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H.R.5612
Medicare, Medicaid, and SCHIP Benefits Improvement and Beneficiary
Protection Act of 2000 (Introduced in the House)
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).
`(3) INTERNAL REDETERMINATIONS-
`(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 180-day period beginning on the date the individual receives notice
of the initial determination under paragraph (2).
`(ii) CONCLUDING REDETERMINATIONS- Except as provided in subsection
(d), redeterminations shall be made and notice of the redetermination
shall be provided 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.
`(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.
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.
`(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 benefits 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 described in
subparagraphs (B) and (C) of subsection (b)(1) that involve only the amount
of payment or the type of payment available with respect to an item or
service.
`(2) QUALIFIED INDEPENDENT CONTRACTOR DEFINED- 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 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.
`(B) RECONSIDERATIONS- Subject to subsection (b)(1)(A)(ii), the
qualified independent contractor shall review initial determinations. In
the case of 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 physician or other appropriate health care professional based on the
medical condition of the
individual (including the medical records of the individual)
and any decisions with respect to the reconsideration shall be based on
applicable information, including clinical experience and valid, relevant
medical , technical, and
scientific evidence.
`(C) DEADLINES FOR DECISIONS-
`(i) RECONSIDERATIONS- Except as provided in clauses (iii) and (iv),
and in accordance with subsection (e), 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 subsection (e), 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), in accordance with the medical needs of the
individual and 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 may 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- In any case in which an individual requests an
extension, or the qualified
independent contractor determines that an extension is in the best interests
of the individual, an extension of not greater than 14 days may be granted.
`(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.
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