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H.R.5661
Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act
of 2000 (Introduced in the House)
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) SPECIAL RULE FOR PAYMENT FOR 2001- Notwithstanding the amendments made
by subsection (a), for purposes of making payments for durable medical equipment under section 1834(a) of the
Social Security Act (42 U.S.C. 1395m(a)), other than for oxygen and oxygen
equipment specified in paragraph
(9) of such section, the payment basis recognized for 2001 under such
section--
(1) for items furnished on or after January 1, 2001, and before July 1,
2001, shall be the payment basis for 2001 as determined under the provisions
of law in effect on the day before the date of the enactment of this Act
(including the application of section 228(a)(1) of BBRA); and
(2) for items furnished on or after July 1, 2001, and before January 1,
2002, shall be the payment basis that is determined under such section
1834(a) if such section 228(a)(1) did not apply and taking into account the
amendment made by subsection (a), increased by a transitional percentage
allowance equal to 3.28 percent (to account for the timing of implementation
of the CPI update).
SEC. 426. FULL UPDATE FOR ORTHOTICS AND PROSTHETICS.
(a) IN GENERAL- 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'.
(b) SPECIAL RULE FOR PAYMENT FOR 2001- Notwithstanding the amendments made
by subsection (a), for purposes of making payments for prosthetic devices and
orthotics and prosthetics (as defined in subparagraphs (B) and (C) of
paragraph (4) of section 1834(h) of the Social Security Act (42 U.S.C.
1395m(h)) under such section, the payment basis recognized for 2001 under
paragraph (2) of such section--
(1) for items furnished on or after January 1, 2001, and before July 1,
2001, shall be the payment basis for 2001 as determined under the provisions
of law in effect on the day before the date of the enactment of this Act;
and
(2) for items furnished on or after July 1, 2001, and before January 1,
2002, shall be the payment basis that is determined under such section
taking into account the amendments made by subsection (a), increased by a
transitional percentage allowance equal to 2.6 percent (to account for the
timing of implementation of the CPI update).
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 DEVICE OR PART BEING REPLACED
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 replacement part, as the case may
be.'.
(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) MORATORIUM ON DECREASES IN PAYMENT RATES- Notwithstanding any other
provision of law, effective for drugs and biologicals furnished on or after
January 1, 2001, the Secretary may not directly or indirectly decrease the
rates of reimbursement (in effect as of such date) 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))) 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
agents 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 July 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) shall apply 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.
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