l)).
(3) The prospective payment system for inpatient hospital services under
section 1886 of such Act (42 U.S.C. 1395ww).
(4) The prospective payment system for routine service costs of skilled
nursing facilities under section 1888(e) of such Act (42 U.S.C.
1395yy(e)).
(5) The prospective payment system for home health services under
section 1895 of such Act (42 U.S.C. 1395fff).
TITLE III--PROVISIONS RELATING TO PART A
Subtitle A--Inpatient Hospital Services
SEC. 301. ELIMINATING REDUCTION IN PPS HOSPITAL PAYMENT UPDATE.
(a) IN GENERAL- Section 1886(b)(3)(B)(i) (42 U.S.C. 1395ww(b)(3)(B)(i)) is
amended--
(1) in subclause (XVI), by striking `minus 1.1 percentage points for
hospitals (other than sole community hospitals) in all areas, and the market
basket percentage increase for sole community hospitals,' and inserting `for
hospitals in all areas,';
(2) in subclause (XVII)--
(A) by striking `minus 1.1 percentage points'; and
(B) by striking `and' at the end;
(3) by redesignating subclause (XVIII) as subclause (XIX);
(4) in subclause (XIX), as so redesignated, by striking `fiscal year
2003' and inserting `fiscal year 2004'; and
(5) by inserting after subclause (XVII) the following new
subclause:
`(XVIII) for fiscal year 2003, the market basket percentage increase
minus 0.55 percentage points for hospitals in all areas, and'.
(b) SPECIAL RULE FOR PAYMENT FOR FISCAL YEAR 2001- Notwithstanding the
amendment made by subsection (a), for purposes of making payments for fiscal
year 2001 for inpatient hospital services furnished by subsection (d)
hospitals (as defined in section 1886(d)(1)(B) of the Social Security Act (42
U.S.C. 1395ww(d)(1)(B)), the `applicable percentage increase' referred to in
section 1886(b)(3)(B)(i) of such Act (42 U.S.C. 1395ww(b)(3)(B)(i))--
(1) for discharges occurring on or after October 1, 2000, and before
April 1, 2001, shall be determined in accordance with subclause (XVI) of
such section as in effect on the day before the date of the enactment of
this Act; and
(2) for discharges occurring on or after April 1, 2001, and before
October 1, 2001, shall be equal to--
(A) the market basket percentage increase plus 1.1 percentage points
for hospitals (other than sole community hospitals) in all areas;
and
(B) the market basket percentage increase for sole community
hospitals.
(c) CONSIDERATION OF PRICE OF BLOOD AND BLOOD PRODUCTS IN MARKET BASKET
INDEX- The Secretary of Health and Human Services shall, when next (after the
date of the enactment of this Act) rebasing and revising the hospital market
basket index (as defined in section 1886(b)(3)(B)(iii) of the Social Security
Act (42 U.S.C. 1395ww(b)(3)(B)(iii))), consider the prices of blood and blood
products purchased by hospitals and determine whether those prices are
adequately reflected in such index.
(d) MEDPAC STUDY AND REPORT REGARDING CERTAIN HOSPITAL COSTS-
(1) STUDY- The Medicare Payment Advisory Commission shall conduct a
study on--
(A) any increased costs incurred by subsection (d) hospitals (as
defined in paragraph (1)(B) of section 1886(d) of the Social Security Act
(42 U.S.C. 1395ww(d))) in providing inpatient hospital services to
medicare beneficiaries under title XVIII of such Act during the period
beginning on October 1, 1983, and ending on September 30, 1999, that were
attributable to--
(i) complying with new blood safety measure requirements;
and
(ii) providing such services using new technologies;
(B) the extent to which the prospective payment system for such
services under such section provides adequate and timely recognition of
such increased costs;
(C) the prospects for (and to the extent practicable, the magnitude
of) cost increases that hospitals will incur in providing such services
that are attributable to complying with new blood safety measure
requirements and providing such services using new technologies during the
10 years after the date of the enactment of this Act; and
(D) the feasibility and advisability of establishing mechanisms under
such payment system to provide for more timely and accurate recognition of
such cost increases in the future.
(2) CONSULTATION- In conducting the study under this subsection, the
Commission shall consult with representatives of the blood community,
including--
(B) organizations involved in the collection, processing, and delivery
of blood; and
(C) organizations involved in the development of new blood safety
technologies.
(3) REPORT- Not later than 1 year after the date of the enactment of
this Act, the Commission shall submit to Congress a report on the study
conducted under paragraph (1) together with such recommendations for
legislation and administrative action as the Commission determines
appropriate.
(e) ADJUSTMENT FOR INPATIENT CASE MIX CHANGES-
(1) IN GENERAL- Section 1886(d)(3)(A) (42 U.S.C. 1395ww(d)(3)(A)) is
amended by adding at the end the following new clause:
`(vi) Insofar as the Secretary determines that the adjustments under
paragraph (4)(C)(i) for a previous fiscal year (or estimates that such
adjustments for a future fiscal year) did (or are likely to) result in a
change in aggregate payments under this subsection during the fiscal year
that are a result of changes in the coding or classification of discharges
that do not reflect real changes in case mix, the Secretary may adjust the
average standardized amounts computed under this paragraph for subsequent
fiscal years so as to eliminate the effect of such coding or classification
changes.'.
(2) EFFECTIVE DATE- The amendment made by paragraph (1) applies to
discharges occurring on or after October 1, 2001.
SEC. 302. ADDITIONAL MODIFICATION IN TRANSITION FOR INDIRECT MEDICAL
EDUCATION (IME) PERCENTAGE ADJUSTMENT.
(a) IN GENERAL- Section 1886(d)(5)(B)(ii) (42 U.S.C. 1395ww(d)(5)(B)(ii))
is amended--
(1) in subclause (V) by striking `and' at the end;
(2) by redesignating subclause (VI) as subclause (VII);
(3) in subclause (VII) as so redesignated, by striking `2001' and
inserting `2002'; and
(4) by inserting after subclause (V) the following new subclause:
`(VI) during fiscal year 2002, `c' is equal to 1.6; and'.
(b) SPECIAL RULE FOR PAYMENT FOR FISCAL YEAR 2001- Notwithstanding
paragraph (5)(B)(ii)(V) of section 1886(d) of the Social Security Act (42
U.S.C. 1395ww(d)(5)(B)(ii)(V)), for purposes of making payments for subsection
(d) hospitals (as defined in paragraph (1)(B) of such section) with indirect
costs of medical education, the indirect teaching adjustment factor referred
to in paragraph (5)(B)(ii) of such section shall be determined, for discharges
occurring on or after April 1, 2001, and before October 1, 2001, as if `c' in
paragraph (5)(B)(ii)(V) of such section equalled 1.66 rather than 1.54.
(c) CONFORMING AMENDMENT RELATING TO DETERMINATION OF STANDARDIZED AMOUNT-
Section 1886(d)(2)(C)(i) (42 U.S.C. 1395ww(d)(2)(C)(i)) is amended by
inserting `or of section 302 of the Medicare, Medicaid, and SCHIP Benefits
Improvement and Protection Act of 2000' after `Balanced Budget Refinement Act
of 1999'.
(d) CLERICAL AMENDMENTS- Section 1886(d)(5)(B) (42 U.S.C.
1395ww(d)(5)(B)), as amended by subsection (a), is further amended by moving
the indentation of each of the following 2 ems to the left:
(1) Clauses (ii), (v), and (vi).
(2) Subclauses (I) (II), (III), (IV), (V), and (VII) of clause
(ii).
(3) Subclauses (I) and (II) of clause (vi) and the flush sentence at the
end of such clause.
SEC. 303. DECREASE IN REDUCTIONS FOR DISPROPORTIONATE SHARE HOSPITAL (DSH)
PAYMENTS.
(a) IN GENERAL- Section 1886(d)(5)(F)(ix) (42 U.S.C. 1395ww(d)(5)(F)(ix))
is amended--
(1) in subclause (III), by striking `each of' and by inserting `and 2
percent, respectively' after `3 percent'; and
(2) in subclause (IV), by striking `4 percent' and inserting `3
percent'.
(b) SPECIAL RULE FOR PAYMENT FOR FISCAL YEAR 2001- Notwithstanding the
amendment made by subsection (a)(1), for purposes of making disproportionate
share payments for subsection (d) hospitals (as defined in section
1886(d)(1)(B) of the Social Security Act (42 U.S.C. 1395ww(d)(1)(B)) for
fiscal year 2001, the additional payment amount otherwise determined under
clause (ii) of section 1886(d)(5)(F) of the Social Security Act (42 U.S.C.
1395ww(d)(5)(F))--
(1) for discharges occurring on or after October 1, 2000, and before
April 1, 2001, shall be adjusted as provided by clause (ix)(III) of such
section as in effect on the day before the date of the enactment of this
Act; and
(2) for discharges occurring on or after April 1, 2001, and before
October 1, 2001, shall, instead of being reduced by 3 percent as provided by
clause (ix)(III) of such section as in effect after the date of the
enactment of this Act, be reduced by 1 percent.
(c) CONFORMING AMENDMENTS RELATING TO DETERMINATION OF STANDARDIZED
AMOUNT- Section 1886(d)(2)(C)(iv) (42 U.S.C. 1395ww(d)(2)(C)(iv)), is
amended--
(1) by striking `1989 or' and inserting `1989,'; and
(2) by inserting `, or the enactment of section 303 of the Medicare,
Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000' after
`Omnibus Budget Reconciliation Act of 1990'.
(1) IN GENERAL- Section 1886(d)(5)(F)(i) (42 U.S.C. 1395ww(d)(5)(F)(i))
is amended by striking `and before October 1, 1997,'.
(2) EFFECTIVE DATE- The amendment made by paragraph (1) is effective as
if included in the enactment of BBA.
(e) REFERENCE TO CHANGES IN DSH FOR RURAL HOSPITALS- For additional
changes in the DSH program for rural hospitals, see section 211.
SEC. 304. WAGE INDEX IMPROVEMENTS.
(a) DURATION OF WAGE INDEX RECLASSIFICATION; USE OF 3-YEAR WAGE DATA-
Section 1886(d)(10)(D) (42 U.S.C. 1395ww(d)(10)(D)) is amended by adding at
the end the following new clauses:
`(v) Any decision of the Board to reclassify a subsection (d) hospital for
purposes of the adjustment factor described in subparagraph (C)(i)(II) for
fiscal year 2001 or any fiscal year thereafter shall be effective for a period
of 3 fiscal years, except that the Secretary shall establish procedures under
which a subsection (d) hospital may elect to terminate such reclassification
before the end of such period.
`(vi) Such guidelines shall provide that, in making decisions on
applications for reclassification for the purposes described in clause (v) for
fiscal year 2003 and any succeeding fiscal year, the Board shall base any
comparison of the average hourly wage for the hospital with the average hourly
wage for hospitals in an area on--
`(I) an average of the average hourly wage amount for the hospital from
the most recently published hospital wage survey data of the Secretary (as
of the date on which the hospital applies for reclassification) and such
amount from each of the two immediately preceding surveys; and
`(II) an average of the average hourly wage amount for hospitals in such
area from the most recently published hospital wage survey data of the
Secretary (as of the date on which the hospital applies for
reclassification) and such amount from each of the two immediately preceding
surveys.'.
(b) PROCESS TO PERMIT STATEWIDE WAGE INDEX CALCULATION AND APPLICATION-
(1) IN GENERAL- The Secretary of Health and Human Services shall
establish a process (based on the voluntary process utilized by the
Secretary of Health and
Human Services under section 1848 of the Social Security Act (42 U.S.C.
1395w-4) for purposes of computing and applying a statewide geographic wage
index) under which an appropriate statewide entity may apply to have all the
geographic areas in a State treated as a single geographic area for purposes of
computing and applying the area wage index under section 1886(d)(3)(E) of such
Act (42 U.S.C. 1395ww(d)(3)(E)). Such process shall be established by October 1,
2001, for reclassifications beginning in fiscal year 2003.
(2) PROHIBITION ON INDIVIDUAL HOSPITAL RECLASSIFICATION- Notwithstanding
any other provision of law, if the Secretary applies a statewide geographic
wage index under paragraph (1) with respect to a State, any application
submitted by a hospital in that State under section 1886(d)(10) of the
Social Security Act (42 U.S.C. 1395ww(d)(10)) for geographic
reclassification shall not be considered.
(c) COLLECTION OF INFORMATION ON OCCUPATIONAL MIX-
(1) IN GENERAL- The Secretary of Health and Human Services shall provide
for the collection of data every 3 years on occupational mix for employees
of each subsection (d) hospital (as defined in section 1886(d)(1)(D) of the
Social Security Act (42 U.S.C. 1395ww(d)(1)(D))) in the provision of
inpatient hospital services, in order to construct an occupational mix
adjustment in the hospital area wage index applied under section
1886(d)(3)(E) of such Act (42 U.S.C. 1395ww(d)(3)(E)).
(2) APPLICATION- The third sentence of section 1886(d)(3)(E) (42 U.S.C.
1395ww(d)(3)(E)) is amended by striking `To the extent determined feasible
by the Secretary, such survey shall measure' and inserting `Not less often
than once every 3 years the Secretary (through such survey or otherwise)
shall measure'.
(3) EFFECTIVE DATE- By not later than September 30, 2003, for
application beginning October 1, 2004, the Secretary shall first
complete--
(A) the collection of data under paragraph (1); and
(B) the measurement under the third sentence of section 1886(d)(3)(E),
as amended by paragraph (2).
SEC. 305. PAYMENT FOR INPATIENT SERVICES OF REHABILITATION HOSPITALS.
(a) ASSISTANCE WITH ADMINISTRATIVE COSTS ASSOCIATED WITH COMPLETION OF
PATIENT ASSESSMENT- Section 1886(j)(3)(B) (42 U.S.C. 1395ww(j)(3)(B)) is
amended by striking `98 percent' and inserting `98 percent for fiscal year
2001 and 100 percent for fiscal year 2002'.
(b) ELECTION TO APPLY FULL PROSPECTIVE PAYMENT RATE WITHOUT PHASE-IN-
(1) IN GENERAL- Paragraph (1) of section 1886(j) (42 U.S.C. 1395ww(j))
is amended--
(A) in subparagraph (A), by inserting `other than a facility making an
election under subparagraph (F)' before `in a cost reporting
period';
(B) in subparagraph (B), by inserting `or, in the case of a facility
making an election under subparagraph (F), for any cost reporting period
described in such subparagraph,' after `2002,'; and
(C) by adding at the end the following new subparagraph:
`(F) ELECTION TO APPLY FULL PROSPECTIVE PAYMENT SYSTEM- A
rehabilitation facility may elect, not later than 30 days before its first
cost reporting period for which the payment methodology under this
subsection applies to the facility, to have payment made to the facility
under this subsection under the provisions of subparagraph (B) (rather
than subparagraph (A)) for each cost reporting period to which such
payment methodology applies.'.
(2) CLARIFICATION- Paragraph (3)(B) of such section is amended by
inserting `but not taking into account any payment adjustment resulting from
an election permitted under paragraph (1)(F)' after `paragraphs (4) and
(6)'.
(c) EFFECTIVE DATE- The amendments made by this section take effect as if
included in the enactment of BBA.
SEC. 306. PAYMENT FOR INPATIENT SERVICES OF PSYCHIATRIC HOSPITALS.
With respect to hospitals described in clause (i) of section 1886(d)(1)(B)
of the Social Security Act (42 U.S.C. 1395ww(d)(1)(B)) and psychiatric units
described in the matter following clause (v) of such section, in making
incentive payments to such hospitals under section 1886(b)(1)(A) of such Act
(42 U.S.C. 1395ww(b)(1)(A)) for cost reporting periods beginning on or after
October 1, 2000, and before October 1, 2001, the Secretary of Health and Human
Services, in clause (ii) of such section, shall substitute `3 percent' for `2
percent'.
SEC. 307. PAYMENT FOR INPATIENT SERVICES OF LONG-TERM CARE HOSPITALS.
(a) INCREASED TARGET AMOUNTS AND CAPS FOR LONG-TERM CARE HOSPITALS BEFORE
IMPLEMENTATION OF THE PROSPECTIVE PAYMENT SYSTEM-
(1) IN GENERAL- Section 1886(b)(3) (42 U.S.C. 1395ww(b)(3)) is
amended--
(A) in subparagraph (H)(ii)(III), by inserting `subject to
subparagraph (J),' after `2002,'; and
(B) by adding at the end the following new subparagraph:
`(J) For cost reporting periods beginning during fiscal year 2001, for a
hospital described in subsection (d)(1)(B)(iv)--
`(i) the limiting or cap amount otherwise determined under subparagraph
(H) shall be increased by 2 percent; and
`(ii) the target amount otherwise determined under subparagraph (A)
shall be increased by 25 percent (subject to the limiting or cap amount
determined under subparagraph (H), as increased by clause (i)).'.
(2) APPLICATION- The amendments made by subsection (a) and by section
122 of BBRA (113 Stat. 1501A-331) shall not be taken into account in the
development and implementation of the prospective payment system under
section 123 of BBRA (113 Stat. 1501A-331).
(b) IMPLEMENTATION OF PROSPECTIVE PAYMENT SYSTEM FOR LONG-TERM CARE
HOSPITALS-
(1) MODIFICATION OF REQUIREMENT- In developing the prospective payment
system for payment for inpatient hospital services provided in long-term
care hospitals described in section 1886(d)(1)(B)(iv) of the Social Security
Act (42 U.S.C. 1395ww(d)(1)(B)(iv)) under the medicare program under title
XVIII of such Act required under section 123 of BBRA, the Secretary of
Health and Human Services shall examine the feasibility and the impact of
basing payment under such a system on the use of existing (or refined)
hospital diagnosis-related groups (DRGs) that have been modified to account
for different resource use of long-term care hospital patients as well as
the use of the most recently available hospital discharge data. The
Secretary shall examine and may provide for appropriate adjustments to the
long-term hospital payment system, including adjustments to DRG weights,
area wage adjustments, geographic reclassification, outliers, updates, and a
disproportionate share adjustment consistent with section 1886(d)(5)(F) of
the Social Security Act (42 U.S.C. 1395ww(d)(5)(F)).
(2) DEFAULT IMPLEMENTATION OF SYSTEM BASED ON EXISTING DRG METHODOLOGY-
If the Secretary is unable to implement the prospective payment system under
section 123 of the BBRA by October 1, 2002, the Secretary shall implement a
prospective payment system for such hospitals that bases payment under such
a system using existing hospital diagnosis-related groups (DRGs), modified
where feasible to account for resource use of long-term care hospital
patients using the most recently available hospital discharge data for such
services furnished on or after that date.
SEC. 308. INCREASE IN BASE PAYMENT TO PUERTO RICO ACUTE CARE HOSPITALS.
(a) IN GENERAL- Section 1886(d)(9)(A) (42 U.S.C. 1395ww(d)(9)(A)) is
amended--
(1) in clause (i), by striking `on or after October 1, 1997, 50 percent
(' and inserting `on or after October 1, 2000, 25 percent (and for
discharges between October 1, 1997, and September 30, 2000, 50 percent';
and
(2) in clause (ii), in the matter preceding subclause (I), by striking
`on or after October 1, 1997, 50 percent (' and inserting `on or after
October 1, 2000, 75 percent (and for discharges between October 1, 1997, and
September 30, 2000, 50 percent'.
(b) SPECIAL RULE FOR PAYMENT FOR FISCAL YEAR 2001-
(1) IN GENERAL- Notwithstanding the amendment made by subsection (a),
for purposes of making payments for the operating costs of inpatient
hospital services of a Puerto Rico hospital for fiscal year 2001, the amount
referred to in the matter preceding clause (i) of section 1886(d)(9)(A) of
the Social Security Act (42 U.S.C. 1395ww(d)(9)(A))--
(A) for discharges occurring on or after October 1, 2000, and before
April 1, 2001, shall be determined in accordance with such section as in
effect on the day before the date of enactment of this Act; and
(B) for discharges occurring on or after April 1, 2001, and before
October 1, 2001, shall be determined--
(i) using 0 percent of the Puerto Rico adjusted DRG prospective
payment rate referred to in clause (i) of such section; and
(ii) using 100 percent of the discharge-weighted average referred to
in clause (ii) of such section.
(2) PUERTO RICO HOSPITAL- For purposes of this subsection, the term
`Puerto Rico hospital' means a subsection (d) Puerto Rico hospital as
defined in the last sentence of section 1886(d)(9)(A) of the Social Security
Act (42 U.S.C. 1395ww(d)(9)(A)).
Subtitle B--Adjustments to PPS Payments for Skilled Nursing
Facilities
SEC. 311. ELIMINATION OF REDUCTION IN SKILLED NURSING FACILITY (SNF) MARKET
BASKET UPDATE IN 2001.
(a) IN GENERAL- Section 1888(e)(4)(E)(ii) (42 U.S.C. 1395yy(e)(4)(E)(ii))
is amended--
(1) by redesignating subclauses (II) and (III) as subclauses (III) and
(IV), respectively;
(2) in subclause (III), as so redesignated--
(A) by striking `each of fiscal years 2001 and 2002' and inserting
`each of fiscal years 2002 and 2003'; and
(B) by striking `minus 1 percentage point' and inserting `minus 0.5
percentage points'; and
(3) by inserting after subclause (I) the following new subclause:
`(II) for fiscal year 2001, the rate computed for the previous
fiscal year increased by the skilled nursing facility market basket
percentage change for the fiscal year;'.
(b) SPECIAL RULE FOR PAYMENT FOR FISCAL YEAR 2001- Notwithstanding the
amendments made by subsection (a), for purposes of making payments for covered
skilled nursing facility services under section 1888(e) of the Social Security
Act (42 U.S.C. 1395yy(e)) for fiscal year 2001, the Federal per diem rate
referred to in paragraph (4)(E)(ii) of such section--
(1) for the period beginning on October 1, 2000, and ending on March 31,
2001, shall be the rate determined in
accordance with the law as in effect on the day before the date of the
enactment of this Act; and
(2) for the period beginning on April 1, 2001, and ending on September
30, 2001, shall be the rate that would have been determined under such
section if `plus 1 percentage point' had been substituted for `minus 1
percentage point' under subclause (II) of such paragraph (as in effect on
the day before the date of the enactment of this Act).
(c) RELATION TO TEMPORARY INCREASE IN BBRA- The increases provided under
section 101 of BBRA (113 Stat. 1501A-325) shall be in addition to any increase
resulting from the amendments made by subsection (a).
(d) GAO REPORT ON ADEQUACY OF SNF PAYMENT RATES- Not later than July 1,
2002, the Comptroller General of the United States shall submit to Congress a
report on the adequacy of medicare payment rates to skilled nursing facilities
and the extent to which medicare contributes to the financial viability of
such facilities. Such report shall take into account the role of private
payors, medicaid, and case mix on the financial performance of these
facilities, and shall include an analysis (by specific RUG classification) of
the number and characteristics of such facilities.
(e) HCFA STUDY OF CLASSIFICATION SYSTEMS FOR SNF RESIDENTS-
(1) STUDY- The Secretary of Health and Human Services shall conduct a
study of the different systems for categorizing patients in medicare skilled
nursing facilities in a manner that accounts for the relative resource
utilization of different patient types.
(2) REPORT- Not later than January 1, 2005, the Secretary shall submit
to Congress a report on the study conducted under subsection (a). Such
report shall include such recommendations regarding changes in law as may be
appropriate.
SEC. 312. INCREASE IN NURSING COMPONENT OF PPS FEDERAL RATE.
(a) IN GENERAL- The Secretary of Health and Human Services shall increase
by 16.66 percent the nursing component of the case-mix adjusted Federal
prospective payment rate specified in Tables 3 and 4 of the final rule
published in the Federal Register by the Health Care Financing Administration
on July 31, 2000 (65 Fed. Reg. 46770), effective for services furnished on or
after April 1, 2001, and before October 1, 2002.
(b) GAO AUDIT OF NURSING STAFF RATIOS-
(1) AUDIT- The Comptroller General of the United States shall conduct an
audit of nursing staffing ratios in a representative sample of medicare
skilled nursing facilities. Such sample shall cover selected States and
shall include broad representation with respect to size, ownership,
location, and medicare volume. Such audit shall include an examination of
payroll records and medicaid cost reports of individual facilities.
(2) REPORT- Not later than August 1, 2002, the Comptroller General shall
submit to Congress a report on the audits conducted under paragraph (1).
Such report shall include an assessment of the impact of the increased
payments under this subtitle on increased nursing staff ratios and shall
make recommendations as to whether increased payments under subsection (a)
should be continued.
SEC. 313. APPLICATION OF SNF CONSOLIDATED BILLING REQUIREMENT LIMITED TO
PART A COVERED STAYS.
(a) IN GENERAL- Section 1862(a)(18) (42 U.S.C. 1395y(a)(18)) is amended by
striking `or of a part of a facility that includes a skilled nursing facility
(as determined under regulations),' and inserting `during a period in which
the resident is provided covered post-hospital extended care services (or, for
services described in section 1861(s)(2)(D), which are furnished to such an
individual without regard to such period),'.
(b) CONFORMING AMENDMENTS- (1) Section 1842(b)(6)(E) (42 U.S.C.
1395u(b)(6)(E)) is amended--
(A) by inserting `by, or under arrangements made by, a skilled nursing
facility' after `furnished';
(B) by striking `or of a part of a facility that includes a skilled
nursing facility (as determined under regulations)'; and
(C) by striking `(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)'.
(2) Section 1842(t) (42 U.S.C. 1395u(t)) is amended by striking `by a
physician' and `or of a part of a facility that includes a skilled nursing
facility (as determined under regulations),'.
(3) Section 1866(a)(1)(H)(ii)(I) (42 U.S.C. 1395cc(a)(1)(H)(ii)(I)) is
amended by inserting after `who is a resident of the skilled nursing facility'
the following: `during a period in which the resident is provided covered
post-hospital extended care services (or, for services described in section
1861(s)(2)(D), that are furnished to such an individual without regard to such
period)'.
(c) EFFECTIVE DATE- The amendments made by subsections (a) and (b) apply
to services furnished on or after January 1, 2001.
(d) OVERSIGHT- The Secretary of Health and Human Services, through the
Office of the Inspector General in the Department of Health and Human Services
or otherwise, shall monitor payments made under part B of the title XVIII of
the Social Security Act for items and services furnished to residents of
skilled nursing facilities during a time in which the residents are not being
provided medicare covered post-hospital extended care services to ensure that
there is not duplicate billing for services or excessive services provided.
SEC. 314. ADJUSTMENT OF REHABILITATION RUGS TO CORRECT ANOMALY IN PAYMENT
RATES.
(a) Adjustment for Rehabilitation RUGs-
(1) IN GENERAL- For purposes of computing payments for covered skilled
nursing facility services under paragraph (1) of section 1888(e) of the
Social Security Act (42 U.S.C. 1395yy(e)) for such services furnished on or
after April 1, 2001, and before the date described in section 101(c)(2) of
BBRA (113 Stat. 1501A-324), the Secretary of Health and Human Services shall
increase by 6.7 percent the adjusted Federal per diem rate otherwise
determined under paragraph (4) of such section (but for this section) for
covered skilled nursing facility services for RUG-III rehabilitation groups
described in paragraph (2) furnished to an individual during the period in
which such individual is classified in such a RUG-III category.
(2) REHABILITATION GROUPS DESCRIBED- The RUG-III rehabilitation groups
for which the adjustment described in paragraph (1) applies are RUC, RUB,
RUA, RVC, RVB, RVA, RHC, RHB, RHA, RMC, RMB, RMA, RLB, and RLA, as specified
in Tables 3 and 4 of the final rule published in the Federal Register by the
Health Care Financing Administration on July 31, 2000 (65 Fed. Reg.
46770).
(b) CORRECTION WITH RESPECT TO REHABILITATION RUGS-
(1) IN GENERAL- Section 101(b) of BBRA (113 Stat. 1501A-324) is amended
by striking `CA1, RHC, RMC, and RMB' and inserting `and CA1'.
(2) EFFECTIVE DATE- The amendment made by paragraph (1) applies to
services furnished on or after April 1, 2001.
(c) REVIEW BY OFFICE OF INSPECTOR GENERAL- The Inspector General of the
Department of Health and Human Services shall review the medicare payment
structure for services classified within rehabilitation resource utilization
groups (RUGs) (as in effect after the date of the enactment of the BBRA) to
assess whether payment incentives exist for the delivery of inadequate care.
Not later than October 1, 2001, the Inspector General shall submit to Congress
a report on such review.
SEC. 315. ESTABLISHMENT OF PROCESS FOR GEOGRAPHIC RECLASSIFICATION.
(a) IN GENERAL- The Secretary of Health and Human Services may establish a
procedure for the geographic reclassification of a skilled nursing facility
for purposes of payment for covered skilled nursing facility services under
the prospective payment system established under section 1888(e) of the Social
Security Act (42 U.S.C. 1395yy(e)). Such procedure may be based upon the
method for geographic reclassifications for inpatient hospitals established
under section 1886(d)(10) of the Social Security Act (42 U.S.C.
1395ww(d)(10)).
(b) REQUIREMENT FOR SKILLED NURSING FACILITY WAGE DATA- In no case may the
Secretary implement the procedure under subsection (a) before such time as the
Secretary has collected data necessary to establish an area wage index for
skilled nursing facilities based on wage data from such facilities.
Subtitle C--Hospice Care
SEC. 321. FULL MARKET BASKET INCREASE FOR 2001 AND 2002.
(a) IN GENERAL- Section 1814(i)(1)(C)(ii) (42 U.S.C. 1395f(i)(1)(C)(ii))
is amended--
(1) by redesignating subclause (VII) as subclause (VIII);
(A) by striking `through 2002' and inserting `through 2000';
and
(B) by striking `and' at the end; and
(3) by inserting after subclause (VI) the following new subclause:
`(VII) for each of fiscal years 2001 and 2002, the market basket
percentage increase for the fiscal year; and'.
(b) TRANSITION DURING FISCAL YEAR 2001- Notwithstanding the amendments
made by subsection (a), for purposes of making payments for hospice care under
section 1814(i) of the Social Security Act (42 U.S.C. 1395f(i)) for fiscal
year 2001, the payment rates referred to in paragraph (1)(C) of such
section--
(1) for the period beginning on October 1, 2000, and ending on March 31,
2001, shall be the rate determined in accordance with the law as in effect
on the day before the date of the enactment of this Act; and
(2) for the period beginning on April 1, 2001, and ending on September
30, 2001, shall be the rate that would have been determined under paragraph
(1) if `plus 1.0 percentage points' were substituted for `minus 1.0
percentage points' under paragraph (1)(C)(ii)(VI) of such section for fiscal
year 2001.
(c) CONFORMING AMENDMENTS TO BBRA-
(1) IN GENERAL- Section 131 of BBRA (113 Stat. 1501A-333) is
repealed.
(2) EFFECTIVE DATE- The amendment made by paragraph (1) shall take
effect as if included in the enactment of BBRA.
(d) TECHNICAL AMENDMENT- Section 1814(a)(7)(A)(ii) (42 U.S.C.
1395f(a)(7)(A)(ii)) is amended by striking the period at the end and inserting
a semicolon.
SEC. 322. CLARIFICATION OF PHYSICIAN CERTIFICATION.
(a) CERTIFICATION BASED ON NORMAL COURSE OF ILLNESS-
(1) IN GENERAL- Section 1814(a) (42 U.S.C. 1395f(a)) is amended by
adding at the end the following new sentence: `The certification regarding
terminal illness of an individual under paragraph (7) shall be based on the
physician's or medical director's clinical judgment regarding the normal
course of the individual's illness.'.
(2) EFFECTIVE DATE- The amendment made by paragraph (1) applies to
certifications made on or after the date of the enactment of this Act.
(b) STUDY AND REPORT ON PHYSICIAN CERTIFICATION REQUIREMENT FOR HOSPICE
BENEFITS-
(1) STUDY- The Secretary of Health and Human Services shall conduct a
study to examine the appropriateness of the certification regarding terminal
illness of an individual under section 1814(a)(7) of the Social Security Act
(42 U.S.C. 1395f(a)(7)) that is required in order for such individual to
receive hospice benefits under the medicare program under title XVIII of
such Act. In conducting such study, the Secretary shall take into account
the effect of the amendment made by subsection (a).
(2) REPORT- Not later than 2 years after the date of the enactment of
this Act, the Secretary of Health and Human Services shall submit to
Congress a report on the study conducted under paragraph (1), together with
any recommendations for legislation that the Secretary deems
appropriate.
SEC. 323. MEDPAC REPORT ON ACCESS TO, AND USE OF, HOSPICE BENEFIT.
(a) IN GENERAL- The Medicare Payment Advisory Commission shall conduct a
study to examine the factors affecting the use of hospice benefits under the
medicare program under title XVIII of the Social Security Act, including a
delay in the time (relative to death) of entry into a hospice program, and
differences in such use between urban and rural hospice programs and based
upon the presenting condition of the patient.
(b) REPORT- Not later than 18 months after the date of the enactment of
this Act, the Commission shall submit to Congress a report on the study
conducted under subsection (a), together with any recommendations for
legislation that the Commission deems appropriate.
Subtitle D--Other Provisions
SEC. 331. RELIEF FROM MEDICARE PART A LATE ENROLLMENT PENALTY FOR GROUP
BUY-IN FOR STATE AND LOCAL RETIREES.
(a) IN GENERAL- Section 1818 (42 U.S.C. 1395i-2) is amended--
(1) in subsection (c)(6), by inserting before the semicolon at the end
the following: `and shall be subject to reduction in accordance with
subsection (d)(6)'; and
(2) by adding at the end of subsection (d) the following new
paragraph:
`(6)(A) In the case where a State, a political subdivision of a State, or
an agency or instrumentality of a State or political subdivision thereof
determines to pay, for the life of each individual, the monthly premiums due
under paragraph (1) on behalf of each of the individuals in a qualified State
or local government retiree group who meets the conditions of subsection (a),
the amount of any increase otherwise applicable under section 1839(b) (as
applied and modified by subsection (c)(6) of this section) with respect to the
monthly premium for benefits under this part for an individual who is a member
of such group shall be reduced by the total amount of taxes paid under section
3101(b) of the Internal Revenue Code of 1986 by such individual and under
section 3111(b) by the employers of such individual on behalf of such
individual with respect to employment (as defined in section 3121(b) of such
Code).
`(B) For purposes of this paragraph, the term `qualified State or local
government retiree group' means all of the individuals who retire prior to a
specified date that is before January 1, 2002, from employment in 1 or more
occupations or other broad classes of employees of--
`(ii) a political subdivision of the State; or
`(iii) an agency or instrumentality of the State or political
subdivision of the State.'.
(b) EFFECTIVE DATE- The amendments made by subsection (a) apply to
premiums for months beginning with July 1, 2001.
SEC. 332. 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.
TITLE IV--PROVISIONS RELATING TO PART B
Subtitle A--Hospital Outpatient Services
SEC. 401. REVISION OF HOSPITAL OUTPATIENT PPS PAYMENT UPDATE.
(a) IN GENERAL- Section 1833(t)(3)(C)(iii) (42 U.S.C. 1395l(t)(3)(C)(iii))
is amended by striking `in each of 2000, 2001, and 2002' and inserting `in
each of 2000 and 2002'.
(b) ADJUSTMENT FOR CASE MIX CHANGES-
(1) IN GENERAL- Section 1833(t)(3)(C) (42 U.S.C. 1395l(t)(3)(C)) is
amended--
(A) by redesignating clause (iii) as clause (iv); and
(B) by inserting after clause (ii) the following new clause:
`(iii) ADJUSTMENT FOR SERVICE MIX CHANGES- Insofar as the Secretary
determines that the adjustments for service mix under paragraph (2) for
a previous year (or estimates that such adjustments for a future year)
did (or are likely to) result in a change in aggregate payments under
this subsection during the year that are a result of changes in the
coding or classification of covered OPD services that do not reflect
real changes in service mix, the Secretary may adjust the conversion
factor computed under this subparagraph for subsequent years so as to
eliminate the effect of such coding or classification
changes.'.
(2) EFFECTIVE DATE- The amendments made by paragraph (1) shall take
effect as if included in the enactment of BBA.
SEC. 402. 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 new
subparagraphs:
`(B) USE OF CATEGORIES IN DETERMINING ELIGIBILITY OF A DEVICE FOR
PASS-THROUGH PAYMENTS- The following provisions apply for purposes of
determining whether a medical device qualifies for additional payments
under clause (ii) or (iv) of subparagraph (A):
`(i) ESTABLISHMENT OF INITIAL CATEGORIES- The Secretary shall
initially establish under this clause categories of medical devices
based on type of device by April 1, 2001. Such categories 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 January 1,
2001, is included in such a category and no such device is included in
more than one category. For purposes of the preceding sentence, whether
a medical device meets such requirements as of such date shall be
determined on the basis of the program memoranda issued before such date
or if the Secretary determines the medical device would have been
included in the program memoranda but for the requirement of
subparagraph (A)(iv)(I). The categories may be established under this
clause by program memorandum or otherwise, after consultation with
groups representing hospitals, manufacturers of medical devices, and
other affected parties.
`(ii) ESTABLISHING CRITERIA FOR ADDITIONAL CATEGORIES-
`(I) IN GENERAL- The Secretary shall establish criteria that will
be used for creation of additional categories (other than those
established under clause (i)) through rulemaking (which may include
use of an interim final rule with comment period).
`(II) STANDARD- Such categories shall be established under this
clause 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 and are
in use at the time the category is established is not insignificant,
as described in subparagraph (A)(iv)(II).
`(III) DEADLINE- Criteria shall first be established under this
clause by July 1, 2001. The Secretary may establish in compelling
circumstances categories under this clause before the date such
criteria are established.
`(IV) ADDING CATEGORIES- The Secretary shall promptly establish a
new category of medical devices 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) is appropriate.
`(iii) PERIOD FOR WHICH CATEGORY IS IN EFFECT- A category of medical
devices established under clause (i) or clause (ii) 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 clause (i), 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 April 1, 2001); and
`(II) in the case of any other category, on the first date on
which payment is made under this paragraph for any medical device that
is described by such category.
`(iv) 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 and in
effect under clause (i); or
`(II) the device is described by a category established and in
effect under clause (ii) and 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.
Nothing in this clause shall be construed as requiring an
application or prior approval (other than that described in subclause
(II)) in order for a covered device to qualify for payment under this
paragraph.
`(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- 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 and
in effect under subparagraph (B); 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 under such subparagraph.'.
(b) CONFORMING AMENDMENTS- Section 1833(t) (42 U.S.C. 1395l(t)) is further
amended--
(1) in paragraph (6)(A)(iv)(II), 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';
(2) 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)'; and
(3) 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))'.
(c) EFFECTIVE DATE- The amendments made by this section take effect on the
date of the enactment of this Act.
(1) IN GENERAL- In the case of a medical device provided as part of a
service (or group of services) furnished during the period before initial
categories are implemented under subparagraph (B)(i) of section 1833(t)(6)
of the Social Security Act (as amended by subsection (a)), payment shall be
made for such device under such section in accordance with the provisions in
effect before the date of the enactment of this Act, except that, beginning
on the date that is 30 days after the date of the enactment of this Act,
payment shall also be made for such a device that is not included in a
program memorandum described in such subparagraph if the Secretary of Health
and Human Services determines that the device is likely to be described by
such an initial category or would have been included in such program
memoranda but for the requirement of subparagraph (A)(iv)(I) of that
section.
(2) APPLICATION OF CURRENT PROCESS- Notwithstanding any other provision
of law, the Secretary shall continue to accept applications with respect to
medical devices under the process established pursuant to paragraph (6) of
section 1833(t) of the Social Security Act (as in effect on the day before
the date of the enactment of this Act) through December 1, 2000, and any
device--
(A) with respect to which an application was submitted (pursuant to
such process) on or before such date; and
(B) that meets the requirements of clause (ii) or (iv) of subparagraph
(A) of such paragraph (as determined pursuant to such process),
shall be treated as a device with respect to which an initial category
is required to be established under subparagraph (B)(i) of such paragraph
(as amended by subsection (a)(2)).
SEC. 403. APPLICATION OF OPD PPS TRANSITIONAL CORRIDOR PAYMENTS TO CERTAIN
HOSPITALS THAT DID NOT SUBMIT A 1996 COST REPORT.
(a) IN GENERAL- Section 1833(t)(7)(F)(ii)(I) (42 U.S.C.
1395l(t)(7)(F)(ii)(I)) is amended by inserting `(or in the case of a hospital
that did not submit a cost report for such period, during the first subsequent
cost reporting period ending before 2001 for which the hospital submitted a
cost report)' after `1996'.
(b) EFFECTIVE DATE- The amendment made by subsection (a) shall take effect
as if included in the enactment of BBRA.
SEC. 404. APPLICATION OF RULES FOR DETERMINING PROVIDER-BASED STATUS FOR
CERTAIN ENTITIES.
(a) GRANDFATHER- Notwithstanding any other provision of law, for purposes
of making determinations of provider-based status under title XVIII of the
Social Security Act on or after October 1, 2000, any facility or organization
that is treated as provider-based in relation to a hospital or critical access
hospital under such title as of October 1, 2000--
(1) shall continue to be treated as provider-based in relation to such
hospital or critical access hospital under such title during the 2-year
period beginning on October 1, 2000; and
(2) the requirements, limitations, and exclusions specified in
paragraphs (d), (e), (f), and (h) of section 413.65 of title 42, Code of
Federal Regulations shall not apply to such facility or organization in
relation to such hospital or critical access hospital until after the end of
such 2-year period.
(b) TEMPORARY CRITERIA- For purposes of title XVIII of the Social Security
Act--
(1) a facility or organization for which a determination of
provider-based status in relation to a hospital or critical access hospital
is requested on or after October 1, 2000, and before October 1, 2002, may
not be treated as not having provider-based status in relation to such a
hospital for any period before a determination is made with respect to such
status pursuant to such request; and
(2) in making a determination with respect to such status for any
facility or organization in relationship to such a hospital on or after
October 1, 2000, the following rules apply:
(A) The facility or organization shall be treated as satisfying any
requirements and standards for geographic location in relation to such a
hospital if the facility or organization--
(i) satisfies the requirements of section 413.65(d)(7) of title 42,
Code of Federal Regulations; or
(ii) is located not more than 35 miles from the main campus of the
hospital or critical access hospital.
(B) The facility or organization shall be treated as satisfying any of
the requirements and standards for geographic location in relation to such
a hospital if the facility or organization is owned and operated by a
hospital or critical access hospital that--
(i) is owned or operated by a unit of State or local government, is
a public or private nonprofit corporation that is formally granted
governmental powers by a unit of State or local government, or is a
private hospital that has a contract with a State or local government
that includes the operation of clinics located off the main campus of
the hospital to assure access in a well-defined service area to health
care services for low-income individuals who are not entitled to
benefits under title XVIII (or medical assistance under a State plan
under title XIX) of such Act; and
(ii) has a disproportionate share adjustment percentage (as
determined under section 1886(d)(5)(F) of such Act (42 U.S.C.
1395ww(d)(5)(F))) greater than 11.75 percent or is described in clause
(i)(II) of such section.
(c) DEFINITIONS- For purposes of this section, the terms `hospital' and
`critical access hospital' have the meanings given such terms in subsections
(e) and (mm)(1), respectively, of section 1861 of the Social Security Act (42
U.S.C. 1395x).
SEC. 405. TREATMENT OF CHILDREN'S HOSPITALS UNDER PROSPECTIVE PAYMENT
SYSTEM.
(a) IN GENERAL- Section 1833(t) (42 U.S.C. 1395l(t)) is amended--
(1) in the heading of paragraph (7)(D)(ii), by inserting `AND CHILDREN'S
HOSPITALS' after `CANCER HOSPITALS'; and
(2) in paragraphs (7)(D)(ii) and (11), by striking `section
1886(d)(1)(B)(v)' and inserting `clause (iii) or (v) of section
1886(d)(1)(B)'.
(b) EFFECTIVE DATE- The amendments made by subsection (a) apply as if
included in the enactment of section 202 of BBRA (113 Stat. 1501A-342).
SEC. 406. INCLUSION OF TEMPERATURE MONITORED CRYOABLATION IN TRANSITIONAL
PASS-THROUGH FOR CERTAIN MEDICAL DEVICES, DRUGS, AND BIOLOGICALS UNDER OPD
PPS.
(a) IN GENERAL- Section 1833(t)(6)(A)(ii) (42 U.S.C. 1395l(t)(6)(A)(ii))
is amended by inserting `or temperature monitored cryoablation' after `device
of brachytherapy'.
(b) EFFECTIVE DATE- The amendment made by subsection (a) applies to
devices furnished on or after April 1, 2001.
Subtitle B--Provisions Relating to Physicians' Services
SEC. 411. GAO STUDIES RELATING TO PHYSICIANS' SERVICES.
(a) STUDY OF SPECIALIST PHYSICIANS' SERVICES FURNISHED IN PHYSICIANS'
OFFICES AND HOSPITAL OUTPATIENT DEPARTMENT SERVICES-
(1) STUDY- The Comptroller General of the United States shall conduct a
study to examine the appropriateness of furnishing in physicians' offices
specialist physicians' services (such as gastrointestinal endoscopic
physicians' services) which are ordinarily furnished in hospital outpatient
departments. In conducting this study, the Comptroller General shall--
(A) review available scientific and clinical evidence about the safety
of performing procedures in physicians' offices and hospital outpatient
departments;
(B) 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 such specialist physicians' 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
(C) assess the implications for access to care for medicare
beneficiaries if the medicare program were not to cover such services in
physicians' offices.
(2) REPORT- Not later than July 1, 2001, the Comptroller General shall
submit to Congress a report on such study and include such recommendations
as the Comptroller General determines to be appropriate.
(b) STUDY OF THE RESOURCE-BASED PRACTICE EXPENSE SYSTEM-
(1) STUDY- The Comptroller General of the United States shall conduct a
study on the refinements to the practice expense relative value units during
the transition to a resource-based practice expense system for physician
payments under the medicare program under title XVIII of the Social Security
Act. Such study shall examine how the Secretary of Health and Human Services
has accepted and used the practice expense data submitted under section 212
of BBRA (113 Stat. 1501A-350).
(2) REPORT- Not later than July 1, 2001, the Comptroller General shall
submit to Congress a report on the study conducted under paragraph (1)
together with recommendations regarding--
(A) improvements in the process for acceptance and use of practice
expense data under section 212 of BBRA;
(B) any change or adjustment that is appropriate to ensure full access
to a spectrum of care for beneficiaries under the medicare program;
and
(C) the appropriateness of payments to physicians.
SEC. 412. PHYSICIAN GROUP PRACTICE DEMONSTRATION.
(a) IN GENERAL- 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.
Such projects shall focus on the efficiencies of furnishing health care
in a group-practice setting as compared to the efficiencies of furnishing
health care in other health care delivery systems.
`(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 requires, 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.
`(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 that market items or services under the program without
the Secretary's prior review and approval.
`(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 demonstration 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
demonstration 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 demonstration 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 demonstration 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 the
enactment of this section, and biennially thereafter for six years, the
Secretary shall report to 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.'.
(b) GAO REPORT- Not later than 2 years after the date on which the
demonstration project under section 1866A of the Social Security Act, as added
by subsection (a), is implemented, the Comptroller General of the United
States shall submit to Congress a report on such demonstration project. The
report shall include such recommendations with respect to changes to the
demonstration project that the Comptroller General determines appropriate.
SEC. 413. STUDY ON ENROLLMENT PROCEDURES FOR GROUPS THAT RETAIN INDEPENDENT
CONTRACTOR PHYSICIANS.
(a) IN GENERAL- The Comptroller General of the United States shall conduct
a study of the current medicare enrollment process for groups that retain
independent contractor physicians with particular emphasis on hospital-based
physicians, such as emergency department staffing groups. In conducting the
evaluation, the Comptroller General shall consult with groups that retain
independent contractor physicians and shall--
(1) review the issuance of individual medicare provider numbers and the
possible medicare program integrity vulnerabilities of the current
process;
(2) review direct and indirect costs associated with the current process
incurred by the medicare program and groups that retain independent
contractor physicians;
(3) assess the effect on program integrity by the enrollment of groups
that retain independent contractor hospital-based physicians; and
(4) 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 Comptroller General shall submit to Congress a report on the study
conducted under subsection (a).
Subtitle C--Other Services
SEC. 421. 1-YEAR EXTENSION OF MORATORIUM ON THERAPY CAPS; REPORT ON
STANDARDS FOR SUPERVISION OF PHYSICAL THERAPY ASSISTANTS.
(a) IN GENERAL- Section 1833(g)(4) (42 U.S.C. 1395l(g)(4)) is amended by
striking `2000 and 2001.' and inserting `2000, 2001, and 2002.'.
(b) CONFORMING AMENDMENT TO CONTINUE FOCUSED MEDICAL REVIEWS OF CLAIMS
DURING MORATORIUM PERIOD- Section 221(a)(2) of BBRA (113 Stat. 1501A-351) is
amended by striking `(under the amendment made by paragraph (1)(B))'.
(c) STUDY ON STANDARDS FOR SUPERVISION OF PHYSICAL THERAPIST
ASSISTANTS-
(1) STUDY- The Secretary of Health and Human Services shall conduct a
study of the implications--
(A) of eliminating the `in the room' supervision requirement for
medicare payment for services of physical therapy assistants who are
supervised by physical therapists; and
(B) of such requirement on the cap imposed under section 1833(g) of
the Social Security Act (42 U.S.C. 1395l(g)) on physical therapy
services.
(2) REPORT- Not later than 18 months after the date of the enactment of
this Act, the Secretary shall submit to Congress a report on the study
conducted under paragraph (1).
SEC. 422. UPDATE IN RENAL DIALYSIS COMPOSITE RATE.
(1) IN GENERAL- The last sentence of section 1881(b)(7) (42 U.S.C.
1395rr(b)(7)) is amended by striking `for such services furnished on or
after January 1, 2001, by 1.2 percent' and inserting `for such services
furnished on or after January 1, 2001, by 2.4 percent'.
(2) PROHIBITION ON EXEMPTIONS-
(A) IN GENERAL- Subject to subparagraph (B), the Secretary of Health
and Human Services may not provide for an exception under section
1881(b)(7) of the Social Security Act (42 U.S.C. 1395rr(b)(7)) on or after
December 31, 2000.
(B) SPECIAL RULES FOR 2000-
(i) IN GENERAL- Any exemption rate under such section 1881(b)(7) in
effect on December 31, 2000, shall continue in effect so long as such
rate is greater than the composite rate as updated by the amendment made
by paragraph (1).
(ii) RESUBMISSION OF CERTAIN APPLICATIONS- In the case of an
application for an exemption rate under such section that was filed by a
facility during 2000 that was not approved by the Secretary of Health
and Human Services, the facility may submit an application for an
exemption rate for that year by not later than July 1, 2001.
(b) DEVELOPMENT OF ESRD MARKET BASKET-
(1) DEVELOPMENT- The Secretary of Health and Human Services shall
collect data and develop an ESRD market basket whereby the Secretary can
estimate, before the beginning of a year, the percentage by which the costs
for the year of the mix of labor and nonlabor goods and services included in
the ESRD composite rate under section 1881(b)(7) of the Social Security Act
(42 U.S.C. 1395rr(b)(7)) will exceed the costs of such mix of goods and
services for the preceding year. In developing such index, the Secretary may
take into account measures of changes in--
(A) technology used in furnishing dialysis services;
(B) the manner or method of furnishing dialysis services; and
(C) the amounts by which the payments under such section for all
services billed by a facility for a year exceed the aggregate allowable
audited costs of such services for such facility for such year.
(2) REPORT- The Secretary of Health and Human Services shall submit to
Congress a report on the index developed under paragraph (1) no later than
July 1, 2002, and shall include in the report recommendations on the
appropriateness of an annual or periodic update mechanism for renal dialysis
services under the medicare program under title XVIII of the Social Security
Act based on such index.
(c) INCLUSION OF ADDITIONAL SERVICES IN COMPOSITE RATE-
(1) DEVELOPMENT- The Secretary of Health and Human Services shall
develop a system which includes, to the maximum extent feasible, in the
composite rate used for payment under section 1881(b)(7) of the Social
Security Act (42 U.S.C. 1395rr(b)(7)), payment for clinical diagnostic
laboratory tests and drugs (including drugs paid under section
1881(b)(11)(B) of such Act (42 U.S.C. 1395rr(b)(11)(B)) that are routinely
used in furnishing dialysis services to medicare beneficiaries but which are
currently separately billable by renal dialysis facilities.
(2) REPORT- The Secretary shall include, as part of the report submitted
under subsection (b)(2), a report on the system developed under paragraph
(1) and recommendations on the appropriateness of incorporating the system
into medicare payment for renal dialysis services.
(d) GAO STUDY ON ACCESS TO SERVICES-
(1) STUDY- The Comptroller General of the United States shall study
access of medicare beneficiaries to renal dialysis services. Such study
shall include whether there is a sufficient supply of facilities to furnish
needed renal dialysis services, whether medicare payment levels are
appropriate, taking into account audited costs of facilities for all
services furnished, to ensure continued access to such services, and
improvements in access (and quality of care) that may result in the
increased use of long nightly and short daily hemodialysis modalities.
(2) REPORT- Not later than January 1, 2003, the Comptroller General
shall submit to Congress a report on the study conducted under paragraph
(1).
SEC. 423. PAYMENT FOR AMBULANCE SERVICES.
(a) RESTORATION OF FULL CPI INCREASE FOR 2001- Section 1834(l)(3) (42
U.S.C. 1395m(l)(3)) is amended by striking `reduced in the case of 2001 and
2002' each place it appears and inserting `reduced in the case of 2002'.
(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, beginning on the date on which the Secretary implements such fee
schedule, such phase-in shall provide for full payment of any national mileage
rate for ambulance services provided by suppliers that are paid
by carriers in any of the 50 States where payment by a carrier for such
services for all such suppliers in such State did not, prior to the
implementation of the fee schedule, include a separate amount for all mileage
within the county from which the beneficiary is transported'.
(c) EFFECTIVE DATE- The amendment made by subsection (a) applies to
services furnished on or after the date on which the Secretary of Health and
Human Services implements the fee schedule under section 1834(l) of the Social
Security Act (42 U.S.C. 1395m(l)).
SEC. 424. 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 (113 Stat.
1501A-354) 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
(113 Stat. 1501A-354) 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. 425. FULL UPDATE FOR DURABLE MEDICAL EQUIPMENT.
(a) IN GENERAL- Section 1834(a)(14) (42 U.S.C. 1395m(a)(14)) is
amended--
(1) by redesignating subparagraph (D) as subparagraph (F);
(2) in subparagraph (C)--
(A) by striking `through 2002' and inserting `through 2000';
and
(B) by striking `and' at the end; and
(3) by inserting after subparagraph (C) the following new
subparagraphs:
`(D) for 2001, the percentage increase in the Consumer Price Index for
all urban consumers (U.S. city average) for the 12-month period ending
with June 2000;
`(E) for 2002, 0 percentage points; and'.
(b) CONFORMING AMENDMENTS TO BBRA- Subsection (a) of section 228 of BBRA
(113 Stat. 1501A-356) is amended--
(1) in the matter preceding paragraph (1), by striking `for such
items';
(2) in paragraph (1), by inserting `oxygen and oxygen equipment for'
after `(1)'; and
(3) in paragraph (2), by inserting `all such covered items for' after
`(2)'.
(c) EFFECTIVE DATE- The amendments made by subsection (b) shall take
effect as if included in the enactment of BBRA.
SEC. 426. FULL UPDATE FOR ORTHOTICS AND PROSTHETICS.
Section 1834(h)(4)(A) (42 U.S.C. 1395m(h)(4)(A)) is amended--
(1) by redesignating clause (vi) as clause (viii);
(A) by striking `through 2002' and inserting `through 2000';
and
(B) by striking `and' at the end; and
(3) by inserting after clause (v) the following new clause:
`(vi) for 2001, the percentage increase in the consumer price index
for all urban consumers (U.S. city average) for the 12-month period
ending with June 2000;
`(vii) for 2002, 1 percent; and'.
SEC. 427. ESTABLISHMENT OF SPECIAL PAYMENT PROVISIONS AND REQUIREMENTS FOR
PROSTHETICS AND CERTAIN CUSTOM FABRICATED ORTHOTIC ITEMS.
(a) IN GENERAL- Section 1834(h)(1) (42 U.S.C. 1395m(h)(1)) is amended by
adding at the end the following:
`(F) SPECIAL PAYMENT RULES FOR CERTAIN PROSTHETICS AND CUSTOM
FABRICATED ORTHOTICS-
`(i) IN GENERAL- No payment shall be made under this subsection for
an item of custom fabricated orthotics described in clause (ii) or for
an item of prosthetics unless such item is--
`(I) furnished by a qualified practitioner; and
`(II) fabricated by a qualified practitioner or a qualified
supplier at a facility that meets such criteria as the Secretary
determines appropriate.
`(ii) DESCRIPTION OF CUSTOM FABRICATED ITEM-
`(I) IN GENERAL- An item described in this clause is an item of
custom fabricated orthotics that requires education, training, and
experience to custom fabricate and that is included in a list
established by the Secretary in subclause (II). Such an item does not
include shoes and shoe inserts.
`(II) LIST OF ITEMS- The Secretary, in consultation with
appropriate experts in
orthotics (including national organizations representing manufacturers of
orthotics), shall establish and update as appropriate a list of items to which
this subparagraph applies. No item may be included in such list unless the item
is individually fabricated for the patient over a positive model of the patient.
`(iii) QUALIFIED PRACTITIONER DEFINED- In this subparagraph, the
term `qualified practitioner' means a physician or other individual
who--
`(I) is a qualified physical therapist or a qualified occupational
therapist;
`(II) in the case of a State that provides for the licensing of
orthotics and prosthetics, is licensed in orthotics or prosthetics by
the State in which the item is supplied; or
`(III) in the case of a State that does not provide for the
licensing of orthotics and prosthetics, is specifically trained and
educated to provide or manage the provision of prosthetics and
custom-designed or fabricated orthotics, and is certified by the
American Board for Certification in Orthotics and Prosthetics, Inc. or
by the Board for Orthotist/Prosthetist Certification, or is
credentialed and approved by a program that the Secretary determines,
in consultation with appropriate experts in orthotics and prosthetics,
has training and education standards that are necessary to provide
such prosthetics and orthotics.
`(iv) QUALIFIED SUPPLIER DEFINED- In this subparagraph, the term
`qualified supplier' means any entity that is accredited by the American
Board for Certification in Orthotics and Prosthetics, Inc. or by the
Board for Orthotist/Prosthetist Certification, or accredited and
approved by a program that the Secretary determines has accreditation
and approval standards that are essentially equivalent to those of such
Board.'.
(b) EFFECTIVE DATE- Not later than 1 year after the date of the enactment
of this Act, the Secretary of Health and Human Services shall promulgate
revised regulations to carry out the amendment made by subsection (a) using a
negotiated rulemaking process under subchapter III of chapter 5 of title 5,
United States Code.
(c) GAO STUDY AND REPORT-
(1) STUDY- The Comptroller General of the United States shall conduct a
study on HCFA Ruling 96-1, issued on September 1, 1996, with respect to
distinguishing orthotics from durable medical equipment under the medicare
program under title XVIII of the Social Security Act. The study shall assess
the following matters:
(A) The compliance of the Secretary of Health and Human Services with
the Administrative Procedures Act (under chapter 5 of title 5, United
States Code) in making such ruling.
(B) The potential impact of such ruling on the health care furnished
to medicare beneficiaries under the medicare program, especially those
beneficiaries with degenerative musculoskeletal conditions.
(C) The potential for fraud and abuse under the medicare program if
payment were provided for orthotics used as a component of durable medical
equipment only when made under the special payment provision for certain
prosthetics and custom fabricated orthotics under section 1834(h)(1)(F) of
the Social Security Act, as added by subsection (a) and furnished by
qualified practitioners under that section.
(D) The impact on payments under titles XVIII and XIX of the Social
Security Act if such ruling were overturned.
(2) REPORT- Not later than 6 months after the date of the enactment of
this Act, the Comptroller General shall submit to Congress a report on the
study conducted under paragraph (1).
SEC. 428. REPLACEMENT OF PROSTHETIC DEVICES AND PARTS.
(a) IN GENERAL- Section 1834(h)(1) (42 U.S.C. 1395m(h)(1)), as amended by
section 427(a), is further amended by adding at the end the following new
subparagraph:
`(G) REPLACEMENT OF PROSTHETIC DEVICES AND PARTS-
`(i) IN GENERAL- Payment shall be made for the replacement of
prosthetic devices which are artificial limbs, or for the replacement of
any part of such devices, without regard to continuous use or useful
lifetime restrictions if an ordering physician determines that the
provision of a replacement device, or a replacement part of such a
device, is necessary because of any of the following:
`(I) A change in the physiological condition of the
patient.
`(II) An irreparable change in the condition of the device, or in
a part of the device.
`(III) The condition of the device, or the part of the device,
requires repairs and the cost of such repairs would be more than 60
percent of the cost of a replacement device, or, as the case may be,
of the part being replaced.
`(ii) CONFIRMATION MAY BE REQUIRED IF REPLACEMENT DEVICE OR PART IS
LESS THAN 3 YEARS OLD- If a physician determines that a replacement
device, or a replacement part, is necessary pursuant to clause
(i)--
`(I) such determination shall be controlling; and
`(II) such replacement device or part shall be deemed to be
reasonable and necessary for purposes of section
1862(a)(1)(A);
except that if the device, or part, being replaced is less than 3 years old
(calculated from the date on which the beneficiary began to use the device or
part), the Secretary may also require confirmation of necessity of the
replacement device, or, as the case may be, the replacement part.'.
(b) PREEMPTION OF RULE- The provisions of section 1834(h)(1)(G) as added
by subsection (a) shall supersede any rule that as of the date of the
enactment of this Act may have applied a 5-year replacement rule with regard
to prosthetic devices.
(c) EFFECTIVE DATE- The amendment made by subsection (a) shall apply to
items replaced on or after April 1, 2001.
SEC. 429. REVISED PART B PAYMENT FOR DRUGS AND BIOLOGICALS AND RELATED
SERVICES.
(a) RECOMMENDATIONS FOR REVISED PAYMENT METHODOLOGY FOR DRUGS AND
BIOLOGICALS-
(A) IN GENERAL- The Comptroller General of the United States shall
conduct a study on the reimbursement for drugs and biologicals under the
current medicare payment methodology (provided under section 1842(o) of
the Social Security Act (42 U.S.C. 1395u(o)) and for related services
under part B of title XVIII of such Act. In the study, the Comptroller
General shall--
(i) identify the average prices at which such drugs and biologicals
are acquired by physicians and other suppliers;
(ii) quantify the difference between such average prices and the
reimbursement amount under such section; and
(iii) determine the extent to which (if any) payment under such part
is adequate to compensate physicians, providers of services, or other
suppliers of such drugs and biologicals for costs incurred in the
administration, handling, or storage of such drugs or
biologicals.
(B) CONSULTATION- In conducting the study under subparagraph (A), the
Comptroller General shall consult with physicians, providers of services,
and suppliers of drugs and biologicals under the medicare program under
title XVIII of such Act, as well as other organizations involved in the
distribution of such drugs and biologicals to such physicians, providers
of services, and suppliers.
(2) REPORT- Not later than 9 months after the date of the enactment of
this Act, the Comptroller General shall submit to Congress and to the
Secretary of Health and Human Services a report on the study conducted under
this subsection, and shall include in such report recommendations for
revised payment methodologies described in paragraph (3).
(3) RECOMMENDATIONS FOR REVISED PAYMENT METHODOLOGIES-
(A) IN GENERAL- The Comptroller General shall provide specific
recommendations for revised payment methodologies for reimbursement for
drugs and biologicals and for related services under the medicare program.
The Comptroller General may include in the recommendations--
(i) proposals to make adjustments under subsection (c) of section
1848 of the Social Security Act (42 U.S.C. 1395w-4) for the practice
expense component of the physician fee schedule under such section for
the costs incurred in the administration, handling, or storage of
certain categories of such drugs and biologicals, if appropriate;
and
(ii) proposals for new payments to providers of services or
suppliers for such costs, if appropriate.
(B) ENSURING PATIENT ACCESS TO CARE- In making recommendations under
this paragraph, the Comptroller General shall ensure that any proposed
revised payment methodology is designed to ensure that medicare
beneficiaries continue to have appropriate access to health care services
under the medicare program.
(C) MATTERS CONSIDERED- In making recommendations under this
paragraph, the Comptroller General shall consider--
(i) the method and amount of reimbursement for similar drugs and
biologicals made by large group health plans;
(ii) as a result of any revised payment methodology, the potential
for patients to receive inpatient or outpatient hospital services in
lieu of services in a physician's office; and
(iii) the effect of any revised payment methodology on the delivery
of drug therapies by hospital outpatient departments.
(D) COORDINATION WITH BBRA STUDY- In making recommendations under this
paragraph, the Comptroller General shall conclude and take into account
the results of the study provided for under section 213(a) of BBRA (113
Stat. 1501A-350).
(b) IMPLEMENTATION OF NEW PAYMENT METHODOLOGY-
(1) IN GENERAL- Notwithstanding any other provision of law, based on the
recommendations contained in the report under subsection (a), the Secretary
of Health and Human Services, subject to paragraph (2), shall revise the
payment methodology under section 1842(o) of the Social Security Act (42
U.S.C. 1395u(o)) for drugs and biologicals furnished under part B of the
medicare program. To the extent the Secretary determines appropriate, the
Secretary may provide for the adjustments to payments amounts referred to in
subsection (a)(3)(A)(i) or additional payments referred to in subsection
(a)(2)(A)(ii).
(2) LIMITATION- In revising the payment methodology under paragraph (1),
in no case may the estimated
aggregate payments for drugs and biologicals under the revised system
(including additional payments referred to in subsection (a)(3)(A)(ii)) exceed
the aggregate amount of payment for such drugs and biologicals, as projected by
the Secretary, that would have been made under the payment methodology in effect
under such section 1842(o).
(c) TEMPORARY INJUNCTION AGAINST REDUCTIONS IN PAYMENT RATES-
Notwithstanding any other provision of law, the Administrator of the Health
Care Financing Administration may not directly or indirectly increase or
decrease the rates of reimbursement (in effect on October 1, 2000) for drugs
and biologicals under the current medicare payment methodology (provided under
section 1842(o) of such Act (42 U.S.C. 1395u(o)) until such time as the
Secretary has reviewed the report submitted under subsection (a)(2).
SEC. 430. 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 apply to items and
services furnished on or after January 1, 2001.
SEC. 431. QUALIFICATIONS FOR COMMUNITY MENTAL HEALTH CENTERS.
(a) MEDICARE PROGRAM- Section 1861(ff)(3)(B) (42 U.S.C. 1395x(ff)(3)(B))
is amended by striking `entity' and all that follows and inserting the
following: `entity that--
`(i)(I) provides the mental health services described in section
1913(c)(1) of the Public Health Service Act; or
`(II) in the case of an entity operating in a State that by law
precludes the entity from providing itself the service described in
subparagraph (E) of such section, provides for such service by contract with
an approved organization or entity (as determined by the Secretary);
`(ii) meets applicable licensing or certification requirements for
community mental health centers in the State in which it is located;
and
`(iii) meets such additional conditions as the Secretary shall specify
to ensure (I) the health and safety of individuals being furnished such
services, (II) the effective and efficient furnishing of such services, and
(III) the compliance of such entity with the criteria described in section
1931(c)(1) of the Public Health Service Act.'.
(b) EFFECTIVE DATE- The amendment made by subsection (a) applies with
respect to community mental health centers with respect to services furnished
on or after the first day of the third month beginning after the date of the
enactment of this Act.
SEC. 432. MODIFICATION OF MEDICARE BILLING REQUIREMENTS FOR CERTAIN INDIAN
PROVIDERS.
(a) IN GENERAL- Section 1880(a) (42 U.S.C. 1395qq(a)) is amended by adding
at the end the following new sentence: `A hospital or a free-standing
ambulatory care clinic (as defined by the Secretary), whether operated by the
Indian Health Service or by an Indian tribe or tribal organization (as those
terms are defined in section 4 of the Indian Health Care Improvement Act),
shall be eligible for payments for services for which payment is made pursuant
to section 1848, notwithstanding sections 1814(c) and 1835(d), if and for so
long as it meets all of the requirements which are applicable generally to
such payments, services, hospitals, and clinics.'.
(b) EFFECTIVE DATE- The amendment made by this section shall apply to
services furnished on or after January 1, 2001.
SEC. 433. GAO STUDY ON COVERAGE OF SURGICAL FIRST ASSISTING SERVICES OF
CERTIFIED REGISTERED NURSE FIRST ASSISTANTS.
(a) STUDY- The Comptroller General of the United States shall conduct a
study on the effect on the medicare program under title XVIII of the Social
Security Act and on medicare beneficiaries of coverage under the program of
surgical first assisting services of certified registered nurse first
assistants. The Comptroller General shall consider the following when
conducting the study:
(1) Any impact on the quality of care furnished to medicare
beneficiaries by reason of such coverage.
(2) Appropriate education and training requirements for certified
registered nurse first assistants who furnish such first assisting
services.
(3) Appropriate rates of payment under the program to such certified
registered nurse first assistants for furnishing such services, taking into
account the costs of compensation, overhead, and supervision attributable to
certified registered nurse first assistants.
(b) REPORT- Not later than 1 year after the date of the enactment of this
Act, the Comptroller General shall submit to Congress a report on the study
conducted under subsection (a).
SEC. 434. MEDPAC STUDY AND REPORT ON MEDICARE REIMBURSEMENT FOR SERVICES
PROVIDED BY CERTAIN PROVIDERS.
(a) STUDY- The Medicare Payment Advisory Commission shall conduct a study
on the appropriateness of the current payment rates under the medicare program
under title XVIII of the Social Security Act for services provided by a--
(1) certified nurse-midwife (as defined in subsection (gg)(2) of section
1861 of such Act (42 U.S.C. 1395x);
(2) physician assistant (as defined in subsection (aa)(5)(A) of such
section);
(3) nurse practitioner (as defined in such subsection); and
(4) clinical nurse specialist (as defined in subsection (aa)(5)(B) of
such section).
(b) REPORT- Not later than 18 months after the date of the enactment of
this Act, the Commission shall submit to Congress a report on the study
conducted under subsection (a), together with any recommendations for
legislation that the Commission determines to be appropriate as a result of
such study.
SEC. 435. MEDPAC STUDY AND REPORT ON MEDICARE COVERAGE OF SERVICES PROVIDED
BY CERTAIN NONPHYSICIAN PROVIDERS.
(1) IN GENERAL- The Medicare Payment Advisory Commission shall conduct a
study to determine the appropriateness of providing coverage under the
medicare program under title XVIII of the Social Security Act for services
provided by a--
(A) surgical technologist;
(C) marriage and family therapist;
(D) pastoral care counselor; and
(E) licensed professional counselor of mental health.
(2) COSTS TO PROGRAM- The study shall consider the short-term and
long-term benefits, and costs to the medicare program, of providing the
coverage described in paragraph (1).
(b) REPORT- Not later than 18 months after the date of the enactment of
this Act, the Commission shall submit to Congress a report on the study
conducted under subsection (a), together with any recommendations for
legislation that the Commission determines to be appropriate as a result of
such study.
SEC. 436. GAO STUDY AND REPORT ON THE COSTS OF EMERGENCY AND MEDICAL
TRANSPORTATION SERVICES.
(a) STUDY- The Comptroller General of the United States shall conduct a
study on the costs of providing emergency and medical transportation services
across the range of acuity levels of conditions for which such transportation
services are provided.
(b) REPORT- Not later than 18 months after the date of the enactment of
this Act, the Comptroller General shall submit to Congress a report on the
study conducted under subsection (a), together with recommendations for any
changes in methodology or payment level necessary to fairly compensate
suppliers of emergency and medical transportation services and to ensure the
access of beneficiaries under the medicare program under title XVIII of the
Social Security Act.
SEC. 437. GAO STUDIES AND REPORTS ON MEDICARE PAYMENTS.
(a) GAO STUDY ON HCFA POST-PAYMENT AUDIT PROCESS-
(1) STUDY- The Comptroller General of the United States shall conduct a
study on the post-payment audit process under the medicare program under
title XVIII of the Social Security Act as such process applies to
physicians, including the proper level of resources that the Health Care
Financing Administration should devote to educating physicians
regarding--
(B) documentation requirements; and
(C) the calculation of overpayments.
(2) REPORT- Not later than 18 months after the date of the enactment of
this Act, the Comptroller General shall submit to Congress a report on the
study conducted under paragraph (1) together with specific recommendations
for changes or improvements in the post-payment audit process described in
such paragraph.
(b) GAO STUDY ON ADMINISTRATION AND OVERSIGHT-
(1) STUDY- The Comptroller General of the United States shall conduct a
study on the aggregate effects of regulatory, audit, oversight, and
paperwork burdens on physicians and other health care providers
participating in the medicare program under title XVIII of the Social
Security Act.
(2) REPORT- Not later than 18 months after the date of the enactment of
this Act, the Comptroller General shall submit to Congress a report on the
study conducted under paragraph (1) together with recommendations regarding
any area in which--
(A) a reduction in paperwork, an ease of administration, or an
appropriate change in oversight and review may be accomplished;
or
(B) additional payments or education are needed to assist physicians
and other health care providers in understanding and complying with any
legal or regulatory requirements.
SEC. 438. MEDPAC STUDY ON ACCESS TO OUTPATIENT PAIN MANAGEMENT
SERVICES.
(a) STUDY- The Medicare Payment Advisory Commission shall conduct a study
on the barriers to coverage and payment for outpatient interventional pain
medicine procedures under the medicare program under title XVIII of the Social
Security Act. Such study shall examine--
(1) the specific barriers imposed under the medicare program on the
provision of pain management procedures in hospital outpatient departments,
ambulatory surgery centers, and physicians' offices; and
(2) the consistency of medicare payment policies for pain management
procedures in those different settings.
(b) REPORT- Not later than 1 year after the date of the enactment of this
Act, the Commission shall submit to Congress a report on the study.
TITLE V--PROVISIONS RELATING TO PARTS A AND B
Subtitle A--Home Health Services
SEC. 501. 2-YEAR ADDITIONAL DELAY IN APPLICATION OF 15 PERCENT REDUCTION ON
PAYMENT LIMITS FOR HOME HEALTH SERVICES.
(a) IN GENERAL- Section 1895(b)(3)(A)(i) (42 U.S.C. 1395fff(b)(3)(A)(i))
is amended--
(1) by redesignating subclause (II) as subclause (III);
(2) in subclause (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 each of the two 12-month periods 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) CHANGE IN REPORT- Section 302(c) of BBRA (113 Stat. 1501A-360) is
amended--
(1) by striking `Not later than' and all that follows through `(42
U.S.C. 1395fff)' and inserting `Not later than April 1, 2002'; and
(2) by striking `Secretary' and inserting `Comptroller General of the
United States'.
(c) CASE MIX ADJUSTMENT CORRECTIONS-
(1) IN GENERAL- Section 1895(b)(3)(B) (42 U.S.C. 1395fff(b)(3)(B)) is
amended by adding at the end the following new clause:
`(iv) ADJUSTMENT FOR CASE MIX CHANGES- Insofar as the Secretary
determines that the adjustments under paragraph (4)(A)(i) for a previous
fiscal year (or estimates that such adjustments for a future fiscal
year) did (or are likely to) result in a change in aggregate payments
under this subsection during the fiscal year that are a result of
changes in the coding or classification of different units of services
that do not reflect real changes in case mix, the Secretary may adjust
the standard prospective payment amount (or amounts) under paragraph (3)
for subsequent fiscal years so as to eliminate the effect of such coding
or classification changes.'.
(2) EFFECTIVE DATE- The amendment made by paragraph (1) applies to
episodes concluding on or after October 1, 2001.
SEC. 502. RESTORATION OF FULL HOME HEALTH MARKET BASKET UPDATE FOR HOME
HEALTH SERVICES FOR FISCAL YEAR 2001.
(a) IN GENERAL- Section 1861(v)(1)(L)(x) (42 U.S.C. 1395x(v)(1)(L)(x)) is
amended--
(1) by striking `2001,'; and
(2) by adding at the end the following: `With respect to cost reporting
periods beginning during fiscal year 2001, the update to any limit under
this subparagraph shall be the home health market basket index.'.
(b) SPECIAL RULE FOR PAYMENT FOR FISCAL YEAR 2001 BASED ON ADJUSTED
PROSPECTIVE PAYMENT AMOUNTS-
(1) IN GENERAL- Notwithstanding the amendments made by subsection (a),
for purposes of making payments under section 1895(b) of the Social Security
Act (42 U.S.C. 1395fff(b)) for home health services for fiscal year 2001,
the Secretary of Health and Human Services shall--
(A) with respect to episodes and visits ending on or after October 1,
2000, and before April 1, 2001, use the final standardized and budget
neutral prospective payment amounts for 60 day episodes and standardized
average per visit amounts for fiscal year 2001 as published by the
Secretary in the Federal Register of July 3, 2000 (65 Federal Register
41128-41214); and
(B) with respect to episodes and visits ending on or after April 1,
2001, and before October 1, 2001, use such amounts increased by 2.2
percent.
(2) NO EFFECT ON OTHER PAYMENTS OR DETERMINATIONS- The Secretary shall
not take the provisions of paragraph (1) into account for purposes of
payments, determinations, or budget neutrality adjustments under section
1895 of the Social Security Act.
SEC. 503. TEMPORARY TWO-MONTH EXTENSION OF PERIODIC INTERIM PAYMENTS.
(a) TEMPORARY EXTENSION- Notwithstanding subsection (d) of section 4603 of
BBA (42 U.S.C. 1395fff note), as amended by section 5101(c)(2) of the Tax and
Trade Relief Extension Act of 1998 (contained in division J of Public Law
105-277), the amendments made by subsection (b) of such section 4603 shall not
take effect until December 1, 2000, in the case of a home health agency that
was receiving periodic interim payments under section 1815(e)(2) as of
September 30, 2000.
(b) PAYMENT RULE- The amount of such periodic interim payment made to a
home health agency by reason of subsection (a) during each of November and
December, 2000, shall be equal to the amount of such payment made to the
agency in their last full monthly periodic interim payment. Such amount of
payment shall be included in the tentative settlement of the last cost report
for the home health agency under the payment system in effect prior to the
implementation of the prospective payment system under section 1895(b) of the
Social Security Act (42 U.S.C. 1395fff(b)).
SEC. 504. USE OF TELEHEALTH IN DELIVERY OF HOME HEALTH SERVICES.
Section 1895 (42 U.S.C. 1395fff) is amended by adding at the end the
following new subsection:
`(e) CONSTRUCTION RELATED TO HOME HEALTH SERVICES-
`(1) TELECOMMUNICATIONS- Nothing in this section 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 by
this section for such units of service from furnishing services via a
telecommunication system if such services--
`(A) do not substitute for in-person home health services ordered as
part of a plan of care certified by a physician pursuant to section
1814(a)(2)(C) or section 1835(a)(2)(A); and
`(B) are not considered a home health visit for purposes of
eligibility or payment under this title.
`(2) PHYSICIAN CERTIFICATION- 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.'.
SEC. 505. STUDY ON COSTS TO HOME HEALTH AGENCIES OF PURCHASING NONROUTINE
MEDICAL SUPPLIES.
(a) STUDY- The Comptroller General of the United States shall conduct a
study on variations in prices paid by home health agencies furnishing home
health services under the medicare program under title XVIII of the Social
Security Act in purchasing nonroutine medical supplies, including ostomy
supplies, and volumes if such supplies used, shall determine the effect (if
any) of variations on prices and volumes in the provision of such services.
(b) REPORT- Not later than October 1, 2001, the Comptroller General shall
submit to Congress a report on the study conducted under subsection (a), and
shall include in the report recommendations respecting whether payment for
nonroutine medical supplies furnished in connection with home health services
should be made separately from the prospective payment system for such
services.
SEC. 506. TREATMENT OF BRANCH OFFICES; GAO STUDY ON SUPERVISION OF HOME
HEALTH CARE PROVIDED IN ISOLATED RURAL AREAS.
(a) 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 may include forms of technology
in determining what constitutes `supervision' for purposes of determining a
home health agency's branch office status under paragraph (1).
(1) STUDY- The Comptroller General of the United States shall conduct a
study of the provision of adequate supervision to maintain quality of home
health services delivered under the medicare program under title XVIII of
the Social Security Act in isolated rural areas. The study shall evaluate
the methods that home health agency branches and subunits use to maintain
adequate supervision in the delivery of services to clients residing in
those areas, how these methods of supervision compare to requirements that
subunits independently meet medicare conditions of participation, and the
resources utilized by subunits to meet such conditions.
(2) REPORT- Not later than January 1, 2002, the Comptroller General
shall submit to Congress a report on the study conducted under paragraph
(1). The report shall include recommendations on whether exceptions are
needed for subunits and branches of home health agencies under the medicare
program to maintain access to the home health benefit or whether alternative
policies should be developed to assure adequate supervision and access and
recommendations on whether a national standard for supervision is
appropriate.
SEC. 507. CLARIFICATION OF THE HOMEBOUND DEFINITION UNDER THE MEDICARE HOME
HEALTH BENEFIT.
(1) IN GENERAL- Sections 1814(a) and 1835(a) (42 U.S.C. 1395f(a) and
1395n(a)) are each amended--
(A) in the last sentence, by striking `, 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'; and
(B) by adding at the end the following new sentences: `Any absence of
an individual from the home attributable to the need to receive health
care treatment, including regular absences for the purpose of
participating in therapeutic, psychosocial, or medical treatment in an
adult day-care program that is licensed or certified by a State, or
accredited, to furnish adult day-care services in the State shall not
disqualify an individual from being considered to be `confined to his
home'. Any other absence of an individual from the home shall not so
disqualify an individual if the absence is of infrequent or of relatively
short duration. For purposes of the preceding sentence, any absence for
the purpose of attending a religious service shall be deemed to be an
absence of infrequent or short duration.'.
(2) EFFECTIVE DATE- The amendments made by paragraph (1) shall apply to
items and services provided on or after the date of enactment of this
Act.
(1) IN GENERAL- The Comptroller General of the United States shall
conduct an evaluation of the effect of the amendment on the cost of and
access to home health services under the medicare program under title XVIII
of the Social Security Act.
(2) REPORT- Not later than 1 year after the date of the enactment of
this Act, the Comptroller General shall submit to Congress a report on the
study conducted under paragraph (1).
SEC. 508. BONUS PAYMENTS FOR RURAL HOME HEALTH AGENCIES IN 2001 AND
2002.
(a) INCREASE IN PAYMENT RATES FOR RURAL AGENCIES IN 2001 AND 2002- Section
1895(b) (42 U.S.C. 1395fff(b)) is amended by adding at the end the following
new paragraph:
`(7) ADDITIONAL PAYMENT AMOUNT FOR SERVICES FURNISHED IN RURAL AREAS IN
2001 AND 2002- In the case of home health services furnished in a rural area
(as defined in section 1886(d)(2)(D)) during April 1, 2001 through December
31, 2001, or 2002, the Secretary shall provide for an addition or adjustment
to the payment amount otherwise made under this section for services
furnished in a rural area in an amount equal to 10 percent of the amount
otherwise determined under this subsection.'.
(b) WAIVING BUDGET NEUTRALITY- Section 1895(b)(3) (42 U.S.C.
1395fff(b)(3)) is amended by adding at the end the following new
subparagraph:
`(D) NO ADJUSTMENT FOR ADDITIONAL PAYMENTS FOR RURAL SERVICES- The
Secretary shall not reduce the standard prospective payment amount (or
amounts) under this paragraph applicable to home health services furnished
during a period to offset the increase in payments resulting from the
application of paragraph (7) (relating to services furnished in rural
areas).'.
Subtitle B--Direct Graduate Medical Education
SEC. 511. INCREASE IN FLOOR FOR DIRECT GRADUATE MEDICAL EDUCATION
PAYMENTS.
Section 1886(h)(2)(D)(iii) (42 U.S.C. 1395ww(h)(2)(D)(iii)) is
amended--
(1) in the heading, by striking `IN FISCAL YEAR 2001 AT 70 PERCENT OF'
and inserting `FOR'; and
(2) by inserting after `70 percent' the following: `, and for the cost
reporting period beginning during fiscal year 2002 shall not be less than 85
percent,'.
SEC. 512. CHANGE IN DISTRIBUTION FORMULA FOR MEDICARE+CHOICE-RELATED NURSING
AND ALLIED HEALTH EDUCATION COSTS.
(a) IN GENERAL- Section 1886(l)(2)(C) (42 U.S.C. 1395ww(l)(2)(C)) is
amended by striking all that follows `multiplied by' and inserting the
following: `the ratio of--
`(i) the product of (I) the Secretary's estimate of the ratio of the
amount of payments made under section 1861(v) to the hospital for
nursing and allied health education activities for the hospital's cost
reporting period ending in the second preceding fiscal year, to the
hospital's total inpatient days for such period, and (II) the total
number of inpatient days (as established by the Secretary) for such
period which are attributable to services furnished to individuals who
are enrolled under a risk sharing contract with an eligible organization
under section 1876 and who are entitled to benefits under part A or who
are enrolled with a Medicare+Choice organization under part C;
to
`(ii) the sum of the products determined under clause (i) for such
cost reporting periods.'.
(b) EFFECTIVE DATE- The amendment made by subsection (a) applies to
portions of cost reporting periods occurring on or after January 1, 2001.
Subtitle C--Changes in Medicare Coverage and Appeals
Process
SEC. 521. REVISIONS TO MEDICARE APPEALS PROCESS.
(a) CONDUCT OF RECONSIDERATIONS OF DETERMINATIONS BY INDEPENDENT
CONTRACTORS- Section 1869 (42 U.S.C. 1395ff) is amended to read as follows:
`DETERMINATIONS; APPEALS
`SEC. 1869. (a) INITIAL DETERMINATIONS-
`(1) PROMULGATIONS OF REGULATIONS- The Secretary shall promulgate
regulations and make initial determinations with respect to benefits under
part A or part B in accordance with those regulations for the
following:
`(A) The initial determination of whether an individual is entitled to
benefits under such parts.
`(B) The initial determination of the amount of benefits available to
the individual under such parts.
`(C) Any other initial determination with respect to a claim for
benefits under such parts, including an initial determination by the
Secretary that payment may not be made, or may no longer be made, for an
item or service under such parts, an initial determination made by a
utilization and quality control peer review organization under section
1154(a)(2), and an initial determination made by an entity pursuant to a
contract (other than a contract under section 1852) with the Secretary to
administer provisions of this title or title XI.
`(2) DEADLINES FOR MAKING INITIAL DETERMINATIONS-
`(A) IN GENERAL- Subject to subparagraph (B), in promulgating
regulations under paragraph (1), initial determinations shall be concluded
by not later than the 45-day period beginning on the date the fiscal
intermediary or the carrier, as the case may be, receives a claim for
benefits from an individual as described in paragraph (1). Notice of such
determination shall be mailed to the individual filing the claim before
the conclusion of such 45-day period.
`(B) CLEAN CLAIMS- Subparagraph (A) shall not apply with respect to
any claim that does not meet the requirements of section 1816(c)(2) or
section 1842(c)(2).
`(A) IN GENERAL- In promulgating regulations under paragraph (1) with
respect to initial determinations, such regulations shall provide for a
fiscal intermediary or a carrier to make a redetermination with respect to
a claim for benefits that is denied in whole or in part.
`(i) APPEALS RIGHTS- No initial determination may be reconsidered or
appealed under subsection (b) unless the fiscal intermediary or carrier
has made a redetermination of that initial determination under this
paragraph.
`(ii) DECISION MAKER- No redetermination may be made by any
individual involved in the initial determination.
`(i) FILING FOR REDETERMINATION- A redetermination under
subparagraph (A) shall be available only if notice is filed with the
Secretary to request the redetermination by not later than the end of
the 120-day period beginning on the date the individual receives notice
of the initial determination under paragraph (2).
`(ii) CONCLUDING REDETERMINATIONS- Except as provided in subsections
(d) through (f), redeterminations shall be made in accordance with the
medical needs of the individual, but no later than 30 days after the
fiscal intermediary or the carrier, as the case may be, receives a
request for a redetermination. Notice of such determination
shall be mailed to the individual filing the claim before the conclusion of
such 30-day period.
`(D) CONSTRUCTION- For purposes of the succeeding provisions of this
section a redetermination under this paragraph shall be considered to be
part of the initial determination.
`(A) RECONSIDERATION OF INITIAL DETERMINATION- (i) Subject to
subparagraph (D), any individual dissatisfied with any initial
determination under subsection (a)(1) shall be entitled to reconsideration
of the determination, and, subject to subparagraphs (D) and (E), a hearing
thereon by the Secretary to the same extent as is provided in section
205(b) and to judicial review of the Secretary's final decision after such
hearing as is provided in section 205(g). For purposes of the preceding
sentence, any reference to the Commissioner of Social Security or the
Social Security Administration in subsection (g) or (l) of section 205
shall be considered a reference to the Secretary or the Department of
Health and Human Services, respectively.
`(ii) In making determinations under this subsection, local and
national coverage determinations that involve the consideration of
medical facts of application of medical judgment shall not be binding on
qualified independent contractors, administrative law judges or the
Departmental Appeals Board when determining whether a particular item or
service is covered with respect to an individual making a claim for
benefit or the amount, duration or scope of an item or service to which
an individual making a claim for benefits is eligible.
`(B) REPRESENTATION BY PROVIDER OR SUPPLIER-
`(i) IN GENERAL- Sections 206(a), 1102 and 1871 shall not be
construed as authorizing the Secretary to prohibit an individual from
being represented under this section by a person that furnishes or
supplies the individual, directly or indirectly, with services or items,
solely on the basis that the person furnishes or supplies the individual
with such a service or item.
`(ii) MANDATORY WAIVER OF RIGHT TO PAYMENT FROM BENEFICIARY- Any
person that furnishes services or items to an individual may not
represent an individual under this section with respect to the issue
described in section 1879(a)(2) unless the person has waived any rights
for payment from the beneficiary with respect to the services or items
involved in the appeal.
`(iii) PROHIBITION ON PAYMENT FOR REPRESENTATION- If a person
furnishes services or items to an individual and represents the
individual under this section, the person may not impose any financial
liability on such individual in connection with such
representation.
`(iv) REQUIREMENTS FOR REPRESENTATIVES OF A BENEFICIARY- The
provisions of section 205(j) and section 206 (other than subsection
(a)(4) of such section) regarding representation of claimants shall
apply to representation of an individual with respect to appeals under
this section in the same manner as they apply to representation of an
individual under those sections.
`(C) SUCCESSION OF RIGHTS IN CASES OF ASSIGNMENT- The right of an
individual to an appeal under this section with respect to an item or
service may be assigned to the provider of services or supplier of the
item or service upon the written consent of such individual using a
standard form established by the Secretary for such an
assignment.
`(D) TIME LIMITS FOR FILING APPEALS-
`(i) RECONSIDERATIONS- Reconsideration under subparagraph (A) shall
be available only if the individual described in subparagraph (A) files
notice with the Secretary to request reconsideration by not later than
the end of the 180-day period beginning on the date the individual
receives notice of the redetermination under subsection (a)(3), or
within such additional time as the Secretary may allow.
`(ii) HEARINGS CONDUCTED BY THE SECRETARY- The Secretary shall
establish in regulations time limits for the filing of a request for a
hearing by the Secretary in accordance with provisions in sections 205
and 206.
`(E) AMOUNTS IN CONTROVERSY-
`(i) IN GENERAL- A hearing (by the Secretary) shall not be available
to an individual under this section if the amount in controversy is less
than $100, and judicial review shall not be available to the individual
if the amount in controversy is less than $1,000.
`(ii) AGGREGATION OF CLAIMS- In determining the amount in
controversy, the Secretary, under regulations, shall allow two or more
appeals to be aggregated if the appeals involve--
`(I) the delivery of similar or related services to the same
individual by one or more providers of services or suppliers,
or
`(II) common issues of law and fact arising from services
furnished to two or more individuals by one or more providers of
services or suppliers.
`(F) EXPEDITED PROCEEDINGS-
`(i) EXPEDITED DETERMINATION- In the case of an individual who has
received notice by a provider of services that the provider of services
plans--
`(I) to terminate services provided to an individual and a
physician certifies that failure to continue the provision of such
services is likely to place the individual's health at significant
risk, or
`(II) to discharge the individual from the provider of services,
the individual may request, in writing or orally, an expedited
determination or an expedited reconsideration of an initial
determination made under subsection (a)(1), as the case may be, and
the Secretary shall provide such expedited determination or expedited
reconsideration.
`(ii) EXPEDITED HEARING- In a hearing by the Secretary under this
section, in which the moving party alleges that no material issues of
fact are in dispute, the Secretary shall make an expedited determination
as to whether any such facts are in dispute and, if not, shall render a
decision expeditiously.
`(G) REOPENING AND REVISION OF DETERMINATIONS- The Secretary may
reopen or revise any initial determination or reconsidered determination
described in this subsection under guidelines established by the Secretary
in regulations.
`(c) CONDUCT OF RECONSIDERATIONS BY INDEPENDENT CONTRACTORS-
`(1) IN GENERAL- The Secretary shall enter into contracts with qualified
independent contractors to conduct reconsiderations of initial
determinations made under subparagraphs (B) and (C) of subsection (a)(1), if
such determinations involve either whether a particular item or service is
covered with respect to an individual making a claim for benefit or the
amount, duration or scope of an item or service to which an individual
making a claim for benefits is eligible. Contracts shall be for an initial
term of three years and shall be renewable on a triennial basis thereafter.
This subsection shall not apply to claims for persons that involve only the
amount of payment or the type of payment available with respect to an item
or service.
`(2) QUALIFIED INDEPENDENT CONTRACTOR- For purposes of this subsection,
the term `qualified independent contractor' means an entity or organization
that is independent of any organization under contract with the Secretary
that makes initial determinations under subsection (a)(1), and that meets
the requirements established by the Secretary consistent with paragraph
(3).
`(3) REQUIREMENTS- Any qualified independent contractor entering into a
contract with the Secretary under this subsection shall meet the all of the
following requirements:
`(A) IN GENERAL- The qualified independent contractor shall perform
such duties and functions and assume such responsibilities as may be
required by the Secretary to carry out the provisions of this subsection,
and shall have sufficient training and expertise in medical science and
legal matters to make reconsiderations under this subsection.
`(i) IN GENERAL- Subject to subsection (b)(1)(A)(ii), the qualified
independent contractor shall review initial determinations. In the case
an initial determination made with respect to whether an item or service
is reasonable and necessary for the diagnosis or treatment of illness or
injury (under section 1862(a)(1)(A)), such review shall include
consideration of the facts and circumstances of the initial
determination by a panel of physicians or other appropriate health care
professionals and any decisions with respect to the reconsideration
shall be based on applicable information, including clinical experience
and medical, technical, and scientific evidence.
`(C) DEADLINES FOR DECISIONS-
`(i) RECONSIDERATIONS- Except as provided in clauses (iii) and (iv),
and in accordance with subsections (d), (e), and (f), the qualified
independent contractor shall conduct and conclude a reconsideration
under subparagraph (B), and mail the notice of the decision with respect
to the reconsideration in accordance with the medical needs of the
individual but not later than the end of the 30-day period beginning on
the date a request for reconsideration has been timely
filed.
`(ii) CONSEQUENCES OF FAILURE TO MEET DEADLINE- In the case of a
failure by the qualified independent contractor to mail the notice of
the decision by the end of the period described in clause (i), or by the
end of the applicable period described in subsections (d) through (f),
or to provide notice by the end of the period described in clause (iii),
as the case may be, the party requesting the reconsideration or appeal
may request a hearing before the Secretary, notwithstanding any
requirements for a reconsidered determination for purposes of the
party's right to such hearing.
`(iii) EXPEDITED RECONSIDERATIONS- The qualified independent
contractor shall perform an expedited reconsideration under subsection
(b)(1)(F) as follows:
`(I) DEADLINE FOR DECISION- Notwithstanding section 216(j) and
subject to clause (iv), not later than the end of the 72-hour period
beginning on the date the qualified independent contractor has
received a request for such reconsideration and has received such
medical or other records needed for such reconsideration, the
qualified independent contractor shall provide notice (by telephone
and in writing) to the individual and the provider of services and
attending physician of the individual of the results of the
reconsideration. Such reconsideration shall be conducted regardless of
whether the provider of services or supplier will charge the
individual for continued services or whether the individual will be
liable for payment for such continued services.
`(II) CONSULTATION WITH BENEFICIARY- In such reconsideration, the
qualified independent contractor shall solicit the views of the
individual involved.
`(III) SPECIAL RULE FOR HOSPITAL DISCHARGES- A reconsideration of
a discharge from a hospital shall be conducted under this clause in
accordance with the provisions of paragraphs (2), (3),
and
`(4) of section 1154(e) as in effect on the date that precedes the date
of the enactment of this subparagraph.
`(iv) EXTENSION- An individual requesting a reconsideration under
this subparagraph may be granted such additional time as the individual
specifies (not to exceed 14 days) for the qualified independent
contractor to conclude the reconsideration. The individual may request
such additional time orally or in writing.
`(D) LIMITATION ON INDIVIDUAL REVIEWING DETERMINATIONS-
`(i) PHYSICIANS AND HEALTH CARE PROFESSIONAL- No physician or health
care professional under the employ of a qualified independent contractor
may review--
`(I) determinations regarding health care services furnished to a
patient if the physician or health care professional was directly
responsible for furnishing such services; or
`(II) determinations regarding health care services provided in or
by an institution, organization, or agency, if the physician or any
member of the family of the physician or health
care professional has, directly or indirectly, a significant financial
interest in such institution, organization, or agency.
`(ii) FAMILY DESCRIBED- For purposes of this paragraph, the family
of a physician or health care professional includes the spouse (other
than a spouse who is legally separated from the physician or health care
professional under a decree of divorce or separate maintenance),
children including stepchildren and legally adopted children),
grandchildren, parents, and grandparents of the physician or health care
professional.
`(E) EXPLANATION OF DECISION- Any decision with respect to a
reconsideration of a qualified independent contractor shall be in writing,
and shall include a detailed explanation of the decision as well as a
discussion of the pertinent facts and applicable regulations applied in
making such decision, and in the case of a determination of whether an
item or service is reasonable and necessary for the diagnosis or treatment
of illness or injury (under section 1862(a)(1)(A)) an explanation of the
medical and scientific rationale for the decision.
`(F) NOTICE REQUIREMENTS- Whenever a qualified independent contractor
makes a decision with respect to a reconsideration under this subsection,
the qualified independent contractor shall promptly notify the entity
responsible for the payment of claims under part A or part B of such
decision.
`(G) DISSEMINATION OF DECISIONS ON RECONSIDERATIONS- Each qualified
independent contractor shall make available all decisions with respect to
reconsiderations of such qualified independent contractors to fiscal
intermediaries (under section 1816), carriers (under section 1842), peer
review organizations (under part B of title XI), Medicare+Choice
organizations offering Medicare+Choice plans under part C, other entities
under contract with the Secretary to make initial determinations under
part A or part B or title XI, and to the public. The Secretary shall
establish a methodology under which qualified independent contractors
shall carry out this subparagraph.
`(H) ENSURING CONSISTENCY IN DECISIONS- Each qualified independent
contractor shall monitor its decisions with respect to reconsiderations to
ensure the consistency of such decisions with respect to requests for
reconsideration of similar or related matters.
`(i) IN GENERAL- Consistent with the requirements of clause (ii), a
qualified independent contractor shall collect such information relevant
to its functions, and keep and maintain such records in such form and
manner as the Secretary may require to carry out the purposes of this
section and shall permit access to and use of any such information and
records as the Secretary may require for such purposes.
`(ii) TYPE OF DATA COLLECTED- Each qualified independent contractor
shall keep accurate records of each decision made, consistent with
standards established by the Secretary for such purpose. Such records
shall be maintained in an electronic database in a manner that provides
for identification of the following:
`(I) Specific claims that give rise to appeals.
`(II) Situations suggesting the need for increased education for
providers of services, physicians, or suppliers.
`(III) Situations suggesting the need for changes in national or
local coverage policy.
`(IV) Situations suggesting the need for changes in local medical
review policies.
`(iii) ANNUAL REPORTING- Each qualified independent contractor shall
submit annually to the Secretary (or otherwise as the Secretary may
request) records maintained under this paragraph for the previous
year.
`(J) HEARINGS BY THE SECRETARY- The qualified independent contractor
shall (i) prepare such information as is required for an appeal of a
decision of the contractor with respect to a reconsideration to the
Secretary for a hearing, including as necessary, explanations of issues
involved in the decision and relevant policies, and
`(ii) participate in such hearings as required by the
Secretary.
`(4) NUMBER OF QUALIFIED INDEPENDENT CONTRACTORS- The Secretary shall
enter into contracts with not fewer than 12 qualified independent
contractors under this subsection.
`(5) LIMITATION ON QUALIFIED INDEPENDENT CONTRACTOR LIABILITY- No
qualified independent contractor having a contract with the Secretary under
this subsection and no person who is employed by, or who has a fiduciary
relationship with, any such qualified independent contractor or who
furnishes professional services to such qualified independent contractor,
shall be held by reason of the performance of any duty, function, or
activity required or authorized pursuant to this subsection or to a valid
contract entered into under this subsection, to have violated any criminal
law, or to be civilly liable under any law of the United States or of any
State (or political subdivision thereof) provided due care was exercised in
the performance of such duty, function, or activity.
`(d) MEDICAL EXIGENT PROCESS FOR CONTRACTORS-
`(1) IN GENERAL- An individual may request, either orally or in writing,
a medically exigent review under subsection (b). Such request shall be made
to the contractor who made the initial determination.
`(2) CONDITIONS FOR GRANTING A MEDICAL EXIGENT REVIEW-
`(A) the contractor determines that the application of the standard
time frame for conducting a redetermination under subsection (a)(3) could
seriously jeopardize the life or health of the individual or such
individual's ability to attain, maintain, or regain maximum function,
or
`(B) the individual submits a certification from a physician that the
jeopardy could occur.
`(3) DEADLINE FOR MEDICAL EXIGENT REVIEWS- If an individual is granted a
medical exigent review under this subsection, the review shall be conducted
and notice of the review shall be made, in accordance with the individual's
medical needs, but no later than 72 hours after the request was made.
`(4) FAILURE TO MEET TIME FRAMES- In the event the contractor who made
the initial determination to meet the time frame in paragraph (3), the
individual may proceed to the next level of review.
`(e) MEDICAL EXIGENT PROCESS FOR QUALIFIED INDEPENDENT CONTRACTORS-
`(1) IN GENERAL- An individual may request, either orally or in writing,
a medically exigent reconsideration of a determination made under subsection
(d). Such request shall be made to the qualified independent
contractor.
`(2) CONDITIONS FOR GRANTING A MEDICAL EXIGENT REVIEW-
`(A) the qualified independent contractor determines that the
application of the standard time frame for conducting a review could
seriously jeopardize the life or health of the individual or such
individual's ability to attain, maintain, or regain maximum function,
or
`(B) the individual submits a certification from a physician that the
jeopardy could occur.
`(3) DEADLINE FOR MEDICAL EXIGENT REVIEWS- If an individual is granted a
medical exigent reconsideration under this paragraph, the review shall be
conducted and notice of the review shall be made, in accordance with the
individuals medical needs, but no later than 72 hours after the request was
made.
`(4) FAILURE TO MEET TIME FRAMES- In the event the qualified independent
contractor or the Secretary fails to meet the time frame in paragraph (3),
the individual may proceed to the next level of review.
`(f) TIME FRAME FOR REVIEW BY SECRETARY- The Secretary shall conduct all
reviews in a time frame that is in accordance with the medical exigencies of
the case.
`(g) ADMINISTRATIVE PROVISIONS-
`(1) LIMITATION ON REVIEW OF CERTAIN REGULATIONS- A regulation or
instruction that relates to a method for determining the amount of payment
under part B and that was initially issued before January 1, 1981, shall not
be subject to judicial review.
`(2) OUTREACH- The Secretary shall perform such outreach activities as
are necessary to inform individuals entitled to benefits under this title
and providers of services and suppliers with respect to their rights of, and
the process for, appeals made under this section. The Secretary shall use
the toll-free telephone number maintained by the Secretary under section
1804(b) to provide information regarding appeal rights and respond to
inquiries regarding the status of appeals.
`(3) CONTINUING EDUCATION REQUIREMENT FOR QUALIFIED INDEPENDENT
CONTRACTORS AND ADMINISTRATIVE LAW JUDGES- The Secretary shall provide to
each qualified independent contractor, and, in consultation with the
Commissioner of Social Security, to administrative law judges that decide
appeals of reconsiderations of initial determinations or other decisions or
determinations under this section, such continuing education with respect to
coverage of items and services under this title or policies of the Secretary
with respect to part B of title XI as is necessary for such qualified
independent contractors and administrative law judges to make informed
decisions with respect to appeals.
`(A) ANNUAL REPORT TO CONGRESS- The Secretary shall submit to Congress
an annual report describing the number of appeals for the previous year,
identifying issues that require administrative or legislative actions, and
including any recommendations of the Secretary with respect to such
actions. The Secretary shall include in such report an analysis of
determinations by qualified independent contractors with respect to
inconsistent decisions and an analysis of the causes of any such
inconsistencies.
`(B) SURVEY- Not less frequently than every 5 years, the Secretary
shall conduct a survey of a valid sample of individuals entitled to
benefits under this title who have filed appeals of determinations under
this section, providers of services, and suppliers to determine the
satisfaction of such individuals or entities with the process for appeals
of determinations provided for under this section and education and
training provided by the Secretary with respect to that process. The
Secretary shall submit to Congress a report describing the results of the
survey, and shall include any recommendations for administrative or
legislative actions that the Secretary determines appropriate.
`(b) APPLICABILITY OF REQUIREMENTS AND LIMITATIONS ON LIABILITY OF
QUALIFIED INDEPENDENT CONTRACTORS TO MEDICARE+CHOICE INDEPENDENT APPEALS
CONTRACTORS- Section 1852(g)(4) (42 U.S.C. 1395w 22(g)(4)) is amended by
adding at the end the following: The provisions of section 1869(c)(5) shall
apply to independent outside entities under contract with the Secretary under
this paragraph.
`(c) CONFORMING AMENDMENT- Section 1154(e) (42 U.S.C. 1320c-3(e)) is
amended by striking paragraphs (2), (3), and (4).
`(d) EFFECTIVE DATE- The amendments made by this section apply with
respect to initial determinations made on or after October 1, 2002.'.
SEC. 522. REVISIONS TO MEDICARE COVERAGE PROCESS.
(a) REVIEW OF DETERMINATIONS- Section 1869 (42 U.S.C. 1395ff), as amended
by section 521, is further amended by adding at the end the following new
subsection:
`(h) REVIEW OF COVERAGE DETERMINATIONS-
`(1) NATIONAL COVERAGE DETERMINATIONS-
`(A) IN GENERAL- Review of any national coverage determination shall
be subject to the following limitations:
`(i) Such a determination shall not be reviewed by any
administrative law judge.
`(ii) Such a determination shall not be held unlawful or set aside
on the ground that a requirement of section 553 of title 5, United
States Code, or section 1871(b) of this title, relating to publication
in the Federal Register or opportunity for public comment, was not
satisfied.
`(iii) Upon the filing of a complaint by an aggrieved party, the
Secretary shall provide for the review of a national coverage
determination by the advisory panel established pursuant to paragraph
(3) (hereinafter referred to as the `Panel'). In conducting such a
review, the Panel shall review the record to evaluate whether the
determination is in accord with sound medical practice, taking into
account medical, technological, or clinical advancements, and any other
medical, scientific, or other relevant information that the Panel deems
reliable and may consider information that was not available or was not
considered at the time of the determination. The Panel shall make a
recommendation to the Secretary as to whether the determination should
be upheld, modified, or set aside, and the Secretary shall have 30 days
from the receipt of such recommendation to issue a decision.
`(iv) A decision of the Secretary under (h)(1)(A)(iii) constitutes a
final agency action and is subject to judicial review.
`(B) DEFINITION OF NATIONAL COVERAGE DETERMINATION- For purposes of
this section, the term `national coverage determination' means a
determination by the Secretary with respect to whether or not a particular
item or service is covered nationally under this title, but does not
include a determination of what code, if any, is assigned to a particular
item or service covered under this title or a determination with respect
to the amount of payment made for a particular item or service so
covered.
`(2) LOCAL COVERAGE DETERMINATION-
`(A) Upon the filing of a complaint by an aggrieved party (except in
the cases of issues regarding the coding or supporting documentation), the
Secretary shall provide for the review of a local coverage determination
by the Panel as provided in (h)(3) except that for purposes of a review
under this subclause, the Panel shall also consider any special
circumstances that may be relevant to the practice of medicine in the
locality. The Panel shall make a recommendation to the Secretary as to
whether the determination should be upheld, modified, or set aside, and
the Secretary shall have 30 days from the receipt of such recommendation
to issue a decision to uphold the determination or to remand it to the
fiscal intermediary or carrier for revision. A fiscal intermediary or
carrier shall have 30 days from the receipt of any remand instructions
from the Secretary in which to complete such revision. The decision of the
Secretary shall have effect only with respect to the local coverage
determination. Such a decision constitutes a final agency action and is
subject to judicial review.
`(B) DEFINITION OF LOCAL COVERAGE DETERMINATION- For purposes of this
section, the term `local coverage determination' means a determination by
a fiscal intermediary or a carrier under part A or part B, as applicable,
respecting whether or not a particular item or service is covered on an
intermediary- or carrier-wide basis under such parts, in accordance with
section 1862(a)(1)(A).
`(3) ESTABLISHMENT OF MEDICAL ADVISORY PANEL- For the purposes of
providing expert clinical and scientific advice and recommendations to the
Secretary regarding reconsiderations of national or local coverage
determinations under paragraphs (1) and (2), the Secretary shall establish
panels of experts or use panels of experts (or members of such panels)
established before the date of enactment [insert name of Act] or both. The
Secretary shall appoint as members of any such panel persons the Secretary
determines to have an appropriate level of expertise in the subject matter,
but shall not appoint any individual who is in the regular full-time employ
of the Health Care Financing Administration or nay individual who
participated in the initial coverage determination that is the subject of a
reconsideration request.
`(4) PENDING NATIONAL COVERAGE DETERMINATIONS-
`(A) IN GENERAL- In the event the Secretary has not issued a national
coverage or noncoverage determination with respect to a particular type or
class of items or services, an aggrieved person (as described in paragraph
(5)) may submit to the Secretary a request to make such a determination
with respect to such items or services. By not later than the end of the
90-day period beginning on the date the Secretary receives such a request
(notwithstanding the receipt by the Secretary of new evidence (if any)
during such 90-day period), the Secretary shall take one of the following
actions:
`(i) Issue a national coverage determination, with or without
limitations.
`(ii) Issue a national noncoverage determination.
`(iii) Issue a determination that no national coverage or
noncoverage determination is appropriate as of the end of such 90-day
period with respect to national coverage of such items or
services.
`(iv) Issue a notice that states that the Secretary has not
completed a review of the request for a national coverage determination
and that includes an identification of the remaining steps in the
Secretary's review process and a deadline by which the Secretary will
complete the review and take an action described in subclause (I), (II),
or (III).
`(B) In the case of an action described in clause (i)(IV), if the
Secretary fails to take an action referred to in such clause by the
deadline specified by the Secretary under such clause, then the Secretary
is deemed to have taken an action described in clause (i)(III) as of the
deadline.
`(C) When issuing a determination under clause (i), the Secretary
shall include an explanation of the basis for the determination. An action
taken under clause (i) (other than subclause (IV)) is deemed to be a
national coverage determination for purposes of review under subparagraph
(A).
`(5) STANDING- An action under this subsection seeking review of a
national coverage determination or local coverage determination may be
initiated only by individuals entitled to benefits under part A, or enrolled
under part B, or both, who are in need of the items or services that are the
subject of the coverage determination.
`(6) PUBLICATION ON THE INTERNET OF DECISIONS OF HEARINGS OF THE
SECRETARY- Each decision of a hearing by the Secretary with respect to a
national coverage determination shall be made public, and the Secretary
shall publish each decision on the Medicare Internet site of the Department
of Health and Human Services. The Secretary shall remove from such decision
any information that would identify any individual, provider of services, or
supplier.
`(7) ANNUAL REPORT ON NATIONAL COVERAGE DETERMINATIONS-
`(A) IN GENERAL- Not later than December 1 of each year, beginning in
2001, the Secretary 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 national coverage determinations that were
made in the previous fiscal year for items, services, or medical devices
not previously covered as a benefit under this title, including, with
respect to each new item, service, or medical device, a statement of the
time taken by the Secretary to make and implement the necessary coverage,
coding, and payment determinations, including the time taken to complete
each significant step in the process of making and implementing such
determinations.
`(B) PUBLICATION OF REPORTS ON THE INTERNET- The Secretary shall
publish each report submitted under clause (i) on the medicare Internet
site of the Department of Health and Human Services.
`(8) CONSTRUCTION- Nothing in this subsection shall be construed as
permitting administrative or judicial review pursuant to this section
insofar as such review is explicitly prohibited or restricted under another
provision of law.'.
(b) ESTABLISHMENT OF A PROCESS FOR COVERAGE DETERMINATIONS- Section
1862(a) (42 U.S.C. 1395y(a)) is amended by adding at the end the following new
sentence: `In making a national coverage determination (as defined in
paragraph (1)(B) of section 1869(f)) the Secretary shall ensure that the
public is afforded notice and opportunity to comment prior to implementation
by the Secretary of the determination; meetings of advisory committees
established under section 1114(f) with respect to the determination are made
on the record; in making the determination, the Secretary has considered
applicable information (including clinical experience and medical, technical,
and scientific evidence) with respect to the subject matter of the
determination; and in the determination, provide a clear statement of the
basis for the determination (including responses to comments received from the
public), the assumptions underlying that basis, and make available to the
public the data (other than proprietary data) considered in making the
determination.
(c) IMPROVEMENTS TO THE MEDICARE ADVISORY COMMITTEE PROCESS- Section 1114
(42 U.S.C. 1314) is amended by adding at the end the following new
subsection:
`(i)(1) Any advisory committee appointed under subsection (f) to advise
the Secretary on matters relating to the interpretation, application, or
implementation of section 1862(a)(1) shall assure the full participation of a
nonvoting member in the deliberations of the advisory committee, and shall
provide such nonvoting member access to all information and data made
available to voting members of the advisory committee, other than information
that--
`(A) is exempt from disclosure pursuant to subsection q(a) of section
552 of title 5, United States Code, by reason of subsection (b)(4) of such
section (relating to trade secrets); or
`(B) the Secretary determines would present a conflict of interest
relating to such nonvoting member.
`(2) If an advisory committee described in paragraph (1) organizes into
panels of experts according to types of items or services considered by the
advisory committee, any such panel of experts may report any recommendation
with respect to such items or services directly to the Secretary without the
prior approval of the advisory committee or an executive committee
thereof.'.
(d) EFFECTIVE DATE- The amendments made by this section apply with respect
to--
(1) a review of any national or local coverage determination
filed,
(2) a request to make such a determination made,
(3) a national coverage determination made, on or after October 1,
2001.
Subtitle D--Improving Access to New Technologies
SEC. 531. REIMBURSEMENT IMPROVEMENTS FOR NEW CLINICAL LABORATORY TESTS AND
DURABLE MEDICAL EQUIPMENT.
(a) PAYMENT RULE FOR NEW LABORATORY TESTS- Section 1833(h)(4)(B)(viii) (42
U.S.C. 1395l(h)(4)(B)(viii)) is amended by inserting before the period at the
end the following: `(or 100 percent of such median in the case of a clinical
diagnostic laboratory test performed on or after January 1, 2001, that the
Secretary determines is a new test for which no limitation amount has
previously been established under this subparagraph)'.
(b) ESTABLISHMENT OF CODING AND PAYMENT PROCEDURES FOR NEW CLINICAL
DIAGNOSTIC LABORATORY TESTS AND OTHER ITEMS ON A FEE SCHEDULE- Not later than
1 year after the date of the enactment of this Act, the Secretary of Health
and Human Services shall establish procedures for coding and payment
determinations for the categories of new clinical diagnostic laboratory tests
and new durable medical equipment under part B of the title XVIII of the
Social Security Act that permit public consultation in a manner consistent
with the procedures established for implementing coding modifications for
ICD-9-CM.
(c) REPORT ON PROCEDURES USED FOR ADVANCED, IMPROVED TECHNOLOGIES- Not
later than 1 year after the date of the enactment of this Act, the Secretary
of Health and Human Services shall submit to Congress a report that identifies
the specific procedures used by the Secretary under part B of title XVIII of
the Social Security Act to adjust payments for clinical diagnostic laboratory
tests and durable medical equipment which are classified to existing codes
where, because of an advance in technology with respect to the test or
equipment, there has been a significant increase or decrease in the resources
used in the test or in the manufacture of the equipment, and there has been a
significant improvement in the performance of the test or equipment. The
report shall include such recommendations for changes in law as may be
necessary to assure fair and appropriate payment levels under such part for
such improved tests and equipment as reflects increased costs necessary to
produce improved results.
SEC. 532. RETENTION OF HCPCS LEVEL III CODES.
(a) IN GENERAL- The Secretary of Health and Human Services shall maintain
and continue the use of level III codes of the HCPCS coding system (as such
system was in effect on August 16, 2000) through December 31, 2003, and shall
make such codes available to the public.
(b) DEFINITION- For purposes of this section, the term `HCPCS Level III
codes' means the alphanumeric codes for local use under the Health Care
Financing Administration Common Procedure Coding System (HCPCS).
SEC. 533. RECOGNITION OF NEW MEDICAL TECHNOLOGIES UNDER INPATIENT HOSPITAL
PPS.
(a) EXPEDITING RECOGNITION OF NEW TECHNOLOGIES INTO INPATIENT PPS CODING
SYSTEM-
(1) REPORT- Not later than April 1, 2001, the Secretary of Health and
Human Services shall submit to Congress a report on methods of expeditiously
incorporating new medical services and technologies into the clinical coding
system used with respect to payment for inpatient hospital services
furnished under the medicare program under title XVIII of the Social
Security Act, together with a detailed description of the Secretary's
preferred methods to achieve this purpose.
(2) IMPLEMENTATION- Not later than October 1, 2001, the Secretary shall
implement the preferred methods described in the report transmitted pursuant
to paragraph (1).
(b) ENSURING APPROPRIATE PAYMENTS FOR HOSPITALS INCORPORATING NEW MEDICAL
SERVICES AND TECHNOLOGIES-
(1) ESTABLISHMENT OF MECHANISM- Section 1886(d)(5) (42 U.S.C.
1395ww(d)(5)) is amended by adding at the end the following new
subparagraphs:
`(K)(i) Effective for discharges beginning on or after October 1, 2001,
the Secretary shall establish a mechanism to recognize the costs of new
medical services and technologies under the payment system established under
this subsection. Such mechanism shall be established after notice and
opportunity for public comment (in the publications required by subsection
(e)(5) for a fiscal year or otherwise).
`(ii) The mechanism established pursuant to clause (i) shall--
`(I) apply to a new medical service or technology if, based on the
estimated costs incurred with respect to discharges involving such service
or technology, the DRG prospective payment rate otherwise applicable to such
discharges under this subsection is inadequate;
`(II) provide for the collection of data with respect to the costs of a
new medical service or technology described in subclause (I) for a period of
not less than two years and not more than three years beginning on the date
on which an inpatient hospital code is issued with respect to the service or
technology;
`(III) subject to paragraph (4)(C)(iii), provide for additional payment
to be made under this subsection with respect to discharges involving a new
medical service or technology described in subclause (I) that occur during
the period described in subclause (II) in an amount that adequately reflects
the estimated average cost of such service or technology; and
`(IV) provide that discharges involving such a service or technology
that occur after the close of the period described in subclause (II) will be
classified within a new or existing diagnosis-related group with a weighting
factor under paragraph (4)(B) that is derived from cost data collected with
respect to discharges occurring during such period.
`(iii) For purposes of clause (ii)(II), the term `inpatient hospital code'
means any code that is used with respect to inpatient hospital services for
which payment may be made under this subsection and includes an alphanumeric
code issued under the International Classification of Diseases, 9th Revision,
Clinical Modification (`ICD-9-CM') and its subsequent revisions.
`(iv) For purposes of clause (ii)(III), the term `additional payment'
means, with respect to a discharge for a new medical service or technology
described in clause (ii)(I), an amount that exceeds the prospective payment
rate otherwise applicable under this subsection to discharges involving such
service or technology that would be made but for this subparagraph.
`(v) The requirement under clause (ii)(III) for an additional payment may
be satisfied by means of a new-technology group (described in subparagraph
(L)), an add-on payment, a payment adjustment, or any other similar mechanism
for increasing the amount otherwise payable with respect to a discharge under
this subsection. The Secretary may not establish a separate fee schedule for
such additional payment for such services and technologies, by utilizing a
methodology established under subsection (a) or (h) of section 1834 to
determine the amount of such additional payment, or by other similar
mechanisms or methodologies.
`(vi) For purposes of this subparagraph and subparagraph (L), a medical
service or technology will be considered a `new medical service or technology'
if the service or technology meets criteria established by the Secretary after
notice and an opportunity for public comment.
`(L)(i) In establishing the mechanism under subparagraph (K), the
Secretary may establish new-technology groups into which a new medical service
or technology will be classified if, based on the estimated average costs
incurred with respect to
discharges involving such service or technology, the DRG prospective payment
rate otherwise applicable to such discharges under this subsection is
inadequate.
`(I) shall not be based on the costs associated with a specific new
medical service or technology; but
`(II) shall, in combination with the applicable standardized amounts and
the weighting factors assigned to such groups under paragraph (4)(B),
reflect such cost cohorts as the Secretary determines are appropriate for
all new medical services and technologies that are likely to be provided as
inpatient hospital services in a fiscal year.
`(iii) The methodology for classifying specific hospital discharges within
a diagnosis-related group under paragraph (4)(A) or a new-technology group
shall provide that a specific hospital discharge may not be classified within
both a diagnosis-related group and a new-technology group.'.
(2) PRIOR CONSULTATION- The Secretary of Health and Human Services shall
consult with groups representing hospitals, physicians, and manufacturers of
new medical technologies before publishing the notice of proposed rulemaking
required by section 1886(d)(5)(K)(i) of the Social Security Act (as added by
paragraph (1)).
(3) CONFORMING AMENDMENT- Section 1886(d)(4)(C)(i) (42 U.S.C.
1395ww(d)(4)(C)(i)) is amended by striking `technology,' and inserting
`technology (including a new medical service or technology under paragraph
(5)(K)),'.
Subtitle E--Other Provisions
SEC. 541. INCREASE IN REIMBURSEMENT FOR BAD DEBT.
Section 1861(v)(1)(T) (42 U.S.C. 1395x(v)(1)(T)) is amended--
(1) in clause (ii), by striking `and' at the end;
(A) by striking `during a subsequent fiscal year' and inserting
`during fiscal year 2000'; and
(B) by striking the period at the end and inserting `, and';
and
(3) by adding at the end the following new clause:
`(iv) for cost reporting periods beginning during a subsequent fiscal
year, by 30 percent of such amount otherwise allowable.'.
SEC. 542. TREATMENT OF CERTAIN PHYSICIAN PATHOLOGY SERVICES UNDER
MEDICARE.
(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 an inpatient or outpatient of a covered 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 1833(t) of such Act (42 U.S.C.
1395l(t)).
(b) DEFINITIONS- For purposes of this section:
(1) COVERED HOSPITAL- The term `covered hospital' means, with respect to
an inpatient or an outpatient, 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 inpatients or
outpatients, respectively, and submitted claims for payment for such
component to a medicare carrier (that has a contract with the Secretary
under section 1842 of the Social Security Act, 42 U.S.C. 1395u) and not to
such 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, or
both, of such title; and
(B) is not enrolled in any of the following:
(i) A Medicare+Choice plan under part C of such title.
(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 1894 of such Act (42 U.S.C. 1395eee).
(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).
(c) EFFECTIVE DATE- This section applies to services furnished during the
2-year period beginning on January 1, 2001.
(1) STUDY- The Comptroller General of the United States shall conduct a
study of the effects of the previous provisions of this section on hospitals
and laboratories and access of fee-for-service medicare beneficiaries to the
technical component of physician pathology services.
(2) REPORT- Not later than April 1, 2002, the Comptroller General shall
submit to Congress a report on such study. The report shall include
recommendations about whether such provisions should be extended after the
end of the period specified in subsection (c) for either or both inpatient
and outpatient hospital services, and whether the provisions should be
extended to other hospitals.
SEC. 543. EXTENSION OF 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'.
SEC. 544. CHANGE IN ANNUAL MEDPAC REPORTING.
(a) REVISION OF DEADLINES FOR SUBMISSION OF REPORTS-
(1) IN GENERAL- Section 1805(b)(1)(D) (42 U.S.C. 1395b-6(b)(1)(D)) is
amended by striking `June 1 of each year (beginning with 1998),' and
inserting `June 15 of each year,'.
(2) EFFECTIVE DATE- The amendment made by paragraph (1) applies
beginning with 2001.
(b) REQUIREMENT FOR ON THE RECORD VOTES ON RECOMMENDATIONS- Section
1805(b) (42 U.S.C. 1395b-6(b)) is amended by adding at the end the following
new paragraph:
`(7) VOTING AND REPORTING REQUIREMENTS- With respect to each
recommendation contained in a report submitted under paragraph (1), each
member of the Commission shall vote on the recommendation, and the
Commission shall include, by member, the results of that vote in the report
containing the recommendation.'.
SEC. 545. DEVELOPMENT OF PATIENT ASSESSMENT INSTRUMENTS.
(1) IN GENERAL- Not later than January 1, 2005, the Secretary of Health
and Human Services 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 a report on the development of standard instruments
for the assessment of the health and functional status of patients, for whom
items and services described in subsection (b) are furnished, and include in
the report a recommendation on the use of such standard instruments for
payment purposes.
(2) DESIGN FOR COMPARISON OF COMMON ELEMENTS- The Secretary shall design
such standard instruments in a manner such that--
(A) elements that are common to the items and services described in
subsection (b) may be readily comparable and are statistically
compatible;
(B) only elements necessary to meet program objectives are collected;
and
(C) the standard instruments supersede any other assessment instrument
used before that date.
(3) CONSULTATION- In developing an assessment instrument under paragraph
(1), the Secretary shall consult with the Medicare Payment Advisory
Commission, the Agency for Healthcare Research and Quality, and qualified
organizations representing providers of services and suppliers under title
XVIII.
(b) DESCRIPTION OF SERVICES- For purposes of subsection (a), items and
services described in this subsection are those items and services furnished
to individuals entitled to benefits under part A, or enrolled under part B, or
both of title XVIII of the Social Security Act for which payment is made under
such title, and include the following:
(1) Inpatient and outpatient hospital services.
(2) Inpatient and outpatient rehabilitation services.
(3) Covered skilled nursing facility services.
(4) Home health services.
(5) Physical or occupational therapy or speech-language pathology
services.
(6) Items and services furnished to such individuals determined to have
end stage renal disease.
(7) Partial hospitalization services and other mental health
services.
(8) Any other service for which payment is made under such title as the
Secretary determines to be appropriate.
SEC. 546. GAO REPORT ON IMPACT OF THE EMERGENCY MEDICAL TREATMENT AND ACTIVE
LABOR ACT (EMTALA) ON HOSPITAL EMERGENCY DEPARTMENTS.
(a) REPORT- The Comptroller General of the United States shall submit a
report to the Committee on Commerce and the Committee on Ways and Means of the
House of Representatives and the Committee on Finance of the Senate 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.
(b) 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, and other hospital
services;
(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,
other hospital services, emergency physicians, and physicians covering
emergency department call.
(c) 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).
SEC. 547. APPLICATION OF BLOODBORNE PATHOGEN STANDARD TO CERTAIN
HOSPITALS.
(a) IN GENERAL- Section 1866 (42 U.S.C. 1395cc) is amended--
(1) in subsection (a)(1)--
(A) in subparagraph (R), by striking `and' at the end;
(B) in subparagraph (S), by striking the period at the end and
inserting `, and'; and
(C) by inserting after subparagraph (S) the following new
subparagraph:
`(T) in the case of hospitals that are not otherwise subject to
regulation by the Occupational Safety and Health Administration, to comply
with the Bloodborne Pathogens standard under section 1910.1030 of title 29
of the Code of Federal Regulations (or as subsequently redesignated).';
and
(2) by adding at the end of subsection (b) the following new
paragraph:
`(4) With respect to a failure to comply with the requirement of
subsection (a)(1)(T), the Secretary shall not terminate an agreement under
this section but shall impose a monetary fine in an amount similar to the
amount of civil penalties that may be imposed under section 17 of the
Occupational Safety and Health Act of 1970 for a violation of the standard
referred to in such subsection by a hospital subject to regulation by the
Occupational Safety and Health Administration. Such penalty shall be imposed
and collected in the same manner as civil money penalties under subsection (a)
of section 1128A are imposed and collected under that section.'.
(b) EFFECTIVE DATE- The amendments made by this section apply to hospitals
as of January 1, 2002.
TITLE VI--PROVISIONS RELATING TO PART C (MEDICARE+CHOICE PROGRAM) AND
OTHER MEDICARE MANAGED CARE PROVISIONS
Subtitle A--Medicare+Choice Payment Reforms
SEC. 601. INCREASED PAYMENT FOR ACCOUNTABLE MEDICARE+CHOICE PLANS.
Section 1853 (42 U.S.C. 1395w-23) is amended--
(1) in subsection (a)(1)(A), by striking `and (i)' and inserting `(i),
and (j)'; and
(2) by adding at the end the following new subsection:
`(j) INCREASED PAYMENT FOR ACCOUNTABLE MEDICARE+CHOICE COORDINATED CARE
PLANS-
`(1) IN GENERAL- In the case of a Medicare+Choice coordinated care plan
that enters into a 3-year contract for the period of 2001 through 2003, the
amount of the monthly payment otherwise made under this section (taking into
account, if applicable, subsection (i)), shall be increased for each year of
the contract period by the amount necessary to ensure that the total monthly
payment is equal to the greater of the adjusted minimum amount specified in
paragraph (2) or an amount equal to the otherwise applicable rate increased
by 1/3 of 1 percent.
`(2) ADJUSTED MINIMUM AMOUNT- For purposes of this subsection, the
adjusted minimum amount shall equal--
`(i) for any payment area in a Metropolitan Statistical Area or a
Primary Metropolitan Statistical Area, $525 per month; and
`(ii) for any other payment area, $475;
however, in the case of a payment area outside the 50 States and the
District of Columbia, such amount shall not exceed 110 percent of the
minimum amount for such area for 2000.
`(B) in 2002 and 2003, the adjusted minimum amount for months during
the previous year increased by the national per capita Medicare+Choice
growth percentage, described in subsection (c)(6)(A) for that succeeding
year.
`(3) PENALTY FOR CONTRACT TERMINATION- In the case of a Medicare+Choice
coordinated care plan described in paragraph (1) whose contract is
terminated prior to the end of the 3-year contract period, the
Medicare+Choice organizations that offered such plan shall return to the
Secretary an amount equal to twice the total of the increased payments
provided under this section. Such moneys shall be deposited in the Federal
Hospital Insurance Trust Funds and the Federal Supplementary Medical
Insurance Trust Funds in such proportion as the Secretary deems to be fair
and equitable.'.
SEC. 602. INCREASE IN MINIMUM PERCENTAGE INCREASE.
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. 603. 10-YEAR PHASE-IN OF RISK ADJUSTMENT.
Section 1853(a)(3)(C)(ii) (42 U.S.C. 1395w-23(a)(3)(C)(ii)) is
amended--
(1) in subclause (I), by striking `and 2001' and inserting `and each
succeeding year through the first year in which risk adjustment is based on
data from inpatient hospital and ambulatory settings'; and
(2) by amending subclause (II) to read as follows:
`(II) beginning after such first year, insofar as such risk
adjustment is based on data from inpatient hospital and ambulatory
settings, the methodology shall be phased in equal increments over a
10-year period that begins with such first year.'.
SEC. 604. 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 before the date of the enactment of this Act 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 2 weeks after the date revised rates are
announced by the Secretary under subsection (a).
(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 payment area 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 2 weeks
after the date revised rates are announced by the Secretary under subsection
(a).
(d) DISREGARD OF NEW RATE ANNOUNCEMENT IN APPLYING PASS-THROUGH FOR NEW
NATIONAL COVERAGE DETERMINATIONS- For purposes of applying section 1852(a)(5)
of the Social Security Act (42 U.S.C. 1395w-22(a)(5)), the announcement of
revised rates under subsection (a) shall not be treated as an announcement
under section 1853(b) of such Act (42 U.S.C. 1395w-23(b)).
SEC. 605. REVISION OF PAYMENT RATES FOR ESRD PATIENTS ENROLLED IN
MEDICARE+CHOICE PLANS.
(a) IN GENERAL- Section 1853(a)(1)(B) (42 U.S.C. 1395w-23(a)(1)(B)) is
amended by adding at the end the following: `In establishing such rates, the
Secretary shall provide for appropriate adjustments to increase each rate to
reflect the demonstration rate (including the risk adjustment methodology
associated with such rate) of the social health maintenance organization
end-stage renal disease capitation demonstrations (established by section 2355
of the Deficit Reduction Act of 1984, as amended by section 13567(b) of the
Omnibus Budget Reconciliation Act of 1993), and shall compute such rates by
taking into account such factors as renal treatment modality, age, and the
underlying cause of the end-stage renal disease.'.
(b) EFFECTIVE DATE- The amendment made by subsection (a) shall apply to
payments for months beginning with January 2002.
(c) PUBLICATION- Not later than 6 months after the date of the enactment
of this Act, the Secretary of Health and Human Services shall publish for
public comment a description of the appropriate adjustments described in the
last sentence of section 1853(a)(1)(B) of the Social Security Act (42 U.S.C.
1395w-23(a)(1)(B)), as added by subsection (a). The Secretary shall publish
such adjustments in final form by not later than July 1, 2001, so that the
amendment made by subsection (a) is implemented on a timely basis consistent
with subsection (b).
SEC. 606. PERMITTING PREMIUM REDUCTIONS AS ADDITIONAL BENEFITS UNDER
MEDICARE+CHOICE PLANS.
(1) AUTHORIZATION OF PART B PREMIUM REDUCTIONS- Section 1854(f)(1) (42
U.S.C. 1395w-24(f)(1)) is amended--
(A) by redesignating subparagraph (E) as subparagraph (F);
and
(B) by inserting after subparagraph (D) the following new
subparagraph:
`(i) IN GENERAL- Subject to clause (ii), as part of providing any
additional benefits required under subparagraph (A), a Medicare+Choice
organization may elect a reduction in its payments under section
1853(a)(1)(A) with respect to a Medicare+Choice plan and the Secretary
shall apply such reduction to reduce the premium under section 1839 of
each enrollee in such plan as provided in section 1840(i).
`(ii) AMOUNT OF REDUCTION- The amount of the reduction under clause
(i) with respect to any enrollee in a Medicare+Choice plan--
`(I) may not exceed 125 percent of the premium described under
section 1839(a)(3); and
`(II) shall apply uniformly to each enrollee of the
Medicare+Choice plan to which such reduction applies.'.
(2) CONFORMING AMENDMENTS-
(A) ADJUSTMENT OF PAYMENTS TO MEDICARE+CHOICE ORGANIZATIONS- Section
1853(a)(1)(A) (42 U.S.C. 1395w-23(a)(1)(A)) is amended by inserting
`reduced by the amount of any
reduction elected under section 1854(f)(1)(E) and' after `for that area,'.
(B) ADJUSTMENT AND PAYMENT OF PART B PREMIUMS-
(i) ADJUSTMENT OF PREMIUMS- Section 1839(a)(2) (42 U.S.C.
1395r(a)(2)) is amended by striking `shall' and all that follows and
inserting the following: `shall be the amount determined under paragraph
(3), adjusted as required in accordance with subsections (b), (c), and
(f), and to reflect 80 percent of any reduction elected under section
1854(f)(1)(E).'.
(ii) PAYMENT OF PREMIUMS- Section 1840 (42 U.S.C. 1395s) is amended
by adding at the end the following new subsection:
`(i) In the case of an individual enrolled in a Medicare+Choice plan, the
Secretary shall provide for necessary adjustments of the monthly beneficiary
premium to reflect 80 percent of any reduction elected under section
1854(f)(1)(E). This premium adjustment may be provided directly or as an
adjustment to any social security, railroad retirement, and civil service
retirement benefits, to the extent which the Secretary determines that such an
adjustment is appropriate with the concurrence of the agencies responsible for
the administration of such benefits.'.
(C) INFORMATION COMPARING PLAN PREMIUMS UNDER PART C- Section
1851(d)(4)(B) (42 U.S.C. 1395w-21(d)(4)(B)) is amended--
(i) by striking `PREMIUMS- The' and inserting `PREMIUMS-
`(i) IN GENERAL- The'; and
(ii) by adding at the end the following new clause:
`(ii) REDUCTIONS- The reduction in part B premiums, if
any.'.
(D) TREATMENT OF REDUCTION FOR PURPOSES OF DETERMINING GOVERNMENT
CONTRIBUTION UNDER PART B- Section 1844 (42 U.S.C. 1395w) is amended by
adding at the end the following new subsection:
`(c) The Secretary shall determine the Government contribution under
subparagraphs (A) and (B) of subsection (a)(1) without regard to any premium
reduction resulting from an election under section 1854(f)(1)(E).'.
(b) EFFECTIVE DATE- The amendments made by subsection (a) shall apply to
years beginning with 2002.
SEC. 607. FULL IMPLEMENTATION OF RISK ADJUSTMENT FOR CONGESTIVE HEART
FAILURE ENROLLEES FOR 2001.
(a) IN GENERAL- Section 1853(a)(3)(C) (42 U.S.C. 1395w-23(a)(3)(C)) is
amended--
(1) in clause (ii), by striking `Such risk adjustment' and inserting
`Except as provided in clause (iii), such risk adjustment'; and
(2) by adding at the end the following new clause:
`(iii) FULL IMPLEMENTATION OF RISK ADJUSTMENT FOR CONGESTIVE HEART
FAILURE ENROLLEES FOR 2001-
`(I) EXEMPTION FROM PHASE-IN- Subject to subclause (II), the
Secretary shall fully implement the risk adjustment methodology
described in clause (i) with respect to each individual who has had a
qualifying congestive heart failure inpatient diagnosis (as determined
by the Secretary under such risk adjustment methodology) during the
period beginning on July 1, 1999, and ending on June 30, 2000, and who
is enrolled in a coordinated care plan that is the only coordinated
care plan offered on January 1, 2001, in the service area of the
individual.
`(II) PERIOD OF APPLICATION- Subclause (I) shall only apply during
the 1-year period beginning on January 1, 2001.'.
(b) EXCLUSION FROM DETERMINATION OF THE BUDGET NEUTRALITY FACTOR- Section
1853(c)(5) (42 U.S.C. 1395w-23(c)(5)) is amended by striking `subsection (i)'
and inserting `subsections (a)(3)(C)(iii) and (i)'.
SEC. 608. EXPANSION OF APPLICATION OF MEDICARE+CHOICE NEW ENTRY BONUS.
(a) IN GENERAL- Section 1853(i)(1) (42 U.S.C. 1395w-23(i)(1)) is amended
in the matter preceding subparagraph (A) by inserting `, or filed notice with
the Secretary as of October 3, 2000, that they will not be offering such a
plan as of January 1, 2001' after `January 1, 2000'.
(b) EFFECTIVE DATE- The amendment made by subsection (a) shall apply as if
included in the enactment of BBRA.
SEC. 609. REPORT ON INCLUSION OF CERTAIN COSTS OF THE DEPARTMENT OF VETERANS
AFFAIRS AND MILITARY FACILITY SERVICES IN CALCULATING MEDICARE+CHOICE PAYMENT
RATES.
The Secretary of Health and Human Services shall report to Congress by not
later than January 1, 2003, on a method to phase-in the costs of military
facility services furnished by the Department of Veterans Affairs, and the
costs of military facility services furnished by the Department of Defense, to
medicare-eligible beneficiaries in the calculation of an area's
Medicare+Choice capitation payment. Such report shall include on a
county-by-county basis--
(1) the actual or estimated cost of such services to medicare-eligible
beneficiaries;
(2) the change in Medicare+Choice capitation payment rates if such costs
are included in the calculation of payment rates;
(3) one or more proposals for the implementation of payment adjustments
to Medicare+Choice plans in counties where the payment rate has been
affected due to the failure to calculate the cost of such services to
medicare-eligible beneficiaries; and
(4) a system to ensure that when a Medicare+Choice enrollee receives
covered services through a facility of the Department of Veterans Affairs or
the Department of Defense there is an appropriate payment recovery to the
medicare program under title XVIII of the Social Security Act.
Subtitle B--Other Medicare+Choice Reforms
SEC. 611. PAYMENT OF ADDITIONAL AMOUNTS FOR NEW BENEFITS COVERED DURING A
CONTRACT TERM.
(a) IN GENERAL- Section 1853(c)(7) (42 U.S.C. 1395w-23(c)(7)) is amended
to read as follows:
`(7) ADJUSTMENT FOR NATIONAL COVERAGE DETERMINATIONS AND LEGISLATIVE
CHANGES IN BENEFITS- If the Secretary makes a determination with respect to
coverage under this title or there is a change in benefits required to be
provided under this part that the Secretary projects will result in a
significant increase in the costs to Medicare+Choice of providing benefits
under contracts under this part (for periods after any period described in
section 1852(a)(5)), the Secretary shall adjust appropriately the payments
to such organizations under this part. Such projection and adjustment shall
be based on an analysis by the Chief Actuary of the Health Care Financing
Administration of the actuarial costs associated with the new
benefits.'.
(b) CONFORMING AMENDMENT- Section 1852(a)(5) (42 U.S.C. 1395w-22(a)(5)) is
amended--
(1) in the heading, by inserting `AND LEGISLATIVE CHANGES IN BENEFITS'
after `NATIONAL COVERAGE DETERMINATIONS';
(2) by inserting `or legislative change in benefits required to be
provided under this part' after `national coverage determination';
(3) in subparagraph (A), by inserting `or legislative change in
benefits' after `such determination';
(4) in subparagraph (B), by inserting `or legislative change' after `if
such coverage determination'; and
(5) by adding at the end the following:
`The projection under the previous sentence shall be based on an
analysis by the Chief Actuary of the Health Care Financing Administration of
the actuarial costs associated with the coverage determination or
legislative change in benefits.'.
(c) EFFECTIVE DATE- The amendments made by this section are effective on
the date of the enactment of this Act and apply to national coverage
determinations and legislative changes in benefits occurring on or after such
date.
SEC. 612. RESTRICTION ON IMPLEMENTATION OF SIGNIFICANT NEW REGULATORY
REQUIREMENTS MIDYEAR.
(a) IN GENERAL- Section 1856(b) (42 U.S.C. 1395w-26(b)) is amended by
adding at the end the following new paragraph:
`(4) PROHIBITION OF MIDYEAR IMPLEMENTATION OF SIGNIFICANT NEW REGULATORY
REQUIREMENTS- The Secretary may not implement, other than at the beginning
of a calendar year, regulations under this section that impose new,
significant regulatory requirements on a Medicare+Choice organization or
plan.'.
(b) EFFECTIVE DATE- The amendment made by subsection (a) takes effect on
the date of the enactment of this Act.
SEC. 613. TIMELY APPROVAL OF MARKETING MATERIAL THAT FOLLOWS MODEL MARKETING
LANGUAGE.
(a) IN GENERAL- Section 1851(h) (42 U.S.C. 1395w-21(h)) is amended--
(1) in paragraph (1)(A), by inserting `(or 10 days in the case described
in paragraph (5))' after `45 days'; and
(2) by adding at the end the following new paragraph:
`(5) SPECIAL TREATMENT OF MARKETING MATERIAL FOLLOWING MODEL MARKETING
LANGUAGE- In the case of marketing material of an organization that uses,
without modification, proposed model language specified by the Secretary,
the period specified in paragraph (1)(A) shall be reduced from 45 days to 10
days.'.
(b) EFFECTIVE DATE- The amendments made by subsection (a) apply to
marketing material submitted on or after January 1, 2001.
SEC. 614. AVOIDING DUPLICATIVE REGULATION.
(a) IN GENERAL- Section 1856(b)(3)(B) (42 U.S.C. 1395w-26(b)(3)(B)) is
amended--
(1) in clause (i), by inserting `(including cost-sharing requirements)'
after `Benefit requirements'; and
(2) by adding at the end the following new clause:
`(iv) Requirements relating to marketing materials and summaries and
schedules of benefits regarding a Medicare+Choice plan.'.
(b) EFFECTIVE DATE- The amendments made by subsection (a) take effect on
the date of the enactment of this Act.
SEC. 615. ELECTION OF UNIFORM LOCAL COVERAGE POLICY FOR MEDICARE+CHOICE PLAN
COVERING MULTIPLE LOCALITIES.
Section 1852(a)(2) (42 U.S.C. 1395w-22(a)(2)) is amended by adding at the
end the following new subparagraph:
`(C) ELECTION OF UNIFORM COVERAGE POLICY- In the case of a
Medicare+Choice organization that offers a Medicare+Choice plan in an area
in which more than one local coverage policy is applied with respect to
different parts of the area, the organization may elect to have the local
coverage policy for the part of the area that is most beneficial to
Medicare+Choice enrollees (as identified by the Secretary) apply with
respect to all Medicare+Choice enrollees enrolled in the plan.'.
SEC. 616. ELIMINATING HEALTH DISPARITIES IN MEDICARE+CHOICE PROGRAM.
(a) QUALITY ASSURANCE PROGRAM FOCUS ON RACIAL AND ETHNIC MINORITIES-
Subparagraphs (A) and (B) of
section 1852(e)(2) (42 U.S.C. 1395w-22(e)(2)) are each amended by adding at
the end the following:
`Such program shall include a separate focus (with respect to all the
elements described in this subparagraph) on racial and ethnic
minorities.'.
(b) REPORT- Section 1852(e) (42 U.S.C. 1395w-22(e)) is amended by adding
at the end the following new paragraph:
`(A) IN GENERAL- Not later than 2 years after the date of the
enactment of this paragraph, and biennially thereafter, the Secretary
shall submit to Congress a report regarding how quality assurance programs
conducted under this subsection focus on racial and ethnic
minorities.
`(B) CONTENTS OF REPORT- Each such report shall include the
following:
`(i) A description of the means by which such programs focus on such
racial and ethnic minorities.
`(ii) An evaluation of the impact of such programs on eliminating
health disparities and on improving health outcomes, continuity and
coordination of care, management of chronic conditions, and consumer
satisfaction.
`(iii) Recommendations on ways to reduce clinical outcome
disparities among racial and ethnic minorities.'.
SEC. 617. 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) MEDICARE+CHOICE 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. 618. SPECIAL MEDIGAP ENROLLMENT ANTIDISCRIMINATION PROVISION FOR
CERTAIN BENEFICIARIES.
(a) DISENROLLMENT WINDOW IN ACCORDANCE WITH BENEFICIARY'S CIRCUMSTANCE-
Section 1882(s)(3) (42 U.S.C. 1395ss(s)(3)) is amended--
(1) in subparagraph (A), in the matter following clause (iii), by
striking `, subject to subparagraph (E), seeks to enroll under the policy
not later than 63 days after the date of the termination of enrollment
described in such subparagraph' and inserting `seeks to enroll under the
policy during the period specified in subparagraph (E)'; and
(2) by striking subparagraph (E) and inserting the following new
subparagraph:
`(E) For purposes of subparagraph (A), the time period specified in this
subparagraph is--
`(i) in the case of an individual described in subparagraph (B)(i), the
period beginning on the date the individual receives a notice of termination
or cessation of all supplemental health benefits (or, if no such notice is
received, notice that a claim has been denied because of such a termination
or cessation) and ending on the date that is 63 days after the applicable
notice;
`(ii) in the case of an individual described in clause (ii), (iii), (v),
or (vi) of subparagraph (B) whose enrollment is terminated involuntarily,
the period beginning on the date that the individual receives a notice of
termination and ending on the date that is 63 days after the date the
applicable coverage is terminated;
`(iii) in the case of an individual described in subparagraph
(B)(iv)(I), the period beginning on the earlier of (I) the date that the
individual receives a notice of termination, a notice of the issuer's
bankruptcy or insolvency, or other such similar notice, if any, and (II) the
date that the applicable coverage is terminated, and ending on the date that
is 63 days after the date the coverage is terminated;
`(iv) in the case of an individual described in clause (ii), (iii),
(iv)(II), (iv)(III), (v), or (vi) of subparagraph (B) who disenrolls
voluntarily, the period beginning on the date that is 60 days before the
effective date of the disenrollment and ending on the date that is 63 days
after such effective date; and
`(v) in the case of an individual described in subparagraph (B) but not
described in the preceding provisions of this subparagraph, the period
beginning on the effective date of the disenrollment and ending on the date
that is 63 days after such effective date.'.
(b) EXTENDED MEDIGAP ACCESS FOR INTERRUPTED TRIAL PERIODS- Section
1882(s)(3) (42 U.S.C. 1395ss(s)(3)), as amended by subsection (a), is further
amended by adding at the end the following new subparagraph:
`(F)(i) Subject to clause (ii), for purposes of this paragraph--
`(I) in the case of an individual described in subparagraph (B)(v) (or
deemed to be so described, pursuant to this subparagraph) whose enrollment
with an organization or provider described in subclause (II) of such
subparagraph is involuntarily terminated within the first 12 months of such
enrollment, and who, without an intervening enrollment, enrolls with another
such organization or provider, such subsequent enrollment shall be deemed to
be an initial enrollment described in such subparagraph; and
`(II) in the case of an individual described in clause (vi) of
subparagraph (B) (or deemed to be so described, pursuant to this
subparagraph) whose enrollment with a plan or in a program described in such
clause is involuntarily terminated within the first 12 months of such
enrollment, and who, without an intervening enrollment, enrolls in another
such plan or program, such subsequent enrollment shall be deemed to be an
initial enrollment described in such clause.
`(ii) For purposes of clauses (v) and (vi) of subparagraph (B), no
enrollment of an individual with an organization or provider described in
clause (v)(II), or with a plan or in a program described in clause (vi), may
be deemed to be an initial enrollment under this clause after the 2-year
period beginning on the date on which the individual first enrolled with such
an organization, provider, plan, or program.'.
SEC. 619. RESTORING EFFECTIVE DATE OF ELECTIONS AND CHANGES OF ELECTIONS OF
MEDICARE+CHOICE PLANS.
(a) OPEN ENROLLMENT- Section 1851(f)(2) (42 U.S.C. 1395w-21(f)(2)) is
amended by striking `, except that if such election or change is made after
the 10th day of any calendar month, then the election or change shall not take
effect until the first day of the second calendar month following the date on
which the election or change is made'.
(b) EFFECTIVE DATE- The amendment made by this section shall apply to
elections and changes of coverage made on or after January 1, 2001.
SEC. 620. PERMITTING ESRD BENEFICIARIES TO ENROLL IN ANOTHER MEDICARE+CHOICE
PLAN IF THE PLAN IN WHICH THEY ARE ENROLLED IS TERMINATED.
(a) IN GENERAL- Section 1851(a)(3)(B) (42 U.S.C. 1395w-21(a)(3)(B)) is
amended by striking `except that' and all that follows and inserting the
following: `except that--
`(i) an individual who develops end-stage renal disease while
enrolled in a Medicare+Choice plan may continue to be enrolled in that
plan; and
`(ii) in the case of such an individual who is enrolled in a
Medicare+Choice plan under clause (i) (or subsequently under this
clause), if the enrollment is discontinued under circumstances described
in section 1851(e)(4)(A), then the individual will be treated as a
`Medicare+Choice eligible individual' for purposes of electing to
continue enrollment in another Medicare+Choice plan.'.
(1) IN GENERAL- The amendment made by subsection (a) shall apply to
terminations and discontinuations occurring on or after the date of the
enactment of this Act.
(2) APPLICATION TO PRIOR PLAN TERMINATIONS- Clause (ii) of section
1851(a)(3)(B) of the Social Security Act (as inserted by subsection (a))
also shall apply to individuals whose enrollment in a Medicare+Choice plan
was terminated or discontinued after December 31, 1998, and before the date
of the enactment of this Act. In applying this paragraph, such an individual
shall be treated, for purposes of part C of title XVIII of the Social
Security Act, as having discontinued enrollment in such a plan as of the
date of the enactment of this Act.
SEC. 621. PROVIDING CHOICE FOR SKILLED NURSING FACILITY SERVICES UNDER THE
MEDICARE+CHOICE PROGRAM.
(a) IN GENERAL- Section 1852 (42 U.S.C. 1395w-22) is amended by adding at
the end the following new subsection:
`(l) RETURN TO HOME SKILLED NURSING FACILITIES FOR COVERED POST-HOSPITAL
EXTENDED CARE SERVICES-
`(1) ENSURING RETURN TO HOME SNF-
`(A) IN GENERAL- In providing coverage of post-hospital extended care
services, a Medicare+Choice plan shall provide for such coverage through a
home skilled nursing facility if the following conditions are
met:
`(i) ENROLLEE ELECTION- The enrollee elects to receive such coverage
through such facility.
`(ii) SNF AGREEMENT- The facility has a contract with the
Medicare+Choice organization for the provision of such services, or the
facility agrees to accept substantially similar payment under the same
terms and conditions that apply to similarly situated skilled nursing
facilities that are under contract with the Medicare+Choice organization
for the provision of such services and through which the enrollee would
otherwise receive such services.
`(B) MANNER OF PAYMENT TO HOME SNF- The organization shall provide
payment to the home skilled nursing facility consistent with the contract
or the agreement described in subparagraph (A)(ii), as the case may
be.
`(2) NO LESS FAVORABLE COVERAGE- The coverage provided under paragraph
(1) (including scope of services, cost-sharing, and other criteria of
coverage) shall be no less favorable to the enrollee than the coverage that
would be provided to the enrollee with respect to a skilled nursing facility
the post-hospital extended care services of which are otherwise covered
under the Medicare+Choice plan.
`(3) RULE OF CONSTRUCTION- Nothing in this subsection shall be construed
to do the following:
`(A) To require coverage through a skilled nursing facility that is
not otherwise qualified to provide benefits under part A for medicare
beneficiaries not enrolled in a Medicare+Choice plan.
`(B) To prevent a skilled nursing facility from refusing to accept, or
imposing conditions upon the acceptance of, an enrollee for the receipt of
post-hospital extended care services.
`(4) DEFINITIONS- In this subsection:
`(A) HOME SKILLED NURSING FACILITY- The term `home skilled nursing
facility' means, with respect to an enrollee who is entitled to receive
post-hospital extended care services under a Medicare+Choice plan, any of
the following skilled nursing facilities:
`(i) SNF RESIDENCE AT TIME OF ADMISSION- The skilled nursing
facility in which the enrollee resided at the time of admission to the
hospital preceding the receipt of such post-hospital extended care
services.
`(ii) SNF IN CONTINUING CARE RETIREMENT COMMUNITY- A skilled nursing
facility that is providing such services through a continuing care
retirement community (as defined in subparagraph (B)) which provided
residence to the enrollee at the time of such admission.
`(iii) SNF RESIDENCE OF SPOUSE AT TIME OF DISCHARGE- The skilled
nursing facility in which the spouse of the enrollee is residing at the
time of discharge from such hospital.
`(B) CONTINUING CARE RETIREMENT COMMUNITY- The term `continuing care
retirement community' means, with respect to an enrollee in a
Medicare+Choice plan, an arrangement under which housing and
health-related services are provided (or arranged) through an organization
for the enrollee under an agreement that is effective for the life of the
enrollee or for a specified period.'.
(b) EFFECTIVE DATE- The amendment made by subsection (a) applies with
respect to contracts entered into or renewed on or after the date of the
enactment of this Act.
(1) STUDY- The Medicare Payment Advisory Commission shall conduct a
study analyzing the effects of the amendment made by subsection (a) on
Medicare+Choice organizations. In conducting such study, the Commission
shall examine the effects (if any) such amendment has had on--
(A) the scope of additional benefits provided under the
Medicare+Choice program;
(B) the administrative and other costs incurred by Medicare+Choice
organizations;
(C) the contractual relationships between such organizations and
skilled nursing facilities.
(2) REPORT- Not later than 2 years after the date of the enactment of
this Act, the Commission shall submit to Congress a report on the study
conducted under paragraph (1).
SEC. 622. PROVIDING FOR ACCOUNTABILITY OF MEDICARE+CHOICE PLANS.
(a) MANDATORY REVIEW OF ACR SUBMISSIONS BY THE CHIEF ACTUARY OF THE HEALTH
CARE FINANCING ADMINISTRATION- Section 1854(a)(5)(A) (42 U.S.C.
1395w-24(a)(5)(A)) is amended--
(1) by striking `value' and inserting `values'; and
(2) by adding at the end the following: `The Chief Actuary of the Health
Care Financing Administration shall review the actuarial assumptions and
data used by the Medicare+Choice organization with respect to such rates,
amounts, and values so submitted to determine the appropriateness of such
assumptions and data.'.
(b) EFFECTIVE DATE- The amendment made by subsection (a) applies to
submissions made on or after January 1, 2001.
SEC. 623. CIVIL MONETARY PENALTIES FOR CONTRACT DEFAULT BY A MEDICARE+CHOICE
ORGANIZATION.
(a) IN GENERAL- Section 1857(g)(3) is amended by adding at the end the
following new subparagraph:
`(D) Civil monetary penalties of up to $25,000 per enrollee or
$100,000 per organization, whichever is greater, where the finding under
subsection (c)(2)(A) is based on the organization's defaulting on its
contract.'.
Subtitle C--Other Managed Care Reforms
SEC. 631. 1-YEAR EXTENSION OF SOCIAL HEALTH MAINTENANCE ORGANIZATION (SHMO)
DEMONSTRATION PROJECT.
Section 4018(b)(1) of the Omnibus Budget Reconciliation Act of 1987, as
amended by section 531(a)(1) of BBRA (113 Stat. 1501A-388), is amended by
striking `18 months' and inserting `30 months'.
SEC. 632. REVISED TERMS AND CONDITIONS FOR EXTENSION OF MEDICARE COMMUNITY
NURSING ORGANIZATION (CNO) DEMONSTRATION PROJECT.
(a) IN GENERAL- Section 532 of BBRA (113 Stat. 1501A-388) is amended--
(1) in subsection (a), by striking the second sentence; and
(2) by striking subsection (b) and inserting the following new
subsection:
`(b) TERMS AND CONDITIONS-
`(1) JANUARY THROUGH SEPTEMBER 2000- For the 9-month period beginning
with January 2000, any such demonstration project shall be conducted under
the same terms and conditions as applied to such demonstration during
1999.
`(2) OCTOBER 2000 THROUGH DECEMBER 2001- For the 15-month period
beginning with October 2000, any such demonstration project shall be
conducted under the same terms and conditions as applied to such
demonstration during 1999, except that the following modifications shall
apply:
`(A) BASIC CAPITATION RATE- The basic capitation rate paid for
services covered under the project (other than case management services)
per enrollee per month and furnished during--
`(i) the period beginning with October 1, 2000, and ending with
December 31, 2000, shall be
determined by actuarially adjusting the actual capitation rate paid for such
services in 1999 for inflation, utilization, and other changes to the CNO
service package, and by reducing such adjusted capitation rate by 10 percent in
the case of the demonstration sites located in Arizona, Minnesota, and Illinois,
and 15 percent for the demonstration site located in New York; and
`(ii) 2001 shall be determined by actuarially adjusting the
capitation rate determined under clause (i) for inflation, utilization,
and other changes to the CNO service package.
`(B) TARGETED CASE MANAGEMENT FEE- Effective October 1,
2000--
`(i) the case management fee per enrollee per month
for--
`(I) the period described in subparagraph (A)(i) shall be
determined by actuarially adjusting the case management fee for 1999
for inflation; and
`(II) 2001 shall be determined by actuarially adjusting the amount
determined under subclause (I) for inflation; and
`(ii) such case management fee shall be paid only for enrollees who
are classified as moderately frail or frail pursuant to criteria
established by the Secretary.
`(C) GREATER UNIFORMITY IN CLINICAL FEATURES AMONG SITES- Each project
shall implement for each site--
`(i) protocols for periodic telephonic contact with enrollees based
on--
`(I) the results of such standardized written health assessment;
and
`(II) the application of appropriate care planning
approaches;
`(ii) disease management programs for targeted diseases (such as
congestive heart failure, arthritis, diabetes, and hypertension) that
are highly prevalent in the enrolled populations;
`(iii) systems and protocols to track enrollees through
hospitalizations, including pre-admission planning, concurrent
management during inpatient hospital stays, and post-discharge
assessment, planning, and follow-up; and
`(iv) standardized patient educational materials for specified
diseases and health conditions.
`(D) QUALITY IMPROVEMENT- Each project shall implement at each site
once during the 15-month period--
`(i) enrollee satisfaction surveys; and
`(ii) reporting on specified quality indicators for the enrolled
population.
`(1) PRELIMINARY REPORT- Not later than July 1, 2001, the Secretary of
Health and Human Services shall submit to the Committees on Ways and Means
and Commerce of the House of Representatives and the Committee on Finance of
the Senate a preliminary report that--
`(A) evaluates such demonstration projects for the period beginning
July 1, 1997, and ending December 31, 1999, on a site-specific basis with
respect to the impact on per beneficiary spending, specific health
utilization measures, and enrollee satisfaction; and
`(B) includes a similar evaluation of such projects for the portion of
the extension period that occurs after September 30, 2000.
`(2) FINAL REPORT- The Secretary shall submit a final report to such
Committees on such demonstration projects not later than July 1, 2002. Such
report shall include the same elements as the preliminary report required by
paragraph (1), but for the period after December 31, 1999.
`(3) METHODOLOGY FOR SPENDING COMPARISONS- Any evaluation of the impact
of the demonstration projects on per beneficiary spending included in such
reports shall include a comparison of--
`(A) data for all individuals who--
`(i) were enrolled in such demonstration projects as of the first
day of the period under evaluation; and
`(ii) were enrolled for a minimum of 6 months thereafter;
with
`(B) data for a matched sample of individuals who are enrolled under
part B of title XVIII of the Social Security Act and are not enrolled in
such a project, or in a Medicare+Choice plan under part C of such title, a
plan offered by an eligible organization under section 1876 of such Act,
or a health care prepayment plan under section 1833(a)(1)(A) of such
Act.'.
(b) EFFECTIVE DATE- The amendments made by subsection (a) shall be
effective as if included in the enactment of section 532 of BBRA (113 Stat.
1501A-388).
SEC. 633. EXTENSION OF MEDICARE MUNICIPAL HEALTH SERVICES DEMONSTRATION
PROJECTS.
Section 9215(a) of the Consolidated Omnibus Budget Reconciliation Act of
1985 (42 U.S.C. 1395b-1 note), as amended by section 6135 of the Omnibus
Budget Reconciliation Act of 1989, section 13557 of the Omnibus Budget
Reconciliation Act of 1993, section 4017 of BBA, and section 534 of BBRA (113
Stat. 1501A-390), is amended by striking `December 31, 2002' and inserting
`December 31, 2004'.
SEC. 634. SERVICE AREA EXPANSION FOR MEDICARE COST CONTRACTS DURING
TRANSITION PERIOD.
Section 1876(h)(5) (42 U.S.C. 1395mm(h)(5)) is amended--
(1) by redesignating subparagraph (B) as subparagraph (C); and
(2) by inserting after subparagraph (A), the following new
subparagraph:
`(B) Subject to subparagraph (C), the Secretary shall approve an
application for a modification to a reasonable cost contract under this
section in order to expand the service area of such contract if--
`(i) such application is submitted to the Secretary on or before
September 1, 2003; and
`(ii) the Secretary determines that the organization with the contract
continues to meet the requirements applicable to such organizations and
contracts under this section.'.
TITLE VII--MEDICAID
SEC. 701. DSH PAYMENTS.
(a) Continuation of Medicaid DSH Allotments at Fiscal Year 2000 Levels for
Fiscal Years 2001 and 2002- 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--
(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
(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 new subsection:
`(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 such
patients receive medical assistance 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)'.
(A) The amendment made by paragraph (1) applies to contracts as of
January 1, 2001.
(B) The amendments made by paragraph (2) apply to payments made on or
after January 1, 2001.
(f) APPLICATION OF MEDICAID DSH TRANSITION RULE TO PUBLIC HOSPITALS IN ALL
STATES-
(1) IN GENERAL- During the period described in paragraph (3), with
respect to a State, section 4721(e) of the Balanced Budget Act of 1997
(Public Law 105-33; 111 Stat. 514), as amended by section 607 of BBRA (113
Stat. 1501A-321) shall be applied as though--
(A) `September 30, 2002' were substituted for `July 1, 1997' each
place it appears;
(B) `hospitals owned or operated by a State (as defined for purposes
of title XIX of such Act), or by an instrumentality or a unit of
government within a State (as so defined)' were substituted for `the State
of California';
(C) paragraph (3) were redesignated as paragraph (4);
(D) `and' were omitted from the end of paragraph (2); and
(E) the following new paragraph were inserted after paragraph
(2):
`(3) `(as defined in subparagraph (B) but without regard to clause (ii)
of that subparagraph and subject to subsection (d))' were substituted for
`(as defined in subparagraph (B))' in subparagraph (A) of such section;
and'.
(2) SPECIAL RULE- With respect to California, section 4721(e) of the
Balanced Budget Act of 1997 (Public Law 105-33; 111 Stat. 514) shall be
applied without regard to paragraph (1).
(3) PERIOD DESCRIBED- The period described in this paragraph is the
period that begins, with respect to a State, on the first day of the first
State fiscal year that begins after September 30, 2002, and ends on the last
day of the succeeding State fiscal year.
(4) APPLICATION TO WAIVERS- With respect to a State operating under a
waiver of the requirements of title XIX of the Social Security Act (42
U.S.C. 1396 et seq.) under section 1115 of such Act (42 U.S.C. 1315), the
amount by which any payment adjustment made by the State under title XIX of
such Act (42 U.S.C. 1396 et seq.), after the application of section 4721(e)
of the Balanced Budget Act of 1997 under paragraph (1) to such State,
exceeds the costs of furnishing hospital services provided by hospitals
described in such section shall be fully reflected as an increase in the
baseline expenditure limit for such waiver.
(g) ASSISTANCE FOR CERTAIN PUBLIC HOSPITALS-
(1) IN GENERAL- Beginning with fiscal year 2002, notwithstanding section
1923(f) of the Social Security Act (42 U.S.C. 1396r-4(f)) and subject to
paragraph (3), with respect to a State, payment adjustments made under title
XIX of the Social Security Act (42 U.S.C. 1396 et seq.) to a hospital
described in paragraph (2) shall be made without regard to the DSH allotment
limitation for the State determined under section 1923(f) of that Act (42
U.S.C. 1396r-4(f)).
(2) HOSPITAL DESCRIBED- A hospital is described in this paragraph if the
hospital--
(A) is owned or operated by a State (as defined for purposes of title
XIX of the Social Security Act), or by an instrumentality or a unit of
government within a State (as so defined);
(B) as of October 1, 2000--
(i) is in existence and operating as a hospital described in
subparagraph (A); and
(ii) is not receiving disproportionate share hospital payments from
the State in which it is located under title XIX of such Act;
and
(C) has a low-income utilization rate (as defined in section
1923(b)(3) of the Social Security Act (42 U.S.C. 1396r-4(b)(3))) in excess
of 65 percent.
(3) LIMITATION ON EXPENDITURES-
(A) IN GENERAL- With respect to any fiscal year, the aggregate amount
of Federal financial participation that may be provided for payment
adjustments described in paragraph (1) for that fiscal year for all States
may not exceed the amount described in subparagraph (B) for the fiscal
year.
(B) AMOUNT DESCRIBED- The amount described in this subparagraph for a
fiscal year is as follows:
(i) For fiscal year 2002, $15,000,000.
(ii) For fiscal year 2003, $176,000,000.
(iii) For fiscal year 2004, $269,000,000.
(iv) For fiscal year 2005, $330,000,000.
(v) For fiscal year 2006 and each fiscal year thereafter,
$375,000,000.
(h) DSH PAYMENT ACCOUNTABILITY STANDARDS- Not later than September 30,
2002, the Secretary of Health and Human Services shall implement
accountability standards to ensure that Federal funds provided with respect to
disproportionate share hospital adjustments made under section 1923 of the
Social Security Act (42 U.S.C. 1396r-4) are used to reimburse States and
hospitals eligible for such payment adjustments for providing uncompensated
health care to low-income patients and are otherwise made in accordance with
the requirements of section 1923 of that Act.
SEC. 702. 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--
(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.
`(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 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-
`(A) IN GENERAL- 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 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.
`(B) PAYMENT SCHEDULE- The supplemental payment required under
subparagraph (A) shall be made pursuant to a payment schedule agreed to by
the State and the Federally-qualified health center or rural health
clinic, but in no case less frequently than every 4 months.
`(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 BBA (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 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. 703. STREAMLINED APPROVAL OF CONTINUED STATE-WIDE SECTION 1115 MEDICAID
WAIVERS.
(a) IN GENERAL- Section 1115 (42 U.S.C. 1315) is amended by adding at the
end the following new subsection:
`(f) An application by the chief executive officer of a State for an
extension of a waiver project the State is operating under an extension under
subsection (e) (in this subsection referred to as the `waiver project') shall
be submitted and approved or disapproved in accordance with the following:
`(1) The application for an extension of the waiver project shall be
submitted to the Secretary at least 120 days prior to the expiration of the
current period of the waiver project.
`(2) Not later than 45 days after the date such application is received
by the Secretary, the Secretary shall notify the State if the Secretary
intends to review the terms and conditions of the waiver project. A failure
to provide such notification shall be deemed to be an approval of the
application.
`(3) Not later than 45 days after the date a notification is made in
accordance with paragraph (2), the Secretary shall inform the State of
proposed changes in the terms and conditions of the waiver project. A
failure to provide such information shall be deemed to be an approval of the
application.
`(4) During the 30-day period that begins on the date information
described in paragraph (3) is provided to a State, the Secretary shall
negotiate revised terms and conditions of the waiver project with the
State.
`(5)(A) Not later than 120 days after the date an application for an
extension of the waiver project is submitted to the Secretary (or such later
date agreed to by the chief executive officer of the State), the Secretary
shall--
`(i) approve the application subject to such modifications in the
terms and conditions--
`(I) as have been agreed to by the Secretary and the State;
or
`(II) in the absence of such agreement, as are determined by the
Secretary to be reasonable, consistent with the overall objectives of
the waiver project, and not in violation of applicable law;
or
`(ii) disapprove the application.
`(B) A failure by the Secretary to approve or disapprove an application
submitted under this subsection in accordance with the requirements of
subparagraph (A) shall be deemed to be an approval of the application
subject to such modifications in the terms and conditions as have been
agreed to (if any) by the Secretary and the State.
`(6) An approval of an application for an extension of a waiver project
under this subsection shall be for a period not to exceed 3 years.
`(7) An extension of a waiver project under this subsection shall be
subject to the final reporting and evaluation requirements of paragraphs (4)
and (5) of subsection (e) (taking into account the extension under this
subsection with respect to any timing requirements imposed under those
paragraphs).'.
(b) EFFECTIVE DATE- The amendment made by subsection (a) applies to
requests for extensions of demonstration projects pending or submitted on or
after the date of the enactment of this Act.
SEC. 704. MEDICAID COUNTY-ORGANIZED HEALTH SYSTEMS.
(a) IN GENERAL- Section 9517(c)(3)(C) of the Comprehensive Omnibus Budget
Reconciliation Act of 1985 is amended by striking `10 percent' and inserting
`14 percent'.
(b) EFFECTIVE DATE- The amendment made by subsection (a) takes effect on
the date of the enactment of this Act.
SEC. 705. DEADLINE FOR ISSUANCE OF FINAL REGULATION RELATING TO MEDICAID
UPPER PAYMENT LIMITS.
(a) IN GENERAL- Not later than December 31, 2000, the Secretary of Health
and Human Services (in this section referred to as the `Secretary'),
notwithstanding any requirement of the Administrative Procedures Act under
chapter 5 of title 5, United States Code, or any other provision of law, shall
issue under sections 447.272, 447.304, and 447.321 of title 42, Code of
Federal Regulations (and any other section of part 447 of title 42, Code of
Federal Regulations that the Secretary determines is appropriate), a final
regulation based on the proposed rule announced on October 5, 2000, that--
(1) modifies the upper payment limit test applied to State medicaid
spending for inpatient hospital services, outpatient hospital services,
nursing facility services, intermediate care facility services for the
mentally retarded, and clinic services by applying an aggregate upper
payment limit to payments made to government facilities that are not
State-owned or operated facilities; and
(2) provides for a transition period in accordance with subsection
(b).
(1) IN GENERAL- The final regulation required under subsection (a) shall
provide that, with respect to a State described in paragraph (3), the State
shall be considered to be in compliance with the final regulation required
under subsection (a) so long as, for each State fiscal year during the
period described in paragraph (4), the State reduces payments under a State
medicaid plan payment provision or methodology described in paragraph (3),
or reduces the actual dollar payment levels described in paragraph (3)(B),
so that the amount of the payments that would otherwise have been made under
such provision, methodology, or payment
levels by the State for any State fiscal year during such period is reduced
by 15 percent in the first such State fiscal year, and by an additional 15
percent in each of next 5 State fiscal years.
(2) REQUIREMENT- Notwithstanding paragraph (1), the final regulation
required under subsection (a) shall provide that, for any period (or portion
of a period) that occurs on or after October 1, 2008, medicaid payments made
by a State described in paragraph (3) shall comply with such final
regulation.
(3) STATE DESCRIBED- A State described in this paragraph is a State with
a State medicaid plan payment provision or methodology which--
(A) was approved, deemed to have been approved, or was in effect on or
before October 1, 1992 (including any subsequent amendments or successor
provisions or methodologies and whether or not a State plan amendment was
made to carry out such provision or methodology after such date) or under
which claims for Federal financial participation were filed and paid on or
before such date; and
(B) provides for payments that are in excess of the upper payment
limit test established under the final regulation required under
subsection (a) (or which would be noncompliant with such final regulation
if the actual dollar payment levels made under the payment provision or
methodology in the State fiscal year which begins during 1999 were
continued).
(4) PERIOD DESCRIBED- The period described in this paragraph is the
period that begins on the first State fiscal year that begins after
September 30, 2002, and ends on September 30, 2008.
SEC. 706. ALASKA FMAP.
Notwithstanding the first sentence of section 1905(b) of the Social
Security Act (42 U.S.C. 1396d(b)), only with respect to each of fiscal years
2001 through 2005, for purposes of titles XIX and XXI of the Social Security
Act, the State percentage used to determine the Federal medical assistance
percentage for Alaska shall be that percentage which bears the same ratio to
45 percent as the square of the adjusted per capita income of Alaska
(determined by dividing the State's 3-year average per capita income by 1.05)
bears to the square of the per capita income of the 50 States.
SEC. 707. 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 States 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. 708. 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. 709. 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.
TITLE VIII--STATE CHILDREN'S HEALTH INSURANCE PROGRAM
SEC. 801. 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. 802. AUTHORITY TO PAY MEDICAID EXPANSION SCHIP COSTS FROM TITLE XXI
APPROPRIATION.
(a) AUTHORITY TO PAY MEDICAID EXPANSION SCHIP COSTS FROM TITLE XXI
APPROPRIATION- Section 2105(a) (42 U.S.C. 1397ee(a)) is amended--
(1) by redesignating subparagraphs (A) through (D) of paragraph (2) as
clauses (i) through (iv), respectively, and indenting appropriately;
(2) by redesignating paragraph (1) as subparagraph (C), and indenting
appropriately;
(3) by redesignating paragraph (2) as subparagraph (D), and indenting
appropriately;
(4) by striking `(a) IN GENERAL- ' and the remainder of the text that
precedes subparagraph (C), as so redesignated, and inserting the
following:
`(1) IN GENERAL- Subject to the succeeding provisions of this section,
the Secretary shall pay to each State with a plan approved under this title,
from its allotment under section 2104, an amount for each quarter equal to
the enhanced FMAP (or, in the case of expenditures described in subparagraph
(B), the Federal medical assistance percentage (as defined in the first
sentence of section 1905(b))) of expenditures in the quarter--
`(A) for child health assistance under the plan for targeted
low-income children in the form of providing medical assistance for which
payment is made on the basis of an enhanced FMAP under the fourth sentence
of section 1905(b);
`(B) for the provision of medical assistance on behalf of a child
during a presumptive eligibility period under section 1920A;';
and
(5) by adding after subparagraph (D), as so redesignated, the following
new paragraph:
`(2) ORDER OF PAYMENTS- Payments under paragraph (1) from a State's
allotment shall be made in the following order:
`(A) First, for expenditures for items described in paragraph
(1)(A).
`(B) Second, for expenditures for items described in paragraph
(1)(B).
`(C) Third, for expenditures for items described in paragraph
(1)(C).
`(D) Fourth, for expenditures for items described in paragraph
(1)(D).'.
(b) ELIMINATION OF REQUIREMENT TO REDUCE TITLE XXI ALLOTMENT BY MEDICAID
EXPANSION SCHIP COSTS- Section 2104 (42 U.S.C. 1397dd) is amended by striking
subsection (d).
(c) AUTHORITY TO TRANSFER TITLE XXI APPROPRIATIONS TO TITLE XIX
APPROPRIATION ACCOUNT AS REIMBURSEMENT FOR MEDICAID EXPENDITURES FOR MEDICAID
EXPANSION SCHIP SERVICES- Notwithstanding any other provision of law, all
amounts appropriated under title XXI and allotted to a State pursuant to
subsection (b) or (c) of section 2104 of the Social Security Act (42 U.S.C.
1397dd) for fiscal
years 1998 through 2000 (including any amounts that, but for this provision,
would be considered to have expired) and not expended in providing child health
assistance or related services for which payment may be made pursuant to
subparagraph (C) or (D) of section 2105(a)(1) of such Act (42 U.S.C.
1397ee(a)(1)) (as amended by subsection (a)), shall be available to reimburse
the Grants to States for Medicaid account in an amount equal to the total
payments made to such State under section 1903(a) of such Act (42 U.S.C.
1396b(a)) for expenditures in such years for medical assistance described in
subparagraphs (A) and (B) of section 2105(a)(1) of such Act (42 U.S.C.
1397ee(a)(1) (as so amended).
(d) CONFORMING AMENDMENTS-
(1) Section 1905(b) (42 U.S.C. 1396d(b)) is amended in the fourth
sentence by striking `the State's allotment under section 2104 (not taking
into account reductions under section 2104(d)(2)) for the fiscal year
reduced by the amount of any payments made under section 2105 to the State
from such allotment for such fiscal year' and inserting `the State's
available allotment under section 2104'.
(2) Section 1905(u)(1)(B) (42 U.S.C. 1396d(u)(1)(B)) is amended by
striking `and section 2104(d)'.
(3) Section 2104 (42 U.S.C. 1397dd), as amended by subsection (b), is
further amended--
(A) in subsection (b)(1), by striking `and subsection (d)';
and
(B) in subsection (c)(1), by striking `subject to subsection
(d),'.
(4) Section 2105(c) (42 U.S.C. 1397ee(c)) is amended--
(A) in paragraph (2)(A), by striking all that follows `Except as
provided in this paragraph,' and inserting `the amount of payment that may
be made under subsection (a) for a fiscal year for expenditures for items
described in paragraph (1)(D) of such subsection shall not exceed 10
percent of the total amount of expenditures for which payment is made
under subparagraphs (A), (C), and (D) of paragraph (1) of such
subsection.';
(B) in paragraph (2)(B), by striking `described in subsection (a)(2)'
and inserting `described in subsection (a)(1)(D)'; and
(C) in paragraph (6)(B), by striking `Except as otherwise provided by
law,' and inserting `Except as provided in subparagraph (A) or (B) of
subsection (a)(1) or any other provision of law,'.
(5) Section 2110(a) (42 U.S.C. 1397jj(a)) is amended by striking
`section 2105(a)(2)(A)' and inserting `section 2105(a)(1)(D)(i)'.
(e) TECHNICAL AMENDMENT- Section 2105(d)(2)(B)(ii) (42 U.S.C.
1397ee(d)(2)(B)(ii)) is amended by striking `enhanced FMAP under section
1905(u)' and inserting `enhanced FMAP under the fourth sentence of section
1905(b)'.
(f) EFFECTIVE DATE- The amendments made by this section shall be effective
as if included in the enactment of section 4901 of the BBA (111 Stat. 552).
SEC. 803. OPTIONAL COVERAGE OF CERTAIN LEGAL IMMIGRANTS UNDER SCHIP.
(a) IN GENERAL- Section 2107(e)(1) (42 U.S.C. 1397gg(e)(1)) as amended in
section 707(d), is further 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 subsection (a) takes effect
October 1, 2000, and applies to medical assistance and child health assistance
furnished on or after such date.
TITLE IX--OTHER PROVISIONS
Subtitle A--PACE Program
SEC. 901. EXTENSION OF TRANSITION FOR CURRENT WAIVERS.
Section 4803(d)(2) of BBA is amended--
(1) in subparagraph (A), by striking `24 months' and inserting `36
months';
(2) in subparagraph (A), by striking `the initial effective date of
regulations described in subsection (a)' and inserting `July 1, 2000';
and
(3) in subparagraph (B), by striking `3 years' and inserting `4
years'.
SEC. 902. CONTINUING OF CERTAIN OPERATING ARRANGEMENTS PERMITTED.
(a) IN GENERAL- Section 1894(f)(2) (42 U.S.C. 1395eee(f)(2)) is amended by
adding at the end the following new subparagraph:
`(C) CONTINUATION OF MODIFICATIONS OR WAIVERS OF OPERATIONAL
REQUIREMENTS UNDER DEMONSTRATION STATUS- If a PACE program operating under
demonstration authority has contractual or other operating arrangements
which are not otherwise recognized in regulation and which were in effect
on July 1, 2000, the Secretary (in close consultation with, and with the
concurrence of, the State administering agency) shall permit any such
program to continue such arrangements so long as such arrangements are
found by the Secretary and the State to be reasonably consistent with the
objectives of the PACE program.'.
(b) CONFORMING AMENDMENT- Section 1934(f)(2) (42 U.S.C. 1396u-4(f)(2)) is
amended by adding at the end the following new subparagraph:
`(C) CONTINUATION OF MODIFICATIONS OR WAIVERS OF OPERATIONAL
REQUIREMENTS UNDER DEMONSTRATION STATUS- If a PACE program operating under
demonstration authority has contractual or other operating arrangements
which are not otherwise recognized in regulation and which were in effect
on July 1 2000, the Secretary (in close consultation with, and with the
concurrence of, the State administering agency) shall permit any such
program to continue such arrangements so long as such arrangements are
found by the Secretary and the State to be reasonably consistent with the
objectives of the PACE program.'.
(c) EFFECTIVE DATE- The amendments made by this section shall be effective
as included in the enactment of BBA.
SEC. 903. FLEXIBILITY IN EXERCISING WAIVER AUTHORITY.
In applying sections 1894(f)(2)(B) and 1934(f)(2)(B) of the Social
Security Act (42 U.S.C. 1395eee(f)(2)(B), 1396u-4(f)(2)(B)), the Secretary of
Health and Human Services--
(1) shall approve or deny a request for a modification or a waiver of
provisions of the PACE protocol not later than 90 days after the date the
Secretary receives the request; and
(2) may exercise authority to modify or waive such provisions in a
manner that responds promptly to the needs of PACE programs relating to
areas of employment and the use of community-based primary care
physicians.
Subtitle B--Outreach to Eligible Low-Income Medicare
Beneficiaries
SEC. 911. OUTREACH ON AVAILABILITY OF MEDICARE COST-SHARING ASSISTANCE TO
ELIGIBLE LOW-INCOME MEDICARE BENEFICIARIES.
(1) IN GENERAL- Title XI (42 U.S.C. 1301 et seq.) is amended by
inserting after section 1143 the following new section:
`OUTREACH EFFORTS TO INCREASE AWARENESS OF THE AVAILABILITY OF MEDICARE
COST-SHARING
`SEC. 1144. (a) OUTREACH-
`(1) IN GENERAL- The Commissioner of Social Security (in this section
referred to as the `Commissioner') shall conduct outreach efforts to--
`(A) identify individuals entitled to benefits under the medicare
program under title XVIII who may be eligible for medical assistance for
payment of the cost of medicare cost-sharing under the medicaid program
pursuant to sections 1902(a)(10)(E) and 1933; and
`(B) notify such individuals of the availability of such medical
assistance under such sections.
`(2) CONTENT OF NOTICE- Any notice furnished under paragraph (1) shall
state that eligibility for medicare cost-sharing assistance under such
sections is conditioned upon--
`(A) the individual providing to the State information about income
and resources (in the case of an individual residing in a State that
imposes an assets test for such eligibility); and
`(B) meeting the applicable eligibility criteria.
`(b) COORDINATION WITH STATES-
`(1) IN GENERAL- In conducting the outreach efforts under this section,
the Commissioner shall--
`(A) furnish the agency of each State responsible for the
administration of the medicaid program and any other appropriate State
agency with information consisting of the name and address of individuals
residing in the State that the Commissioner determines may be eligible for
medical assistance for payment of the cost of medicare cost-sharing under
the medicaid program pursuant to sections 1902(a)(10)(E) and 1933;
and
`(B) update any such information not less frequently than once per
year.
`(2) INFORMATION IN PERIODIC UPDATES- The periodic updates described in
paragraph (1)(B) shall include information on individuals who are or may be
eligible for the medical assistance described in paragraph (1)(A) because
such individuals have experienced reductions in benefits under title
II.'.
(2) AMENDMENT TO TITLE XIX- Section 1905(p) (42 U.S.C. 1396d(p)) is
amended by adding at the end the following new paragraph:
`(5) For provisions relating to outreach efforts to increase awareness of
the availability of medicare cost-sharing, see section 1144.'.
(b) GAO REPORT- The Comptroller General of the United States shall conduct
a study of the impact of section 1144 of the Social Security Act (as added by
subsection (a)(1)) on the enrollment of individuals for medicare cost-sharing
under the medicaid program. Not later than 18 months after the date that the
Commissioner of Social Security first conducts outreach under section 1144 of
such Act, the Comptroller General shall submit to Congress a report on such
study. The report shall include such recommendations for legislative changes
as the Comptroller General deems appropriate.
(c) EFFECTIVE DATE- The amendments made by subsections (a) shall take
effect one year after the date of the enactment of this Act.
Subtitle C--Maternal and Child Health Block Grant
SEC. 921. INCREASE IN AUTHORIZATION OF APPROPRIATIONS FOR THE MATERNAL AND
CHILD HEALTH SERVICES BLOCK GRANT.
(a) IN GENERAL- Section 501(a) (42 U.S.C. 701(a)) is amended in the matter
preceding paragraph (1) by striking `$705,000,000 for fiscal year 1994' and
inserting `$850,000,000 for fiscal year 2001'.
(b) EFFECTIVE DATE- The amendment made by subsection (a) takes effect on
October 1, 2000.
Subtitle D--Diabetes
SEC. 931. INCREASE IN APPROPRIATIONS FOR SPECIAL DIABETES PROGRAMS FOR TYPE
I DIABETES AND INDIANS.
(a) SPECIAL DIABETES PROGRAMS FOR TYPE I DIABETES- Section 330B(b) of the
Public Health Service Act (42 U.S.C. 254c-2(b)) is amended--
(1) by striking `Notwithstanding' and inserting the following:
`(1) TRANSFERRED FUNDS- Notwithstanding'; and
(2) by adding at the end the following:
`(2) APPROPRIATIONS- For the purpose of making grants under this
section, there is appropriated, out of any funds in the Treasury not
otherwise appropriated--
`(A) $70,000,000 for each of fiscal years 2001 and 2002 (which shall
be combined with amounts transferred under paragraph (1) for each such
fiscal years); and
`(B) $100,000,000 for fiscal year 2003.'.
(b) SPECIAL DIABETES PROGRAMS FOR INDIANS- Section 330C(c) of such Act (42
U.S.C. 254c-3(c)) is amended--
(1) by striking `Notwithstanding' and inserting the following:
`(1) TRANSFERRED FUNDS- Notwithstanding'; and
(2) by adding at the end the following:
`(2) APPROPRIATIONS- For the purpose of making grants under this
section, there is appropriated, out of any money in the Treasury not
otherwise appropriated--
`(A) $70,000,000 for each of fiscal years 2001 and 2002 (which shall
be combined with amounts transferred under paragraph (1) for each such
fiscal years); and
`(B) $100,000,000 for fiscal year 2003.'.
(c) EXTENSION OF FINAL REPORT ON GRANT PROGRAMS- Section 4923(b)(2) of BBA
is amended by striking `2002' and inserting `2003'.
SEC. 932. APPROPRIATIONS FOR RICKY RAY HEMOPHILIA RELIEF FUND.
Section 101(e) of the Ricky Ray Hemophilia Relief Fund Act of 1998 (42
U.S.C. 300c-22 note) is amended by adding at the end the following: `There is
appropriated to the Fund $475,000,000 for fiscal year 2001, to remain
available until expended.'.
Subtitle E--Nurse Staffing and Quality Improvement Act of
2000
SEC. 941. SHORT TITLE.
This subtitle may be cited as the `Nursing Home Staffing and Quality
Improvement Act of 2000'.
SEC. 942. GRANTS TO STATES FOR IMPROVEMENTS IN NURSING HOME STAFFING AND
QUALITY.
(a) SECRETARY'S AUTHORITY TO AWARD GRANTS- The Secretary shall establish a
program of competitive grants to States, in accordance with the provisions of
this section, for the purpose of improving the quality of care furnished in
nursing homes operating in the State.
(b) APPLICATIONS AND ELIGIBILITY FOR GRANTS-
(1) INITIAL APPLICATION- A State seeking a grant to conduct a project
under this section shall submit an application containing such information
and assurances as the Secretary may require, including--
(A) a commitment to submit annual reports describing the State's
progress in increasing staffing levels and making other quality
improvements in nursing homes in the State; and
(B) a description of a plan for evaluation of the activities carried
out under the grant, including a plan for measurement of progress toward
the goals and objectives of the program, consistent with the principles of
the Government Performance and Results Act.
(2) CONSULTATION WITH PUBLIC- Before submitting an application for a
grant under this section, States shall solicit and consider the views of
members of the public, nursing home residents or their representatives, and
other persons concerned with the administration of nursing homes within the
State with respect to the design of the proposed State program.
(A) INITIAL ELIGIBILITY- A State shall not be eligible for a grant
award under this section unless it makes assurances satisfactory to the
Secretary that the skilled nursing facilities (as defined in section
1819(a)) and nursing facilities (as defined in section 1919(a)) within the
State will reach or exceed the minimum staff level described in subsection
(d)(2) within two years after enactment of this Act and will maintain such
level throughout the remainder of the grant program.
(B) CONTINUING ELIGIBILITY- A State shall not be eligible for the
continuation of grant funding under a multi-year grant under this section
unless the State demonstrates to the Secretary's satisfaction that it
continues to meet the requirement described in subparagraph (A) and has
made sufficient progress in meeting the goals described in its grant
application.
(c) USE OF GRANT FUNDS- Funds received by a State under this section may
be provided to entities including nursing homes, labor management
partnerships, and educational institutions, and may be used for any or all of
the following purposes:
(1) To enable a nursing home to recruit additional nursing staff or to
retain existing nursing staff (including through the use of reasonable
financial incentives or reasonable benefit enhancements).
(2) To increase education and training of nursing staff (including
designing or implementing programs to promote the career advancement of
certified nurse aides).
(3) To provide bonuses to nursing homes meeting State quality standards
or avoiding serious quality violations for a period of one or more
years.
(4) Such other nursing home staffing and quality improvement initiatives
as the Secretary may approve.
(d) DISTRIBUTION OF FUNDS-
(1) IN GENERAL- Subject to subsection (b), in awarding grants under this
section, the Secretary shall award no more than 25 percent of the funds to
States in which, as of the date of the enactment of this section, skilled
nursing facilities (as defined in section 1819(a)) and nursing facilities
(as defined in section 1919(a)) have reached or exceeded the minimum staff
level specified in paragraph (2) (as determined by the
Secretary).
(2) Minimum nursing home staff level-
(A) IN GENERAL- Subject to subparagraph (B), for purposes of
subsection (b) and paragraph (1), the level specified in this paragraph
for a skilled nursing facility or nursing facility is a staff level
sufficient to ensure that each resident receives from a certified nurse
aide at least 2 hours per day of direct care (including repositioning the
resident and changing wet clothes, assisting with feeding, exercise, and
toileting, and working to enhance a resident's independence with respect
to activities of daily living).
(B) SECRETARY'S AUTHORITY TO INCREASE MINIMUM STAFF LEVEL- The
Secretary may establish a minimum staff level that is higher than that
specified in subparagraph (A). Any such revised staff level shall be
effective no earlier than six months after the date on which Secretary
provides notice to States of the new requirement.
(3) MULTI-YEAR GRANT FUNDS- The Secretary shall award any multi-year
grant under this section from amounts appropriated (or available pursuant to
subsection (e)(2)) for the first fiscal year of the grant.
(e) APPROPRIATIONS AND AVAILABILITY OF CIVIL MONEY PENALTY (CPM)
Collections-
(1) APPROPRIATIONS- There are appropriated for all costs to the
Secretary for carrying out the program under this section $200,000,000 for
each of fiscal years 2001 through 2005, such funds to remain available to
the Secretary through the end of the first succeeding fiscal year.
(2) AVAILABILITY OF CMP COLLECTIONS- In addition to the amounts
appropriated pursuant to paragraph (1), there shall be available to the
Secretary for such costs for such fiscal years any amounts deposited in the
Nursing Facility Civil Money Penalties Collection Account established under
section 4.
SEC. 943. ENHANCED NURSING FACILITY REPORTING REQUIREMENTS.
(1) SUBMISSION OF NURSING STAFF LEVEL DATA TO THE SECRETARY- Section
1819(b) (42 U.S.C. 1395i-3(b)) is amended by adding at the end the following
new paragraph:
`(8) Data on staffing levels-
`(A) SUBMISSION TO SECRETARY- A skilled nursing facility shall submit
to the Secretary, in such form and manner and at such intervals as the
Secretary may require, data with respect to nursing staff of the facility.
Such data shall include the total number of nursing staff hours furnished
during the period specified by the Secretary (including totals for each
shift worked during such period) by the facility to residents for which
payment is made under section 1888(e), broken down by total certified
nurse aide hours, total licensed practical or vocational nurse hours, and
total registered nurse hours, and shall also include the average wage rate
for each class of nursing staff employed by the facility.
`(B) PUBLICATION- The Secretary shall provide for the publication on
the Internet Site of the Department of Health and Human Services known
as
Nursing Home Compare the facility-specific nursing staff information
collected pursuant to subparagraph (A). The Secretary shall update such
information periodically.'.
(2) POSTING OF INFORMATION ON NURSING FACILITY STAFFING- Section 1819(b)
(42 U.S.C. 1395i-3(b)), as amended by paragraph (1), is further amended by
adding at the end the following new paragraph:
`(9) Information on nurse staffing-
`(A) IN GENERAL- A skilled nursing facility shall post daily for each
nursing unit of the facility and for each shift the current number of
licensed and unlicensed nursing staff directly responsible for resident
care. The information shall be displayed in a uniform manner (as specified
by the Secretary) and in a clearly visible place.
`(B) PUBLICATION OF DATA- A skilled nursing facility shall, upon
request, make available to the public the nursing staff data described in
subparagraph (A).'.
(3) INFORMATION CONCERNING PATIENT CLASSIFICATION- Section 1819(b)(4)(C)
(42 U.S.C. 1395i-3(b)(4)(C)) is amended by adding at the end the following
new clause:
`(iii) INFORMATION CONCERNING RESIDENTS- The skilled nursing
facility shall provide the Secretary, in such form and manner and at
such intervals as the Secretary may require, a classification of all
residents of the skilled nursing facility that accords with the patient
classification system described in section 1888(e)(3)(B)(ii), or such
successor system as the Secretary may identify.'.
(1) IN GENERAL- Section 1919(b) (42 U.S.C. 1396r) is amended by adding
at the end the following new paragraph:
`(8) Data on staffing levels-
`(A) SUBMISSION TO SECRETARY- A nursing facility shall submit to the
Secretary, in such form and manner and at such intervals as the Secretary
may require, data with respect to nursing staff of the facility. Such data
shall include the total number of nursing staff hours furnished during the
period specified by the Secretary (including totals for each shift worked
during such period) by the facility to residents for which payment is made
under this title, broken down by total certified nurse aide hours, total
licensed practical or vocational nurse hours, and total registered nurse
hours, and shall also include the average wage rate for each class of
nursing staff employed by the facility.
`(B) PUBLICATION- The Secretary shall provide for the publication on
the Internet Site of the Department of Health and Human Services known as
Nursing Home Compare the facility-specific nursing staff information
collected pursuant to subparagraph (A). The Secretary shall update such
information periodically.'.
(2) POSTING OF INFORMATION ON NURSING FACILITY STAFFING- Section 1919(b)
(42 U.S.C. 1395r(b)), as amended by paragraph (1), is further amended by
adding at the end the following new paragraph:
`(9) Information on nurse staffing-
`(A) IN GENERAL- A nursing facility shall post daily for each nursing
unit of the facility and for each shift the current number of licensed and
unlicensed nursing staff directly responsible for resident care. The
information shall be displayed in a uniform manner (as specified by the
Secretary) and in a clearly visible place.
`(B) PUBLICATION OF DATA- A nursing facility shall, upon request, make
available to the public the nursing staff data described in subparagraph
(A).'.
(3) INFORMATION CONCERNING PATIENT CLASSIFICATION- Section 1919(b)(4)(C)
(42 U.S.C. 1396r(b)(4)(C)) is amended by adding at the end the following new
clause:
`(iv) INFORMATION CONCERNING RESIDENTS- The nursing facility shall
provide the Secretary, in such form and manner and at such intervals as
the Secretary may require, a classification of all residents of the
nursing facility that accords with the patient classification system
described in section 1888(e)(3)(B)(ii), or such successor system as the
Secretary may identify.'.
SEC. 944. NURSING FACILITY CIVIL MONEY PENALTY COLLECTIONS.
(a) ESTABLISHMENT OF NURSING FACILITY CIVIL MONEY PENALTY COLLECTIONS
ACCOUNT- Section 1128A (42 U.S.C. 1320a-7a) is amended by adding at the end
the following new subsection:
`(o) ESTABLISHMENT OF NURSING FACILITY CIVIL MONEY PENALTY COLLECTIONS
ACCOUNT- There is hereby established an account to be known as the `Nursing
Facility Civil Money Penalties Collection Account' (hereafter in this
subsection referred to as the `Account'). Notwithstanding any other provision
of law, there shall be deposited into the Account the Secretary's share of any
civil monetary penalties collected under sections 1819 and 1919, all such
amounts to be available without fiscal year limitation for repaying the
Secretary's share of amounts owed to nursing facilities or skilled nursing
facilities pursuant to the final sentence of sections 1819(h)(2)(B)(ii) and
1919(h)(2)(B)(ii), and for awarding grants under section 2 of the Nursing Home
Staffing and Quality Improvement Act of 2000.'.
(b) Authority To Collect CMPS Immediately-
(1) MEDICARE- Section 1819(h)(2)(B)(ii) (42 U.S.C. 1395i-3(h)(2)(B)(ii))
is amended by inserting before the final period `, except that,
notwithstanding section 1128A(c)(2) or any other provision of law, the
Secretary, upon determining that a civil money penalty should be imposed
against a skilled nursing facility pursuant to this paragraph, shall take
immediate action to collect such penalty (except where the Secretary finds
that such action could jeopardize the health or welfare of residents of the
skilled nursing facility). In collecting such penalty, the Secretary may
deduct the amount of the penalty from amounts otherwise payable to the
facility under this title or take such other actions as the Secretary
considers appropriate. If the Secretary's imposition of a penalty under this
paragraph is set aside, in whole or in part, as a result of a hearing under
section 1128A(c)(2) (or an appeal therefrom) or by a court of competent
jurisdiction, and the Secretary elects not to pursue an appeal of such
judgment; or has exhausted all appeals, the Secretary shall repay any amount
owed to the skilled nursing facility with accrued interest.'
(2) MEDICAID- Section 1919(h)(3)(B)(ii) (42 U.S.C. 1396r(h)(3)(B)(ii))
is amended by inserting before the final period `, except that,
notwithstanding section 1128A(c)(2) or any other provision of law, the
Secretary, upon determining that a civil money penalty should be imposed
against a nursing facility pursuant to this paragraph, shall take immediate
action to collect the penalty (except where the Secretary finds that such
action could jeopardize the health or welfare of residents of the nursing
facility). In collecting such penalty, the Secretary may direct the State to
deduct the amount of the penalty from amounts otherwise payable to the
nursing facility under this title or take such other actions as the
Secretary, in consultation with the State, considers appropriate. If the
Secretary's imposition of a penalty under this paragraph is set aside, in
whole or in part, as a result of a hearing under section 1128A(c)(2) (or an
appeal therefrom) or by a court of competent jurisdiction, and the Secretary
elects not to pursue an appeal of such judgment, or has exhausted all
appeals, the Secretary shall repay, or shall direct the State to repay, any
amount owed to the nursing facility with accrued interest.'
Subtitle F--Family Opportunities Act
SEC. 951. SHORT TITLE.
This subtitle may be cited as the `Family Opportunity Act of 2000'.
SEC. 952. OPPORTUNITY FOR FAMILIES OF DISABLED CHILDREN TO PURCHASE MEDICAID
COVERAGE FOR SUCH CHILDREN.
(a) STATE OPTION TO ALLOW FAMILIES OF DISABLED CHILDREN TO PURCHASE
MEDICAID COVERAGE FOR SUCH CHILDREN-
(1) IN GENERAL- Section 1902 (42 U.S.C. 1396a), as amended by the Foster
Care Independence Act of 1999 (Public Law 106-169; 113 Stat. 1822) and the
Ticket to Work and Work Incentives Improvement Act of 1999 (Public Law
106-170; 113 Stat. 1860), is amended--
(A) in subsection (a)(10)(A)(ii)--
(i) by striking `or' at the end of subclause (XVI);
(ii) by adding `or' at the end of subclause (XVII); and
(iii) by adding at the end the following new subclause:
`(XVIII) who are disabled children described in subsection (aa);';
and
(B) by adding at the end the following new subsection:
`(aa) Individuals described in this subsection are individuals--
`(1) who have not attained 18 years of age;
`(2) who would be considered disabled under section 1614(a)(3)(C)
(determined without regard to the reference to age in that section) but for
having earnings or deemed income or resources (as determined under title XVI
for children) that exceed the requirements for receipt of supplemental
security income benefits; and
`(3) whose family income does not exceed such income level as the State
establishes and does not exceed--
`(A) 300 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; or
`(B) such higher percent of such poverty line as a State may
establish, except that no Federal financial participation shall be
provided under section 1903(a) for any medical assistance provided to an
individual who would not be described in this subsection but for this
clause.'.
(2) INTERACTION WITH EMPLOYER-SPONSORED FAMILY COVERAGE- Section
1902(aa) (42 U.S.C. 1396a(aa)), as added by paragraph (1), is amended by
adding at the end the following new paragraph:
`(3)(A) If an employer of a parent of an individual described in paragraph
(1) offers family coverage under a group health plan (as defined in section
2791(a) of the Public Health Service Act), the State may--
`(i) require such parent to apply for, enroll in, and pay premiums for,
such coverage as a condition of such parent's child being or remaining
eligible for medical assistance under subsection (a)(10)(A)(ii)(XVIII) if
the parent is determined eligible for such coverage and the employer
contributes at least 50 percent of the total cost of annual premiums for
such coverage; and
`(ii) if such coverage is obtained--
`(I) subject to paragraph (2) of section 1916(h), reduce the premium
imposed by the State under that section (if any) in an amount that
reasonably reflects the premium contribution made by the parent for
private coverage on behalf of a child with a disability; and
`(II) treat such coverage as a third party liability under subsection
(a)(25).
`(B) In the case of a parent to which subparagraph (A) applies--
`(i) if the family income of such parent does not exceed 300 percent of
the income official poverty line (referred to in paragraph (1)(C)(i)), a
State may provide for payment of any portion of the annual premium for such
family coverage that the parent is required to pay; and
`(ii) any payments made by the State under clause (i) shall be
considered, for purposes of section 1903(a), to be payments for medical
assistance.'.
(b) STATE OPTION TO IMPOSE INCOME-RELATED PREMIUMS- Section 1916 (42
U.S.C. 1396o), as amended by the Ticket to Work and Work Incentives
Improvement Act of 1999 (Public Law 106-170; 113 Stat. 1860), is amended--
(1) in subsection (a), by striking `subsection (g)' and inserting
`subsections (g) and (h)'; and
(2) by adding at the end the following new subsection:
`(h)(1) With respect to disabled children provided medical assistance
under section 1902(a)(10)(A)(ii)(XVIII), subject to paragraph (2), a State may
(in a uniform manner for such children) require the families of such children
to pay monthly premiums set on a sliding scale based on family income.
`(2) A premium requirement imposed under paragraph (1) may only apply to
the extent that--
`(A) the aggregate amount of such premium and any premium that the
parent is required to pay for family coverage under section
1902(aa)(3)(A)(i) does not exceed 5 percent of the family's income;
and
`(B) the requirement is imposed consistent with section
1902(aa)(3)(A)(ii)(I).
`(3) A State shall not require prepayment of a premium imposed pursuant to
paragraph (1) and shall not terminate eligibility of a child under section
1902(a)(10)(A)(ii)(XVIII) for medical assistance under this title on the basis
of failure to pay any such premium until such failure continues for a period
of not less than 60 days from the date on which the premium became past due.
The State may waive payment of any such premium in any case where the State
determines that requiring such payment would create an undue hardship.'.
(c) CONFORMING AMENDMENT- Section 1903(f)(4) (42 U.S.C. 1396b(f)(4)) is
amended in the matter preceding subparagraph (A) by inserting
`1902(a)(10)(A)(ii)(XVIII),' after `1902(a)(10)(A)(ii)(XVI),'.
(d) EFFECTIVE DATE- The amendments made by this section shall apply to
medical assistance for items and services furnished on or after October 1,
2000.
SEC. 953. TREATMENT OF INPATIENT PSYCHIATRIC HOSPITAL SERVICES FOR
INDIVIDUALS UNDER AGE 21 IN HOME OR COMMUNITY-BASED SERVICES WAIVERS.
(a) IN GENERAL- Section 1915(c) (42 U.S.C. 1396n(c)) is amended--
(A) in the first sentence, by inserting `, or inpatient psychiatric
hospital services for individuals under age 21,' after `intermediate care
facility for the mentally retarded'; and
(B) in the second sentence, by inserting `, or inpatient psychiatric
hospital services for individuals under age 21' before the
period;
(2) in paragraph (2)(B), by striking `or services in an intermediate
care facility for the mentally retarded' each place it appears and inserting
`, services in an intermediate care facility for the mentally retarded, or
inpatient psychiatric hospital services for individuals under age 21';
(3) by striking paragraph (2)(C) and inserting the following:
`(C) such individuals who are determined to be likely to require the
level of care provided in a hospital, nursing facility, or intermediate care
facility for the mentally retarded, or inpatient psychiatric hospital
services for individuals under age 21, are informed of the feasible
alternatives, if available under the waiver, at the choice of such
individuals, to the provision of inpatient hospital services, nursing
facility services, services in an intermediate care facility for the
mentally retarded, or inpatient psychiatric hospital services for
individuals under age 21;'; and
(4) in paragraph (7)(A)--
(A) by inserting `, or inpatient psychiatric hospital services for
individuals under age 21,' after `intermediate care facility for the
mentally retarded'; and
(B) by inserting `, or who would require inpatient psychiatric
hospital services for individuals under age 21' before the
period.
(b) EFFECTIVE DATE- The amendments made by subsection (a) apply with
respect to medical assistance provided on or after October 1, 2000.
SEC. 954. DEMONSTRATION OF COVERAGE UNDER THE MEDICAID PROGRAM OF CHILDREN
WITH POTENTIALLY SEVERE DISABILITIES.
(a) STATE APPLICATION- A State may apply to the Secretary of Health and
Human Services (in this section referred to as the `Secretary') for approval
of a demonstration project (in this section referred to as a `demonstration
project') under which up to a specified maximum number of children with a
potentially severe disability (as defined in subsection (b)) are provided
medical assistance under the State medicaid plan under title XIX of the Social
Security Act (42 U.S.C. 1396 et seq.).
(b) CHILD WITH A POTENTIALLY SEVERE DISABILITY DEFINED-
(1) IN GENERAL- In this section, the term `child with a potentially
severe disability' means, with respect to a demonstration project, an
individual who--
(A) has not attained 21 years of age;
(B) has a physical or mental condition, disease, disorder (including a
congenital birth defect or a metabolic condition), injury, or
developmental disability that was incurred before the individual attained
such age; and
(C) is reasonably expected, but for the receipt of medical assistance
under the State medicaid plan, to reach the level of disability defined
under section 1614(a)(3) of the Social Security Act (42 U.S.C.
1382c(a)(3)), (determined without regard to the reference to age in
subparagraph (C) of that section).
(2) EXCEPTION- Such term does not include an individual who would be
considered disabled under section 1614(a)(3)(C) of the Social Security Act
(42 U.S.C. 1382c(a)(3)(C)) (determined without regard to the reference to
age in that section).
(c) APPROVAL OF DEMONSTRATION PROJECTS-
(1) IN GENERAL- Subject to paragraph (3), the Secretary shall approve
applications under subsection (a) that meet the requirements of paragraph
(2) and such additional terms and conditions as the Secretary may require.
The Secretary may waive the requirement of section 1902(a)(1) of the Social
Security Act (42 U.S.C. 1396a(a)(1)) to allow for sub-State
demonstrations.
(2) TERMS AND CONDITIONS OF DEMONSTRATION PROJECTS- The Secretary may
not approve a demonstration project under this section unless the State
provides assurances satisfactory to the Secretary that the following
conditions are or will be met:
(A) INDEPENDENT EVALUATION- The State provides for an independent
evaluation of the project to be conducted during fiscal year
2005.
(B) CONSULTATION FOR DEVELOPMENT OF CRITERIA- The State consults with
appropriate pediatric health professionals in establishing the criteria
for determining whether a child has a potentially severe
disability.
(C) ANNUAL REPORT- The State submits an annual report to the Secretary
(in a uniform form and manner established by the Secretary) on the use of
funds provided under the grant that includes the following:
(i) Enrollment and financial statistics on--
(I) the total number of children with a potentially severe
disability enrolled in the demonstration project, disaggregated by
disability;
(II) the services provided by category or code and the cost of
each service so categorized or coded; and
(III) the number of children enrolled in the demonstration project
who also receive services through private insurance.
(ii) With respect to the report submitted for fiscal year 2005, the
results of the independent evaluation conducted under subparagraph
(A).
(iii) Such additional information as the Secretary may
require.
(3) LIMITATIONS ON FEDERAL FUNDING-
(i) IN GENERAL- Out of any funds in the Treasury not otherwise
appropriated, there is appropriated to carry out this section
$16,667,000 for each of fiscal years 2001 through 2006.
(ii) BUDGET AUTHORITY- Clause (i) constitutes budget authority in
advance of appropriations Acts and represents the obligation of the
Federal Government to provide for the payment of the amounts
appropriated under clause (i).
(B) LIMITATION ON PAYMENTS- In no case may--
(i) the aggregate amount of payments made by the Secretary to States
under this section exceed $100,000,000;
(ii) the aggregate amount of payments made by the Secretary to
States for administrative expenses relating to the evaluations and
annual reports required under subparagraphs (A) and (C) of paragraph (2)
exceed $2,000,000 of such $100,000,000; or
(iii) payments be provided by the Secretary for a fiscal year after
fiscal year 2009.
(C) FUNDS ALLOCATED TO STATES-
(i) IN GENERAL- The Secretary shall allocate funds to States based
on their applications and the availability of funds. In making such
allocations, the Secretary shall ensure an equitable distribution of
funds among States with large populations and States with small
populations.
(ii) AVAILABILITY- Funds allocated to a State under a grant made
under this section for a fiscal year shall remain available until
expended.
(D) FUNDS NOT ALLOCATED TO STATES- Funds not allocated to States in
the fiscal year for which they are appropriated shall remain available in
succeeding fiscal years for allocation by the Secretary using the
allocation formula established under this section.
(E) PAYMENTS TO STATES- The Secretary shall pay to each State with a
demonstration project approved under this section, from its allocation
under subparagraph (C), an amount for each quarter equal to the Federal
medical assistance percentage (as defined in section 1905(b) of the Social
Security Act (42 U.S.C. 1395d(b))) of expenditures in the quarter for
medical assistance provided to children with a potentially severe
disability.
(d) RECOMMENDATION- Not later than October 1, 2004, the Secretary shall
submit a recommendation to the Committee on Commerce of the House of
Representatives and the Committee on Finance of the Senate regarding whether
the demonstration project established under this section should be continued
after fiscal year 2006.
(e) STATE DEFINED- In this section, the term `State' has the meaning given
such term for purposes of title XIX of the Social Security Act (42 U.S.C. 1396
et seq.).
SEC. 955. DEVELOPMENT AND SUPPORT OF FAMILY-TO-FAMILY HEALTH INFORMATION
CENTERS.
Section 501 (42 U.S.C. 701) is amended by adding at the end the following
new subsection:
`(c)(1)(A) In addition to amounts appropriated under subsection (a) and
retained under section 502(a)(1) for the purpose of carrying out activities
described in subsection (a)(2), there is appropriated to the Secretary, out of
any money in the Treasury not otherwise appropriated, for the purpose of
enabling the Secretary (through grants, contracts, or otherwise) to provide
for special projects of regional and national significance for the development
and support of family-to-family health information centers described in
paragraph (2), $10,000,000 for each of fiscal years 2001 through 2006.
`(B) Funds appropriated under subparagraph (A) shall remain available
until expended.
`(2) The family-to-family health information centers described in this
paragraph are centers that--
`(A) assist families of children with disabilities or special health
care needs to make informed choices about health care in order to promote
good treatment decisions, cost-effectiveness, and improved health outcomes
for such children;
`(B) provide information regarding the health care needs of, and
resources available for, children with disabilities or special health care
needs;
`(C) identify successful health delivery models for such children;
`(D) develop with representatives of health care providers, managed care
organizations, health care purchasers, and appropriate State agencies a
model for collaboration between families of such children and health
professionals;
`(E) provide training and guidance regarding caring for such
children;
`(F) conduct outreach activities to the families of such children,
health professionals, schools, and other appropriate entities and
individuals; and
`(G) are staffed by families of children with disabilities or special
health care needs who have expertise in Federal and State public and private
health care systems and health professionals.
`(3) The provisions of this title that are applicable to the funds made
available to the Secretary under section 502(a)(1) apply in the same manner to
funds made available to the Secretary under paragraph (1).'.
SEC. 956. RESTORATION OF MEDICAID ELIGIBILITY FOR CERTAIN SSI
BENEFICIARIES.
(a) IN GENERAL- Section 1902(a)(10)(A)(i)(II) (42 U.S.C.
1396a(a)(10)(A)(i)(II)) is amended--
(1) by inserting `(aa)' after `(II)';
(2) by striking `or who are' and inserting `(bb) who are'; and
(3) by inserting before the comma at the end the following: `, or (cc)
who are under 21 years of age and with respect to whom supplemental security
income benefits would be paid under title XVI but for section
1611(c)(7)'.
(b) EFFECTIVE DATE- The amendments made by subsection (a) apply to medical
assistance for items and services furnished on or after January 1, 2002,
except that a State may elect to apply such amendments to items and services
furnished on or after any date after the date of the enactment of this Act and
before October 1, 2000.
END