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S.980
Promoting Health in Rural Areas Act of 1999 (Introduced in the
Senate)
SEC. 103. GRADUATE MEDICAL EDUCATION TECHNICAL AMENDMENTS.
(a) INDIRECT GRADUATE MEDICAL EDUCATION ADJUSTMENT-
(1) IN GENERAL- Section 1886(d)(5)(B)(v) of the Social Security Act (42
U.S.C. 1395ww(d)(5)(B)(v)) is amended--
(A) by striking `(v) In determining' and inserting `(v)(I) Subject to
subclause (II), in determining';
(B) by striking `in the hospital with respect to the hospital's most
recent cost reporting period ending on or before December 31, 1996' and
inserting `who were appointed by the hospital's approved medical residency training
programs for the hospital's most recent cost reporting period ending on or
before December 31, 1996'; and
(C) by adding at the end the following:
`(II) Beginning on or after January 1, 1997, in the case of a hospital
that sponsors only 1 allopathic or osteopathic residency program, the limit
determined for such hospital under subclause (I) may, at the hospital's
discretion, be increased by 1 for each calendar year but shall not exceed a
total of 3 more than the limit determined for the hospital under subclause
(I).'.
(2) ADDITIONAL TECHNICAL AMENDMENTS- Section 1886(d)(5)(B) of the Social
Security Act (42 U.S.C. 1395ww(d)(5)(B)) is amended by moving clauses (ii),
(v), and (vi) 2 ems to the left.
(b) DIRECT GRADUATE MEDICAL EDUCATION ADJUSTMENT-
(1) LIMITATION ON NUMBER OF RESIDENTS- Section 1886(h)(4)(F) of the
Social Security Act (42 U.S.C. 1395ww(h)(4)(F)) is amended by inserting `who
were appointed by the hospital's approved medical residency training programs'
after `may not exceed the number of such full-time equivalent
residents'.
(2) FUNDING FOR NEW PROGRAMS- The first sentence of section
1886(h)(4)(H)(i) of the Social Security Act (42 U.S.C. 1395ww(h)(4)(H)(i))
is amended by inserting `and before September 30, 1999' after `January 1,
1995'.
(3) FUNDING FOR PROGRAMS MEETING RURAL NEEDS- The second sentence of
section 1886(h)(4)(H)(i) of the Social Security Act (42 U.S.C.
1395ww(h)(4)(H)(i)) is amended by striking the period at the end and
inserting `, including facilities that are not located in an underserved
rural area but have established separately accredited rural training
tracks.'.
(c) EFFECTIVE DATE- The amendments made by this section shall take effect
as if included in the enactment of the Balanced Budget Act of 1997.
SEC. 104. MEDICARE-DEPENDENT SMALL RURAL HOSPITALS.
(a) MAKING PAYMENT PROVISION PERMANENT- Section 1886(d)(5)(G)(i) of the
Social Security Act (42 U.S.C. 1395ww(d)(5)(G)(i)) is amended by striking `and
before October 1, 2001,'.
(b) OPTION TO BASE ELIGIBILITY ON DISCHARGES DURING ANY OF THE 3 MOST
RECENT AUDITED COST REPORTING PERIODS- Section 1886(d)(5)(G)(iv)(IV) of the
Social Security Act (42 U.S.C. 1395ww(d)(5)(G)(iv)(IV)) is amended by
inserting `, or any of the 3 most recent audited cost reporting periods,'
after `1987'.
(c) EFFECTIVE DATE- The amendments made by this section shall apply with
respect to discharges occurring on or after October 1, 1999.
SEC. 105. ALL-INCLUSIVE PAYMENT OPTION FOR OUTPATIENT CRITICAL ACCESS
HOSPITAL SERVICES.
(a) IN GENERAL- Section 1834(g) of the Social Security Act (42 U.S.C.
1395m(g)) is amended to read as follows:
`(g) PAYMENT FOR OUTPATIENT CRITICAL ACCESS HOSPITAL SERVICES- The amount
of payment under this part for outpatient critical access hospital services
shall be determined by using 1 of the 2 following methods, as elected by the
critical access hospital:
`(1) COST-BASED FACILITY FEE PLUS PROFESSIONAL CHARGES-
`(A) FACILITY FEE- With respect to facility services, not including
any services for which payment may be made under subparagraph (B), there
shall be paid amounts equal to the reasonable costs of the critical access
hospital in providing such services, less the amount that such hospital
may charge as described in section 1866(a)(2)(A).
`(B) REASONABLE CHARGES FOR PROFESSIONAL SERVICES- In electing
treatment under this paragraph, payment for professional medical services otherwise
included within outpatient critical access hospital services shall be made
under such other provisions of this part as would apply to payment for
such services if they were not included in outpatient critical access
hospital services.
`(2) ALL-INCLUSIVE RATE- With respect to both facility services and
professional medical services,
there shall be paid amounts equal to the reasonable costs of the critical
access hospital in providing such services, less the amount that such
hospital may charge as described in section 1866(a)(2)(A).
The amount of payment shall be determined under either method without
regard to the amount of the customary or other charge.'.
(b) EFFECTIVE DATE- The amendment made by subsection (a) shall take effect
as if included in the enactment of the Balanced Budget Act of 1997.
SEC. 106. EXCLUSION OF SWING BEDS IN CRITICAL ACCESS HOSPITALS FROM PPS FOR
SNFS.
(a) IN GENERAL- Section 1888(e)(7) of the Social Security Act (42 U.S.C.
1395yy(e)(7)) is amended--
(1) in the heading, by striking `TRANSITION' and inserting `SPECIAL
RULES';
(2) in subparagraph (A), by striking `IN GENERAL- The' and inserting
`TRANSITION- Except as provided in subparagraph (C), the'; and
(3) by adding at the end the following:
`(C) EXEMPTION OF SWING BEDS IN CRITICAL ACCESS HOSPITALS FROM PPS-
The prospective payment system under this subsection shall not apply
(and section 1834(g) shall apply) to services provided by a critical
access hospital under an agreement described in subparagraph
(B).'.
(b) EFFECTIVE DATE- The amendments made by this section shall apply to
services provided on or after October 1, 1999.
SEC. 107. EXCLUSION OF SMALL RURAL PROVIDERS FROM PPS FOR HOSPITAL
OUTPATIENT DEPARTMENT SERVICES.
(a) IN GENERAL- Section 1833(t)(1) of the Social Security Act (42 U.S.C.
1395l(t)(1)) is amended--
(1) in subparagraph (B), by striking `For purposes of this' and
inserting `Subject to subparagraph (C), for purposes of this'; and
(2) by adding at the end the following:
`(C) EXCLUSION FOR SERVICES FURNISHED BY SMALL RURAL PROVIDERS- The term
`covered OPD services' does not include services furnished by a--
`(i) medicare-dependent, small rural hospital, as defined in section
1886(d)(5)(G)(iv);
`(ii) a critical access hospital, as defined in section 1861(mm)(1);
or
`(iii) sole community hospital, as defined in section
1886(d)(5)(D)(iii);
if such hospital, within the 180-day period beginning on the date of
enactment of the Promoting Health in Rural Areas Act of 1999, requests the
Secretary to exclude services furnished by such hospital from the
prospective payment system established under this subsection.'.
(b) EFFECTIVE DATE- The amendments made by subsection (a) shall apply to
payments for covered OPD services furnished on or after January 1, 2000.
SEC. 108. MODIFICATION OF DSH.
(a) COLLECTION OF CHARGE DATA- Section 1886(d)(5)(F) of the Social
Security Act (42 U.S.C. 1395ww(d)(5)(F)) is amended by adding at the end the
following:
`(x) The Secretary shall collect from all subsection (d) hospitals annual
data on inpatient and outpatient charges, including all such charges for each
of the following categories:
`(II) Patients who are eligible for benefits (excluding any State
supplementation) under the supplemental security income program under title
XVI and entitled to benefits under part A.
`(III) Patients who are entitled to (or, if they applied, would be
eligible for) medical
assistance under title XIX.
`(IV) Patients who are beneficiaries of indigent care programs sponsored
by State or local governments.
`(V) To the extent that payment is not made by patients, such
charges.
In collecting the data for patients described in subclause (II), the
Secretary may estimate the charges for such patients based on supplemental
security income program data from other sources and from the data collected
for patients described in subclause (I).'.
(b) REVISION OF FORMULA FOR DISPROPORTIONATE PATIENT PERCENTAGE- Section
1886(d)(5)(F)(vi) of the Social Security Act (42 U.S.C. 1395ww(d)(5)(F)(vi))
is amended to read as follows:
`(vi) In this subparagraph, the term `disproportionate patient percentage'
means, with respect to a cost reporting period of a hospital--
`(I) the charges described in subclauses (II) through (V) of clause (x)
for such period; divided by
`(II) the charges described in clause (x)(I) for such period.'.
(c) ESTABLISHING GENERAL QUALIFYING DISPROPORTIONATE PATIENT PERCENTAGE
THRESHOLD TO COVER HALF OF PPS HOSPITALS- Section 1886(d)(5)(F)(v) of the
Social Security Act (42 U.S.C. 1395ww(d)(5)(F)(v)) is amended by striking
`equals, or exceeds--' and all that follows and inserting `equals or exceeds a
threshold percentage, which is established by the Secretary in a manner so
that, if the amendments to this subparagraph made by section 108 of the
Promoting Health in Rural Areas Act of 1999 had been in effect for cost
reporting periods ending in fiscal year 2000, 50 percent of subsection (d)
hospitals would have been eligible for an additional payment under this
subparagraph for such periods. The Secretary shall establish such threshold
percentage based upon data collected by the Secretary under clause (x) for
such cost reporting periods.'.
(d) ESTABLISHING UNIFORM GENERAL PAYMENT FORMULA- Section 1886(d)(5)(F) of
the Social Security Act (42 U.S.C. 1395ww(d)(5)(F)) is amended--
(1) in clause (iv), by striking `that is not described in clause (i)(II)
and that--' and all that follows and inserting `described in clause (i) is
equal to (P-T)(CF), where--
`(I) `P' is the hospital's disproportionate patient percentage (as
defined in clause (vi));
`(II) `T' is equal to the threshold percentage established by the
Secretary under clause (v); and
`(III) `CF' is equal to such conversion factor as the Secretary may
establish so that, applying such conversion factor as if the amendments to
this subparagraph made by section 108 of the Promoting Health in Rural Areas
Act of 1999 had been in effect for cost reporting periods ending in fiscal
year 2000, the total of the additional payments that would have been made
under this subparagraph is equal to the total of the payments actually made
under this subparagraph (not taking into account such amendments).
The Secretary shall establish the conversion factor under subclause (III)
based upon data collected by the Secretary under clause (x) for cost reporting
periods ending in fiscal year 2000.';
(2) by amending clause (i) to read as follows:
`(i) The Secretary shall provide, in accordance with this subparagraph,
for an additional payment amount for each subsection (d) hospital which serves
a significantly disproportionate number of low-income patients (as defined in
clause (v)).';
(3) in clause (ii), by striking `clause (iii) or (iv)' and inserting
`clause (iv)'; and
(4) by striking clauses (iii), (vii), and (viii).
(e) EFFECTIVE DATE- The amendments made by this section apply to payments
for discharges occurring on or after January 1, 2001.
SEC. 109. HOSPITAL GEOGRAPHIC RECLASSIFICATION FOR LABOR COSTS FOR ALL ITEMS
AND SERVICES REIMBURSED UNDER PROSPECTIVE PAYMENT SYSTEMS.
(a) IN GENERAL- Section 1886 of the Social Security Act (42 U.S.C. 1395ww)
is amended by adding at the end the following:
`(l) APPLICATION OF HOSPITAL GEOGRAPHIC RECLASSIFICATION FOR INPATIENT
SERVICES TO ALL HOSPITAL FURNISHED ITEMS AND SERVICES REIMBURSED UNDER
PROSPECTIVE PAYMENT SYSTEM-
`(1) IN GENERAL- In the case of a hospital with an application approved
by the Medicare Geographic Classification Review Board under subsection
(d)(10)(C) to change the hospital's geographic classification for a fiscal
year for purposes of the factor used to adjust the DRG prospective
payment rate for area differences in hospital wage levels that applies to
such hospital under subsection (d)(3)(E), the change in the hospital's
geographic classification for such purposes shall apply for purposes of
adjustments to payments for variations in costs which are attributable to wages
and wage-related costs for all pps-reimbursed items and services.
`(2) PPS-REIMBURSED ITEMS AND SERVICES DEFINED- For purposes of
paragraph (1), the term `pps-reimbursed items and services' means, for cost
reporting periods beginning during the fiscal year for which such change has
been approved, items and services furnished by the hospital, or by an entity
or department of the hospital which is provider-based (as determined by the
Secretary), for which payments--
`(A) are made under the prospective payment system for hospital
outpatient department services under section 1833(t); and
`(B) are adjusted for variations in costs which are attributable to
wages and wage-related costs.'.
(b) EFFECTIVE DATE- The amendment made by subsection (a) shall apply to
items and services furnished on or after January 1, 2000.
SEC. 110. REQUIREMENT THAT WAGE LEVELS FOR HOSPITALS BE STANDARDIZED WITH
RESPECT TO OCCUPATIONAL MIX BEFORE ADJUSTING PAYMENT RATES; STUDY AND
REPORT.
(1) IN GENERAL- Section 1886(d)(3)(E) of the Social Security Act (42
U.S.C. 1395ww(d)(3)(E)) is amended--
(A) in the first sentence, by inserting `, but only after such wage
levels have been standardized with respect to occupational mix' before the
period; and
(B) in the third sentence, by striking `To the extent determined
feasible by the Secretary, such' and inserting `Such'.
(2) EFFECTIVE DATE- The amendments made by paragraph (1) shall apply to
adjustments made on or after October 1, 2002.
(1) STUDY- The Secretary of Labor shall conduct a study on the
feasibility and costs of having the Bureau of Labor Statistics collect data
on wages that would assist the Secretary of Health and Human Services in
determining (with reasonable accuracy)--
(A) average wage levels, at the metropolitan statistical area,
statewide, and rural level, by--
(i) sector, including hospitals, skilled nursing facilities, home
health agencies, and physicians' offices; and
(ii) occupational category within each sector; and
(B) the proportion of the workforce in each occupational category
within each sector.
(2) REPORT- Not later than June 1, 2000, the Secretary of Labor shall
submit a report to Congress on the study conducted under paragraph (1),
together with any recommendations that the Secretary determines to be
appropriate.
Subtitle B--General Provisions
SEC. 121. PAYMENTS TO MEDICARE+CHOICE ORGANIZATIONS.
(a) ADJUSTMENT TO CALCULATION OF ANNUAL CAPITATION RATES- Section 1853(c)
of the Social Security Act (42 U.S.C. 1395w-23(c)) is amended--
(A) in subparagraph (A), by striking the comma at the end of clause
(ii) and all that follows before the period; and
(B) in subparagraph (C)(ii), by inserting `multiplied by the budget
neutrality adjustment factor determined under paragraph (5)' before the
period at the end; and
(2) in paragraph (5), by striking `paragraph (1)(A)' and inserting
`paragraph (1)(C)(ii)'.
(b) EFFECTIVE DATE- The amendments made by subsection (a) shall apply to
rates calculated for years after 2000.
SEC. 122. DIRECT BILLING OF MEDICARE, MEDICAID, AND OTHER THIRD-PARTY PAYORS
BY INDIAN TRIBES AND ALASKA NATIVE AND TRIBAL ORGANIZATIONS.
(a) PERMANENT AUTHORIZATION- The Indian Health Care Improvement Act (25
U.S.C. 1645) is amended by inserting the following after section 404:
`DIRECT BILLING OF MEDICARE, MEDICAID, AND OTHER THIRD-PARTY PAYORS BY
INDIAN TRIBES AND ALASKA NATIVE AND TRIBAL ORGANIZATIONS
`SEC. 405. (a) ESTABLISHMENT OF DIRECT BILLING PROGRAM-
`(1) IN GENERAL- The Secretary shall establish a program under which
Indian tribes, tribal organizations, and Alaska Native health organizations
that contract or compact for the operation of a hospital or clinic of the
Service under the Indian Self-Determination and Education Assistance Act may elect
to directly bill for, and receive payment for, health care services provided
by such hospital or clinic for which payment is made under title XVIII of
the Social Security Act (42 U.S.C. 1395 et seq.) (in this section referred
to as the `medicare program'), under a State plan for medical assistance approved under
title XIX of the Social Security Act (42 U.S.C. 1396 et seq.) (in this
section referred to as the `medicaid program'), or from any other
third-party payor.
`(2) APPLICATION OF 100 PERCENT FMAP- The third sentence of section
1905(b) of the Social Security Act (42 U.S.C. 1396d(b)) shall apply for
purposes of reimbursement under the medicaid program for health care
services directly billed under the program established under this
section.
`(b) DIRECT REIMBURSEMENT-
`(1) USE OF FUNDS- Each hospital or clinic participating in the program
described in subsection (a) of this section shall be reimbursed directly
under the medicare and medicaid programs for services furnished, without
regard to the provisions of section 1880(c) of the Social Security Act (42
U.S.C. 1395qq(c)) and sections 402(a) and 813(b)(2)(A),
but all funds so reimbursed shall first be used by the hospital or clinic for
the purpose of making any improvements in the hospital or clinic that may be
necessary to achieve or maintain compliance with the conditions and requirements
applicable generally to facilities of such type under the medicare or medicaid
programs. Any funds so reimbursed which are in excess of the amount necessary to
achieve or maintain such conditions shall be used--
`(A) solely for improving the health resources deficiency level of the
Indian tribe; and
`(B) in accordance with the regulations of the Service applicable to
funds provided by the Service under any contract entered into under the
Indian Self-Determination Act (25 U.S.C. 450f et seq.).
`(2) AUDITS- The amounts paid to the hospitals and clinics participating
in the program established under this section shall be subject to all
auditing requirements applicable to programs administered directly by the
Service and to facilities participating in the medicare and medicaid
programs.
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