§ 1395bbb. Conditions of participation for home health agencies; home health quality

Legislative history

Reconstructed from this section’s Code source credit and amendment notes, resolved against the local Statutes at Large. Editorial notes are evidence, not the law that made the change.

1. 1935

   Pub. L. 100–203 title IV · 101 Stat. 1330

   Enacted · 42 U.S.C. § 1395bbb

   Aug. 14, 1935, ch. 531, title XVIII, § 1891, as added and amended Pub. L. 100–203, title IV, §§ 4021(b), 4022(a), 4023(a), Dec. 22, 1987, 101 Stat. 1330–67, 1330–69, 1330–71

   Source evidence

   Code source credit
   Aug. 14, 1935, ch. 531, title XVIII, § 1891, as added and amended Pub. L. 100–203, title IV, §§ 4021(b), 4022(a), 4023(a), Dec. 22, 1987, 101 Stat. 1330–67, 1330–69, 1330–71

   Enacted provision · exact public law
   TITLE IV— MEDICARE, MEDICAID, AND OTHER HEALTH-RELATED PROGRAMS TABLE OF CONTENTS OF TITLE TITLE IV—MEDICARE, MEDICAID, AND OTHER HEALTH-RELATED PROGRAMS Subtitle A— Medicare Part 1— Relating Only to Part A Sec. 4001. Extension of reductions under sequester order. Sec. 4002. Basic hospital prospective payment rates. Sec. 4003. Increase in disproportionate share adjustment and reduction in indirect medical education payments. Sec. 4004. Provisions relating to wage index. Sec. 4005. Rural hospitals. Sec. 4006. Payments for hospital capital. Sec. 4007. Reporting hospital information. Sec. 4008. Other provisions relating to payment for inpatient hospital services. Sec. 4009. Miscellaneous provisions. Part 2— Provisions Relating to Parts A and B subpart a— health maintenance organization reforms Sec. 4011. Beneficiary protection. Sec. 4012. Payments for hospital services. Sec. 4013. Two-year extension on period for benefit stabilization. Sec. 4014. Civil money penalties and intermediate sanctions against HMOs/CMPs. Sec. 4015. Medicare payment demonstration projects. Sec. 4016. Delay in effective date in physician incentive rules for health maintenance organizations. Sec. 4017. GAO study and reports on medicare capitation. Sec. 4018. Special rules. subpart b— home health quality Sec. 4021. Conditions of participation for home health agencies. Sec. 4022. Standard and extended survey. Sec. 4023. Enforcement. Sec. 4024. Requirement that individual be confined to home. Sec. 4025. Home health toll-free hotline and investigative unit. , Sec. 4026. Home health agency cost limits. Sec. 4027. Home health prospective payment demonstration project. subpart c— other provisions Sec. 4031. Payment cycle standards. Sec. 4032. Denials and reconsiderations of claims for home health services, extended care services, and post-hospital extended care services. Sec. 4033. Permitting disabled individuals to renew entitlement to medicare after gainful employment without a 2-year waiting period. Sec. 4034. Application of secondary payer provisions to governmental entities. Sec. 4035. Publication and notification of policies. Sec. 4036. End-stage renal disease amendments. Sec. 4037. Medicare hearings and appeals. Sec. 4038. Rural health medical education demonstration project. Sec. 4039. Miscellaneous and technical provisions. Part 3— Relating to Part B subpart a— provisions relating to payments for physicians’ servicesSec. 4041. Freeze in payments for physicians’ services; extension of sequester order. Sec. 4042. General update in payments for physicians’ services. Sec. 4043. Incentive payments for physicians’ services furnished in underserved areas. Sec. 4044. Adjustment in prevailing charge level for primary care services. Sec. 4045. Reduction in prevailing charge level for overpriced procedures. Sec. 4046. Limits on payment for ophthalmic ultrasound. Sec. 4047. Customary charges for primary care services of new physicians. Sec. 4048. Payment for physician anesthesia services. Sec. 4049. Fee schedules for radiologist services. Sec. 4050. Fee schedules for physician pathology services. Sec. 4051. Elimination of markup for certain purchased services. Sec. 4052. Collection of past-due amounts owed by physicians who breached contracts under the National Health Service Corps Scholarship Program. 99Copy read “Sec. 4052.”Sec. 4053. Elimination of 1975 floor for prevailing physician charges. 1010Copy read “Sec. 4053.”Sec. 4054. Application of maximum allowable actual charge (MAAC). 1111Copy read “Sec. 4054.”.Sec. 4055. Applying copayment and deductible to certain outpatient physicians’ services. 1212Copy read “Sec. 4055.”.Sec. 4056. Physician payment studies. subpart b— provisions relating to payments for other services Sec. 4061. Extension of reduction for other part B items and services payments under sequester order. Sec. 4062. Payments for durable medical equipment, prosthetic devices, orthotics, and prosthetics. Sec. 4063. Payment for intraocular lenses. Sec. 4064. Clinical diagnostic laboratory tests. Sec. 4065. Return on equity payments to outpatient departments. Sec. 4066. Payments to hospital outpatient departments for radiology. Sec. 4067. Updating maximum rate of payment per visit for independent rural health clinics. Sec. 4068. Payment for ambulatory surgery at eye, and eye and ear, specialty hospitals. subpart c— eligibility and benefits changes Sec. 4070. Coverage of mental health services. Sec. 4071. Coverage of influenza vaccine and its administration. Sec. 4072. Payment for therapeutic shoes for individuals with severe diabetic foot disease. Sec. 4073. Coverage of certified nurse-midwife services. Sec. 4074. Coverage of social worker services furnished by a health maintenance organization to its members. Sec. 4075. Clarification of coverage of drugs used in immunosuppressive therapy. Sec. 4076. Services of a physician assistant. Sec. 4077. Psychologist services in clinics. Sec. 4078. Provision of offsite comprehensive outpatient rehabilitation services. Sec. 4079. Demonstration projects to provide payment on a prepaid, capitated basis for community nursing and ambulatory care furnished to medicare beneficiaries. Sec. 4080. Part B premium. subpart d— other provisions Sec. 4081. Submission of claims to supplemental insurance carriers. Sec. 4082. Revision of part B hearings. Sec. 4083. Provisions relating to Physician Payment Review Commission. Sec. 4084. Technical amendments related to certified registered nurse anesthetists. Sec. 4085. Miscellaneous and technical provisions. Part 4— Peer Review organizations Sec. 4091. Contract provisions. Sec. 4092. Preference in contracting with in-State organizations. Sec. 4093. Requiring reasonable notice and opportunity for discussion prior to denial of claim. Sec. 4094. Peer1313Copy read “reer”. review norms and education. Sec. 4095. Pre-exclusion hearings. Sec. 4096. Limitation of beneficiary liability for services disallowed by peer review organizations. Sec. 4097. Separate funding levels. Subtitle B— Medicaid Part 1— Eligibility and Benefits. Sec. 4101. Medicaid benefits for poor children and pregnant women. Sec. 4102. Home and community-based services for the elderly. Sec. 4103. Physicians’ services furnished by dentists. Sec. 4104. Optional medicaid coverage of individuals in certain States receiving only optional State1414Copy read “states”, and “state”, respectively. supplementary payments. Sec. 4105. Miscellaneous SSI-related amendments. Sec. 4106. Clarification of coverage of clinic services furnished to homeless outside facility. Sec. 4107. Medically needy income levels for certain 2-member couples in California.1515Copy read “California.”. Part 2— Other Provisions Sec. 4111. Increasing the maximum annual medicaid payments that may be made to the commonwealths and territories. Sec. 4112. Adjustment in medicaid payment for inpatient hospital services furnished by disproportionate share hospitals. Sec. 4113. HMO-related provisions. Sec. 4114. Medicaid waiver for hospice care for AIDS patients. Sec. 4115. State demonstration projects. Sec. 4116. Waiver authority under the medicaid program for the Northern Mariana Islands.1616Copy read “northern mariana islands.”. Sec. 4117. Delay quality control sanctions for medicaid. Sec. 4118. Technical and miscellaneous amendments. Subtitle C— Nursing Home Reform Part 1— Medicare Program Sec. 4201. Requirements for skilled nursing facilities. Sec. 4202. Survey and certification process. Sec. 4203. Enforcement process. Sec. 4204. Effective dates. Sec. 4205. Annual report. Sec. 4206. Construction. Part 2— Medicaid Program Sec. 4211. Requirements for nursing facilities. Sec. 4212. Survey and certification process. Sec. 4213. Enforcement process. Sec. 4214. Effective dates. Sec. 4215. Annual report. Sec. 4216. Construction. Sec. 4217. Final regulations with respect to plans of correction or reduction. Sec. 4218. Medicaid certifications and recertifications for certain services. Subtitle D— Vaccine Compensation Sec. 4301. Short title, reference. Sec. 4302. Effective date. Sec. 4303. Compensation. Sec. 4304. Petitions. Sec. 4305. Citizen’s actions. Sec. 4306. Vaccine administrators.16a16aCopy read “Vacine”. Sec. 4307. Court jurisdiction. Subtitle E— Rural Health Sec. 4401. Office of Rural Health Policy. Sec. 4402. Impact analyses of medicare rules and regulations on small rural hospitals. Sec. 4403. Set aside for experiments and demonstration projects relating to rural health care issues. PART 1— RELATING ONLY TO PART A SEC. 4001. EXTENSION OF REDUCTIONS UNDER SEQUESTER ORDER. Notwithstanding any other provision of law (including any other President of U.S. provision of this Act), the reductions in the amount of payments required under title XVIII of the Social Security Act made by the final sequester order issued by the President on November 20, 1987, pursuant to section 2520b) of the Balanced Budget Emergency Deficit Control Act of 1985 shall continue to be effective (as provided by sections 252(a)(4)(B) and 256(d)(2) of such Act) through— (1) March 31, 1988, with respect to payments for inpatient hospital services under such title (including payments under section 1886 of such title attributable or allocated to part A of such title); and (2) December 31, 1987, with respect to payments for other items and services under part A of such title. SEC. 4002. BASIC HOSPITAL PROSPECTIVE PAYMENT RATES. (a) Basic Update Factor for PPS Hospitals.— Clause (i) of section 1886(b)(3)(B) of the Social Security Act (42 U.S.C. 1395ww(b)(3)(B)) is amended by striking “and for fiscal year 1988” in subclause (II) and all that follows through the end of such clause and inserting after such subclause the following: “(III) for fiscal year 1988, 3.0 percent for hospitals located in a rural area, 1.5 percent for hospitals located in a large urban area (as defined in subsection (d)(2)(D)), and 1.0 percent for other hospitals, “(IV) for fiscal year 1989, the market basket percentage increase minus 1.5 percent for hospitals located in a rural area, the market basket percentage increase minus 2.0 percent for hospitals located in a large urban area, and the market basket percentage increase minus 2.5 percent for other hospitals, and “(V) for fiscal year 1990 and each subsequent fiscal year, the market basket percentage for hospitals in all areas.”. (b) Large Urban Area Defined.— The second sentence of section 1886(d)(2)(D) of such Act (42 U.S.C. 1395ww(d)(2)(D))16b16bCopy read “(42 U.S.C. 1395www(d)(2)(D))”. is amended by inserting after “under subsection (a) by regulation;” the following: “the term ‘large urban area’ means, with respect to a fiscal year, such an urban area which the Secretary determines (in the publication described in subsection (e)(5)(B) before the fiscal year) has a population of more than 1,000,000 (as determined by the Secretary based on the most recent available population data published by the Bureau of the Census);”. (c) Adjustment for Hospitals in Large Urban Areas or in Rural Areas.— (1) In general.— Section 1886(d)(3) of such Act (42 U.S.C. 1395ww(d)(3)) is amended— (A) in the matter before subparagraph (A), by striking “urban or rural areas” and inserting “large urban, other urban, or rural areas”; (B) in first sentence of subparagraph (A)— (i) by striking “The Secretary” and inserting “(i) For discharges occuring in a fiscal year beginning before October 1, 1987, the Secretary”, (ii) by striking “each of fiscal years 1985, 1986, 1987, and 1988” and inserting “the fiscal year involved”, and (iii) by striking “, and adjusted for subsequent fiscal years in accordance with the final determination of the Secretary under subsection (e)(4), and adjusted to reflect the most recent case-mix data available,”; (C) by adding at the end of subparagraph (A) the following new clauses: “(ii) For discharges occurring in a fiscal year beginning on or after October 1, 1987, the Secretary shall compute an average standardized amount for hospitals located in a large urban area, for hospitals located in a rural area, and for hospitals located in urban areas, within the United States and within each region, equal to the respective average standardized amount computed for the previous fiscal year under this subparagraph increased by the applicable percentage increase under subsection (b)(3)(B)(i) with respect to hospitals located in the respective areas for the fiscal year involved. “(iii) Average standardized amounts computed under this paragraph shall be adjusted to reflect the most recent case-mix data available.”; and (D) in subparagraph (D)— (i) by striking “urban and rural hospitals” in the heading and inserting “hospitals in different areas”, (ii) in clause (i), by inserting “(or, for discharges occurring on or after April 1, 1988, in a large urban area or other urban area)” after “urban area” the first place it appears, and (iii) in clause (i), by inserting “such” before “an urban area” the second place it appears. (2) Conforming amendments.— Section 1886(d)(9)(A) of such Act (42 U.S.C. 1395ww(d)(9)(A)) is amended— (A) in clause (ii)(I), by striking “an urban area, and” and inserting “a large urban area,”; (B) by redesignating subclause (II) of clause (ii) as subclause (III); and (C) by inserting after subclause (I) of clause (ii) the following new subclause: “(II) such rate for hospitals located in other urban areas, and”. (d) Establishment of Regional Floor.— Section 1886(d)(1)(A)(iii) of such Act (42 U.S.C. 1395ww(d)(1)(A)(iii)) is amended by inserting before the period at the end the following: “, or, if greater for discharges occurring during the period beginning on April 1, 1988, and ending on September 30, 1990, the sum of (I) 85 percent of the national adjusted DRG prospective payment rate determined under paragraph (3) for such discharges, and (II) 15 percent of the regional adjusted DRG prospective payment rate determined under such paragraph”. (e) Update for PPS-Exempt Hospitals.— Section 1886(b)(3)(B) of such Act (42 U.S.C. 1395ww(b)(3)(B)) is amended— (1) in clause (i), by striking “subparagraph (A) for 12-month cost reporting periods beginning during a fiscal year and for purposes of”, (2) in clause (ii), by striking “(ii) For purposes of clause (i)” and inserting “(iii) For purposes of this subparagraph”, and (3) by inserting after clause (i) the following new clause: “(ii) For purposes of subparagraph (A), the ‘applicable percentage increase’ for 12-month cost reporting periods beginning during— “(I) fiscal year 1986, is 0.5 percent, “(II) fiscal year 1987, is 1.15 percent, “(III) fiscal year 1988, is the market basket percentage increase minus 2.0 percentage points, and “(IV) subsequent fiscal years is the market basket percentage increase.”. (f) Related Conforming and Technical Amendments.— (1) Section 1886 of such Act (42 U.S.C. 1395ww) is further amended— (A) by adding at the end of subsection (d)(2)(D) the following new sentence: “For purposes of payment under this subsection, a hospital is considered to be located in an urban area or large urban area, respectively, if the hospital is paid under this subsection at the rate for hospitals located in such an area.”; (B) in subsection (e)(3)(B), by striking “or determine”; (C) in subsection (e)(4)— (i) by striking “for fiscal year 1988” and inserting “for each fiscal year (beginning with fiscal year 1988)”, (ii) by striking “and shall determine for each subsequent fiscal year” and all that follows through “fiscal year, and”, and (iii) by amending the last sentence to read as follows: “The appropriate change factor may be different for all large urban subsection (d) hospitals, other urban subsection (d) hospitals, urban subsection (d) Puerto Rico hospitals, rural subsection (d) hospitals, and rural subsection (d) Puerto Rico hospitals, and all other hospitals and units not paid under subsection (d), and may vary among such other hospitals and units.”; and (D) in paragraph (5), by striking “or determination” each place it appears. (2) Subsection (a)(1)(B)(ii) of section 107 of the Balanced Budget and Emergency Deficit Control Reaffirmation Act of 1987 (Public Law 100–119) is amended, effective as of the date of 42 USC 1395WW note. the enactment of such Act, by inserting “, the target percentage and DRG percentage shall be those specified in subsection (d)(1)(C)(iv) of such section, and the applicable percentage increase in a hospital’s target amount shall be deemed to be 0 percent” before the period at the end. (g) Effective Dates.— (1) PPS hospitals, drg portion of payment.— In the case of a subsection (d) hospital (as defined in paragraph (6))— (A) the amendments made by subsections (a) and (c) shall apply to payments made under section 1886(a)(1)(A)(iii) of the Social Security Act on the basis of discharges occurring on or after April 1, 1988, and (B) for discharges occurring on or after October 1, 1988, the applicable percentage increase (described in section 1886(d)(3)(B) of such Act)1717Copy read “Act))”. for discharges occurring during fiscal year 1987 is deemed to have been such percentage increase as amended by subsection (a). (2) PPS sole community hospitals, hospital specific portion of payment.— In the case of a subsection (d) hospital which receives payments made under section 1886(d)(1)(A) of the Social Security Act because it is a sole community hospital— (A) the amendment made by subsections (a) and (c) shall apply to payments under section 1886(d)(1)(A)(ii)(I) of the Social Security Act made on the basis of discharges occurring during a cost reporting period of a hospital, for the hospital’s cost reporting period beginning on or after October 1, 1987; (B) notwithstanding subparagraph (A), for cost reporting period beginning during fiscal year 1988, the applicable percentage increase (as defined in section 1886(d)(3)(B) of such Act) for the— (i) first 51 days of the cost reporting period shall be 0 percent, (ii) next 132 days of such period shall be 2.7 percent, and (iii) remainder of such period of the cost reporting period shall be the applicable percentage increase (as so defined, as amended by subsection (a)); and (C) for cost reporting periods beginning on or after October 1, 1988, the applicable percentage increase (as so defined) with respect to the previous cost reporting period shall be deemed to have been the applicable percentage increase (as so defined, as amended by subsection (a)). (3) PPS-exempt hospitals.— In the case of a hospital that is not a subsection (d) hospital— (A) the amendments made by subsection (e) shall apply to cost reporting periods beginning on or after October 1, 1987; (B) notwithstanding subparagraph (A), for the hospital’s cost reporting period beginning during fiscal year 1988, payment under title XVIII of the Social Security Act shall be made as though the applicable percentage increase de-scribed in section 1886(b)(3)(B) of such Act were equal to the product of 2.7 percent and the ratio of 315 to 366; and (C) for cost reporting periods beginning on or after October 1, 1988, the applicable percentage increase (as so defined) with respect to the cost reporting period beginning during fiscal year 1988 shall be deemed to have been 2.7 percent. (4) Definition, regional floor, and technical and conforming amendments.— The amendments made by subsections (b) and (d) and paragraphs (1) and (2) of subsection (0 shall take effect on the date of the enactment of this Act. (5) Transition for large urban area rates.— In computing the average standardized amount for hospitals located in a large urban area or other urban area under section 1886(d)(3)(A)(ii) of the Social Security Act (as amended by subsection (c)) for fiscal year 1988, the reference to “the respective average standardized amount computed for the previous fiscal year under this subparagraph” is deemed a reference to the average standardized amount computed for hospitals located in an urban area for the 51-day period beginning on October 1, 1987. (6) Definition.— In this subsection, the term “subsection (d) hospital” has the meaning given such term in section 1886(d)(10)(B) of the Social Security Act. SEC. 4003. INCREASE IN DISPROPORTIONATE SHARE ADJUSTMENT AND REDUCTION IN INDIRECT MEDICAL EDUCATION PAYMENTS. (a) Reduction in Indirect Medical Education Payments.— (1) Section 1886(d)(5)(B)(ii) of the Social Security Act (42 U.S.C. 1395ww(d)(5)(B)(ii)) is amended— (A) in subclause (I), by striking “2” and inserting in lieu thereof “1.89”; and (B) in subclause (II), by striking “1.5” and inserting in lieu thereof “1.43”. (2) Section 1886(d)(3)(C)(ii) of such Act (42 U.S.C. 1395ww(d)(3)(C)(ii)) is amended by inserting “and by section 4003(a)(1) of the Omnibus Budget Reconciliation Act of 1987” after “1985” each place it appears in subclauses (I) and (II). (b) Increase in Disproportionate Share Adjustment.— Section 1886(d)(5)(F) of such Act (42 U.S.C. 1395ww(d)(5)(B))— (1) in clause (iii), by striking “15 percent“ and inserting “25 percent”, and (2) in clause (iv)(I), by striking “the lesser of 15 percent, or”. (c) Extension of Disproportionate Share Adjustment.— Sections 1886(d)(2)(C)(iv) (42 U.S.C. 1395ww(d)(2)(C)(iv)), 1886(d)(3)(C)(ii)(I) (42 U.S.C. 1395ww(d)(3)(C)(ii)(I)), 1886(d)(3)(C)(ii)(II) (42 U.S.C. 1395ww(d)(3)(C)(ii)(II)), 1886(d)(5)(B)(ii)(I) (42 U.S.C. 1395ww(d)(5)(B)(ii)(I)), 1886(d)(5)(B)(ii)(II) (42 U.S.C. 1395ww(d)(5)(B)(ii)(II)), and 1886(d)(5)(F)(i) (42 U.S.C. 1395ww(d)(5)(F)(i)) of the Social Security Act are each amended by striking “1989” and inserting in lieu thereof “1990”. (d) Special Rule.— In the case of a hospital which— (1) consists of 2 inpatient hospital facilities which are more than 4 miles apart and each of which is in a separate political jurisdiction within the same State and one of which meets the criteria under section 1886(d)(5)(F) of the Social Security Act for serving a significantly disproportionate number of low-income patients as if that facility were a separate hospital; and (2) receives payments for inpatient hospital services under title XVIII of the Social Security Act which are less than the hospital’s reasonable costs, the Secretary of Health and Human Services, upon application by the hospital, may treat each of the facilities of hospital as separate hospitals for purposes of applying section 1886(d)(5)(F) of the Social Security Act, for discharges occurring on or after October 1, 1988. (e) Effective Date.— The amendments made by this section shall 42 USC 1395WW note. apply to payments for discharges occurring on or after October 1, 1988. SEC. 4004. PROVISIONS RELATING TO WAGE INDEX. (a) Survey.— Section 1886(d)(3)(E) of the Social Security Act (42 U.S.C. 1395ww(d)(3)(E)) is amended by adding at the end the following: “Not later than October 1, 1990 (and at least every 36 months thereafter), the Secretary shall update the factor under the preceding sentence on the basis of a survey conducted by the Secretary (and updated as appropriate) of the wages and wage-related costs of subsection (d) hospitals in the United States. To the extent determined feasible by the Secretary, such survey shall measure the earnings and paid hours of employment by occupational category and shall exclude data with respect to the wages and wage-related costs incurred in furnishing skilled nursing facility services.”. (b) Clinic Hospital Wage Indices.— In calculating the wage index 42 USC 1395WW note. under section 1886(d) of the Social Security Act for purposes of making payment adjustments after September 30, 1988, as required under paragraphs (2)(H) and (3)(E) of such section, in the case of any institution which received the waiver specified in section 602(k) of the Social Security Amendments of 1983, the Secretary of Health and Human Services shall include wage costs paid to related organization employees directly involved in the delivery and administration of care provided by the related organization to hospital inpatients. For purposes of the preceding sentence, the term “wage costs” does not include costs of overhead or home office administrative salaries or any costs that are not incurred in the hospital’s Metropolitan Statistical Area. SEC. 4005. RURAL HOSPITALS. (a) Revision of Standards for Including a Rural County in an Urban Area.— (1) Treating certain rural hospitals adjacent to urban areas as urban hospitals.— Section 1886(d)(8) of the Social Security Act (42 U.S.C. 1395ww(d)(8))— (A) by redesignating clauses (i) and (ii) of subparagraphs (A) and (B) as subclauses (I) and (II), respectively, (B) by redesignating subparagraphs (A) and (B) as clauses (i) and (ii), respectively, (C) by inserting “(A)” after “(8)”, and (D) by adding at the end the following new subparagraph: “(B) The Secretary shall treat a hospital located in a rural county adjacent to one or more urban areas as being located in the urban metropolitan statistical area to which the greatest number of workers in the county commute, if— “(i) the rural county would otherwise be considered part of an urban area but for the fact that the rural county does not meet the standard relating to the rate of commutation between the rural county and the central county or counties of any adjacent urban area; and “(ii) either (I) the number of residents of the rural county who commute for employment to the central county or counties of any adjacent urban area is equal to at least 15 percent of the number of residents of the rural county who are employed, or (II) the sum of the number of residents of the rural county who commute for employment to the central county or counties of any adjacent urban area and the number of residents of any adjacent urban area who commute for employment to the rural county is at least equal to 20 percent of the number of residents of the rural county who are employed. “(C) The Secretary shall make a proportional adjustment in the standardized amount determined under paragraph (3) for hospitals located in an urban area to assure that the provisions of subparagraph (B) do not result in aggregate payments under this section that are greater or less than those that would otherwise be made. The Secretary shall make such adjustment in payments under this section to hospitals located in rural areas as are necessary to assure that the aggregate of payments to rural hospitals not affected by subparagraph (B) are not changed as a result of the application of subparagraph (B).”. (2) Location of hospital.— For purposes of section 1886 of the Social Security Act, Watertown Memorial Hospital in Watertown, Wisconsin is deemed to be located in Jefferson County, Wisconsin. (3) Effective date.— This section, and the amendments made 42 USC 1395WW note. by paragraph (1), shall apply to discharges occurring on or after October 1, 1988. (b) Expansion of Swing-Bed Program.— (1) Expansion to hospitals with fewer than 100 beds.— Section 1883(b)(1) of the Social Security Act (42 U.S.C. 1395tt(b)(l)) is amended by striking “50 beds” and inserting “100 beds”. (2) Requirements for hospitals with more than 49 beds.— Section 1883(d) of such Act (42 U.S.C. 1395dd(d)) is amended— 42 USC 1395tt. (A) by inserting “(1)” after “(d)”, and (B) by adding at the end the following new paragraphs: “(2) (A) Any agreement under this section with a hospital with more than 49 beds shall provide that no payment may be made for extended care services which are furnished to an extended care patient after the end of the 5-day period (excluding weekends and holidays) beginning on an availability date for a skilled nursing facility, unless the patient’s physician certifies, within such 5-day period, that the transfer of that patient to that facility is not medically appropriate on the availability date. The Secretary shall Regulations. prescribe regulations to provide for notice by skilled nursing facilities of availability dates to hospitals which have agreements under this section and which are located within the same geographic region (as defined by the Secretary). “(B) In this paragraph: “(i) The term ‘availability date’ means, with respect to an extended care patient at a hospital, any date on which a bed is available for the patient in a skilled nursing facility located within the geographic region in which the hospital is located. “(ii) The term ‘extended care patient’ means an individual being furnished extended care services at a hospital pursuant to an agreement with the Secretary under this section. “(3) In the case of an agreement for a cost reporting period under this section with a hospital that has more than 49 beds, payment may not be made in the period for patient-days of extended care services that exceed 15 percent of the product of the number of days in the period and the average number of licensed beds in the hospital in the period.”. (3) Report.— The Secretary of Health and Human Services 42 USC 1395tt note. shall report to Congress, not later than February 1, 1989, concerning— (A) the proportion of admissions to hospitals for extended care services under section 1883 of the Social Security Act which are denied or approved by a peer review organization under section 1154(a)(1) of such Act, and (B) on recommendations for methods of encouraging hospitals that— (i) have a low occupancy rate, (ii) are eligible to enter (but have not entered) into an agreement under section 1883 of such Act, and (iii) are located in areas with a need for additional providers of extended care services, to enter into such agreements. (4) Effective date.— The amendments made by paragraphs 42 USC 1395tt note. (1) and (2) shall apply to agreements under section 1883 of the Social Security Act entered into after March 31, 1988. (c) Payments to Sole Community Hospitals.— (1) Section 1886(d)(5)(C)(ii) of the Social Security Act (42 U.S.C. 1395ww(d)(5)(C)(ii)) is amended— (A) by striking “1988” in the second sentence and inserting “1990”, and (B) by inserting after the second sentence the following: “A subsection (d) hospital that meets the criteria for classification as a sole community hospital and otherwise qualifies for the adjustment authorized by the preceding sentence may qualify for such an adjustment without regard to the formula by which payments are determined for the hospital under paragraph (1)(A).”. (2) (A) The amendments made by paragraph (1) shall apply to 42 USC 1395WW note. cost reporting periods beginning on or after October 1, 1987 (B) The Secretary of Health and Human Services shall take appropriate steps to ensure that the total amount paid in a fiscal year under title XVIII of the Social Security Act by reason of the amendment made by paragraph (1)(B) does not exceed $5,000,000 in the case of fiscal year 1988 and $10,000,000 for fiscal year 1989. (d) Medicare Classification of Rural Referral Centers.— (1) Extension of classification.— (A) In general.— The first sentence of section 1886(d)(5)(C)(i)(I) of the Social Security Act (42 U.S.C. 1395ww(d)(5)(C)(i)(I)) is amended by striking “500” and inserting “275”. (B) Effective date.— The amendment made by subparagraph 42 USC 1395WW note. (A) shall apply to discharges occurring on or after April 1, 1988. (2) Study.— (A) In general.— The Secretary of Health and Human Services shall provide for a study of the criteria used for the classification of hospitals as rural referral centers under section 1886(d)(5)(C)(i) of the Social Security Act. The study shall include an examination of— (i) the extent that hospitals classified as rural referral centers receive more or less than their actual costs of providing inpatient hospital services, and (ii) the appropriateness of providing for payment for such centers at a rate other than the rate for a hospital located in an other urban area. (B) Report.— The Secretary shall report to Congress, by not later than March 1, 1989, on the study conducted under subparagraph (A) and on recommendations for the criteria that should be applied under section 1886(d)(5)(C)(i) of the Social Security Act for the classification of hospitals as rural referral centers for cost reporting periods beginning on or after October 1, 1989. (e) Grant Program for Rural Health Care Transition.— (1) The Administrator of the Health Care Financing Administration, in consultation with the Assistant Secretary for Health (or a designee), shall establish a program of grants to assist eligible small rural hospitals and their communities in the planning and implementation of projects to modify the type and extent of services such hospitals provide in order to adjust for one or more of the following factors: (A) Changes in clinical practice patterns. (B) Changes in service populations. (C) Declining demand for acute-care inpatient hospital capacity. (D) Declining ability to provide appropriate staffing for inpatient hospitals. (E) Increasing demand for ambulatory and emergency services. (F) Increasing demand for appropriate integration of community health services. (G) The need for adequate access (including appropriate transportation) to emergency care and inpatient care in areas in which a significant number of underutilized hospital beds are being eliminated. (H) The Administrator shall submit a final report on the program to the Congress not later than 180 days after all projects receiving a grant under the program are completed. Each demonstration project under this subsection shall demonstrate methods of strengthening the financial and managerial capability of the hospital involved to provide necessary services. Such methods may include programs of cooperation with other health care providers, of diversification in services furnished (including the provision of home health services), of physician recruitment, and of improved management systems. (2) For purposes of this subsection, the term “eligible small rural hospital”1818Copy read “ ‘eligible small rural hospital’ ”. means any non-Federal, short-term general acute care hospital that— (A) is located in a rural area (as determined in accordance with subsection (d)), (B) has less than 100 beds, and (C) is not for profit. (3) (A) Any eligible small rural hospital that desires to modify the type or extent of health care services that it provides in order to adjust for one or more of the factors specified in paragraph (1) may submit an application to the Governor of the State in which it is located. The application shall specify the nature of the project proposed by the hospital, the data and information on which the project is based, and a timetable (of not more than 24 months) for completion of the project. The application shall be submitted on or before a date specified by the Administrator and shall be in such form as the Administrator may require. (B) The Governor shall transmit any application submitted pursuant to subparagraph (A) to the Secretary not later than 30 days after it is received by the Governor, accompanied by any comments with respect to the application that the Governor deems appropriate. (C) The Governor of a State may designate an appropriate State agency to receive and comment on applications submitted under subparagraph (A). (4) A hospital shall be considered to be located in a rural area for purposes of this subsection if it is treated as being located in a rural area for purposes of section 1886(d)(3)(D) of the Social Security Act. (5) In determining which hospitals making application under paragraph (3) will receive grants under this subsection, the Administrator shall take into account— (A) any comments received under paragraph (3)(B) with respect to a proposed project; (B) the effect that the project will have on— (i) reducing expenditures from the Federal Hospital Insurance Trust Fund, (ii) improving the access of medicare beneficiaries to health care of a reasonable quality; (C) the extent to which the proposal of the hospital, using appropriate data, demonstrates an understanding of— (i) the primary market or service area of the hospital, and (ii) the health care needs of the elderly and disabled that are not currently being met by providers in such market or area, and (D) the degree of coordination that may be expected between the proposed project and— (i) other local or regional health care providers, and (ii) community and government leaders, as evidenced by the availability of support for the project (in cash or in kind) and other relevant factors. (6) A grant to a hospital under this subsection may not exceed $50,000 a year and may not exceed a term of 2 years. (7) (A) Except as provided in subparagraphs (D) and (C), a hospital receiving a grant under this subsection may use the grant for any of expenses incurred in planning and implementing the project with respect to which the grant is made. (B) A hospital receiving a grant under this subsection for a project may not use the grant to retire debt incurred with respect to any capital expenditure made prior to the date on which the project is initiated. (C) Not more than one-third of any grant made under this subsection may be expended for capital-related costs (as defined by the Secretary for purposes of section 1886(a)(4) of the Social Security Act) of the project. (8) (A) A hospital receiving a grant under this section shall furnish the Administrator with such information as the Administrator may require to evaluate the project with respect to which the grant is made and to ensure that the grant is expended for the purposes for which it was made. (B) The Administrator shall report to the Congress at least Reports. once every 6 months on the program of grants established under this subsection. The report shall assess the functioning and status of the program, shall evaluate the progress made toward achieving the purposes of the program, and shall include any recommendations the Secretary may deem appropriate with respect to the program. In preparing the report, the Secretary shall solicit and include the comments and recommendations of private and public entities with an interest in rural health care. (C) The Administrator shall submit a final report on the Reports. program to the Congress not later than 180 days after all projects receiving a grant under the program are completed. (9) For purposes of carrying out the program of grants under this subsection, there are authorized to be appropriated from the Federal Hospital Insurance Trust Fund $15,000,000 for each of the fiscal years 1989 and 1990. SEC. 4006. PAYMENTS FOR HOSPITAL CAPITAL. (a) Reductions in Payments for Capital.— Section 1886(g)(3)(A) of the Social Security Act (42 U.S.C. 1395ww(g)(3)(A)) is amended— (A) in clause (ii), by striking “, and” and inserting “on or after October 1, 1987, and before January 1, 1988,”, (B) by striking clause (iii) and inserting the following: “(iii) 12 percent for payments attributable to portions of cost reporting periods or discharges (as the case may be) in fiscal year 1988, occurring on or after January 1, 1988, and “(iv) 15 percent to portions of cost reporting periods or discharges (as the case may) be occurring during fiscal year 1989.”. (b) Prospective Payment for Capital-Related Costs.— (1) In general.— Paragraph (1) of section 1886(g) of such Act (42 U.S.C. 1395ww(g)) is amended to read as follows: “(g) (1) (A) Notwithstanding section 1861(v), instead of any amounts that are otherwise payable under this title with respect to the reasonable costs of subsection (d) hospitals and subsection (d) Puerto Rico hospitals for capital-related costs of inpatient hospital services, the Secretary shall, for hospital cost reporting periods beginning on or after October 1, 1991, provide for payments for such costs in accordance with a prospective pa3mient system established by the Secretary. “(B) Such system— “(i) shall provide for (I) a payment on a per discharge basis, and (II) an appropriate weighting of such payment amount as relates to the classification of the discharge; “(ii) may provide for an adjustment to take into account variations in the relative costs of capital and construction for the different types of facilities or areas in which they are located; “(iii) may provide for such exceptions (including appropriate exceptions to reflect capital obligations) as the Secretary determines to be appropriate, and “(iv) may provide for suitable adjustment to reflect hospital occupancy rate. “(C) In this paragraph, the term ‘capital-related costs’ has the meaning given such term by the Secretary under subsection (a)(4) as of September 30, 1987, and does not include a return on equity capital.”. (2) Conforming amendment.— Section 1886 of such Act is 42 USC 1395WW. amended— (A) in subsection (a)(4), by striking “with respect to costs incurred in cost reporting periods beginning prior to October 1 of 1987 (or of such later year as the Secretary may, in his discretion, select), other capital-related costs, as defined by the Secretary” and inserting “other capital-related costs (as defined by the Secretary for periods before October 1, 1987)”, and (B) by striking subparagraph (C) of subsection (g)(3). (3) Effective dates.— The amendment made by paragraph (1) 42 USC 1395WW note. shall take effect on October 1, 1987. The amendments made by paragraph (2) shall apply to cost reporting periods beginning on or after October 1, 1987. (c) Propac Report on Adjustment for Hospital Occupancy.— The Prospective Payment Assessment Commission shall study and report to the Committee on Ways and Means of the House of Representatives and the Committee on Finance of the Senate, by not later than May 1, 1988, on the suitability and feasibility of linking payment for capital-related costs under part A of title XVIII of the Social Security Act to hospital occupancy rates. SEC. 4007. REPORTING HOSPITAL INFORMATION. (a) Development of Data Base.— The Secretary of Health and Human Services (in 1919Copy read “Services, (in”. this section referred to as the “Secretary”) shall develop and place into effect not later than June 1, 1989, a data base of the operating costs of inpatient hospital services with respect to all hospitals under title XVIII of the Social Security Act, which data base shall be updated at least once every quarter (and maintained for the 12-month period preceding any such update). The data base under this subsection may include data from preliminary cost reports (but the Secretary shall make available an updata analysis of the differences between preliminary and settled cost reports). (b) Reporting of Information Electronically.— (1) 2020Copy read “Electronically.—Subject” Subject to paragraph (2), with respect to hospital cost reporting periods beginning on or after October 1, 1989, the Secretary shall place into effect a standardized electronic cost reporting format for hospitals under the medicare program. (2) The Secretary may delay or waive the implementation of such format in particular instances where such implementation would result in financial hardship (in particular with respect to a small percentage of medicare volume), (c) Demonstration Project.— (1) The Secretary of Health and Human Services shall provide for a 3-year demonstration project to develop, and determine the costs and benefits of establishing a uniform system for the reporting by medicare participating hospitals of balance sheet and information described in paragraph (2), In contracting the Contracts. project, the Secretary shall require hospitals in at least 2 States, one of which maintains a uniform hospital reporting system, to report such information based on standard information established by the Secretary. (2) The information described in this paragraph is as follows: (A) Hospital discharges (classified by category of service and by class of primary payer). (B) Patient days (classified by category of service and by class of primary payer). (C) Licensed beds, staffed beds, and occupancy (by category of service). (D) Outpatient visits (classified by class of primary payer). (E) Inpatient charges and revenues (classified by class of primary payer). (F) Outpatient charges and revenues (classified by class of primary payer). (G) Inpatient and outpatient hospital expenses (by cost-center classified for operating and capital). (H) Reasonable costs. (I) Other income. (J) Uncompensated care (classified by bad debt and charity care). (K) Capital acquisitions. (L) Capital assets. (3) The Secretary shall develop the system under subsection (c) in a manner so as— (A) to facilitate the submittal of the information in the report in an electronic form, and (B) to be compatible with the needs of the medicare prospective payment system. (4) The Secretary shall prepare and submit, to the Prospective Payment Assessment Commission, the Comptroller General, the Committee on Ways and Means of the House of Representatives, and the Committee on Finance of the Senate, by not later than 45 days after the end of each calendar quarter, data collected under the system. (5) In paragraph (3): (A) The terms “bad debt” and “charity care” have such meanings as the Secretary establishes. (B) The term “class” means, with respect to payers, the programs under this title VIII of the Social Security Act, a State plan approved under title XIX of such Act, other third party-payers, and self-paying individuals. (6) 2121Copy read “(7)”The Secretary shall set aside at least $1,000,000 for each of fiscal years 1988, 1989, and 1990 from existing research funds to develop the format, according to paragraph (1), and at least $2,000,000 from program operations funds for data collection and analysis, but total funds shall not exceed $15,000,000 over 3 years. (7) 2222Copy read “(8)”. The Comptroller General shall analyze the adequacy of the existing system for reporting of hospital information and the costs and benefits of data reporting under the demonstration system and will recommend improvements in hospital data collection and in analysis and display of data in support of policy making. 2323“(J)” Paragraph had wrong indention.(d) Consultation.— The Secretary shall consult representatives of the hospital industry in carrying out the provisions of this section. SEC. 4008. OTHER PROVISIONS RELATING TO PAYMENT FOR INPATIENT HOSPITAL SERVICES. (a) Massachusetts Medicare Repayment.— The Secretary of Health and Human Services shall not, on or after the date of the enactment of this Act, and before January 1, 1989, recoup from, or otherwise reduce payments to, hospitals in the State of Massachusetts because of alleged overpayments to such hospitals under part A of title XVIII of the Social Security Act which occurred during the period of the statewide hospital reimbursement demonstration project conducted in that State, between October 1, 1982, and June 30, 1986, under section 402 of the Social Security Amendments of 1967 and section 222 of the Social Security Amendments of 1972. (b) Clarification of Section 1814(b) State Waiver Authority.— (1) Application of aggregate test.— Section 181403)(3)(B) of the Social Security Act (42 U.S.C. 1395f(b)(3)(B)) is amended by striking "“ate of increase for the previous three-year period” and inserting “aggregate rate of increase from October 1, 1983, to the most recent date for which annual data are available”. (2) Effective date.— The amendment made by paragraph (1) 42 USC 1395f note. shall take effect on the date of the enactment of this Act. (c) Continuation of Bad Debt Recognition for Hospital Services.— In making payments to hospitals under title XVIII of the Social Security Act, the Secretary of Health and Human Services shall not make any change in the policy in effect on August 1, 1987, with respect to payment under title XVIII of the Social Security Act to providers of service for reasonable costs relating to unrecovered costs associated with unpaid deductible and coinsurance amounts incurred under such title (including criteria for what constitutes a reasonable collection effort). (d) Hospital Outlier Payments and Policy.— (1) Increase in outlier payments for burn center drgs.— (A) In general.— For discharges classified in diagnosis-related groups relating to burn cases and occurring on or after April 1, 1988, and before October 1, 1989, the marginal cost of care permitted by the Secretary of Health and Human Services under section 1886(d)(5)(A)(iii) of the Social Security Act shall be 90 percent of the appropriate per diem cost of care or 90 percent of the cost for cost outliers. (B) Budget neutrality.— Subparagraph (A) shall be implemented in a manner that ensures that total payments under section 1886 of the Social Security Act are not in-creased or decreased by reason of the adjustments required by such subparagraph. (2) Limitation on changes in outlier regulations.— (A) In general.— Notwithstanding any other provision of law, except as required to implement specific provisions required under statute, the Secretary of Health and Human Services is not authorized to issue in final form, after the date of the enactment of this Act and before September 1, 1988, any final regulation which changes the method of payment for outlier cases under section 1886(d)(5)(A) of the Social Security Act. (B) Propac 2424“Copy read “PROPAC”. report.— The chairman of the Prospective Payment Assessment Commission shall report to the Congress and the Secretary of Health and Human Services, by not later than June 1, 1988, on the method of payment for outlier cases under such section and providing more adequate and appropriate payments with respect to burn outlier cases. (3) Report on outlier payments.— The Secretary of Health and Human Services shall include in the annual report submitted to the Congress pursuant to section 1875(b) of the Social Security Act a comparison with respect to hospitals located in an urban area and hospitals located in a rural area in the amount of reductions under section 1886(d)(3)(B) of the Social Security Act and additional payments under section 1886(d)(5)(A) of such Act. (e) Miscellaneous Accounting Provision.— Effective as if included in the enactment of the Omnibus Budget Reconciliation Act of 1986, subsection (d) of section 9307 of such Act is amended to read 42 USC 1395ww note. as follows: “(d) Miscellaneous Accounting Provision.— Notwithstanding any other provision of law, for purposes of section 1886(d)(1)(A) of the Social Security Act, in the case of a hospital that— “(1) had a cost reporting period beginning on September 28, 29, or 30 of 1985, “(2) is located in a State in which inpatient hospital services were paid in fiscal year 1985 pursuant to a Statewide demonstration project under section 402 of the Social Security Amendments of 1967 and section 222 of the Social Security Amendments of 1972, and “(3) elects, by notice to the Secretary of Health and Human Services by not later than April 1, 1988, to have this subsection apply, during the first 7 months of such cost reporting period the ‘target percentage’ shall be 75 percent and the ‘DRG percentage’ shall be 25 percent, and during the remaining 5 months of such period the ‘target percentage’ and the ‘DRG percentage’ shall each be 50 percent.” SEC. 4009. MISCELLANEOUS PROVISIONS. (a) Responsibilities of Medicare Hospitals in Emergency Cases.— (1) Increase in civil monetary penalty.— Section 1867(d)(2) of the Social Security Act (42 U.S.C. 1395dd(d)(2)) is amended by striking “$25,000” and inserting “$50,000”. (2) Exclusion from medicare program for violations— Section 1867(d)(1) of such Act is amended by adding at the end the following new sentence: “If a civil money penalty is imposed on a responsible physician under paragraph (2), the Secretary may impose the sanction described in section 1842(j)(2)(A) (relating to barring from participation in the medicare program) in the same manner as it is imposed under section 1842(j).”. (3) Effective date.— The amendments made by this subsection 42 USC 1395dd note. shall apply to actions occurring on or after the date of the enactment of this Act. (b) Designation of Pediatric Hospitals as Meeting Certification as Heart Transplant Facility.— For purposes of determining whether a pediatric hospital that performs pediatric heart transplants meets the criteria established by the Secretary of Health and Human Services for facilities in which the heart transplants performed will be considered to meet the requirement of section 1862(a)(1)(A) of the Social Security Act, the Secretary shall treat such a hospital as meeting such criteria if— (1) the hospital’s pediatric heart transplant program is operated jointly by the hospital and another facility that meets such criteria, (2) the unified program shares the same transplant surgeons and quality assurance program (including oversight committee, patient protocol, and patient selection criteria), and (3) the hospital demonstrates to the satisfaction of the Secretary that it is able to provide the specialized facilities, services, and personnel that are required by pediatric heart transplant patients. (c) Waiver of Inpatient Limitations for the Connecticut Hospice2525Copy read “limitations for the connecticut hospice.”..— Subsection (a) of section 9307 of the Omnibus Budget Reconciliation Act of 1986 is amended— (1) by striking “Temporary“ in the heading, and (2) by striking “for hospice care provided before October 1, 1988,”. (d) Revision of Appointment Process for Prospective Payment Assessment Commission.— (1) In general.— Section 1886(e)(6)(B) of the Social Security Act (42 U.S.C. 1395ww(e)(6)(B)) is amended— (A) in the first sentence, by striking “provide expertise and experience in the provision and financing of health care” and inserting “include individuals with national recognition for their expertise in health economics, hospital reimbursement, hospital financial management, and other related fields, who provide a mix of different professionals, broad geographic representation, and a balance between urban and rural representatives,”; and (B) by striking the last sentence. (2) Effective date.— The amendments made by paragraph (1) 42 USC 1395WW note. shall apply to appointments made after the date of the enactment of this Act. (e) Psychologists’ Services Furnished to Hospital Inpatients.— (1) In general.— Section 1861(b)(3) of such Act (42 U.S.C. 1395x(b)(3)) is amended by inserting “(including clinical psychologist (as defined by the Secretary))” after “others” the first place it appears. (2) Effective date.— The amendment made by paragraph (1) 42 USC 1395x note. shall apply with respect to services furnished on or after April 1, 1988. (f) Hospital Condition of Participation Related to Individual Responsible for Care of Patient.— Section 1861(e)(4) of such Act (42 U.S.C. 1395x(e)(4)) is amended by inserting “with respect to whom payment may be made under this title” after “patient”, (g) Delay in Requirements Relating to Hospital Standards for Organ Transplants and Standards for Organ Procurement Agencies.— (1) Section 9318(b)(2) of the Omnibus Budget Reconciliation Act of 1986, as amended by section 107(c) of the Balanced Budget and Emergency Deficit Control Reaffirmation Act of 1987, is amended by striking “November 21, 1987” and inserting “March 31, 1988”. (2) The amendment made by paragraph (1) shall be effective Effective date. 42 USC 1320b–8 note. as if included in the enactment of the Omnibus Budget Reconciliation Act of 1986. (h) Propac Studies and Reports.— (1) Propac reports on study of drg rates for hospitals in rural and urban areas.— The Prospective Payment Assessment Commission shall evaluate the study conducted by the Secretary of Health and Human Services pursuant to section 603(a)(2)(C)(i) of the Social Security Amendments of 1983 (relating to the feasibility, impact, and desirability of eliminating or phasing out separate urban and rural DRG prospective payment rates) and report its conclusions and recommendations to the Congress not later than March 1, 1988. (2) Propac report on separate urban payment rates.— The Prospective Payment Assessment Commission shall evaluate the desirability of maintaining separate DRG prospective payment rates for hospitals located in large urban areas (as defined in section 1886(d)(2)(D)) of the Social Security Act) and in other urban areas, and shall report to Congress on such evaluation not later than January 1, 1989. (3) Report on adjustment for non-labor costs.— The Prospective Payment Assessment Commission shall perform an analysis to determine the feasibility and appropriateness of adjusting the non-wage-related portion of the adjusted average standardized amounts under section 1886(d)(3) of the Social Security Act based on area differences in hospitals’ costs (other than wage-related costs) and input prices. The Commission shall report to the Congress on such analysis by not later than October 1, 1989. (i) Special Rule.— In the case of New England county metropolitan 42 USC 1395WW note. areas, the Secretary of Health and Human Services shall apply the second sentence of section 1886(d)(2)(D) of the Social Security Act, as amended by section 4001(b) of this subtitle, as though 970,000 were substituted for 1,000,000. (j) Technical Corrections.— (1) Section 1886(a)(4) of the Social Security Act (42 U.S.C. 1395ww(a)(4)) is amended by inserting a comma after “educational activities”. (2) Section 1886(d)(5)(C)(i)(II) of such Act (42 U.S.C. 1395ww(d)(5)(C)(i)(II)) is amended by inserting “index” after “case mix” both places it appears. (3) Section 1886(d)(5)(F) of such Act (42 U.S.C. 1395ww(d)(5)(F)) is amended— (A) in clause (i)(II), by striking “such revenues” the second place it appears and inserting “such net inpatient care revenues”, and (B) in clause (iv)(I), by striking “subclause (III)” and inserting “clause (v)”. (4) Section 1886(d)(9) of such Act (42 U.S.C. 1395ww(d)(9)) is amended by moving the matter in subparagraph (B) before clause (i) 2 ems to the left so the left margin of such matter is aligned with the left margin of the matter in subparagraph (A) (5) Section 1886(h)(4)(C) of such Act (42 U.S.C. 1395ww(h)(4)(C)) is amended by striking “subparagraph (E)” and inserting “subparagraph (D)”. (6) Effective as if included in the enactment of the Omnibus Budget Reconciliation Act of 1986— (A) subparagraph (B) of section 9307(c)(1) of such Act is 42 USC 1395WW. amended to read as follows: “(B) in paragraph (2)— “(i) by striking subparagraphs (A) and (B), “(ii) in subparagraph (C), by striking ‘such subsection’ and inserting ‘of section 1886(d) of the Social Security Act (42 U.S.C. 1395ww(d)’ and by redesignating such subparagraph as subparagraph (A), and “(iii) by amending subparagraph (D) to read as follows: “ ‘(B) The amendments made by subparagraph (A) apply to 42 USC 1395WW note. discharges occurring on or after May 1, 1986.’ ”; (B) section 9302(a)(2)(C) of such Act is amended by striking 42 USC 1395WW. “1866(e)(5)” and inserting “1886(e)(5)”; (C) section 9320(h)(1) of such Act is amended by striking 42 USC 1395y. “before the period” and inserting “before the semicolon”; (D) section 9321(c)(4) of such Act is amended by striking 42 USC 1395WW note. “second sentence” and all that follows through “operating costs” and inserting “second sentence of section 1886(a)(4) of the Social Security Act, from the term ‘operating costs”; (E) the second sentence of section 9335(d)(2) of such Act is 42 USC 1395rr note. amended by striking “establish” and inserting “designate”; and (F) section 9321(c)(3) of such Act is amended by inserting 42 USC 1395WW note. “section 1861(v)(1)(O) and 1886(g)(2) of the Social Security Act and” after “implementing”. (7) Section 218(v) of the Social Security Act (42 U.S.C. 418(v)) is amended by striking paragraph (3). (8) Effective as if included in the Tax Reform Act of 1986, section 1895(d)(6)(C) of such Act is amended by striking “603” 42 USC 300bb–6. and inserting “2203”. PART 2— PROVISIONS RELATING TO PARTS A AND B Subpart A— Health Maintenance Organization Reforms SEC. 4011. BENEFICIARY PROTECTION. (a) Post-Contract Protection for Enrollees with Eligible Organizations Under2626Copy read “under”. the Medicare Program.— (1) Section 1876(c)(3) of such Act (42 U.S.C. 1395mm(b)(2)) is amended by adding at the end the following new subparagraph: “(F) Each eligible organization that provides items and services pursuant to a contract under this section shall provide assurances to the Secretary that in the event the organization ceases to provide such items and services, the organization shall provide or arrange for supplemental coverage of benefits under this title related to a pre-existing condition with respect to any exclusion period, to all individuals enrolled with the entity who receive benefits under this title, for the lesser of six months or the duration of such period.”. (2) The amendment made by paragraph (1) shall apply with 42 USC 1395mm note. respect to contracts entered into or renewed on or after the date of enactment of this Act. (b) Notification of Termination of Risk-Sharing Contract.— (1) Section 1876(c)(3) of such Act, as amended by subsection (a)(1), is further amended by adding at the end the following new subparagraph: “(G) (i) Each eligible organization having a risk-sharing contract under this section shall notify individuals eligible to enroll with the organization under this section and individuals enrolled with the organization under this section that— “(I) the organization is authorized by law to terminate or refuse to renew the contract, and “(II) termination or nonrenewal of the contract may result in termination of the enrollments of individuals enrolled with the organization under this section. “(ii) The notice required by clause (i) shall be included in— “(I) any marketing materials described in subparagraph (C) that are distributed by an eligible organization to individuals eligible to enroll under this section with the organization, and “(II) any explanation provided to enrollees by the organization pursuant to subparagraph (E).”. (2) The amendment made by paragraph (1) shall apply to 42 USC 1395mm note. contracts entered into or renewed on or after the date of the enactment of this Act. SEC. 4012. PAYMENTS FOR HOSPITAL SERVICES. (a) In General.— Section 1866(a)(1) of such Act (42 U.S.C. 1395cc(a)(1)) is amended by inserting immediately after subparagraph (N) the following new subparagraph: “(O) in the case of hospitals and skilled nursing facilities, to Contracts. accept as payment in full for inpatient hospital and extended care services that are covered under this title and are furnished to any individual enrolled with an eligible organization with a risk-sharing contract under section 1876 the amounts (in the case of hospitals) or limits (in the case of skilled nursing facilities) that would be made as a payment in full under this title if the individuals were not so enrolled.”. (b) Repeal.— Section 1876(g)(4) of the Social Security Act (42 U.S.C. 1395mm(g)(4)) is repealed. (c) Implementation.— The Secretary of Health and Human Services 42 USC 1395mm note. shall provide (in machine readable form) to eligible organizations under section 1876 of the Social Security Act medicare DRG rates for payments required by the amendment made by paragraph (2) and data on cost pass-through items for all inpatient services provided to medicare beneficiaries enrolled with such organizations. (d) Effective Date.— The amendments made by subsections (a) 42 USC 1395mm note. and (b) shall apply to admissions occurring on or after April 1, 1988, or, if later, the earliest date the Secretary can provide the information required under subsection (c) in machine readable form. SEC. 4013. TWO-YEAR EXTENSION ON PERIOD FOR BENEFIT STABILIZATION. (a) In General.— Section 1876(g)(5) of the Social Security Act (42 U.S.C. 1395mm(g)(5)), as added by the amendment made by section 2350(a)(2) of the Deficit Reduction Act of 1984, is amended by striking “four” and inserting “six”. (b) Effective Date.— The amendment made by subsection (a) 42 USC 1395mm note. shall be effective as if included in the enactment of the amendment made by section 2350(a)(2) of the Deficit Reduction Act of 1984. SEC. 4014. CIVIL MONEY PENALTIES AND INTERMEDIATE SANCTIONS AGAINST HMOS/CMPS. Section 1876(i)(6) of the Social Security Act (42 U.S.C. 1395mm) is amended to read as follows: “(6) (A) If the Secretary determines that an eligible organization Contracts. with a contract under this section— “(i) fails substantially to provide medically necessary items and services that are required (under law or under the contract) to be provided to an individual covered under the contract, if the failure has adversely affected (or has substantial likelihood of adversely affecting) the individual; “(ii) imposes premiums on individuals enrolled under this section in excess of the premiums permitted; “(iii) acts to expel or to refuse to re-enroll an individual in violation of the provisions of this section; “(iv) engages in any practice that would reasonably be expected to have the effect of denying or discouraging enrollment (except as permitted by this section) by eligible individuals with the organization whose medical condition or history indicates a need for substantial future medical services; “(v) misrepresents or falsifies information that is furnished— “(I) to the Secretary under this section, or “(II) to an individual or to any other entity under this section; or “(vi) fails to comply with the requirements of subsection (g)(e)(A); the Secretary may provide for any of the remedies described in subparagraph (B). “(B) The remedies described in this subparagraph are— “(i) civil money penalties of not more than $25,000 for each determination under subparagraph (A) or, with respect to a determination under clause (iv) or (v)(I), of not more than $100,000 for each such determination, “(ii) suspension of enrollment of individuals under this section after the date the Secretary notifies the organization of a determination under subparagraph (A) and until the Secretary is satisfied that the basis for such determination has been corrected and is not likely to recur, or “(iii) suspension of payment to the organization under this section for individuals enrolled after the date the Secretary notifies the organization of a determination under subparagraph (A) and until the Secretary is satisfied that the basis for such determination has been corrected and is not likely to recur. The provisions of section 1128A (other than subsections (a) and (b)) shall apply to a civil money penalty under clause (i) in the same manner as they apply to a civil money penalty under that section.” SEC. 4015. MEDICARE PAYMENT DEMONSTRATION PROJECTS. (a) Medicare Insured Group Demonstration Projects.— (1) The Secretary of Health and Human Services (in this Contracts. subsection referred to as the “Secretary”) may provide for capitation demonstration projects (in this subsection referred to as “projects”) with an entity which is an eligible organization with a contract with the Secretary under section 1876 of the Social Security Act or which meets the restrictions and requirements of this subsection. The Secretary may not approve a project unless it meets the requirements of this subsection. (2) The Secretary may not conduct more than 3 projects and may not expend, from funds under title XVIII of the Social Security Act, more than $600,000,000 in any fiscal year for all such projects. (3) The per capita rate of payment under a project— (A) may be based on the adjusted average per capita cost (as defined in section 1876(a)(4) of the Social Security Act) determined only with respect to the group of individuals involved (rather than with respect to medicare beneficiaries generally), but (B) the rate of payment may not exceed the lesser of— (i) 95 percent of the adjusted average per capita cost described in subparagraph (A), or (ii) (I) in the 4th year or 5th year of a project, 115 percent of the adjusted average per capita cost (as defined in section 1876(a)(4) of such Act) for classes of individuals described in section 1876(a)(1)(B) of that Act, or (II) in any subsequent year of a project, 95 percent of the adjusted average per capita cost (as defined in section 1876(a)(4)) for such classes. (4) If the payment amounts made to a project are greater than the costs of the project (as determined by the Secretary or, if applicable, on the basis of adjusted community rates described in section 1876(e)(3) of the Social Security Act), the project— (A) may retain the surplus, but not to exceed 5 percent of the average adjusted per capita cost determined in accordance with paragraph (3)(A), and (B) with respect to any additional surplus not retained by the project, shall apply such surplus to additional benefits for individuals served by the project or return such surplus to the Secretary. (5) Enrollment under the project shall be voluntary. Individuals enrolled with the project may terminate such enrollment as of the beginning of the first calendar month following the date on which the request is made for such termination. Upon such termination, such individuals shall retain the same rights to other health benefits that such individuals would have had if they had never enrolled with the project without any exclusion or waiting period for pre-existing conditions. (6) The requirements of— (A) subsection (c)(3)(C) (relating to dissemination of information), (B) subsection (c)(3)(E) (annual statement of rights), (C) subsection (c)(5) (grievance procedures), (D) subsection (c)(6) (on-going quality), (E) subsection (g)(6) (relating to prompt payment of claims), (F) subsection (i)(3)(A) and (B) (relating to access to information and termination notices), (G) subsection (i)(6) (relating to providing necessary services), and (H) subsection (i)(7) (relating to agreements with peer Contracts. review organizations), of section 1876 of the Social Security Act shall apply to a project in the same manner as they apply to eligible organizations with risk-sharing contracts under such section, (7) The benefits provided under a project must be at least actuarially equivalent to the combination of the benefits available under title XVIII of the Social Security Act and the benefits available through any alternative plans in which the individual can enroll through the the employer. The project shall guarantee the actuarial value of benefits available under the employer plan for the duration of the project. (8) A project shall comply with all applicable State laws. (9) The Secretary may not authorize a project unless the entity offering the project demonstrates to the satisfaction of the Secretary that it has the necessary financial reserves to pay for any liability for benefits under the project (including those liabilities for health benefits under medicare and any supplemental benefits). (10) The Comptroller General shall monitor projects under Reports. this subsection and shall report periodically (not less often than once every year) to the Committee on Finance of the Senate and the Committee on Energy and Commerce and Committee on Ways and Means of the House of Representatives on the status of such projects and the affect on such projects of the requirements of this section and shall submit a final report to each such committee on the results of such projects. (b) Payment Methodology Reform Demonstrations Projects.— (1) The Secretary of Health and Human Services (in this subsection referred to as the “Secretary”) is specifically au-thorized to conduct demonstration projects under this subsection for the purpose of testing alternative payment methodologies pertaining to capitation payments under title XVIII of the Social Security Act, including— (A) computing adjustments to the average per capita cost under section 1876 of such Act on the basis of health status or prior utilization of services, and (B) accounting for geographic variations in cost in the adjusted average per capita costs applicable to an eligible organization under such section which differs from payments currently provided on a county-by-county basis. (2) No project may be conducted under this subsection— (A) with an entity which is not an eligible organization (as defined in section 1876(b) of the Social Security Act), and (B) unless the project meets all the requirements of subsections (c) and (i)(3) of section 1876 of such Act. (3) There are authorized to be appropriated to carry out Appropriation authorization. projects Under this subsection $5,000,000 in each of fiscal years 1989 and 1990. (c) Application of Provisions.— The provisions of subsection (a)(2) and the first sentence of subsection (b) of section 402 of the Social Security Amendments of 1967 shall apply to the demonstration projects under this section in the same manner as they apply to experiments under subsection (a)(1) of that section. SEC. 4016. DELAY IN EFFECTIVE DATE IN PHYSICIAN INCENTIVE RULES FOR HEALTH MAINTENANCE ORGANIZATIONS. Section 9313(c)(2)(B) of the Omnibus Budget Reconciliation Act of 1986 is amended by striking “April 1, 1989” and inserting “April 1, 100 Stat. 2002. 1990”. SEC. 4017. GAO STUDY AND REPORTS ON MEDICARE CAPITATION. (a) Study.— The Comptroller General shall conduct a study on medicare capitation rates that shall include an analysis and assessment of— (1) the current method for computing per capita rates of payment under section 1876 of the Social Security Act (including the method for determining the United States per capita cost); (2) the method for establishing relative costs for geographic areas and the data used to establish age, sex, and other weighting factors; (3) ways to refine the calculation of adjusted average per capita costs under section 1876 of such Act (including making adjustments for health status or prior utilization of services and improvements in the definition of geographic areas); (4) the extent to which individuals enrolled with organizations Contracts. with a risk-sharing contract with the Secretary under section 1876 of such Act differ in utilization and cost from fee-for-service beneficiaries and ways for modifying enrollment patterns through program changes or for reflecting the differences in rates through group experience rating or other means; (5) approaches for limiting the liability of the contracting organization under section 1876 of such Act in catastrophic cases: (6) ways of establishing capitation rates on a basis other than fee-for-service experience in areas with high prepaid market penetration; and (7) methods for providing the rate levels necessary to maintain access to quality prepaid services in rural or medically underserved areas (while maintaining cost savings), (b) Reports.— (1) Not later than January 1 of 1989 and 1990, the Comptroller General shall submit to the Committee on Finance of the Senate and the Committee on Energy and Commerce and Committee on Ways and Means of the House of Representatives interim reports on the progress of the study conducted under subsection (a). (2) Not later than January 1, 1991, the Comptroller General shall submit to each such committee a final report on the g results of such study. SEC. 4018. SPECIAL RULES. (a) Assignment of Members for Hip Health Maintenance Organization.— Section 1876(f) of such Act (42 U.S.C. 1395mm(f)) is amended by redesignating paragraph (3) as paragraph (4) and by inserting after paragraph (2) the following new paragraph: “(3) (A) An eligible organization described in subparagraph (B) may elect, for purposes of determining the compliance of a subdivision, subsidiary, or affiliate described in subparagraph (B)(iii) with the requirement of paragraph (1) for the period before October 1, 1992, to have members of the subdivision, subsidiary, or affiliate considered to be members of the parent organization. “(B) An eligible organization described in this subparagraph is an eligible organization which— “(i) is described in section 1903(m)(2)(B)(iii); “(ii) has members who have a collectively bargained contractual right to obtain health benefits from the organization; “(iii) elects to provide benefits under a risk-sharing contract Contracts. to individuals residing in a service area, who have a collectively bargained contractual right to obtain benefits from the organization, through a subdivision, subsidiary, or affiliate which itself is an eligible organization serving the area and which is owned or controlled by the parent eligible organization; and “(iv) has assumed any risk of insolvency and quality assurance with respect to individuals receiving benefits through such a subdivision, subsidiary, or affiliate.”. (b) Extension of Waivers for Social Health Maintenance Organizations.— (1) The Secretary of Health and Human Services shall extend without interruption, through September 30, 1992, the approval of waivers granted under subsection (a) of section 2355 of the Deficit Reduction Act of 1984 for the demonstration project described in subsection (b) of that section, subject to the terms and conditions (other than duration of the project) established under that section (as amended by paragraph (2) of this subsection). (2) Section 2355(b)(5) of the Deficit Reduction Act of 1984 is 98 Stat. 1103. amended by inserting “and in succeeding years” after “third year” (3) Section 2355(d)(2) of the Deficit Reduction Act of 1984 is 98 Stat. 1103. amended by striking “final” and inserting “interim”. (4) The Secretary of Health and Human Services shall submit Reports. a final report to the Congress on the project referred to in paragraph (1) not later than March 31, 1993. (c) Treatment of Michigan Blue Care HMO Network Under2727Copy read “under”. 50 Percent Rule.— Blue Care, Inc., a nonprofit corporation which is indirectly owned and operated by Blue Cross and Blue Shield of Michigan, Inc. and which enrolls individuals for the purpose of providing them with health care services through assignment to health maintenance organizations which are indirectly or wholly owned and operated by Blue Cross and Blue Shield of Michigan, Inc., is deemed to meet the requirement of section 1876(f)(1) of the Social Security Act (relating to limitation on enrollment of medicare and medicaid beneficiaries with an eligible organization) if— (1) such requirement would be met if applied to all individuals enrolled with (or otherwise assigned to) each of such health maintenance organizations, and (2) not more than 20 percent of the number of individuals who are members of (or otherwise assigned to) each such organization consists of individuals who are entitled to benefits under title XVIII of the Social Security Act. (d) Temporary Waiver for Watts Health Foundation.— Section 9312(c)(3) of the Omnibus Budget Reconciliation Act of 1986 is 42 USC 1395mm note. amended by adding at the end the following new subparagraph: “(D) Treatment of certain waivers.— In the case of an Grants. eligible organization (or successor organization) that is described in clauses (i) and (ii) of subparagraph (C) and that received a grant or grants totaling at least $3,000,000 in fiscal year 1987 under section 329(d)(1)(A) or 330(d)(1) of the Public Health Service Act— “(i) before January 1, 1990, section 1876(f) of the Social Security Act shall not apply to the organization; “(ii) beginning on January 1, 1990, the Secretary of Health and Human Services shall waive the requirement of such section with respect to the organization if— “(I) before such date, the organization has submitted to the Secretary a schedule for the organization to comply with the requirement of section 1876(f)(1) of such Act, and the Secretary has found such schedule to be reasonable and has approved such schedule; and “(II) periodically after such date, the Secretary reviews the organization’s compliance with such schedule and determines that the organization has complied, or made significant progress towards compliance, with such schedule; and “(iii) after January 1, 1990, if the Secretary has approved a schedule under clause (ii)(I) and has determined, in a periodic review under clause (ii)(II), that the organization has not complied, or made significant progress towards compliance, with such schedule, the Secretary may provide for a sanction described in sec- tion 1876(f)(3) of the Social Security Act effective with respect to individuals enrolling with the organization after the date the Secretary notifies the organization of such noncompliance.”. Subpart B— Home Health Quality SEC. 4021. CONDITIONS OF PARTICIPATION FOR HOME HEALTH AGENCIES. (a) Definition of Home Health Agency.— Section 1861(o)(6) of the Social Security Act (42 U.S.C. 1395x(o)(6)) is amended by inserting “the conditions of participation specified in section 1891(a) and” after “meets”. (b) Conditions of Participation.— Title XVIII of such Act is amended by adding at the end the following new section: “conditions of participation for home health agencies; home health quality “Sec. 1891. (a) The conditions of participation that a home health 42 USC 1395bbb. agency is required to meet under this subsection are as follows: “(1) The agency protects and promotes the rights of each individual under its care, including each of the following rights: “(A) The right to be fully informed in advance about the care and treatment to be provided by the agency, to be fully informed in advance of any changes in the care or treatment to be provided by the agency that may affect the individual’s well-being, and (except with respect to an individual adjudged incompetent) to participate in planning care and treatment or changes in care or treatment. “(B) The right to voice grievances with respect to treatment or care that is (or fails to be) furnished without discrimination or reprisal for voicing grievances. “(C) The right to confidentiality of the clinical records described in section 1861(o)(3). “(D) The right to have one’s property treated with respect. “(E) The right to be fully informed orally and in writing (in advance of coming under the care of the agency) of— “(i) all items and services furnished by (or under arrangements with) the agency for which payment may be made under this title, “(ii) the coverage available for such items and services under this title, title XIX, and any other Federal program of which the agency is reasonably aware, “(iii) any charges for items and services not covered under this title and any charges the individual may have to pay with respect to items and services furnished by (or under arrangements with) the agency, and “(iv) any changes in the charges or items and services described in clause (i), (ii), or (iii). “(F) The right to be fully informed in writing (in advance of coming under the care of the agency) of the individual’s rights and obligations under this title. “(G) The right to be informed of the availability of the State home health agency hotline established under seclution 1864(a). “(2) The agency notifies the State entity responsible for the licensing or certification of the agency of a change in— “(A) the persons with an ownership or control interest (as defined in section 1124(a)(3)) in the agency, “(B) the persons who are officers, directors, agents, or managing employees (as defined in section 1126(b)) of the agency, and “(C) the corporation, association, or other company responsible for the management of the agency. Such notice shall be given at the time of the change and shall include the identity of each new person or company described in the previous sentence. “(3) (A) The agency must not use as a home health aide (on a full-time, temporary, per diem, or other basis), any individual who is not a licensed health care professional (as defined in subparagraph (F)) to provide items or services described in section 1861(m) on or after January 1, 1990, unless the individual— “(i) has completed a training and competency evaluation program, or a competency evaluation program, that meets the minimum standards established by the Secretary under subparagraph (D), and “(ii) is competent to provide such items and services. For purposes of clause (i), an individual is not considered to have completed a training and competency evaluation program, or a competency evaluation program if, since the individual’s most recent completion of such a program, there has been a continuous period of 24 consecutive months during none of which the individual provided items and services described in section 1861(m) for compensation. “(B) (i) The agency must provide, with respect to individuals used as a home health aide by the agency as of July 1, 1989, for a competency evaluation program (as described in subparagraph (A)(i)) and such preparation as may be necessary for the individual to complete such a program by January 1, 1990. “(ii) The agency must provide such regular performance review and regular in-service education as assures that individuals used to provide items and services described in section 1861(m) are competent to provide those items and services. “(C) The agency must not permit an individual, other than in a training and competency evaluation program that meets the minimum standards established by the Secretary under subparagraph (D), to provide items or services of a type for which the individual has not demonstrated competency. “(D) (i) The Secretary shall establish minimum standards for the programs described in subparagraph (A) by not later than October 1, 1988. “(ii) Such standards shall include the content of the curriculum, minimum hours of training, qualification of instructors, and procedures for determination of competency. “(iii) Such standards may permit approval of programs offered by or in home health agencies, as well as outside agencies (including employee organizations), and of programs in effect on the date of the enactment of this section; except that they may not provide for the approval of a program offered by or in a home health agency which has been determined to be out of compliance with the requirements specified in or pursuant to section 1861(o) or subsection (a) within the previous 2 years, “(iv) Such standards shall permit a determination that an individual who has completed (before July 1, 1989) a training and competency evaluation program or a competency evaluation program shall be deemed for purposes of subparagraph (A) to have completed a program that is approved by the Secretary under the standards established under this subparagraph if the Secretary determines that, at the time the program was offered, the program met such standards. “(E) In this paragraph, the term ‘home health aide’ means any individual who provides the items and services described in section 1861(m), but does not include an individual— “(i) who is a licensed health professional (as defined in subparagraph (F)), or “(ii) who volunteers to provide such services without monetary compensation. “(F) In this paragraph, the term ‘licensed health professional’ means a physician, physician assistant, nurse practitioner, physical, speech, or occupational therapist, registered professional nurse, licensed practical nurse, or licensed or certified social worker. “(4) With respect to durable medical equipment furnished to individuals for whom the agency provides items and services, suppliers of such equipment do not use (on a full-time, temporary, per diem, or other basis) any individual who does not meet minimum training standards (established by the Secretary by October 1, 1988) for the demonstration and use of any such equipment furnished to individuals with respect to whom payments may be made under this title. “(5) The agency includes an individual’s plan of care required under section 186l(m) as part of the clinical records described in section 1861(o)(3). “(6) The agency operates and provides services in compliance with all applicable Federal, State, and local laws and regulations (including the requirements of section 1124) and with accepted professional standards and principles which apply to professionals providing items and services in such an agency. “(b) It is the duty and responsibility of the Secretary to assure that the conditions of participation and requirements specified in or pursuant to section 1861(o) and subsection (a) of this section and the enforcement of such conditions and requirements are adequate to protect the health and safety of individuals under the care of a home health agency and to promote the effective and efficient use of public moneys.”. (c) Effective Date.— Except as otherwise provided, the amendments 42 USC 1395x note. made by subsections (a) and (b) shall apply to home health agencies as of the first day of the 18th calendar month that begins after the date of the enactment of this Act. SEC. 4022. STANDARD AND EXTENDED SURVEY. (a) In General.— Section 1891 of the Social Security Act (as added by section 4021) is amended by adding at the end the following new subsections: “(c) (1) Any agreement entered into or renewed by the Secretary pursuant to section 1864 relating to home health agencies shall provide that the appropriate State or local agency shall conduct, without any prior notice, a standard survey of each home health agency. Any individual who notifies (or causes to be notified) a home health agency of the time or date on which such a survey is scheduled to be conducted is subject to a civil money penalty of not to exceed $2,000. The Secretary shall provide for imposition of civil money penalties under this clause in a manner similar to that for the imposition of civil money penalties under section 1128A. The Secretary shall review each State’s or local agency’s procedures for scheduling and conduct of standard surveys to assure that the State or agency has taken all reasonable steps to avoid giving notice of such a survey through the scheduling procedures and the conduct of the surveys themselves. “(2) (A) Except as provided in subparagraph (B), each home health agency shall be subject to a standard survey not later than 15 months after the date of the previous standard survey conducted under this paragraph. The statewide 27a27aCopy read “Statewide”. average interval between standard surveys of any home health agency shall not exceed 12 months. “(B) If not otherwise conducted under subparagraph (A), a standard survey (or an abbreviated standard survey) of an agency— “(i) may be conducted within 2 months of any change of a ownership, administration, or management of the agency to determine whether the change has resulted in any decline in the quality of care furnished by the agency, and “(ii) shall be conducted within 2 months of when a significant number of complaints have been reported with respect to the agency to the Secretary, the State, the entity responsible for the licensing of the agency, the State or local agency responsible for maintaining a toll-free hotline and investigative unit (under section 1864(a)), or any other appropriate Federal, State, or local agency. “(C) A standard survey conducted under this paragraph with respect to a home health agency— “(i) shall include (to the extent practicable), for a case-mix stratified sample of individuals furnished items or services by the agency— “(I) visits to the homes of such individuals, but only with the consent of such individuals, for the purpose of evaluating (in accordance with a standardized reproducible assessment instrument (or instruments) approved by the Secretary under subsection (d)) the extent to which the quality and scope of items and services furnished by the agency attained and maintained the highest practicable functional capacity of each such individual as reflected in such individual’s written plan of care required under section 1861(m) and clinical records required under section 1861(o)(3); and “(II) a survey of the quality of care and services furnished by the agency as measured by indicators of medical, nursing, and rehabilitative care; “(ii) shall be based upon a protocol that is developed, tested, and validated by the Secretary not later than January 1, 1989; and “(iii) shall be conducted by an individual— “(I) who meets minimum qualifications established by the Secretary not later than July 1, 1989, “(II) who is not serving (or has not served within the previous 2 years) as a member of the staff of, or as a consultant to, the home health agency surveyed respecting compliance with the conditions of participation specified in or pursuant to section 1861(o) or subsection (a) of this section, and “(III) who has no personal or familial financial interest in the home health agency surveyed. “(D) Each home health agency that is found, under a standard survey, to have provided substandard care shall be subject to an extended survey to review and identify the policies and procedures which produced such substandard care and to determine whether the agency has complied with the conditions of participation specified in or pursuant to section 1861(o) or subsection (a) of this section. Any other agency may, at the Secretary’s or State’s discretion, be subject to such an extended survey (or a partial extended survey). The extended survey shall be conducted immediately after the standard survey (or, if not practical, not later than 2 weeks after the date of completion of the standard survey). “(E) Nothing in this paragraph shall be construed as requiring an extended (or partial extended) survey as a prerequisite to imposing a sanction against an agency under subsection (e) on the basis of the findings of a standard survey. “(d) (1) Not later than January 1, 1989, the Secretary shall designate an assessment instrument (or instruments) for use by an agency in complying with subsection (c)(2)(C)(I). “(2) (A) Not later than January 1, 1991, the Secretary shall— “(i) evaluate the assessment process, “(ii) report to Congress on the results of such evaluation, and Reports. “(iii) based on such evaluation, make such modifications in the assessment process as the Secretary determines are appropriate. “(B) The Secretary shall periodically update the evaluation conducted Reports. under subparagraph (A), report the results of such update to Congress, and, based on such update, make such modifications in the assessment process as the Secretary determines are appropriate. “(3) The Secretary shall provide for the comprehensive training of State and Federal surveyors in matters relating to the performance of standard and extended surveys under this section, including the use of any assessment instrument (or instruments) designated under paragraph (1).”. (b) Effective Date.— Except as otherwise specifically provided in 42 USC 1395bbb note. section 1891(d) of the Social Security Act (as added by subsection (a)), the amendment made by subsection (a) shall become effective on the first day of the 18th calendar month to begin after the date of the enactment of this Act. SEC. 4023. ENFORCEMENT. Section 1891 of the Social Security Act (as added by section 4021 and amended by section 4022) is further amended by adding at the end the following new subsections: “(e) (1) If the Secretary determines on the basis of a standard, extended, or partial extended survey or otherwise, that a home health agency that is certified for participation under this title is no longer in compliance with the requirements specified in or pursuant to section 1861(o) or subsection (a) and determines that the deficiencies involved immediately jeopardize the health and safety of the individuals to whom the agency furnishes items and services, the Secretary shall take immediate action to remove the jeopardy and correct the deficiencies through the remedy specified in subsection (f)(2)(A)(iii) or terminate the certification of the agency, and may provide, in addition, for 1 or more of the other remedies described in subsection (f)(2)(A). “(2) If the Secretary determines on the basis of a standard, extended, or partial extended survey or otherwise, that a home health agency that is certified for participation under this title is no longer in compliance with the requirements specified in or pursuant to section 1861(o) or subsection (a) and determines that the deficiencies involved do not immediately jeopardize the health and safety of the individuals to whom the agency furnishes items and services, the Secretary may (for a period not to exceed 6 months) impose intermediate sanctions developed pursuant to subsection (f), in lieu of terminating the certification of the agency. If, after such a period of intermediate sanctions, the agency is still no longer in compliance with the requirements specified in or pursuant to section 1861(o) or subsection (a), the Secretary shall terminate the certification of the agency. “(3) If the Secretary determines that a home health agency that is certified for participation under this title is in compliance with the requirements specified in or pursuant to section 1861(o) or subsection (a) but, as of a previous period, did not meet such requirements, the Secretary may provide for a civil money penalty under subsection (f)(2)(A)(i) for the days in which it finds that the agency was not in compliance with such requirements. “(4) The Secretary may continue payments under this title with respect to a home health agency not in compliance with the requirements specified in or pursuant to section 1861(o) or subsection (a) over a period of not longer than 6 months, if— “(A) the State or local survey agency finds that it is more appropriate to take alternative action to assure compliance of the agency with the requirements than to terminate the certification of the agency, “(B) the agency has submitted a plan and timetable for corrective action to the Secretary for approval and the Secretary approves the plan of corrective action, and “(C) the agency agrees to repay to the Federal Government payments received under this subparagraph if the corrective action is not taken in accordance with the approved plan and timetable. The Secretary shall establish guidelines for approval of corrective actions requested by home health agencies under this subparagraph. “(f) (1) The Secretary shall develop and implement, by not later than April 1, 1989— “(A) a range of intermediate sanctions to apply to home health agencies under the conditions described in subsection (e), and “(B) appropriate procedures for appealing determinations relating to the imposition of such sanctions. “(2) (A) The intermediate sanctions developed under paragraph (1) shall include— “(i) civil money penalties for each day of noncompliance, “(ii) suspension of all or part of the payments to which a home health agency would otherwise be entitled under this title with respect to items and services furnished by a home health agency on or after the date on which the Secretary determines that intermediate sanctions should be imposed pursuant to subsection (e)(2), and “(iii) the appointment of temporary management to oversee the operation of the home health agency and to protect and assure the health and safety of the individuals under the care of the agency while improvements are made in order to bring the agency into compliance with all the requirements specified in or pursuant to section 1861(o) or subsection (a). The temporary management under clause (iii) shall not be terminated until the Secretary has determined that the agency has the management capability to ensure continued compliance with all the requirements referred to in that clause. “(B) The sanctions specified in subparagraph (A) are in addition to sanctions otherwise available under State or Federal law and shall not be construed as limiting other remedies, including any remedy available to an individual at common law. “(C) A finding to suspend payment under subparagraph (A)(ii) shall terminate when the Secretary finds that the home health agency is in substantial compliance with all the requirements specified in or pursuant to section 1861(o) and subsection (a). “(3) The Secretary shall develop and implement, by not later than April 1, 1989, specific procedures with respect to the conditions under which each of the intermediate sanctions developed under paragraph (1) is to be applied, including the amount of any fines and the severity of each of these sanctions. Such procedures shall be designed so as to minimize the time between identification of deficiencies and imposition of these sanctions and shall provide for the imposition of incrementally more severe fines for repeated or uncorrected deficiencies.”. (b) Effective Date.— Except as otherwise specifically provided in 42 USC 1395bbb note. subsections (e) and (f) of section 1891 of the Social Security Act (as added by subsection (a)), the amendment made by subsection (a) shall become effective on the first day of the 18th calendar month to begin after the date of the enactment of this Act. SEC. 4024. REQUIREMENT THAT INDIVIDUAL BE CONFINED TO HOME. (a) Part A..— Section 1814(a) of the Social Security Act (42 U.S.C. 1395f(a)) is amended by adding at the end the following: “For purposes of paragraph (2)(C), an individual shall be considered to be ‘confined to his home’ if the individual has a condition, due to an illness or injury, that restricts the ability of the individual to leave his or her home except with the assistance of another individual or the aid of a supportive device (such as crutches, a cane, a wheelchair, or a walker), or if the individual has a condition such that leaving his or her home is medically contraindicated. While an individual does not have to be bedridden to be considered ‘confined to his home’, the condition of the individual should be such that there exists a normal inability to leave home, that leaving home requires a considerable and taxing effort by the individual, 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.”. (b) Part B.— Section 1835(a) of such Act (42 U.S.C. 1395n(a)) is amended by adding at the end the following: “For purposes of paragraph (2)(A), an individual shall be considered to be ‘confined to his home’ if the individual has a condition, due to an illness or injury, that restricts the ability of the individual to leave his or her home except with the assistance of another individual or the aid of a supportive device (such as crutches, a cane, a wheelchair, or a walker), or if the individual has a condition such that leaving his or her home is medically contraindicated. While an individual does not have to be bedridden to be considered ‘confined to his home’, the condition of the individual should be such that there exists a normal inability to leave home, that leaving home requires a considerable and taxing effort by the individual, 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.”. (c) Effective Date.— The amendments made by subsections (a) 42 USC 1395f note. and (b) shall apply to items and services provided on or after January 1, 1988. SEC. 4025. HOME HEALTH TOLL-FREE HOTLINE AND INVESTIGATIVE UNIT. (a) In General.— Section 1864(a) of the Social Security Act (42 U.S.C. 1395aa(a)) is amended by adding at the end the following: “Any agreement under this subsection shall provide for the appropriate State or local agency to maintain a toll-free hotline (1) to collect, maintain, and continually update information on home health agencies located in the State or locality that are certified to participate in the program established under this title (which information shall include any significant deficiencies found with respect to patient care in the most recent certification survey conducted with respect to the agency, when that survey was completed, whether corrective actions have been taken or are planned, and the sanctions, if any, imposed under this title with respect to the agency) and (2) to receive complaints (and answer questions) with respect to home health agencies in the State or locality. Any such agreement shall provide for such agency to maintain a unit for investigating such complaints that possesses enforcement authority and has access to survey and certification reports, information gathered by any private accreditation agency pursuant to an agreement with the Secretary under section 1864, and consumer medical records (but only with the consent of the consumer or his or her legal representative).”. (b) Effective Date.— The amendment made by subsection (a) 42 USC 1395aa note. shall apply with respect to agreements entered into or renewed on or after the date of enactment of this Act. SEC. 4026. HOME HEALTH AGENCY COST LIMITS. (a) Data Used to Determine Limits.— (1) Section 1861(v)(1)(L) of the Social Security Act (42 U.S.C. 1395x(v)(1)(L)) is amended by adding at the end the following new clause: “(iii) In establishing limits under this subparagraph, the Secretary shall— “(I) utilize a wage index that is based on audited wage data obtained from home health agencies, and “(II) base such limits on the most recent audited wage data available, which data may be for cost reporting periods beginning no earlier than July 1, 1985.”. (2) The amendment made by paragraph (1) shall apply to cost 42 USC 1395x note. reporting periods beginning on or after July 1, 1988. (b) Study of Limits.— The Secretary of Health and Human Services Reports. shall study and report to the Congress, not later than June 1, 1988, on— (1) whether the separate schedules of cost limits currently applied to home health agencies under title XVIII of the Social Security Act located in urban and rural areas accurately reflect differences in the costs of urban and rural home health agencies, and (2) the appropriateness of modifying such limits to take into account the proportion of agency patients who are from urban and rural areas. SEC. 4027. HOME HEALTH PROSPECTIVE PAYMENT DEMONSTRATION PROJECT. (a) In General.— The Secretary of Health and Human Services (in this section referred to as the “Secretary”) shall provide for a demonstration project to develop and test alternative methods of paying home health agencies on a prospective basis for services furnished under the medicare and medicaid programs. The project shall be designed in a manner to enable the Secretary to evaluate the effects of various methods of prospective payment (including payments on a per-visit, per-case, and per-episode basis) on program expenditures, access to, and quality of, home health care, and home health agency operations. The Secretary shall assure that services Contracts. are first furnished under the project not later than July 1, 1988, and, for this purpose, the Secretary may reinstate a previously awarded contract, or award a sole source contract, to carry out the project. (b) Funding.— The provisions of subsection (a)(2) and the first sentence of subsection (b) of section 402 of the Social Security Amendments of 1967 shall apply to the demonstration project under subsection (a) of this section as they apply to experiments under subsection (a)(1) of that section. (c) Report.— The Secretary shall submit to Congress, not later than one year after the date of the enactment of this Act, an interim report on the demonstration project and, not later than four years after the date of the enactment of this Act, a final report on the results of the project. Subpart C— Other Provisions SEC. 4031. PAYMENT CYCLE STANDARDS. (a) Payment Floor Standards.— (1) Section 1816(c) of the Social Security Act (42 U.S.C. 1395h(c)) is amended by adding at the end the following new paragraph: “(3) (A) Each agreement under this section shall provide that no payment shall be issued, mailed, or otherwise transmitted with respect to any claim submitted under this title within the applicable number of calendar days after the date on which the claim is received. “(B) In this paragraph, the term ‘applicable number of calendar days’ means— “(i) with respect to claims received in the 3-month period beginning July 1, 1988, 10 days, and “(ii) with respect to claims received in the 12-month period beginning October 1, 1988, 14 days.”.27b27bCopy read “days.”. (2) Section 1842(c) of such Act (42 U.S.C. 1395u(c)) is amended by adding at the end the following new paragraph: “(3) (A) Each contract under this section which provides for the Contracts. disbursement of funds, as described in subsection (a)(1)(B), shall provide that no payment shall be issued, mailed, or otherwise transmitted with respect to any claim submitted under this title within the applicable number of calendar days after the date on which the claim is received. “(B) In this paragraph, the term ‘applicable number of calendar days’ means— “(i) with respect to claims received in the 3-month period beginning July 1, 1988, 10 days, and “(ii) with respect to claims received in the 12-month period beginning October 1, 1988, 14 days.”. 27b27bCopy read “days.”. (3) (A) The amendments made by paragraphs (1) and (2) shall 42 USC 1395h note. apply to claims received on or after July 1, 1988. (B) The Secretary of Health and Human Services shall provide Contracts. Regulations. for such timely amendments to agreements under section 1816 of the Social Security Act and contracts under section 1842 of such Act, and regulations, to such extent as may be necessary to implement the provisions of this subsection on a timely basis. (b) Prohibition of Other Policies Intended to Slow Down Medicare Payments.— Notwithstanding any other provision of law, except as specifically provided in this section, the Secretary of Health and Human Services is not authorized to issue, after the date of the enactment of this Act, and before October 1, 1990, any final regulation, instruction, or other policy change which is primarily intended to have the effect of slowing down claims processing, or delaying payment of claims, under title XVIII of the Social Security Act. (c) Budget Considerations.— For purposes of section 202 of the 42 USC 1395h note. Balanced Budget and Emergency Deficit Control Reaffirmation Act of 1987, this section is a necessary (but secondary) result of a significant policy change. SEC. 4032. DENIALS AND RECONSIDERATIONS OF CLAIMS FOR HOME HEALTH SERVICES, EXTENDED CARE SERVICES, AND POSTHOSPITAL EXTENDED CARE SERVICES. (a) Notification and Physician Review.— Section 1816 of the Social Security Act (42 U.S.C. 1395h) is amended by adding at the end the following new subsection: “(j) An agreement with an agency or organization under this section shall require that, with respect to a claim for home health services, extended care services, or post-hospital extended care services submitted by a provider to such agency or organization that is denied, such agency or organization— “(1) furnish the provider and the individual with respect to whom the claim is made with a written explanation of the denial and of the statutory or regulatory basis for the denial; and “(2) promptly notify such individual and the provider of disposition of such reconsideration.”. (b) Performance Standards for Fiscal Intermediaries and Carriers.— Section 1816(f) of such Act (42 U.S.C. 1395h(f)) is amended by adding at the end the following: “Such standards and criteria shall include with respect to claims for services furnished under this part by any provider of services other than a hospital whether such agency or organization is able to process 75 percent of reconsiderations within 60 days (except in the case of the fiscal year 1989, 66 percent of reconsiderations) and 90 percent of reconsiderations within 90 days and the extent to which its determinations are reversed on appeal.”. (c) Effective Date.— (1) (A) The amendment made by subsection (a) shall apply with 42 USC 1395h note. respect to claims received on or after January 1, 1988. (B) The amendment made by subsection (b) shall apply with respect to claims filed on or after October 1, 1988. (2) The Secretary of Health and Human Services shall provide Contracts. Regulations. for such timely amendments to agreements under section 1816 and contracts under section 1842 of the Social Security Act, and regulations, to such extent as may be necessary to implement the amendments made by subsections (a) and (b) on a timely basis. SEC. 4033. PERMITTING DISABLED INDIVIDUALS TO RENEW ENTITLEMENT TO MEDICARE AFTER GAINFUL EMPLOYMENT WITHOUT A 2-YEAR WAITING PERIOD. (a) In General.— (1) Section 226(0 of the Social Security Act (42 U.S.C. 426(f)) is amended by inserting before the period at the end the following: “, unless the physical or mental impairment which is the basis for disability is the same as (or directly related to) the physical or mental impairment which served as the basis for disability in such previous period”. (2) (A) The amendment made by subsection (a) shall apply to 42 USC 426 note. months beginning after the end of the 60-day period beginning on the date of enactment of this Act. (B) The amendment made by subsection (a) shall not apply so as to include (for the purposes described in section 226(f) of the Social Security Act) monthly benefits paid for any month in a previous period (described in that section) that terminated before the end of the 60-day period described in paragraph (1). SEC. 4034. APPLICATION OF SECONDARY PAYER PROVISIONS TO GOVERNMENTAL ENTITIES. (a) In General.— Section 1862(b)(4)(B)(i) of the Social Security Act (42 U.S.C. 1395y(b)(4)(B)(i)), as added by the amendment made by section 9319(a) of the Omnibus Budget Reconciliation Act of 1986, is amended by striking “section 5000(b) of the Internal Revenue Code of 1986” and inserting “subsection (b) of section 5000 of the Internal Revenue Code of 1986 without regard to subsection (d) of such section”. (b) Effective Date.— The amendment made by subsection (a) 42 USC 1395y note. shall be effective as if included in the enactment of section 9319(a) of the Omnibus Budget Reconciliation Act of 1986. SEC. 4035. PUBLICATION AND NOTIFICATION OF POLICIES. (a) Requiring Publication of Intermediary and Carrier Budget Methodology.— (1) Section 1816(c)(1) of the Social Security Act (42 U.S.C. 1395h(c)(1)) is amended by adding at the end the following sentence: “The Secretary shall cause to have published in the Federal Register, by not later than September 1 before each fiscal year, data, standards, and methodology to be used to establish budgets for fiscal intermediaries under this section for that fiscal year, and shall cause to be published in the Federal Register for public comment, at least 90 days before such data, standards, and methodology are published, the data, standards, and methodology proposed to be used.”. (2) Section 1842(c)(1) of such Act (42 U.S.C. 1395u(c)(1)) is amended by adding at the end the following sentence: “The Secretary shall cause to have published in the Federal Register, by not later than September 1 before each fiscal year, data, standards, and methodology to be used to establish budgets for carriers under this section for that fiscal year, and shall cause to be published in the Federal Register for public comment, at least 90 days before such data, standards, and methodology are published, the data, standards, and methodology proposed to be used.”. (3) The amendments made by this section shall take effect on Effective date. 42 USC 1395h note. the date of the enactment of this Act and shall apply to budgets for fiscal years beginning with fiscal year 1989. (b) Publication as Regulations of Significant Policies.— Section 1871(a) of such Act (42 U.S.C. 1395hh(a)) is amended— (1) by inserting “(1)” after “(a)”; and (2) by adding at the end the following new paragraph: “(2) No rule, requirement, or other statement of policy (other than a national coverage determination) that establishes or changes a substantive legal standard governing the scope of benefits, the payment for services, or the eligibility of individuals, entities, or organizations to furnish or receive services or benefits under this title shall take effect unless it is promulgated by the Secretary by regulation under paragraph (1).”. (c) Miscellaneous Publication and Information Access Provisions.— Section 1871 of such Act (42 U.S.C. 1395hh) is amended by adding at the end the following new subsection: “(c) (1) The Secretary shall publish in the Federal Register, not less frequently than every 3 months, a list of all manual instructions, interpretative rules, statements of policy, and guidelines of general applicability which— “(A) are promulgated to carry out this title, but “(B) are not published pursuant to subsection (a)(1) and have not been previously published in a list under this subsection. “(2) Effective June 1, 1988, each fiscal intermediary and carrier Effective date. administering claims for extended care, post-hospital extended care, home health care, and durable medical equipment benefits under this title shall make available to the public all interpretative materials, guidelines, and clarifications of policies which relate to payments for such benefits. “(3) The Secretary shall to the extent feasible make such changes in automated data collection and retrieval by the Secretary and fiscal intermediaries with agreements under section 1816 as are necessary to make easily accessible for the Secretary and other appropriate parties a data base which fairly and accurately reflects the provision of extended care, post-hospital extended care and home health care benefits pursuant to this title, including such categories as benefit denials, results of appeals, and other relevant factors, and selectable by such categories and by fiscal intermediary, service provider, and region.”. SEC. 4036. END-STAGE RENAL DISEASE AMENDMENTS. (a) Implementation of Primary Payer Requirements for Endstage Renal Disease Program.— (1) Section 1862(b)(2)(A) of the Social Security Act (42 U.S.C. 1395y(b)(2)(A)) is amended by striking “(ii)” and all that follows through “under this title” and inserting “(ii) can reasonably be expected to be made under such a plan”. (2) The amendment made by paragraph (1) shall apply with Effective date. 42 USC 1395y note. respect to items and services furnished on or after 30 days after the date of the enactment of this Act. (b) Limitation of Minimum Utilization Rate Requirement for End-Stage Renal Disease Transplantations.— The last sentence of section 1881(b)(1) of such Act (42 U.S.C. 1395rr(b)(1)) is amended by striking “covered procedures and for self-dialysis training programs” and inserting “transplantations”. (c) Extension of Deadline for Establishing Protocols on Reuse of Dialysis Filters and Other Dialysis Supplies as it Relates to the Reuse of Bloodunes.— (1) (A) Section 9335(k)(2) of the Omnibus Budget Reconciliation Act of 1986 is amended by inserting “(or July 1, 1988, with 42 USC 1395rr note. respect to protocols that relate to the reuse of bloodlines)” after “October 1, 1987”. (B) The amendment made by subparagraph (A) shall be effective 42 USC 1395rr note. as if included in the enactment of section 9335(k)(2) of the Omnibus Budget Reconciliation Act of 1986. (2) Section 1881(f)(7)(B) of the Social Security Act (42 U.S.C. 1395rr(f)(7)(B)) is amended by inserting “(or July 1, 1988, with respect to protocols that relate to the reuse of bloodlines)” after “January 1, 1988”. (d) Studies of End-Stage Renal Disease Program.— (1) The Secretary of Health and Human Services (in this subsection referred to as the “Secretary”) shall arrange for a study of the end-stage renal disease program within the medicare program. (2) Among other items, the study shall address— (A) access to treatment by both individuals eligible for medicare benefits and those not eligible for such benefits; (B) the quality of care provided to end-stage renal disease beneficiaries, as measured by clinical indicators, functional status of patients, and patient satisfaction; (C) the effect of reimbursement on quality of treatment; (D) major epidemiological and demographic changes in the end-stage renal disease population that may affect access to treatment, the quality of care, or the resource requirements of the program; and (E) the adequacy of existing data systems to monitor these matters on a continuing basis. (3) The Secretary shall submit to Congress, not later than 3 Reports. years after the date of the enactment of this Act, a report on the study. (4) The Secretary shall request the National Academy of Sciences, acting through the Institute of Medicine, to submit an application to conduct the study described in this section. If the Academy submits an acceptable application, the Secretary shall enter into an appropriate arrangement with the Academy for the conduct of the study. If the Academy does not submit an acceptable application to conduct the study, the Secretary may request one or more appropriate nonprofit private entities to submit an application to conduct the study and may enter into an appropriate arrangement for the conduct of the study by the entity which submits the best acceptable application. (5) Section 1881 of the Social Security Act (42 U.S.C. 1395rr) is amended— (A) in subsection (c)(2)(F), by striking “and subsection (g)”, (B) by striking the last sentence of subsection (c)(6), (C) by striking subsection (g), and (D) by redesignating subsection (h), as added by section 20 of the Medicare and Medicaid Patient and Program Protection Act of 1987 (Public Law 100–93), as subsection (g). SEC. 4037. MEDICARE HEARINGS AND APPEALS. (a) Maintaining Current System for Hearings and Appeals.— Any hearing conducted under section 1869(b)(1) of the Social Security Act prior to the earliest of the date on which the Secretary of Health and Human Services submits the report required to be submitted by the Secretary under subsection (l))(l) or September 1 shall be conducted by Administrative Law Judges of the Office of Hearings and Appeals of the Social Security Administration in the same manner as are hearings conducted under section 205(b)(1) of such Act. (b) Study and Report on Use of Telephone Hearings.— (1) The Secretary of Health and Human Services and the Comptroller General of the United States shall each conduct a study on holding hearings under section 1869(b)(1) of the Social Security Act by telephone and shall each report the results of the study not later than 6 months after the date of enactment of this Act. (2) The studies under paragraph (1) shall focus on whether telephone hearings allow for a full and fair evidentiary hearing, in general, or with respect to any particular category of claims and shall examine the possible improvements to the hearing process (such as cost-effectiveness, convenience to the claimant, and reduction in time under the process) resulting from the use of such hearings as compared to the adoption of other changes to the process (such as expansions in staff and resources). SEC. 4038. RURAL HEALTH MEDICAL EDUCATION DEMONSTRATION PROJECT. (a) In General.— The Secretary of Health and Human Services (in this section referred to as the “Secretary”) shall enter into agreements with four sponsoring hospitals submitting applications under this subsection to conduct demonstration projects to assist resident physicians in developing field clinical experience in rural areas. (b) Nature of Project.— Under a demonstration project conducted under subsection (a), a sponsoring hospital entering into an agreement with the Secretary under such subsection shall enter into arrangements with a small rural hospital to provide to such rural hospital, for a period of one to three months of training, physicians (in such number as the agreement under subsection (a) may provide) who have completed one year of residency training. (c) Selection.— In selecting from among applications submitted under subsection (a), the Secretary shall ensure that four small rural hospitals located in different counties participate in the demonstration project and that— (1) two of such hospitals are located in rural counties of more than 2,700 square miles (one of which is east of the Mississippi River and one of which is west of such river); and (2) two of such hospitals are located in rural counties with (as determined by the Secretary) a severe shortage of physicians (one of which is east of the Mississippi River and one of which is west of such river). (d) Clarification of Payment.— For purposes of section 1886 of the Social Security Act— (1) with respect to subsection (d)(5)(B) of such section, any resident physician participating in the project under subsection (a) for any part of a year shall be treated as if he or she were working at the appropriate sponsoring hospital with an agreement under subsection (a) on September 1 of such year (and shall not be treated as if working at the small rural hospital); and (2) with respect to subsection (h) of such section, the payment amount permitted under such subsection for a sponsoring hospital with an agreement under subsection (a) shall be increased (for the duration of the project only) by an amount equal to the amount of any direct graduate medical education costs (as defined in paragraph (5) of such subsection (h)) incurred by such hospital in supervising the education and training activities under a project under subsection (a). (e) Duration of Project.— Each demonstration project under subsection (a) shall be commenced not later than six months after the date of enactment of this Act and shall be conducted for a period of three years. (f) Definition.— In this section, the term “sponsoring hospital” means a hospital that receives payments under sections 1886(d)(5)(B) and 1886(h) of the Social Security Act. SEC. 4039. MISCELLANEOUS AND TECHNICAL PROVISIONS. (a) Clarification of Criminal Penalties for Willful Misrepresentations.— Subsection (c) of section 1128B of the Social Security Act (42 U.S.C. 1320a–7(b)), 2828Copy read “1320a–7b)),”. as redesignated by section 4(d) of the Medicare and Medicaid Patient and Program Protection Act of 1987 (Public Law 100–93), is amended— (1) by striking “institution or facility” each place it appears and inserting “institution, facility, or entity”, and (2) by inserting “(including an eligible organization under section 1876(b))” after “other entity”. (b) Podiatrists.— (1) Section 1861(r)(3) of the Social Security Act (42 U.S.C. 1395x(r)(3)) is amended— (A) by striking “subsection (s) of this section” and inserting “subsections (k), (m), (p)(1), and (s) of this section and sections 1814(a), 1832(a)(2)(F)(ii), and 1835”, and (B) by striking “; and for the purposes” and all that follows through “which he is legally authorized to perform”. (2) Section 1861(b)(6) of such Act (42 U.S.C. 1395x(b)(6)) is amended by striking “Council on Podiatry Education of the American Podiatry Association” and inserting “Council on Podiatric Medical Education of the American Podiatric Medical Association”. (c) Recovery of Payments for Certain Pacemaker Devices.— (1) Section 1862(h) of such Act (42 U.S.C. 1395y(h)) is amended— (A) in paragraph (1)(B), by striking “law,” and inserting “law (and any amount paid to a provider under any such warranty),”; (B) in paragraph (1)(D), by striking “(3),” and inserting “(3), in determining the amount subject to repayment under paragraph (2)(C),”; (C) in paragraph (2)— (i) by striking “and” at the end of subparagraph (A), (ii) by striking the period at the end of subparagraph (B) and inserting “, and”, and (iii) by adding at the end the following new subparagraph: “(C) to make repayment to the Secretary of amounts paid under this title to the provider with respect to any cardiac pacemaker device or lead which has been replaced by the manufacturer, or for which the manufacturer has made payment to the provider, under an express or implied warranty.”; and (D) in paragraph (4)(B)— (i) by striking “or has” and inserting “, has”, and (ii) by striking “(2)(B),” and inserting “(2)(B), or has failed to make repayment to the Secretary as required under paragraph (2)(C),”. (2) The amendments made by paragraph (1) shall become Effective date. 42 USC 1395y note. effective on January 1, 1988. (d) Extend and Clarify Prohibition on Cost Savings Policies Before Beginning of Fiscal Year.— Notwithstanding any other provision of law, except as required to implement specific provisions required under statute, the Secretary of Health and Human Services is not authorized to issue in final form, after the date of the enactment of this Act and before October 15, 1988, any regulation, instruction, or other policy which is estimated by the Secretary to result in a net reduction in expenditures under title XVIII of the Social Security Act in fiscal year 1989 of more than $50,000,000. (e) Moratorium on Prior Authorization for Home Health and Post-Hospital Extended Care Services.— The Secretary of Health and Human Services shall not implement any voluntary or mandatory program of prior authorization for home health services, extended care services, or post-hospital extended care services under part A or B of title XVIII of the Social Security Act at any time prior to six months after the date on which the Congress receives the report required under section 9305(k)(4) of the Omnibus Budget Reconciliation Act of 1986. (f) Delay in Publishing Regulations with Respect to Deeming the Status of Entities.— The Secretary of Health and Human Services (in this subsection referred to as the “Secretary”) shall not deem any entity to be a provider of services (as defined in section 1861(u) of the Social Security Act) for purposes of title XVIII of such Act— (1) on any date prior to 6 months after the date on which the Secretary has published a proposed rule with respect to the deeming of the entity, and (2) until the Secretary publishes a final rule with respect to the deeming of the entity. (g) Use of Interim Final Regulations.— The Secretary of Health 42 USC 1395hh note. and Human Services shall issue such regulations (on an interim or other basis) as may be necessary to implement this subtitle and the amendments made by this subtitle. PART 3— RELATING TO PART B Subpart A— Provisions Relating to Payments for Physicians’ Services SEC. 4041. FREEZE IN PAYMENTS FOR PHYSICIANS’ SERVICES; EXTENSION OF SEQUESTER ORDER. (a) Three-Month Freeze on Increases In Physician Payments.— (1) In general.— Section 1842 of the Social Security Act (42 U.S.C. 1395u) is amended— (A) in subsection (b)(4)— (i) in subparagraph (A), by redesignating clause (v) as clause (vi) and by inserting after clause (iv) the following new clause: “(v) In determining the prevailing charge levels under the third and fourth sentences of paragraph (3) for physicians’ services furnished during the 3-month period beginning January 1, 1988, the Secretary shall not set any level higher than the same level as was set for the 12-month period beginning January 1, 1987.”, and (ii) in subparagraph (B), by adding at the end the following new clause: “(iii) In determining the reasonable charge under paragraph (3) for physicians’ services furnished during the 3-month period beginning January 1, 1988, the customary charges shall be the same customary charges as were recognized under this section for the 12-month period beginning January 1, 1987.”; and (B) in subsection (j)(1)(C), by adding at the end thereof the following new clause: “(vii) Notwithstanding any other provision of this subparagraph, the maximum allowable actual charge for a particular physician’s service furnished by a nonparticipating physician to individuals enrolled under this part during the 3-month period beginning on January 1, 1988, shall be the amount determined under this subparagraph for 1987. The maximum allowable actual charge for Effective date. any such service otherwise determined under this subparagraph for 1988 shall take effect on April 1, 1988.”. (2) Extension of physician participation agreements and related provisions.— Notwithstanding any other provision of law— (A) subject to the last sentence of this paragraph, each agreement with a participating physician in effect on December 31, 1987, under section 1842(h)(1) of the Social Security Act shall remain in effect for the 3-month period beginning on January 1, 1988; (B) the effective period for agreements under such section entered into for 1988 shall be the nine-month period beginning on April 1, 1988, and the Secretary shall provide an opportunity for physicians to enroll as participating physicians prior to April 1, 1988; (C) instead of publishing, under section 1842(h)(4) of the Social Security Act at the beginning of 1988, directories of participating physicians for 1988, the Secretary shall provide for such publication, at the beginning of the 9-month period beginning on April 1, 1988, of such directories of participating physicians for such period; and (D) instead of providing to nonparticipating physicians, under section 1842(b)(3)(G) of the Social Security Act at the beginning of 1988, a list of maximum allowable actual charges for 1988, the Secretary shall provide, at the beginning of the 9-month period beginning on April 1, 1988, to such physicians such a list for such 9-month period. An agreement with a participating physician in effect on December 31, 1987, under section 1842(h)(1) of the Social Security Act shall not remain in effect for the period described in subparagraph (A) if the participating physician requests on or before December 31, 1987, that the agreement be terminated. (3) (A) Section 1842 of the Social Security Act (42 U.S.C. 1395u) is amended— (i) in subsection (b)(2), by adding at the end the following: In establishing such standards and criteria, the Secretary shall provide a system to measure a carrier’s performance of responsibilities described in paragraph (3)(H) and subsection (h).”; and (ii) in subsection (c)(1), by inserting “(A)” after “(c)(1)” and by adding at the end the following new subparagraph: “(B) Of the amounts appropriated for administrative activities to carry out this part, the Secretary shall provide payments, totaling 1 percent of the total payments to carriers for claims processing in any fiscal year, to carriers under this section, to reward carriers for their success in increasing the proportion of physicians in the carrier’s service area who are participating physicians or in increasing the proportion of total payments for physicians’ services which are payments for such services rendered by participating physicians.”. (B) Section 9332(a) of the Omnibus Budget Reconciliation Act of 1986 is amended— (i) by striking paragraphs (2) and (3), 42 USC 1395u notes. (ii) in paragraph (4)(B), by striking “under paragraph (2)” 42 USC 1395u note. inserting “under the last sentence of section 1842(b)(2) of the Social Security Act”, and (iii) in paragraph (4)(C)— (I) by striking “under paragraph (3)” and inserting “under section 1842(c)(1)(B) of the Social Security Act”, (II) by striking “April” and inserting “July”, and (III) by striking “at the end of 1987” and inserting “before April 1, 1988”. (b) Extension of Reduction Under Sequester Order.— Notwithstanding any other provision of law (including any other provision of this Act), the reductions in the amount of payments required under title XVIII of the Social Security Act made by the final sequester order issued by the President on November 20, 1987, pursuant to section 252(b) of the Balanced Budget Emergency Deficit Control Act of 1985 shall continue to be effective (as provided by sections 252(a)(4)(B) and 256(d)(2) of such Act) through March 31, 1988, with respect to payments for physicians’ services under part B of such title. SEC. 4042. GENERAL UPDATE IN PAYMENTS FOR PHYSICIANS’ SERVICES. (a) Increase in MEI for 1988 and 1989.— Section 1842(b)(4) of the Social Security Act (42 U.S.C. 1395u(b)(4)) is amended by adding at the end the following new subparagraph: “(F) (i) For purposes of this part for physicians’ services furnished in 1987, the percentage increase in the MEI is 3.2 percent. “(ii) For purposes of this part for physicians’ services furnished in 1988, on or after April 1, the percentage increase in the MEI is— “(I) 3.6 percent for primary care services (as defined in subparagraph (E)(iii)), and “(II) 1 percent for other physicians’ services. “(iii) For purposes of this part for physicians’ services furnished in 1989, the percentage increase in the MEI is— “(I) 3.0 percent for primary care services; and “(II) 1 percent for other physician’s services.”. (b) Primary Care Services Defined.— Section 1842(b)(4)(E) of such Act (42 U.S.C. 1395u(b)(4)(E)) is amended by adding at the end thereof the following new clause: “(iii) The term ‘primary care services’ means physicians’ services which constitute office medical services, emergency department services, home medical services, skilled nursing, intermediate care, and long-term care medical services, or nursing home, boarding home, domiciliary, or custodial care medical services.”. (c) Participating Physician Differential.— Section 1842(b)(4)(A)(iv) of such Act (42 U.S.C. 1395u(b)(4)(A)(iv)) is amended— (1) by striking “96 percent” and inserting “applicable percent”, and (2) by adding at the end the following: “In the previous sentence, the term ‘applicable percent’ means for services furnished (I) on or after January 1, 1987, and before April 1, 1988, 96 percent, (II) on or after April 1, 1988, and before January 1, 1988, 95.5 percent, and (III) on or after January 1, 1989, 95 percent.”. SEC. 4043. INCENTIVE PAYMENTS FOR PHYSICIANS’ SERVICES FURNISHED IN UNDERSERVED AREAS. (a) In General.— Section 1833 of the Social Security Act (42 U.S.C. 13951) is amended by adding at the end the following new subsection: “(m) In the case of physicians’ services furnished to an individual, who is covered under the insurance program established by this part and who incurs expenses for such services, in an area that is designated (under section 332(a)(1)(A) of the Public Health Service Act) as a class 1 or class 2 health manpower shortage area, in addition to the amount otherwise paid under this part, there also shall be paid to the physician (or to an employer or facility in the cases described in clause (A) of section 1842(b)(6)) (on a monthly or quarterly basis) from the Federal Supplementary Medical Insurance Trust Fund an amount equal to 5 percent of the payment amount for the service under this part.”. (b) Study.— The Secretary of Health and Human Services shall Reports. 42 USC 1395l note. study and report to Congress, by not later than January 1, 1990, on the feasibility of making additional payments described in section 1833(m) of the Social Security Act with respect to physician services which are performed in health manpower shortage areas located in urban areas. (c) Effective Date.— The amendments made by this subsection (a) 42 USC 1395l note. shall apply with respect to services furnished in a rural area (as defined in section 1886(d)(2)(D) of the Social Security Act) 2929Copy read “Act))”. on or after January 1, 1989, and to other services furnished on or after January 1, 1991. SEC. 4044. ADJUSTMENT IN PREVAILING CHARGE LEVEL FOR PRIMARY CARE SERVICES. (a) Increase in Prevailing Charges for Primary Care Services.— Section 1842(b)(4)(A) of the Social Security Act (42 U.S.C. 1395u(b)(4)(A)), as amended by section 4041(a)(1) of this subtitle, is further amended by redesignating clause (vi) as clause (vii) and by inserting after clause (v) the following new clause: “(vi) Before each year (beginning with 1989), the Secretary shall establish a prevailing charge floor for primary care services (as defined in subparagraph (E)(iii)) equal to 50 percent of the average of the prevailing charge levels (determined, for participating physicians under the third and fourth sentences of paragraph (3) and under paragraph (4), without regard to this clause and without regard to physician specialty) for such service for all localities in the United States (weighted by the relative frequency of the service in each locality) for the year.”. (b) Effective Date.— The amendments made by subsection (a) 42 USC 1395u note. shall apply to payment for physicians’ services furnished on or after January 1, 1989. SEC. 4045. REDUCTION IN PREVAILING CHARGE LEVEL FOR OVERPRICED PROCEDURES. (a) In General.— Paragraph (10) of section 1842(b) of the Social Security Act (42 U.S.C. 1395u(b)) is amended to read as follows: “(10) (A) (i) In determining the reasonable charge under paragraph (3) for procedures described in subparagraph (C) and performed during the 9-month period beginning on April 1, 1988, the prevailing charge for such procedure for participating and nonparticipating physicians shall be the prevailing charge otherwise recognized for such procedure for 1987— “(I) subject to clause (iii), reduced by 2.0 percent, and “(II) further reduced by the applicable percentage specified in clause (ii). “(ii) For purposes of clause (i), the applicable percentage specified in this clause is— “(I) 15 percent, in the case of a prevailing charge otherwise recognized (without regard to this paragraph and determined without regard to physician specialty) that is at least 150 percent of the weighted national average (as determined by the Secretary) of such prevailing charges for such procedure for all localities in the United States for 1987; “(II) 0 percent, in the case of a prevailing charge that does not exceed 85 percent of such weighted national average; and “(III) in the case of any other prevailing charge, a percent determined on the basis of a straight-line sliding scale, equal to 3/13 of a percentage point for each percent by which the prevailing charge exceeds 85 percent of such weighted national average. “(iii) In no case shall the reduction under clause (i) for a procedure result in a prevailing charge in a locality for 1988 which is less than 85 percent of the Secretary’s estimate of the weighted national average of such prevailing charges for such procedure for all localities in the United States for 1987 passed upon the best available data and determined without regard to physician specialty) after making the reduction described in clause (i)(II). “(B) The procedures described in this subparagraph are as follows: bronchoscopy, 29a29aCopy read “bronschoscopy,”. carpal tunnel repair, cataract surgery, coronary artery bypass surgery, diagnostic and/or therapeutic dilation and curettage, knee arthroscopy, knee arthroplasty, pacemaker implantation surgery, total hip replacement, suprapubic prostatectomy, transurethral resection of the prostate, and upper gastrointestinal endoscopy. “(C) In the case of a reduction in the reasonable charge for a physicians’ service under subparagraph (A), if a nonparticipating physician furnishes the service to an individual entitled to benefits under this part, after the effective date of such reduction, the physician’s actual charge is subject to a limit under subsection (j)(1)(D). “(D) There shall be no administrative or judicial review section 1869 or otherwise of any determination under subparagraph (A) or under29b29bCopy read “under under”. paragraph (11)(B)(ii).”. (b) Modification of Geographic Index.— Section 1845(e)(4)(A)(i) of such Act (42 U.S.C. 1395w–l(e)(4)(A)(i)) is amended by inserting “and costs of living” after “costs of practice”. (c) Consolidated Charge Limitation Provisions.— (1) Penalties for excess charges.— Section 1842 of such Act is further amended— (A) in subsection (b)(11)(C)— (i) in clause (i), by striking “(subject to clause (iv))” and all that follows through the end and inserting the following: “, the physician’s actual charge is subject to a limit under subsection (j)(1)(D).”; (ii) in clause (i), by striking “(i)” after “(C)”; and (iii) by striking clauses (ii) through (iv); and (B) in subsection (j)(1), by adding at the end the following new subparagraph: “(D) (i) If an action described in clause (ii) results in a reduction in a reasonable charge for a physicians’ service or item and a nonparticipating physician furnishes the service or item to an individual entitled to benefits under this part after the effective date of such action, the physician may not charge the individual more than 125 percent of the reduced payment allowance (as defined in clause (iii)) plus (for services or items furnished during the 12-month period (or 9-month period in the case of an action described in clause (ii)(II) beginning on the effective date of the action) ½ of the amount by which the physician’s maximum allowable actual charge for the service or item for the previous 12-month period exceeds such 125 percent level. “(ii) The first sentence of clause (i) shall apply to— “(I) an adjustment under subsection (b)(8)(B) (relating to inherent reasonableness), “(II) a reduction under subsection (b)(10)(A) (relating to certain overpriced procedures), “(III) a reduction under subsection (b)(11)(B) (relating to certain cataract procedures), and “(IV) an adjustment under section 1833(1)(3)(B) (relating to physician supervision of certified registered nurse anesthetists), “(iii) In clause (i), the term ‘reduced payment allowance’ means, with respect to an action— “(I) under subsection (b)(8)(B), the inherently reasonable charge established under subsection (b)(8); or “(II) under subsection (b)(10)(A) or (b)(11)(B) or under section 1833(1)(3)(B), the prevailing charge for the service after the action, “(iv) If a physician knowingly and willfully imposes a charge in violation of clause (i) (whether or not such charge violates subparagraph (B)), the Secretary may apply sanctions against such physician in accordance with paragraph (2). “(v) Clause (i) shall not apply to items and services furnished after the earlier of (I) December 31, 1990, or (II) one-year after the date the Secretary reports to Congress, under section 1845(e)(3), on the development of the relative value scale under section 1845.”. (2) Conforming amendments.— (A) Section 1833(1)(6) of such Act (42 U.S.C. 13951(1)(6)) is amended— (i) in subparagraph (A), by striking “(subject to subparagraph (D))” and all that follows through the end and inserting the following: “after the effective date of the reduction, the physician’s actual charge is subject to a limit under section 1842(j)(1)(D).”; (ii) in subparagraph (A), by striking “(A)” after “(6)”; and (iii) by striking subparagraphs (B) through (D). (B) Section 1842(b)(11)(B)(i) of such Act (42 U.S.C. 1395u(b)(11)(B)(i)) is amended by striking “and shall be further reduced” and all that follows through “1988”. (C) Section 9334(b)(2) of the Omnibus Budget Reconciliation Act of 1986 is amended by striking “1842(b)(10)” and inserting 42 USC 1395u note. “1842(j)(1)(D)”. (d) Effective Date.— The amendments made by this section shall 42 USC 1395u note. apply to items and services furnished on or after April 1, 1988, except the amendment made by subsection (c)(2)(B) shall apply to services furnished on or after January 1, 1988. SEC. 4046. LIMITS ON PAYMENT FOR OPHTHALMIC ULTRASOUND. (a) In General.— Section 1842 of the Social Security Act (42 U.S.C. 1395u), as previously amended by this subpart is amended— (1) in subsection (b)(11)— (A) in subparagraph (C), as redesignated under section 4045(c)(1)(A)(ii) of this title, by inserting “or (C)” after “subparagraph (B)”; (B) by redesignating subparagraph (C) as subparagraph (D); and (C) by inserting after subparagraph (B) the following new subparagraph: “(C) The prevailing charge level determined with respect to Amode ophthalmic ultrasound procedures may not exceed 5 percent of the prevailing charge level established with respect to extracapsular cataract removal with lens implantation.”; and (2) in subparagraph (D) of subsection (j)(1), as added by section 4045(c)(1)(B) of this subtitle— (A) in clause (ii), by striking “and” at the end of subclause (III), by redesignating subclause (IV) as subclause (V) and by inserting before such subclause the following new subclause: “(IV) a prevailing charge limit is established under subsection (b)(11)(C)(i), and”; and (B) in clause (iii)(II), by striking “or (b)(11)(B)” and inserting “(b)(11)(B), or (b)(11)(C)(i)”. (b) Effective Date.— The amendments made by subsection (a) 42 USC 1395u note. shall apply to services furnished on or after April 1, 1988. SEC. 4047. CUSTOMARY CHARGES FOR PRIMARY CARE SERVICES OF NEW PHYSICIANS. (a) In General.— Section 1842(b)(4) of the Social Security Act, as amended by section 4042(a), is further amended by adding at the end thereof the following new subparagraph: “(G) In determining the customary charges for physicians’ services (other primary care services and other than services furnished in a rural area (as defined in section 1886(d)(2)(D)) that is designated, under section 332(a)(1)(A) of the Public Health Service Act, as a health manpower shortage area) for which adequate actual charge data are not available because a physician has not yet been in practice for a sufficient period of time, the Secretary shall set a customary charge at a level no higher than 80 percent of the prevailing charge (as determined under the third and fourth sentences of paragraph (3) and under paragraph (4)) for a service.”. (b) Effective Date.— The amendment made by subsection (a) 42 USC 1395u note. shall apply to physicians who first furnish services to medicare beneficiaries after April 1, 1988. SEC. 4048. PAYMENT FOR PHYSICIAN ANESTHESIA SERVICES. (a) In General.— Section 1842(b) of the Social Security Act (42 U.S.C. 1395u(b)) is further amended by adding at the end the following new paragraph: “(14) (A) In determining the reasonable charge under paragraph (3) of a physician for medical direction of two or more nurse anesthetists performing, on or after April 1, 1988, and before January 1, 1991, anesthesia services in whole or in part concurrently, the number of base units which may be recognized with respect to such medical direction for each concurrent procedure (other than cataract surgery or an iridectomy) shall be reduced by— “(i) 10 percent, in the case of medical direction of 2 nurse anesthetists concurrently, “(ii) 25 percent, in the case of medical direction of 3 nurse anesthetists concurrently, and “(iii) 40 percent, in the case of medical direction of 4 nurse anesthetists concurrently. “(B) In determining the reasonable charge under paragraph (3) of a physician for medical direction of two or more nurse anesthetists performing, on or after January 1, 1989, and before January 1, 1991, anesthesia services in whole or in part concurrently, the number of base units which may be recognized with respect to such medical direction for each concurrent cataract surgery or iridectomy procedure shall be reduced by 10 percent. “(C) The Secretary shall require claims for physicians’ services for medical direction of nurse anesthetists during the periods in which the provisions of subparagraph (A) or (B) apply to indicate the number of such anesthetists being medically directed concurrently at any time during the procedure, the name of each nurse anesthetist being directed, and the type of procedure for which the services are provided.”. (b) Development of Uniform Relative Value Guide.— The Secretary Regulations. 42 USC 1395u note. of Health and Human Services, in consultation with groups representing physicians who furnish anesthesia services, shall establish by regulation a relative value guide for use in all carrier localities in making payment for physician anesthesia services furnished under part B of title XVIII of the Social Security Act on and after January 1, 1989. Such guide shall be designed so as to result in expenditures under such title for such services in an amount that would not exceed the amount of such expenditures which would otherwise occur. (c) Study of Prevailing Charges for Anesthesia Services.— The Secretary of Health and Human Services shall conduct a study of the variations in conversion factors used by carriers under section 1842(b) of the Social Security Act to determine the prevailing charge for anesthesia services and shall report the results of the study and make recommendations for appropriate adjustments in such factors not later than January 1, 1989. (d) GAO Studies.— (1) The Comptroller General shall conduct a 42 USC 1395u note. study— (A) to determine the average anesthesia times reported for medicare reimbursement purposes, (B) to verify those times from patient medical records, (C) to compare anesthesia times to average surgical times, and (D) to determine whether the current payments for physician supervision of nurse anesthetists are excessive. The Comptroller General shall report to Congress, by not later than Reports. January 1, 1989, on such study and in the report include recommendations regarding the appropriateness of the anesthesia times recognized by medicare for reimbursement purposes and recommendations regarding adjustments of payments for physician supervision of nurse anesthetists. (2) The Comptroller General shall conduct a study on the impact Reports. of the amendment made by subsection (a), and shall report to Congress on the results of such study by April 1, 1990. SEC. 4049. FEE SCHEDULES FOR RADIOLOGIST SERVICES. (a) In General.— Part B of title XVIII of the Social Security Act is amended— (1) in section 1833(a)(1) (42 U.S.C. 13951(a)(1)), as amended by section 4062(c)(3) of this subtitle by striking “and” before “(I)”, and by adding at the end the following new clause: “and (J) with respect to expenses incurred for radiologist services (as defined in section 1834(b)(5)), the amounts paid shall be 80 percent of the lesser of the actual charge for the services or the amount provided under the fee schedule established under section 1834(b),”; and (2) by adding at the end of section 1834, as subsequently inserted by section 4062(a) of this subtitle, the following new subsection: “(b) Fee Schedules for Radiologist Services.— “(1) Development.— The Secretary shall develop— “(A) a relative value scale to serve as the basis for the payment for radiologist services under this part, and “(B) using such scale and appropriate conversion factors, fee schedules (on a regional, statewide, or carrier service area basis) for payment for radiologist services under this part, to be implemented for such services furnished during 1989. “(2) Consultation.— In carrying out paragraph (1), the Secretary shall regularly consult closely with the Physician Payment Review Commission, the American College of Radiology, and other organizations representing physicians or suppliers who furnish radiologist services and shall share with them the data and data analysis being used to make the determinations under paragraph (1), including data on variations in current medicare payments by geographic area, and by service and physician specialty. “(3) Considerations.— In developing the relative value scale and fee schedules under paragraph (1), the Secretary— “(A) shall take into consideration variations in the cost of furnishing such services among geographic areas and among different sites where services are furnished, and “(B) may also take into consideration such other factors respecting the manner in which physicians in different specialties furnish such services as may be appropriate to assure that payment amounts are equitable and designed to promote effective and efficient provision of radiologist services by physicians in the different specialties. “(4) Savings.— “(A) Budget neutral fee schedules.— The Secretary shall develop preliminary fee schedules for 1989, which are designed to result in the same amount of aggregate payments (net of any insurance and deductibles under section 1835(a)(1)(I) and 1833(b)) for radiologist services furnished in 1989 as would have been made if this subsection had not been enacted. “(B) Initial savings.— The fee schedules established for payment purposes under this subsection for services furnished in 1989 shall be 97 percent of the amounts permitted under these3030Copy read “this”. preliminary fee schedules developed under subparagraph (A). “(C) Subsequent updating.— Radiologist services furnished in subsequent years, the fee schedules shall be the schedules for the previous year updated by the percentage increase in the MEI (as defined in section 1842(b)(4)(E)(ii)) for the year. “(D) 3131Copy read “(C)”. Nonparticipating physicians.— Each fee schedule so established shall provide that the payment rate recognized for nonparticipating physicians and suppliers is equal to the appropriate percent (as defined in section 1842(b)(4)(A)(iv)) of the payment rate recognized for participating physicians and suppliers. “(5) Limiting charges of nonparticipating physicians.— “(A) In general.— In the case of radiologist services furnished after January 1, 1989, for which payment is made under a fee schedule under this subsection, if a nonparticipating physician or supplier furnishes the service to an individual entitled to benefits under this part, the physician or supplier may not charge the individual more than the limiting charge (as defined in subparagraph (B)). “(B) Limiting charge defined.— In subparagraph (A), the term ‘limiting charge’ means, with respect to a service furnished— “(i) in 1989, 125 percent of the amount specified for the service in the appropriate fee schedule established under paragraph (1), “(ii) in 1990, 120 percent of the amount specified for the service in the appropriate fee schedule established under paragraph (1), and “(iii) after 1990, 115 percent of the amount specified for the service in the appropriate fee schedule established under paragraph (1). “(C) Enforcement.— If a physician or supplier knowingly and willfully imposes a charge in violation of subparagraph (A), the Secretary may apply sanctions against such physician or supplier in accordance with section 1842(j)(2). “(6) 3232Copy read “ ‘( 5 )”. Radiologist Services Defined.— For the purposes of this subsection, section 1833(a)(1)(I), and section 1842(h)(1)(B), the term ‘radiologist services’ only includes radiologic services performed by, or under the direction or supervision of, a physician— “(A) who is certified, or eligible to be certified, by the American Board of Radiology, or “(B) for whom radiologic services account for at least 50 percent of billings made under this part.”. (b) Deadlines and Effective Date.— (1) The Secretary of Health and Human Services shall establish the relative value scale and fee schedules for radiologist services (under section 1834(b) of the Social Security Act) by not later than August 1, 1988, and shall report to Congress on the development of such fee schedules not later than August 1, 1988. (2) The amendments made by this section shall apply to services performed on or after January 1, 1989, and until such time as the Secretary of Health and Human Services implements physician fee schedules based on the relative value scale developed under section 1845(e) of the Social Security Act. SEC. 4050. FEE SCHEDULES FOR PHYSICIAN PATHOLOGY SERVICES. (a) In General.— The Secretary of Health and Human Services shall develop— (1) a relative value scale to serve as the basis for the payment for physician pathology services under part B of title XVIII of the Social Security Act, (2) using such scale and appropriate conversion factors, proposed fee schedules (on a regional, statewide, or carrier service area basis) for payment for physician pathology services under such part, that could be implemented for such services furnished during 1990, and (3) an appropriate index to be applied to updating such fee schedules annually for physician pathology services furnished in years after 1990. (b) Consultation.— In carrying out subsection (a), the Secretary shall regularly consult closely with the Physician Payment Review Commission, the College of American Pathologists, and other organizations representing physicians who furnish physician pathology services and shall share with them the data and data analysis being used to make the determinations under subsection (a), including data on variations in current medicare payments by geographic area, and by service and physician specialty. (c) Consideration.— In developing the fee schedules under subsection (a), the Secretary shall take into consideration variations in the cost of furnishing physician pathology services among geographic areas. (d) Report.— The Secretary shall report, not later than April 1, 1989, to the Committees on Energy and Commerce and Ways and Means of the House of Representatives and the Committee on Finance of the Senate on the relative value scale, fee schedules, and the index developed under this section. Such report shall include recommendations on how to protect medicare beneficiaries against excessive charges for physician pathology services above the payment amounts established by the fee schedules. SEC. 4051. ELIMINATION OF MARKUP FOR CERTAIN PURCHASED SERVICES. (a) In General.— Section 1842 of the Social Security Act (42 U.S.C. 42 USC 1395u. 1935u) is amended by adding at the end the following new subsection: “(n) (1) If a physician’s bill or a request for payment for services billed by a physician includes a charge to a patient for a diagnostic test described in section 1861(s)(3) (other than a clinical diagnostic laboratory test) for which payment does not indicate that the billing physician personally performed or supervised the performance of the test or that another physician with whom the physician who shares his practice personally performed or supervised the test, the amount payable with respect to the test shall be determined as follows: “(A) If the bill or request for payment indicates that the test was performed by a supplier, identifies the supplier, and indicates the amount the supplier charged the billing physician, payment for the test (less the applicable deductible and coinsurance amounts) shall be the actual acquisition costs (net of any discounts) or, if lower, the [ --------] [--------] [-------- ] [-------- ] [-------- ] 32a32aCopy not legible. enrolled under [--------] [-------- ] [-------- ] [-------- ] [--------].32a32aCopy not legible. “(B) If the bill or request for payment (i) does not indicate who performed the test, or (ii) indicates that the test was performed by a supplier but does not identify the supplier or include the amount charged by the supplier, no payment shall be made under this part. “(2) A physician may not bill an individual enrolled under this part— “(A) any amount other than any applicable deductible and coinsurance for a diagnostic test for which payment is made pursuant to paragraph (1)(A), or “(B) any amount for a diagnostic test for which payment may not be made pursuant to paragraph (1)(B). “(3) If a physician knowingly and willfully in repeated cases bills one or more individuals in violation of paragraph (2), the Secretary may apply sanctions against such physician or supplier in accordance with section 1842(j)(2).”. (b) Adjustment in Medicare Prevailing Charges.— (1) Review.— The Secretary of Health and Human Services shall review payment levels under part B of title XVIII of the Social Security Act for diagnostic tests (described in section 1861(s)(3) of such Act, but excluding clinical diagnostic laboratory tests) which are commonly performed by independent suppliers, sold as a service to physicians, and billed by such physicians, in order to determine the reasonableness of payment amounts for such tests (and for associated professional services component of such tests). The Secretary may require physicians and suppliers to provide such information on the purchase or sale price (net of any discounts) for such tests as is necessary to complete the review and make the adjustments under this subsection. The Secretary shall also review the reasonableness of payment levels for comparable in-office diagnostic tests. (2) Establishment of revised payment screens.— If, as a result of such review, the Secretary determines, after notice and opportunity of at least 60 days for public comment, that the current prevailing charge levels (under the third and fourth sentences of section 1842(b) of the Social Security Act) for any such tests or associated professional services are excessive, the Secretary shall establish such charge levels at levels which, consistent with assuring that the test is widely and consistently available to medicare beneficiaries, reflect a reasonable price for the test without any markup. Alternatively, the Secretary, Contracts. pursuant to guidelines published after notice and opportunity of at least 60 days for public comment, may delegate to carriers with contracts under section 1842 of the Social Security Act the establishment of new prevailing charge levels under this paragraph. When such charge levels are established, the provisions of section 1842(j)(1)(D) of such Act shall apply in the same manner as they apply to a reduction under section 1842(b)(8)(A) of such Act. (c) Effective Dates.— (1) The amendment made by subsection (a) shall apply to diagnostic tests performed on or sifter April 1, 1988. (2) The Secretary of Health and Human Services shall complete the review and make an appropriate adjustment of prevailing charge levels under subsection (b) for items and services furnished no later than January 1, 1989. SEC. 4052. COLLECTION OF PAST-DUE AMOUNTS OWNED BY PHYSICIANS WHO BREACHED CONTRACTS UNDER THE NATIONAL HEALTH SERVICE CORPS SCHOLARSHIP PROGRAM. (a) In General.— Title XVIII of the Social Security Act, as previously amended by this subtitle, is amended by adding at the end thereof the following new section: “offset of payments to physicians to collect past-due obligations arising from breach of scholarship contract “Sec. 1892. (a) In General.— “(1) (A) Subject to subparagraph (B), the Secretary shall enter into an agreement under this section with any physician who, by reason of a breach of a contract entered into by such physician pursuant to the National Health Service Corps Scholarship Program, owes a past-due obligation to the United States (as defined in subsection (b)). “(B) The Secretary shall not enter into an agreement with a physician under this section to the extent— “(i) (I) the physician has entered into a contract with the Secretary pursuant to section 204(a)(1) of the Public Health Service Amendments of 1987, and “(II) the physician has fulfilled or (as determined by the Secretary) is fulfilling the terms of such contract; or “(ii) the liability of the physician under such section 204(a)(1) has otherwise been relieved under such section; or “(iii) the physician is performing such physician’s service obligation under a forbearance agreement entered into with the Secretary under subpart II of part D of title III of the Public Health Service Act. “(2) The agreement under this section shall provide that— “(A) deductions shall be made from the amounts otherwise payable to the physician under this title, in accordance with a formula and schedule agreed to by the Secretary and the physician, until such past-due obligation (and accrued interest) have been repaid; “(B) payment under this title for services provided by such physician shall be made only on an assignment-related basis; “(C) if the physician does not provide services, for which payment would otherwise be made under this title, of a sufficient quantity to maintain the offset collection according to the agreed upon formula and schedule— “(i) the Secretary shall immediately inform the Attorney General, and the Attorney General shall immediately commence an action to recover the full amount of the past-due obligation, and “(ii) subject to paragraph (3), the Secretary shall immediately exclude the physician from the program under this title, until such time as the entire past-due obligation has been repaid. “(3) If the physician refuses to enter into an agreement or breaches any provision of the agreement— “(A) the Secretary shall immediately inform the Attorney General, and the Attorney General shall immediately commence an action to recover the full amount of the past-due obligation, and “(B) subject to paragraph (3), the Secretary shall immediately exclude the physician from the program under this title, until such time as the entire past-due obligation has been repaid. “(4) The Secretary shall not bar a physician pursuant to paragraph (2)(C)(ii) or paragraph (3)(B) if such physician is a sole community physician or sole source of essential specialized services in a community. “(b) Past-Due Obligation.— For purposes of this section, a past-due obligation is any amount— “(1) owed by a physician to the United States by reason of a breach of a scholarship contract under section 338E of the Public Health Service Act, and “(2) which has not been paid by the deadline established by the Secretary pursuant to section 338E of the Public Health Service Act, and has not been canceled, waived, or suspended by the Secretary pursuant to such section. “(c) Collection Under This Section Shall Not Be Exclusive.— This section shall not preclude the United States from applying other provisions of law otherwise applicable to the collection of obligations owed to the United States, including (but not limited to) the use of tax refund offsets pursuant to section 3720A of title 31, United States Code, and the application of other procedures provided under chapter 37 of title 31, United States Code. “(d) Collection from Providers and Health Maintenance Organizations.— “(1) In the case of a physician who owes a past-due obligation, and who is an employee of, or affiliated by a medical services agreement with, a provider having an agreement under section 1866 or a health maintenance organization or competitive medical plan having a contract under section 1833 or section 1876, the Secretary shall deduct the amounts of such past-due obligation from amounts otherwise payable under this title to such provider, organization, or plan. “(2) Deductions shall be in accordance with a formula and schedule agreed to by the Secretary, the physician and the provider, organization, or plan. The deductions shall be made from the amounts otherwise payable to the physician under this title as long as the physician continued to be employed or affiliated by a medical services agreement. “(3) Such deduction shall not be made until 6 months after the Secretary notifies the provider, organization, or plan of the amount to be deducted and the particular physicians to whom the deductions are attributable. “(4) A deduction made under this subsection shall relieve the physician of the obligation (to the extent of the amount collected) to the United States, but the provider, organization, or plan shall have a right of action to collect from such physician the amount deducted pursuant to this subsection (including accumulated interest). “(5) No deduction shall be made under this subsection if, within the 6-month period after notice is given to the provider, organization, or plan, the physician pays the past-due obligation, or ceases to be employed by the provider, organization, or plan. “(6) The Secretary shall also apply the provisions of this subsection in the case of a physician who is a member of a group practice, if such group practice submits bills under this program as a group, rather than by individual physicians. “(e) Transfer from Trust Funds.— Amounts equal to the amounts deducted pursuant to this section shall be transferred from the Trust Fund from which the payment to the physician, provider, or other entity would otherwise have been made, to the general fund in the Treasury, and shall be credited as payment of the past-due obligation of the physician from whom (or with respect to whom) the deduction was made.”. (b) Conforming Reference.— Section 338E(b)(1) of the Public Health Service Act (42 U.S.C. 254o(b)(l)) is amended by adding at the end thereof the following new sentence: “Amounts not paid within such period shall be subject to collection through deductions in Medicare payments pursuant to section 1892 of the Social Security Act.”. (c) Effective Date.— The amendments made by this section shall 42 USC 1395CCC note. be effective on the date of the enactment of this Act. SEC. 4052. ELIMINATION OF 1975 FLOOR FOR PREVAILING PHYSICIAN CHARGES. (a) In General.— Section 1842(b)(3) of the Social Security Act (42 U.S.C. 1395u(b)(3)) is amended by striking the next-to-last sentence (which begins "Notwithstanding the provisions of). (b) Effective Date.— The amendment made by subsection (a) 42 USC 1395u note. shall apply to payment for services furnished on or after January 1, 1988. SEC. 4053. APPLICATION OF MAXIMUM ALLOWABLE ACTUAL CHARGE (MAAC). (a) Application on Individual Charge Basis.— Section 1842(j)(1) of the Social Security Act (42 U.S.C. 1395u(j)(1)) is amended— (1) in the first sentence of subparagraph (B)(i), by striking “each such physician’s actual charges” and inserting “the actual charges of each such physician”; (2) in the second sentence of subparagraph (B)(i), by striking “for such a service a physician’s actual charge {as defined in subparagraph (C)(vi)” and inserting “on a repeated basis for such a service an actual charge”; and (3) in subparagraph (C)(vi), by striking “and subparagraph (B)”. (b) Adjustment.— In the case of a physician who did not have 42 USC 1395u note. actual charges under title XVIII of the Social Security Act for a procedure in the calendar quarter beginning on April 1, 1984, but who establishes to the satisfaction of a carrier that he or she had actual charges (whether under such title or otherwise) for the procedure performed prior to June 30, 1984, the carrier shall compute the maximum allowable actual charge under section 1842(j) of the Social Security Act for such procedure performed by such physician in 1988 based on such physician’s actual charges for the procedure. (c) Effective Date.— The amendment made by subsection (a) shall 42 USC 1395u note. apply to charges imposed for services furnished on or after April 1, 1988. SEC. 4054. APPLYING COPAYMENT AND DEDUCTIBLE TO CERTAIN OUT-PATIENT PHYSICIANS’ SERVICES. Notwithstanding any other provision of law, payment under part B of title XVIII of the Social Security Act for physicians’ services specified in section 1833(i)(l) of such Act and furnished on or after April 1, 1988, in an ambulatory surgical center or hospital outpatient department on an assignment-related basis shall be subject to the deductible under section 1833(b) of such Act and 20 percent coinsurance. SEC. 4055. PHYSICIAN PAYMENT STUDIES. (a) Definitions of Medical and Surgical Procedures.— (1) Report on variations in carrier payment practice.— The Secretary of Health and Human Services (in this section referred to as the “Secretary”) shall conduct a study of variations in payment practices for physicians’ services among the different carriers under section 1842 of the Social Security Act. Such study shall examine carrier variations in the services included in global fees and pre- and post-operative services included in payment for the operation. The Secretary shall report to Congress on such study by not later than May 1, 1988. (2) Uniform definitions of procedures for payment purposes.— The Secretary shall develop, in consultation with appropriate national medical specialty societies and by not later than July 1, 1989, uniform definitions of physicians’ services (including appropriate classification scheme for procedures) which could serve as the basis for making payments for such services under part B of title XVIII of the Social Security Act. In developing such list, to the extent practicable— (A) ancillary services commonly performed in conjunction with a major procedure would be included with the major procedure; (B) pre- and post-procedure services would be included in the procedure; and (C) similar procedures would be listed together if the procedures are similar in resource requirements. (b) Expansion Of Relative Value Scale (RVS) Study.— (1) Additional services.— The Secretary shall expand the study being conducted, under section 1845(e) of the Social Security Act, to develop a relative value scale for physicians’ services to include physicians’ services in the fields of cardiology, dermatology, emergency medicine, gastroenterology, hematology, infectious disease, nephrology, neurology, neurosurgery, nuclear medicine, oncology, physical medicine and rehabilitation, plastic surgery, pulmonary medicine, and radiation therapy, and for physicians who specialize in osteopathic procedures. (2) No delay in current study.— The expansion under paragraph (1) shall not be conducted in a manner that delays the completion of the current study or the report to Congress required under section 1845(e)(3) of the Social Security Act. The Reports. Secretary shall report to Congress on the services described in paragraph (1) by not later than October 1, 1989. (3) Prompt submittal of study results to physician payment review commission.— The Secretary shall submit to the Physician Payment Review Commission a copy of any report submitted to the Secretary pursuant to a cooperative agreement in the fulfillment of the requirement of section 1845(e) of such Act, with all relevant supporting data (including survey data, analytic data files, and file documentation), by no later than 30 days after the date the final report is received by the Secretary. (c) Other Physician Payment Studies.— (1) Fee schedule implementation.— The Secretary shall conduct a study of changes in the payment system for physicians’ services, under part B of title XVIII of the Social Security Act, that would be required for the implementation of a national fee schedule for such services furnished on or after January 1, 1990. Such study shall identify any major technical problems related to such implementation and recommendations on ways in which to address such problems. The Secretary shall report to the Reports. Congress on such study by not later than July 1, 1989. (2) Volume and intensity of physician services.— The Secretary shall conduct a study of issues relating to the volume and intensity of physicians’ services under part B of title XVIII of the Social Security Act, including— (A) historical trends with regard to increases in the volume and intensity of physicians’ services furnished on a per enrollee basis (with appropriate adjustments to account for changes in the demographic composition of the medicare population); (B) geographic variations in volume and intensity in physicians’ services; (C) an analysis of the effectiveness of methods currently used under such part to ensure that payments under such part are made only for services which are medically necessary; (D) the development and analysis of alternative methods to control the volume of services; and (E) the impact of the implementation of the relative value scale developed under section 1845(e) of such Act on the volume and intensity of physicians’ services. The Secretary shall submit to Congress an interim report on Reports. such study not later than May 1, 1988, and a final report on such study not later than May 1, 1989. (3) Survey of out-of-pocket costs of medicare beneficiaries for health care services.— The Secretary shall conduct a survey to determine the distribution of— (A) the liabilities and expenditures for health care services of individuals entitled to benefits under title XVIII of the Social Security Act, including liabilities for charges (not paid on an assignment-related basis) in excess of the reasonable charge recognized, and (B) the collection rates among different classes of physicians for such liabilities, including collection rates for required coinsurance and for charges (not paid on an assignment-related basis) in excess of the reasonable charge recognized. The Secretary shall report to Congress on such study by not Reports. later than July 1, 1990. (d) Study of Payment for Chemotherapy in Physicians’ Offices.— (1) In general.— The Secretary shall study ways of modifying part B of title XVIII of the Social Security Act to permit adequate payment under such part for the costs associated with providing chemotherapy to cancer patients in physicians’ of-fices. The study shall be performed in consultation with physicians and other health care providers who are experts in cancer therapy and with representation of health insurers who have experience in these payment issues. (2) Report.— The Secretary shall report to Congress on the results of the study by not later than April 1, 1989. Subpart B— Provisions Relating to Payments for Other Services SEC. 4061. EXTENSION OF REDUCTION FOR OTHER PART B ITEMS AND SERVICES PAYMENTS UNDER SEQUESTER ORDER. Notwithstanding any other provision of law (including any other provision of this Act), the reductions in the amount of payments required under title XVIII of the Social Security Act made by the final sequester order issued by the President on November 20, 1987, pursuant to section 252(b) of the Balanced Budget Emergency Deficit Control Act of 1985 shall continue to be effective (as provided by sections 252(a)(4)(B) and 256(d)(2) of such Act) through March 31, 1988, with respect to payments for all items and services (other than physicians’ services) under part B of such title. SEC. 4062. PAYMENTS FOR DURABLE MEDICAL EQUIPMENT, PROSTHETIC DEVICES, ORTHOTICS, AND PROSTHETICS. (a) 1-Year Freeze on Charge Limitations.— (1) In general.— In imposing limitations on allowable charges for items and services (other than physicians’ services) furnished in 1988 under part B of title XVIII of such Act and for which payment is made on the basis of the reasonable charge for the item or service, the Secretary of Health and Human Services shall not impose any limitation at a level higher than the same level as was in effect in December 1987. (2) Transition.— The provisions of section 4041(a)(2) (other than subparagraph (D) thereof) of this subtitle shall apply to suppliers of items and services described in paragraph (1), and directories of participating suppliers of such items and services, in the same manner as such section applies to physicians furnishing physicians’ services, and directories of participating physicians. (b) Amount and Frequency of Payment for Durable Medical Equipment, Prosthetic Devices, Orthotics, and Prosthetics.— Part B of title XVIII of the Social Security Act is amended by inserting after section 1833 the following new section: “special payment rules for particular services “Sec. 1834. (a) Payment for Durable Medical Equipment, Prosthetic Devices, Orthotics, and Prosthetics.— “(1) General rule for payment.— “(A) In general.— With respect to a covered item (as defined in paragraph (13)) for which payment is determined under this subsection, payment shall be made in the frequency specified in paragraphs (2) through (7) and in an amount equal to 80 percent of the payment basis described in subparagraph (B). “(B) Payment basis.— The payment basis described in this subparagraph is the lesser of— “(i) the actual charge for the item, or “(ii) the payment amount recognized under paragraphs (2) through (7) of this subsection for the item; except that clause (i) shall not apply if the covered item is furnished by a public home health agency (or by another home health agency which demonstrates to the satisfaction of the Secretary that a significant portion of its patients are low income) free of charge or at nominal charges to the public. “(C) Exclusive payment rule.— This subsection shall constitute the exclusive provision of this title for payment for covered items under this part. “(2) Payment for inexpensive and other routinely purchased durable medical equipment.— “(A) In general.— Payment for an item of durable medical equipment (as defined in paragraph (13)(A))— “(i) the purchase price of which does not exceed $150, or “(ii) which the Secretary determines is acquired at least 75 percent of the time by purchase, shall be made on a rental basis or in a lump-sum amount for the purchase of the item. The payment amount recognized for purchase or rental of such equipment is the amount specified in subparagraph (B) for purchase or rental, except that the total amount of rental payments with respect to an item may not exceed the payment amount specified in subparagraph (B) with respect to the purchase of the item. “(B) Payment amount.— For purposes of subparagraph (A), the amount specified in this subparagraph, with respect to the purchase or rental of an item furnished in a carrier service area— “(i) in 1989 is the average allowed charge in the area for the purchase or rental, respectively, of the item for the 12-month period ending on June 30, 1987, increased by the percentage increase in the consumer price index for all urban consumers (U.S. city average) for the 6-month period ending with December 1987; or “(ii) in a subsequent year, is the amount specified in this subparagraph for the preceding year increased by the percentage increase in the consumer price index for all urban consumers (U.S. city average) for the 12-month period ending with June of that preceding year. “(3) Payment for items requiring frequent and substantial servicing.— “(A) In general.— Payment for a covered item (such as ventilators , aspirators, IPPB machines, and nebulizers) for which there must be frequent and substantial servicing in order to avoid risk to the patient’s health shall be made on a monthly basis for the rental of the item and the amount recognized is the amount specified in subparagraph (B). “(B) Payment amount.— For purposes of subparagraph (A), the amount specified in this subparagraph, with respect to an item or device furnished in a carrier service area— “(i) in 1989 is the average allowable charge in the area for the rental of the item or device for the 12- month period ending with June 1987, 3333Copy read “June, 1987,” increased by the percentage increase in the consumer price index for all urban consumers (U.S. city average) for the 6-month period ending with December 1987; or “(ii) in a subsequent year, is the amount specified in this subparagraph for the preceding year increased by the percentage increase in the consumer price index for all urban consumers (U.S. city average) for the 12-month period ending with June of that preceding year. “(4) Payment for certain customized items.— Payment with respect to a covered item that is uniquely constructed or substantially modified to meet the specific needs of an individual patient shall be made in a lump-sum 3434Copy read “lump sum”. amount for the purchase of the item in a payment amount based upon the carrier’s individual consideration for that item, and for the reasonable and necessary maintenance and service for parts and labor not covered by the supplier’s or manufacturer’s warranty, when necessary during the period of medical need, and the amount recognized for such maintenance and service shall be paid on a lump-sum, as needed basis based upon the carrier’s individual consideration for that item. “(5) Payment for oxygen and oxygen equipment.— “(A) In general.— Payment for oxygen and oxygen equipment shall be made on a monthly basis in the monthly payment amount recognized under paragraph (9) for oxygen and oxygen equipment (other than portable oxygen equipment), subject to subparagraphs (B) and (C). “(B) Add-on for portable oxygen equipment.— When portable oxygen equipment is used, but subject to subparagraph (D), the payment amount recognized under subparagraph (A) shall be increased by the monthly payment amount recognized under paragraph (9) for portable oxygen equipment. “(C) Volume adjustment.— When the attending physician prescribes an oxygen flow rate— “(i) exceeding 4 liters per minute, the payment amount recognized under subparagraph (A), subject to subparagraph (D), shall be increased by 50 percent, or “(ii) of less than 1 liter per minute, the payment amount recognized under subparagraph (A) shall be decreased by 50 percent. “(D) Limit on adjustment.— When portable oxygen equipment is used and the attending physician prescribes an oxygen flow rate exceeding 4 liters per minute, there shall only be an increase under either subparagraph (B) or (C), whichever increase is larger, and not under both such subparagraphs. “(6) Payment for other covered items (other than durable medical equipment).— Payment for other covered items (other than durable medical equipment and other covered items described in paragraph (3), (4), or (5)) shall be made in a lump-sum amount for the purchase of the item in the amount of the purchase price recognized under paragraph (8). “(7) Payment for other items of durable medical equipment.— “(A) In general.— In the case of an item of durable medical equipment not described in paragraphs (2) through (6)— “(i) payment shall be made on a monthly basis for the rental of such item during the period of medical need (but payments under this subparagraph may not extend over a period of continuous use of longer than 15 months), and, subject to subparagraph (B), the amount recognized for each such month is 10 percent of the purchase price recognized under paragraph (8) with respect to the item; “(ii) during the succeeding 6-month period of medical need, no payment shall be made for rental or servicing of the item; and “(iii) during the first month of each succeeding 6-month period of medical need, a service and maintenance payment may be made (for parts and labor not covered by the supplier’s or manufacturer’s warranty, as determined by the Secretary to be appropriate for the particular type of durable medical equipment) and the amount recognized for each such 6-month period is the lower of (I) a reasonable and necessary maintenance and servicing fee established by the carrier, or (II) 10 percent of the total of the purchase price recognized under paragraph (8) with respect to the item. The Secretary shall determine the meaning of the term ‘continuous’ in subparagraph (A). “(B) Range for rental amounts.— “(i) For 1989.— For items furnished during 1989, the payment amount recognized under subparagraph (A)(i) shall not be more than 115 percent, and shall not be less than 85 percent, of the prevailing charge established for rental of the item January 1987, increased by the percentage increase in the consumer price index for all urban consumers (U.S. city average) for the 6-month period ending with December [------].34a34aCopy not legible. “(ii) For 1990.— For items furnished during 1990, the payment amount recognized under subparagraph (A)(i) shall not be more than the maximum amount established under clause (i), and shall not be less than the minimum amount established under such clause, for 1989, each such amount increased by the percentage increase in the consumer price index for all urban consumers (U.S. city average) for the 12-month period ending with June 1989. “(8) Purchase price recognized for miscellaneous devices and items.— For purposes of paragraphs (6) and (7), the amount that is recognized under this paragraph as the purchase price for a covered item is the amount described in subparagraph (C) of this paragraph, determined as follows: “(A) Computation of local purchase price.— Each carrier under section 1842 shall compute a base local purchase price for the item as follows: “(i) The carrier shall compute a base local purchase price, for each item described— “(I) in paragraph (6) equal to the average allowable charge in the locality for the purchase of the item for the 12-month period ending with June 1987, or “(II) in paragraph (7) equal to the average of the purchase prices on the claims submitted on an assignment-related basis for the unused item supplied during the 6-month period ending with December 1986. “(ii) The carrier shall compute a local purchase price, with respect to the furnishing of each particular item— “(I) in 1989, equal to the base local purchase price computed under clause (i) increased by the percentage increase in the consumer price index for all urban consumers (U.S. city average) for the 6-month period ending with December 1987, or “(II) in 1990, 1991, or 1992, equal to the local purchase price computed under this clause for the previous year increased by the percentage increase in the consumer price index for all urban consumers (U.S. city average) for the 12-month period ending with June of the previous year. “(B) Computation of regional purchase price.— With respect to the furnishing of a particular item in each region (as defined in section 1886(d)(2)(D)), the Secretary shall compute a regional purchase price— “(i) for 1991, and for 1992, equal to the average (weighted by relative volume of all claims among carriers) of the local purchase prices for the carriers in the region computed under subparagraph (A)(ii)(II) for the year, and “(ii) for each subsequent year, equal to the regional purchase price computed under this subparagraph for the previous year increased by the percentage increase in the consumer price index for all urban consumers (U.S. city average) for the 12-month period ending with June of the previous year. “(C) Purchase price recognized.— For purposes of paragraphs (6) and (7) and subject to subparagraph (D), the amount that is recognized under this paragraph as the purchase price for each item furnished— “(i) in 1989 or 1990, is 100 percent of the local purchase price computed under subparagraph (A)(ii)(I); “(ii) in 1991, is the sum of (I) 75 percent of the local purchase price computed under subparagraph (A)(ii)(II) for 1991, and (II) 25 percent of the regional purchase price computed under subparagraph (B) for 1991; “(iii) in 1992, is the sum of (I) 50 percent of the local purchase price computed under subparagraph (A)(ii)(II) for 1992, and (II) 50 percent of the regional purchase price computed under subparagraph (B) for 1992; and “(iv) in 1993 or a subsequent year, is the regional purchase price computed under subparagraph (B) for that year. “(D) Range on amount recognized.— The amount that is recognized under subparagraph (C) as the purchase price for an item furnished— “(i) in 1991, may not exceed 130 percent, and may not be lower than 80 percent, of the average of the purchase prices recognized under such subparagraph for all the carrier service areas in the United States in that year; and “(ii) in a subsequent year, may not exceed 125 percent, and may not be lower than 85 percent, of the average of the purchase prices recognized under such subparagraph for all the carrier service areas in the United States in that year. “(9) Monthly payment amount recognized with respect to oxygen and oxygen equipment.— For purposes of paragraph (5), the amount that is recognized under this paragraph for payment for oxygen and oxygen equipment is the monthly payment amount described in subparagraph (C) of this paragraph. Such amount shall be computed separately (i) for all items of oxygen and oxygen equipment (other than portable oxygen equipment) and (ii) for portable oxygen equipment (each such group referred to in this paragraph as an ‘item‘). “(A) Computation of local monthly payment rate.— Each carrier under this section shall compute a base local payment rate for each item as follows: “(i) The carrier shall compute a base local average monthly payment rate per beneficiary as an amount equal to (I) the total reasonable charges for the item during the 12-month period ending with December 1986, divided by (II) the total number of months for all beneficiaries receiving the item in the area during the 12-month period for which the carrier made payment for the item under this title. “(ii) The carrier shall compute a local average monthly payment rate for the item applicable— “(I) to 1989, equal to 95 percent of the base local average monthly payment rate computed under clause (i) for the item increased by the percentage increase in the consumer price index for all urban consumers (U.S. city average) for the 12-month period ending with December 1987, or “(II) to 1990 and to 1991, equal to the local average monthly payment rate computed under this clause for the item for the previous year increased by the percentage increase in the consumer price index for all urban consumers (U.S. city average) for the 12-month period ending with June of the previous year. “(B) Computation of regional monthly payment rate.— With respect to the furnishing of an item in each region (as defined in section 1886(d)(2)(D)), the Secretary shall compute a regional monthly payment rate— “(i) for 1991, and 1992, equal to the average (weighted by relative volume of all claims among carriers) of the local monthly payment rates for the carriers in the region computed under subparagraph (A)(ii)(II) for the year, and “(ii) for each subsequent year, equal to the regional monthly payment rates computed under this subparagraph for the previous year increased by the percent-age increase in the consumer price index for all urban consumers (U.S. city average) for the 12-month period ending with June of the previous year. “(C) Monthly payment amount recognized.— For purposes of paragraph (5), the amount that is recognized under this paragraph as the base monthly payment amount for each item furnished— “(i) in 1989 and in 1990, is 100 percent of the local average monthly payment rate computed under subparagraph (A)(ii)(I) for the item; “(ii) in 1991, is the sum of (I) 75 percent of the local average monthly payment rate computed under subparagraph (A)(ii)(II) for the item for 1991, and (II) 25 percent of the regional monthly payment rate computed under subparagraph (B)(i) for the item for 1991; “(iii) in 1992, is the sum of (I) 50 percent of the local average monthly payment rate computed under subparagraph (A)(ii)(II) for the item for 1992, and (II) 50 percent of the regional monthly payment rate computed under subparagraph (B)(i) for the item for 1992; and “(iv) in a subsequent year, is the regional monthly payment rate computed under subparagraph (B) for the item for that year. “(D) Range on amount recognized.— The amount that is recognized under subparagraph (C) as the base monthly payment amount for an item furnished— “(i) in 1991, may not exceed 130 percent, and may not be lower than 80 percent, of the average of the base monthly payment amounts recognized under such subparagraph for all the carrier service areas in the United States in that year; and “(ii) in a subsequent year, may not exceed 125 percent, and may not be lower than 85 percent, of the average of the base monthly payment amounts recognized under such subparagraph for all the carrier service areas in the United States in that year. “(10) Exceptions and adjustments.— “(A) Areas outside continental united states.— Exceptions to the amounts recognized under the previous provisions of this subsection shall be made to take into account the unique circumstances of covered items furnished in Alaska, Hawaii, or Puerto Rico. “(B) Adjustment for inherent reasonableness.— For covered items furnished on or after January 1, 1991, the Secretary is authorized to apply the provisions of paragraphs (8) and (9) (other than subparagraph (D)) of section 1842(b) to covered items and suppliers of such items. “(C) Transcutaneous electrical nerve stimulator (tens).— In order to permit an attending physician time to determine whether the purchase of a transcutaneous electrical nerve stimulator is medically appropriate for a particular patient, the Secretary may determine an appropriate payment amount for the initial rental of such item for a period of not more than 2 months. If such item is subsequently purchased, the payment amount with respect to such purchase is the payment amount determined under paragraph (2). “(11) Improper billing and requirement of physician order.— “(A) Improper billing for certain rental items.— Notwithstanding any other provision of this title, a supplier of a covered item for which payment is made under this subsection and which is furnished on a rental basis shall continue to supply the item without charge (other than a charge provided under this subsection for the servicing of the item) after rental payments may no longer be made under this subsection. If a supplier knowingly and willfully violates the previous sentence, the Secretary may apply sanctions against the supplier under subsection (j)(2) in the same manner such sanctions may apply with respect to a physician. “(B) Requirement of physician order.— The Secretary is authorized to require, for specified covered items, that payment may be made under this subsection with respect to the item only if a physician has communicated to the supplier, before delivery of the item, a written order for the item. “(12) Regional carriers.— The Secretary may designate, by regulation under section 1842, one carrier for each region (as defined in section 1886(d)(2)(D)) to process all claims within the region for covered items under this section. “(13) Covered item.— In this subsection, the term ‘covered item’ means— “(A) durable medical equipment (as defined in section 1861(n)), including such equipment described in section 1861(m)(5); “(B) prosthetic devices (described in section 1861(s)(8)), but not including parenteral and enteral nutrition nutrients, supplies, and equipment; and “(C) orthotics and prosthetics (described in section 1861(s)(9)); but does not include intraocular lenses. “(14) Carrier.— In this subsection, any reference to the term ‘carrier’ includes a reference, with respect to durable medical equipment furnished by a home health agency as part of home health services, to a fiscal intermediary.”, (c) Study and Evaluation.— (1) The Secretary of Health and 42 USC 1395m note. Human Services shall monitor the impact of the amendments made by this section on the availability of covered items and shall evaluate the appropriateness of the volume adjustment for oxygen and oxygen equipment under section 1834(a)(5)(C) of the Social Security Act (as amended by subsection (b) of this section). The Secretary Reports. shall report to Congress, by not later than January 1, 1991, on such impact and on the evaluation and shall include in such report recommendations for changes in payment methodology for covered items under section 1834(a) of such Act. (2) Before January 1, 1991, the Secretary may not conduct any demonstration project respecting alternative methods of payment for covered items under title XVIII of the Social Security Act. (3) In this subsection, the term “covered item” has the meaning given such term in section 1834(a)(13) of the Social Security Act (as amended by subsection (b) of this section). (4) The Secretary shall, upon written request, provide the data and information used in determining the payment amounts for covered items under section 1834(a) of the Social Security Act. (5) The Comptroller General shall conduct a study on the appropriateness Reports. of the level of payments allowed for covered items under the medicare program, and shall report to Congress on the results of such study (including recommendations on the transition to regional or national rates) by not later than January 1, 1991. Entities furnishing such items which fail to provide the Comptroller General with reasonable access to necessary records to carry out the study under this paragraph are subject to exclusion from the medicare program under section 1128(a) of the Social Security Act. (d) Conforming Amendments.— (1) Section 1814 of such Act (42 U.S.C. 1395f) is amended— (A) in subsection (j)(2)(B), by amending subparagraph (B) to read as follows: “(B) Section 1834(a)(1)(B).”, and (B) in subsection (k), by striking all that follows “shall be” and insert “the amount described in section 1834(a)(1).”. (2) Section 1832(a) of such Act (42 U.S.C. 1395k(a)) is amended— (A) in paragraph (2)(A), by inserting “(other than items described in subparagraph (G))” after “services”; (B) in paragraph (2)(B), by inserting “(other than items described in subparagraph (G))” after “medical and other health services”; and (C) in paragraph (2)— (i) by striking “and” at the end of subparagraph (E), (ii) by striking the period at the end of subparagraph (F) and inserting “; and”, and (iii) by adding at the end the following new subparagraph: “(G) covered items (described in section 1834(a)(13)) furnished by a provider of services or by others under arrangements with them made by a provider of services.”. (3) Section 1833(a) of such Act (42 U.S.C. 13951(a)) is 42 USC 1395l. amended— (A) in paragraph (1)— (i) by striking “; and” at the end of clause (G) and inserting a comma, and (ii) by adding at the end the following: “and (I) with respect to covered items (described in section 1834(a)(13)), the amounts paid shall be the amounts described in section 1834(a)(1),”; (B) in paragraph (2)— (i) by striking “and (F)” and inserting “(F), and (G)”, and (ii) in subparagraph (A), by striking “(other than durable medical equipment)”; 34b34bCopy read “(B)”. (C) by striking “and” at the end of paragraph (3); 34c34cCopy read “(C)”. (D) by striking the period at the end of paragraph (4) and inserting “; and”; and 34d34dCopy read “(D)”.(E) by adding at the end the following new paragraph: “(5) in the case of covered items (described in section 1834(a)(13)) the amounts described in section 1834(a)(1).”. (4) Section 1866(a)(2)(A) of such Act (42 U.S.C. 1395cc(a)(2)(A)) is amended by adding at the end the following new sentence: “Notwithstanding the first sentence of this subparagraph, a home health agency may charge such an individual or person, with respect to covered items subject to payment under section 1834(a), the amount of a n y deduction imposed under section 1833(b) and 20 percent of the payment basis described in section 1834(a)(2).”. (5) Section 1889 of such Act (42 U.S.C. 1395zz) is repealed. 42 USC 1395zz. (e) Effective Date.— The amendments made by this section shall 42 USC 1395f note. apply to covered items furnished on or after January 1, 1989. SEC. 4063. PAYMENT FOR INTRAOCULAR LENSES. (a) Provided in Physician’s Office.— Section 1842 of the Social Security Act (42 U.S.C. 1395u), a s previously amended is amended— (1) in subsection (b)(11)(C), as inserted by section 4046(a)(1)(C) of this subtitle— (A) by inserting “(i)” after “(C)” and by adding at the end the following new clause: “(ii) The reasonable charge for an intraocular lens implanted during cataract surgery in a physician’s office may not exceed the actual acquisition cost for the lens (taking into account any discount) plus a handling fee (not to exceed 5 percent of such actual acquisition cost).”, and (B) 3535Copy read “(C)”. in subparagraph (D), as so redesignated and as amended by section 4046(a)(1) of this subtitle, by inserting “or item” after “service” or “services” each place either appears; and (2) in subsection (j)(1)(D), as added by section 4045(c)(1)(B) of this subtitle and as amended by 4046(a)(2) of this subtitle— (A) in clause (ii), by striking “and” at the end of subclause (IV), by redesignating subclause (V) as subclause (VI) and by inserting before such subclause the following new subclause: “(IV) a reasonable charge limit is established under subsection (b)(11)(C)(ii), and”; and (B) in clause (iii)— (i) by striking “or” at the end of subclause (I), (ii) in subclause (II), by striking “(b)(11)(C)” and inserting “(b)(11)(C)(i)”, (iii) by striking the period at the end of subclause (II) and inserting “; or”, and (iv) by adding at the end the following new subclause: “(III) under subsection (b)(11)(C)(ii), the payment allowance established under such subsection.”. (b) Provided in Ambulatory Surgical Centers.— Section 1833(i)(2)(A) of such Act (42 U.S.C. 13951(i)(2)(A)) is amended— 42 USC 1395l. (1) by striking “and” at the end of clause (i), (2) by striking the period at the end of clause (ii) and inserting “,and”, and (3) by inserting after clause (ii) the following new clause: “(iii) in the case of implantation of an intraocular lens during cataract surgery includes payment which is reasonable and related to the cost of acquiring the class of lens involved.”. (c) Effective Date.— The amendments made by this section shall 42 USC 1395l note. apply to items furnished on or after July 1, 1988. (d) Special Rule.— With respect to the35a35aCopy read “the the”. establishment of a 42 USC 1395u note. reasonable charge limit under section 1842(b)(11)(C)(ii) of the Social Security Act, in applying section 1842(j)(1)(D)(i) of such Act, the matter beginning with “plus” shall be considered to have been deleted. SEC. 4064. CLINICAL DIAGNOSTIC LABORATORY TESTS. (a) Limitation on Changes in Fee Schedules.— (1) 3-month freeze in fee schedules.— Notwithstanding any other provision of law, any change in the fee schedules for clinical laboratory diagnostic laboratory tests under part B of title XVIII of such Act which would have become effective for tests furnished on or after January 1, 1988, shall not be effective for tests furnished during the 3-month period beginning on January 1, 1988. (2) No cpi increase in 1988.— Notwithstanding any other provision of law, the Secretary of Health and Human Services shall not adjust the fee schedules established under section 1833(h) of the Social Security Act for 1988 to take into account any increase in the consumer price index. (b) Fee Schedules and Payment Limits.— (1) Rebasing of fee schedules for certain automated and similar tests.— Section 1833(h)(2) of the Social Security Act (42 U.S.C. 13951(h)(2)) is amended by adding at the end the following: “In establishing fee schedules under the first sentence of this paragraph with respect to automated tests and tests (other than cytopathology tests) which before July 1, 1984, the Secretary made subject to a limit based on lowest charge levels under the sixth sentence of section 1842(b)(3) performed after March 31, 1988, the Secretary shall reduce by 8.3 percent the fee schedules otherwise established for 1988.”. (2) Nationwide payment limits.— (A) in clause (i), by striking “January” and inserting “April”, and (B) by amending clause (ii) to read as follows: “(ii) March 31, 1988, and so long as a fee schedule for the test has not been established on a nationwide basis, is equal to the median of all the fee schedules established for that test for that laboratory setting under paragraph (1).”. (3) Effective dates.— The amendments made by paragraphs 42 USC 1395l note. (1) and (2) shall apply with respect to services furnished on or after April 1, 1988. (4) GAO study of fee schedules.— The Comptroller General 42 USC 1395l note. shall conduct a study of the level of the fee schedules established for clinical diagnostic laboratory services under section 1833(h)(2) of the Social Security Act to determine, based on the costs of, and revenues received for, such tests the appropriateness Reports. of such schedules. The Comptroller General shall report to the Congress on the results of such study by not later than January 1, 1990. Suppliers of such tests which fail to provide the Comptroller General with reasonable access to necessary records to carry out the study under this paragraph are subject to exclusion from the medicare program under section 1128(a) of the Social Security Act. (c) Limitation on Application of 2 Percent Hospital Lab Differential.— Section 1833(h)(2) of such Act is amended by striking 42 USC 1395l. “hospital laboratory” and inserting “laboratory in a sole community hospital”. (d) Intermediate Sanctions.— (1) Part B of title XVIII of such Act is amended by adding at the end thereof the following new section: “intermediate sanctions for providers of clinical diagnostic laboratory tests35b35bCopy read “tests” ”. “Sec. 1846. (a) If the Secretary determines that any provider or 42 USC 1395w–2. clinical laboratory certified for participation under this title no longer substantially meets the conditions of participation specified under this title with respect to the provision of clinical diagnostic laboratory tests under this part, the Secretary may (for a period not to exceed one year) impose intermediate sanctions developed pursuant to subsection (b), in lieu of canceling immediately the certification of the provider or clinical laboratory. “(b) (1) The Secretary shall develop and implement— “(A) a range of intermediate sanctions to apply to providers or certified clinical laboratories under the conditions described in subsection (a), and “(B) appropriate procedures for appealing determinations relating to the imposition of such sanctions. “(2) (A) The intermediate sanctions developed under paragraph (1) shall include— “(i) directed plans of correction, “(ii) civil fines and penalties, “(iii) payment for the costs of onsite monitoring by an agency responsible for conducting certification surveys, and “(iv) suspension of all or part of the payments to which a provider or certified clinical laboratory would otherwise be entitled under this title with respect to clinical diagnostic laboratory tests provided on or after the date in which the Secretary determines that intermediate sanctions should be imposed pursuant to subsection (a).3636Subparagraphs “ ‘(i)”, “ ‘(ii)”, “ ‘(iii)”, and “ ‘(iv)” indented incorrectly. “(B) The sanctions specified in subparagraph (A) are in addition to sanctions otherwise available under State or Federal law. “(3) The Secretary shall develop and implement specific procedures with respect to when and how each of the intermediate sanctions developed under paragraph (1) is to be applied, the amounts of any fines, and the severity of each of these penalties. Such procedures shall be designed so as to minimize the time between identification of violations and imposition of these sanctions and shall provide for the imposition of incrementally more severe fines for repeated or uncorrected deficiencies.”. (2) The amendment made by paragraph (1) shall become Effective date. 42 USC l395w–2 note. effective on January 1, 1990. (e) State Certification of High-Volume Physician Office Labs.— (1) Section 1861(s) of such Act (42 U.S.C. 1395x(s)) is amended, in the sentence following paragraph (11), by inserting “a labora-tory not independent of a physician’s office that has a volume of clinical diagnostic laboratory tests exceeding 5,000 per year” after “physician’s office,”. (2) The amendment made by paragraph (1) shall apply to 42 USC 1395x note. diagnostic tests performed on or after January 1, 1990. SEC. 4065. RETURN ON EQUITY PAYMENTS TO OUTPATIENT DEPARTMENTS. (a) In General.— Section 1861(v)(1) of the Social Security Act (42 U.S.C. 1395x(v)(1)) is amended by adding at the end thereof the following new subparagraph: “(S) Such regulations shall not include provision for specific recognition of any return on equity capital with respect to hospital outpatient departments.”. (b) Conforming Amendment.— Section 1881(b)(2)(C) of such Act (42 U.S.C. 1395rr(b)(2)(C)) is amended by striking “facilities” and inserting “facilities (other than hospital outpatient departments)”. (c) Effective Date.— The amendments made by this section shall 42 USC 1395x note. become effective on January 1, 1988. SEC. 4066. PAYMENTS TO HOSPITAL OUTPATIENT DEPARTMENTS FOR RADIOLOGY. (a) Amounts Payable.— Section 1833 of the Social Security Act (42 U.S.C. 13951) is amended— (1) in subsection (a)(2)— (A) by striking “and” in subparagraph (C), (B) by adding “and” at the end of subparagraph (D), and (C) by adding at the end thereof the following new subparagraph: “(E) with respect to— “(i) outpatient hospital radiology services (including diagnostic and therapeutic radiology, nuclear medicine and CAT scan procedures, magnetic resonance imaging, and ultrasound and other imaging services), and “(ii) effective for procedures performed on or after October 1, 1989, diagnostic procedures (as defined by the Secretary) described in section 1861(s)(3) (other than diagnostic x-ray tests and diagnostic laboratory tests), the amount determined under subsection (n);”; and (2) by adding at the end, as previously amended, the following new subsection: “(n) (1) (A) The aggregate amount of the payments to be made for all or part of a cost reporting period beginning on or after October 1, 1988 under this part for services described in subsection (a)(2)(E) shall be equal to the lesser of— “(i) the amount determined with respect to such services under subsection (a)(2)(B), or “(ii) the blend amount for radiology services and diagnostic procedures determined in accordance with subparagraph (B). “(B) (i) The blend amount for radiology services and diagnostic procedures for a cost reporting period is the sum of— “(I) the cost proportion (as defined in clause (ii)) of the amount described in subparagraph (A)(i); and “(II) the charge proportion (as defined in clause (ii)(II) of 62 percent (for services described in subsection (a)(2)(E)(i)), or (for procedures described in subsection (a)(2)(E)(ii)), 42 percent or such other percent established by the Secretary (or carriers acting pursuant to guidelines issued by the Secretary) based on prevailing charges established with actual charge data, of 80 percent of the prevailing charge for participating physicians for the same services as if they were furnished in a physician’s office in the same locality as determined under section 1842(b). “(ii) In this subparagraph: “(I) The term ‘cost proportion’ means 65 percent for all or any part of cost reporting periods which occur in fiscal year 1989 and 50 percent for other cost reporting periods. “(II) The term ‘charge proportion’ means 35 percent for all or any parts of cost reporting periods which occur in fiscal year 1989 and 50 percent for other cost reporting periods.”. (b) Conforming Amendment.— Section 1833(a)(2)(B) of such Act (42 U.S.C. 13951(a)(2)(B)) is amended in the matter preceding clause (i) by striking “(C) or (D)” and inserting “(C), (D), or (E)”. (c) Effective Date.— The amendments made by subsection (a) 42 USC 1395l note. shall apply with respect to outpatient hospital radiology services furnished on or after October 1, 1988, and other diagnostic procedures performed on or after October 1, 1989. SEC. 4067. UPDATING MAXIMUM RATE OF PAYMENT PER VISIT FOR INDEPENDENT RURAL HEALTH CLINICS. (a) In General.— Section 1833 of the Social Security Act (42 U.S.C. 13951) is further amended by inserting after subsection (e) the following new subsection: “(f) In establishing limits under subsection (a) on payment for rural health clinic services provided by independent rural health clinics, the Secretary shall establish such limit, for services provided— “(1) in 1988, after March 31, at $46, and “(2) in a subsequent year, at the limit established under this subsection for the previous year increased by the percentage increase in the medicare economic index (referred to in the fourth sentence of section 1842(b)(3)) applicable to physicians’ services furnished as of the first day of that year.”. (b) Report on Rates.— The Secretary of Health and Human Services 42 USC 1395l note. shall report to Congress, by not later than March 1, 1989, on the adequacy of the amounts paid under title XVIII of the Social Security Act for rural health clinic services provided by independent rural health clinics. (c) Effective Date.— The amendment made by subsection (a) shall 42 USC 1395l note. apply to services furnished on or after April 1, 1988. SEC. 4068. PAYMENT FOR AMBULATORY SURGERY AT EYE, AND EYE AND EAR, SPECIALTY HOSPITALS. (a) In General.— Section 1833(i)(3)(B)(ii) of the Social Security Act (42 U.S.C. 13951(i)(3)(B)(ii)) is amended— (1) by striking “In” and inserting “Subject to the last sentence of this clause, in”; and (2) by adding at the end thereof the following: “In the case of a hospital that makes application to the Secretary and demonstrates that it specializes in eye services or eye and ear services (as determined by the Secretary), receives more than 30 percent of its total revenues from outpatient services and was an eye specialty hospital or an eye and ear specialty hospital on October 1, 1987, the cost proportion and ASC proportion in effect under subclauses (I) and (II) for cost reporting periods beginning in fiscal year 1988 shall remain in effect for cost reporting periods beginning in fiscal year 1989 or fiscal year 1990.”. (b) Development of Prospective Payment Methodology for Outpatient Hospital Services.— Section 1135(d) of the Social Security Act (42 U.S.C. 1320b–5(d)) is amended— (1) by adding at the end of paragraph (3) the following: “In establishing such rates, the Secretary shall consider whether a differential payment rate is appropriate for speciality hospitals.”; and (2) by adding at the end the following new paragraph: “(7) The Secretary shall solicit the views of the Prospective Payment Assessment Commission in developing the systems under paragraphs (1) and (6), and shall include in the Secretary’s reports under this subsection any views the Commission may submit with respect to such systems.”. (c) Effective Date.— The amendments made by subsection (a) 42 USC 1395l. shall be effective as if included in the amendment made by section 9343(a)(1)(B) of the Omnibus Budget Reconciliation Act of 1986. Subpart C— Eligibility and Benefits Changes SEC. 4070. COVERAGE OF MENTAL HEALTH SERVICES. (a) Outpatient Services Under Part B.— Section 1833(c) of the Social Security Act (42 U.S.C. 13951(c)) is amended— (1) by striking “$312.50” and inserting “$1375.00”; and 42 USC 1395l note. (2) by adding at the end thereof the following: “For purposes of this subsection, the term ‘treatment’ does not include brief office visits (as defined by the Secretary) for the sole purpose of prescribing or monitoring prescription drugs used in the treatment of such disorders.”. (b) Partial Hospitalization Coverage.— (1) Section 1861(s)(2)(B) of such Act (42 U.S.C. 1395x(s)(2)(B)) is amended by inserting “and partial hospitalization services incident to such services” before the semicolon. (2) Section 1861 of such Act (42 U.S.C. 1395x) is amended by adding at the end thereof the following new subsection: “(ff) (1) The term ‘partial hospitalization services’ means the items and services described in paragraph (2) prescribed by a physician and provided under a program described in paragraph (3) under the supervision of a physician pursuant to an individualized, written plan of treatment established and periodically reviewed by a physician (in consultation with appropriate staff participating in such program), which plan sets forth the physician’s diagnosis, the type, amount, frequency, and duration of the items and services provided under the plan, and the goals for treatment under the plan. “(2) The items and services described in this paragraph are— “(A) individual and group therapy with physicians or psychologists (or other mental health professionals to the extent authorized under State law), “(B) occupational therapy requiring the skills of a qualified occupational therapist, “(C) services of social workers, trained psychiatric nurses, and other staff trained to work with psychiatric patients, “(D) drugs and biologicals furnished for therapeutic purposes (which cannot, as determined in accordance with regulations, be self-administered), “(E) individualized activity therapies that are not primarily recreational or diversionary, “(F) family counseling (the primary purpose of which is treatment of the individual’s condition), “(G) patient training and education (to the extent that training and educational activities are closely and clearly related to individual’s care and treatment), “(H) diagnostic services, and “(I) such other items and services as the Secretary may provide (but in no event to include meals and transportation); that are reasonable and necessary for the diagnosis or active treatment of the individual’s condition, reasonably expected to improve or maintain the individual’s condition and functional level and to prevent relapse or hospitalization, and furnished pursuant to such guidelines relating to frequency and duration of services as the Secretary shall by regulation establish (taking into account accepted norms of medical practice and the reasonable expectation of patient improvement). “(3) A program described in this paragraph is a program which is hospital-based or hospital-affiliated (as defined by the Secretary) and which is a distinct and organized intensive ambulatory treatment service offering less than 24-hour-daily care.”. (3) Section 1835(a)(2) of such Act (42 U.S.C. 1395n(a)(2)) is amended— (A) by striking “and” at the end of subparagraph (D); (B) by striking the period at the end of subparagraph (E) and inserting “; and”; and (C) by inserting sifter subparagraph (E) the following new subparagraph: “(F) in the case of partial hospitalization services, (i) the individual would require inpatient psychiatric care in the absence of such services, (ii) an individualized, written plan for furnishing such services has been established by a physician and is reviewed periodically by a physician, and (iii) such services are or were furnished while the individual is or was under the care of a physician.”. (4) Section 1833(c) of such Act, as amended by subsection (a), is further amended at the end thereof by inserting “or partial hospitalization services that are not directly provided by a physician” before the period. (c) Effective Date; Implementation.— (1) The amendment made by subsection (a)(1) shall apply with 42 USC 1395l note. respect to calendar years beginning with 1988; except that with respect to 1988, any reference in section 1833(c) of the Social Security Act, as amended by subsection (a), to “$1375.00” is deemed a reference to “$562.50”. The amendment made by subsection (a)(2) shall apply to services furnished on or after January 1, 1989. (2) (A) The amendments made by subsection (b) shall become 42 USC 1395x note. effective on the date of enactment of this Act. (B) The Secretary of Health and Human Services shall implement the amendments made by subsection (b) so as to ensure that there is no additional cost to the medicare program by reason of such amendments. SEC. 4071. COVERAGE OF INFLUENZA VACCINE AND ITS ADMINISTRATION. (a) In General.— Section 1861(s)(10)(A) of the Social Security Act (42 U.S.C. 1395x(a)(10)(A)) is amended by inserting before the semicolon the following: “and influenza vaccine and its administration”. (b) Contingent Effective Date; Demonstration Project.— (1) The provisions of subsection (e) of section 4072 of this subpart shall apply to this section in the same manner as it applies to section 4072. (2) In conducting the demonstration project pursuant to paragraph (1), in order to determine the cost effectiveness of including influenza vaccine in the medicare program, the Secretary of Health and Human Services is required to conduct a demonstration of the provision of influenza vaccine as a service for medicare beneficiaries and to expend $25,000,000 each year of the demonstration project for this purpose. In conducting this demonstration, the Secretary is authorized to purchase in bulk influenza vaccine and to distribute it in a manner to make it widely available to medicare beneficiaries, to develop projects to provide vaccine in the same manner as other covered medicare services in large scale demonstration projects, including statewide projects, and to engage in other appropriate use of moneys to provide influenza vaccine to medicare beneficiaries and evaluate the cost effectiveness of its use. In determining cost effectiveness, the Secretary shall consider the direct cost of the vaccine, the utilization of vaccine which might otherwise not have occurred, the costs of illnesses and nursing home days avoided, and other relevant factors, except that extended life for beneficiaries shall not be considered to reduce the cost effectiveness of the vaccine. SEC. 4072. PAYMENT FOR THERAPEUTIC SHOES FOR INDIVIDUALS WITH SEVERE DIABETIC FOOT DISEASE. (a) Coverage Under Part B.— Section 1861(s) of the Social Security Act (42 U.S.C. 1395x(s)) is amended— (1) by redesignating paragraphs (12) through (15) as paragraphs (13) through (16), respectively, (2) by striking out “and” at the end of paragraph (10), (3) by striking out the period at the end of paragraph (11) and inserting “; and”, and (4) by inserting after paragraph (11) the following new paragraph: “(12) extra-depth shoes with inserts or custom molded shoes for an individual with diabetes, if— “(A) the physician who is managing the individual’s diabetic condition (i) documents that the individual has peripheral neuropathy with evidence of callus formation, a history of pre-ulcerative calluses, a history of previous ulceration, foot deformity, or previous amputation, or poor circulation, and (ii) certifies that the individual needs such shoes under a comprehensive plan of care related to the individual’s diabetic condition; “(B) the particular type of shoes are prescribed by a podiatrist or other qualified physician (as established by the Secretary); and “(C) the shoes are fitted and furnished by a podiatrist or other qualified individual (such as a pedorthist or orthotist, as established by the Secretary) who is not the physician described in subparagraph (A) (unless the Secretary finds that the physician is the only such qualified individual in the area).”. (b) Limitation on Benefit.— Section 1833 of such Act (42 U.S.C. 42 USC 1395l. 1395) is amended by inserting after subsection (e) the following new subsection: “(f) (1) In the case of shoes described in section 1861(s)(12)— “(A) no payment may be made under this part for the furnishing of more than one pair of shoes for any individual for any calendar year, and “(B) with respect to expenses incurred in any calendar year, no more than the limit established under paragraph (2) shall be considered as incurred expenses for purposes of subsections (a) and (b). Payment for shoes under this part shall be considered to include payment for any expenses for the fitting of such shoes. “(2) (A) Except as provided by the Secretary under subparagraphs (B) and (C), the limit established under this paragraph— “(i) for the furnishing of one pair of custom molded shoes is $300; “(ii) for the furnishing of extra-depth shoes and inserts is— “(I) $100 for the pair of shoes itself, and “(II) $50 for inserts for a pair of shoes. “(B) The Secretary or a carrier may establish limits for shoes that are lower than the limits established under subparagraph (A) if the Secretary finds that shoes and inserts of an appropriate quality are readily available at or below such lower limits. “(C) For each year after 1988, each dollar amount under subparagraph (A) or (B) (as previously adjusted under this subparagraph) shall be increased by the same percentage increase as the Secretary provides with respect to durable medical equipment for that year, except that if such increase is not a multiple of $1, it shall be rounded to the nearest multiple of $1. “(3) In this title, the term ‘shoes’ includes, except for purposes of subparagraphs (A)(ii) and (B) of paragraph (2), inserts for extra-depth shoes.”. (c) Modification of Exclusion.— Section 1862(a)(8) of such Act (42 U.S.C. 1395y(a)(8)) is amended by inserting “, other than shoes furnished pursuant to section 1861(s)(12)” before the semicolon. (d) Conforming Amendments.— Sections 1864(a), 1865(a), 1902(a)(9)(C), and 1915(a)(1)(B)(ii)(I) of such Act (42 U.S.C. 1395aa(a), 1395bb(a), 1396a(a)(9)(C), 1396n(a)(1)(B)(ii)(I)) are each amended by striking out “paragraphs (12) and (13)” and inserting “paragraphs (13) and (14)”. (e) Contingent Effective Date; Demonstration Project.— (1) The amendments made by this section shall become effective (if at all) in accordance with paragraph (2). (2) (A) The Secretary of Health and Human Services (in this paragraph referred to as the “Secretary”), shall establish a demonstration project to begin on October 1, 1988, to test the cost-effectiveness of furnishing therapeutic shoes under the medicare program to the extent provided under the amendments made by this section to a sample group of medicare beneficiaries. (B) (i) The demonstration project under subparagraph (A) shall be conducted for an initial period of 24 months. Not later than Reports. October 1, 1990, the Secretary shall report to the Congress on the results of such project. If the Secretary finds, on the basis of Effective date. existing data, that furnishing therapeutic shoes under the medicare program to the extent provided under the amendments made by this section is cost-effective, the Secretary shall include such finding in such report, such project shall be discontinued, and the amendments made by this section shall become effective on November 1, 1990. (ii) If the Secretary determines that such finding cannot be made on the basis of existing data, such project shall continue for an additional 24 months. Not later than April 1, 1993, the Reports. Secretary shall submit a final report to the Congress on the results of such project. The amendments made by this section Effective date. shall become effective on the first day of the first month to begin after such report is submitted to the Congress unless the report contains a finding by the Secretary that furnishing therapeutic shoes under the medicare program to the extent provided under the amendments made by this section is not cost-effective (in which case the amendments made by this section shall not become effective). SEC. 4073. COVERAGE OF CERTIFIED NURSE-MIDWIFE SERVICES. (a) Coverage of Services.— Section 1861(s)(2) of the Social Security Act (42 U.S.C. 1395x(s)(2)) is amended— (1) by striking “and” at the end of subparagraph (J); (2) by adding “and” at the end of subparagraph (K); and (3) by adding at the end thereof the following new subparagraph: “(L) certified nurse-midwife services;”. (b) Payment of Benefits.— (1) Section 1832(a)(2)(B) of such Act (42 U.S.C. 1395k(a)(2)(B)) is amended— (A) by striking “and” at the end of clause (ii); (B) by striking the semicolon at the end of clause (iii) and inserting a comma; and (C) by adding at the end thereof the following new clause: “(iv) certified nurse-midwife services; and”. (2) Section 1833(a)(1) of such Act (42 U.S.C. 1395k(a)(l)) is 42 USC 1395l. amended— (A) by striking “and” at the end of clause (F); (B) by striking “services; and” in clause (G) and inserting “services,”; and (C) 3737Copy read “(D)”. by adding at the end thereof the following: “and (I) with respect to certified nurse-midwife services under section 1861(s)(2)(L), the amounts paid shall be the amount determined by a fee schedule established by the Secretary for the purposes of this subparagraph (but in no event more than 65 percent of the prevailing charge that would be allowed for the same service performed by a physician);”. (3) Section 1833 of such Act (42 U.S.C. 13951) is amended by adding at the end the following new subsection: “(m) In the case of certified nurse-midwife services for which payment may be made under this part only pursuant to section 1861(s)(2)(L), payment may only be made under this part for such services on an assignment-related basis.”. (c) Definition.— Section 1861 of such Act (42 U.S.C. 1395x) is amended by adding at the end thereof the following new subsection: “Certified Nurse-Midwife Services (1) The term ‘certified nurse-midwife services’ means such services furnished by a certified nurse-midwife (as defined in paragraph (2)) and such services and supplies furnished as an incident to his service which the certified nurse-midwife is legally authorized to perform under State law (or the State regulatory mechanism provided by State law) as would otherwise be covered if furnished by a physician or as an incident to a physician’s service. “(2) The term ‘certified nurse-midwife’ means a registered nurse who has successfully completed a program of study and clinical experience meeting guidelines prescribed by the Secretary, or has been certified by an organization recognized by the Secretary, and performs services in the area of management of the care of mothers and babies throughout the maternity cycle.”. (d) 3838Copy read “(c)”. Conforming Changes.— (1) Section 1905(a)(17) of such Act (42 U.S.C. 1396d(a)(17)) is amended by striking “as defined in subsection (m)” and inserting “as defined in section 1861(ff)”. (2) Section 1905 of such Act (42 U.S.C. 1396d) is amended by striking subsection (m). (e) 3939Copy read “(d)”. Effective Date.— The amendments made by this section 42 USC 1395k note. shall be effective with respect to services performed on or after July 1, 1988. SEC. 4074. COVERAGE OF SOCIAL WORKER SERVICES FURNISHED BY A HEALTH MAINTENANCE ORGANIZATION TO ITS MEMBERS. (a) In General.— Section 1861(s)(2)(H)(ii) of the Social Security Act (42 U.S.C. 1395x(s)(2)(H)(ii)) is amended— (1) by inserting “or by a clinical social worker (as defined in subsection (ff))” after “clinical psychologist (as defined by the Secretary)”; and (2) by striking “incident to his services” and inserting “incident to such clinical psychologist’s services or clinical social worker’s services”. (b) Clinical Social Worker Defined.— Section 1861 of such Act (42 U.S.C. 1395x) is amended by adding at the end the following new subsection: “Clinical Social Worker The term ‘clinical social worker’ means an individual who— “(1) possesses a master’s or doctor’s degree in social work; “(2) after obtaining such degree has performed at least 2 years of supervised clinical social work; and “(3) (A) is licensed or certified as a clinical social worker by the State in which the services are performed, or “(B) in the case of an individual in a State which does not provide for licensure or certification— “(i) has completed at least 2 years or 3,000 hours of post-master’s degree supervised clinical social work practice under the supervision of a master’s level social worker in an appropriate setting (as determined by the Secretary), and “(ii) meets such other criteria as the Secretary establishes.”, (c) Effective Date.— The amendments made by this section shall 42 USC 1395x note. be effective with respect to services performed on or after January 1, 1988. SEC. 4075. CLARIFICATION OF COVERAGE OF DRUGS USED IN IMMUNOSUPPRESSIVE THERAPY. (a) In General.— Section 1861(s)(2)(J) of the Social Security Act (42 U.S.C. 1395x(s)(2)(J)) is amended by striking “immunosuppressive drugs” and inserting “prescription drugs used in immunosuppressive therapy”. (b) Effective Date.— The amendment made by subsection (a) 42 USC 1395x note. shall apply to drugs dispensed on or after the date of the enactment of this Act. SEC. 4076. SERVICES OF A PHYSICIAN ASSISTANT. (a) Services Covered.— Section 1861(s)(2)(K) of the Social Security Act (42 U.S.C. 1395x(s)(2)(K)) is amended by inserting “, in a rural area (as defined in section 1886(d)(2)(D)) that is designated, under section 332(a)(1)(A) of the Public Health Service Act, as a health manpower shortage area,” after “1905(c))”. (b) Effective Date.— The amendments made by this section shall 42 USC 1395x note. apply with respect to services furnished on or after January 1, 1989. SEC. 4077. PSYCHOLOGIST SERVICES IN CLINICS. (a) Coverage of Psychologists’ Services Furnished at Rural Health Clinics.— (1) Section 1861(aa)(1)(B) of the Social Security Act (42 U.S.C. 1395x(aa)(1)(B)) is amended by striking “physician assistant or by a nurse practitioner” and inserting “physician assistant or a nurse practitioner (as defined in paragraph (3)), or by a clinical psychologist (as defined by the Secretary),”. (2) The amendment made by paragraph (1) shall be effective 42 USC 1395x note. with respect to services furnished on or after the date of enactment of this Act. (b) Direct Payment for Psychologists’ Services Furnished at a Community Mental Health Center.— (1) Section 1861(s)(2) of the Social Security Act (42 U.S.C. 1395x(s)(2)), as amended, is amended— (A) by striking “and” at the end of subparagraph (K); (B) by adding “and” at the end of subparagraph (L); and (C) by adding at the end thereof the following new subparagraph: “(M) qualified psychologist services;”. (2) Section 1832(a)(2)(B) of such Act (42 U.S.C. 1395k(a)(2)(B)) is amended— (A) by striking “and” at the end of clause (ii); (B) by striking the semicolon in clause (iii) and inserting a comma; and (C) by adding at the end thereof the following new clause: “(iv) qualified psychologist services; and”. (3) Section 1833(a)(1) of such Act (42 U.S.C. 1395k(a)(1) is 42 USC 1395l. amended— (A) by striking “and” at the end of subparagraph (G); (B) by striking “services; and” in subparagraph (H) and inserting “services,”; (C) by adding “and” at the end of subparagraph (I); and (D) by adding at the end thereof the following new subparagraph: “(J) with respect to qualified psychologist services under section 1861(s)(2)(M), the amounts paid shall be the amount determined by a fee schedule established by the Secretary for the purposes of this subparagraph;”. (4) The subsection added by section 4073(b)(3) of this subpart is 42 USC 1395l. amended by inserting “and in the case of qualified psychologists services for which payment may be made under this part only pursuant to section 1861(s)(2)(M)” after “1861(s)(2)(L)”. (5) Section 1861 of such Act (42 U.S.C. 1395x) is amended by adding at the end thereof the following new subsection: “Qualified Psychologist Services “(gg) The term ‘qualified psychologist services“ means such services and such services and supplies furnished as an incident to his service furnished by a clinical psychologist (as defined by the Secretary) at a community mental health center (as such term is used in the Public Health Service Act) which the psychologist is legally authorized to perform under State law (or the State regulatory mechanism provided by State law) as would otherwise be covered if furnished by a physician or as an incident to a physician’s service.”.4040Copy read “service.”. (6) 4141Copy read “(5)”. The amendments made by this subsection shall be Effective date. 42 USC 1395k note. effective with respect to services performed on or after July 1, 1988. SEC. 4078. PROVISION OF OFFSITE COMPREHENSIVE OUTPATIENT REHABILITATION SERVICES. Section 1861(cc)(1) of the Social Security Act (42 U.S.C. 1395x(cc)(1)) is amended by adding at the end thereof the following: “In the case of physical therapy, occupational therapy, and speech pathology services, there shall be no requirement that the item or service be furnished at any single fixed location if the item or service is furnished pursuant to such plan and payments are not otherwise made for the item or service under this title.”. SEC. 4079. DEMONSTRATION PROJECTS TO PROVIDE PAYMENT ON A PREPAID, CAPITATED BASIS FOR COMMUNITY NURSING AND AMBULATORY CARE FURNISHED TO MEDICARE BENEFICIARIES. (a) In General.— The Secretary of Health and Human Services (in this section referred to as the "Secretary") shall enter into an agreement with not less than four eligible organizations submitting applications under this section to conduct demonstration projects to provide payment on a prepaid, capitated basis for community nursing and ambulatory care furnished to any individual entitled to benefits under part A and enrolled under part B of title XVIII of the Social Security Act (other than an individual medically determined to have end-stage renal disease) who resides in the geographic area served by the organization and enrolls with such organization (in accordance with subsection (c)(2)). (b) Definitions of Community Nursing and Ambulatory Care and Eligible Organization.— As used in this section: (1) The term “community nursing and ambulatory care” means the following services: (A) Part-time or intermittent nursing care furnished by or under the supervision of registered professional nurses. (B) Physical, occupational, or speech therapy. (C) Social and related services supportive of a plan of ambulatory care. (D) Part-time or intermittent services of a home health aide. (E) Medical supplies (other than drugs and biologicals) and durable medical equipment while under a plan of care. (F) Medical and other health services described in paragraphs (2)(H)(ii) and (5) through (9) of section 1861(s) of the Social Security Act. (G) Rural health clinic services described in section 1861(aa)(1)(C) of such Act. (H) Certain other related services listed in section 1915(c)(4)(B) of such Act to the extent the Secretary finds such services are appropriate to prevent the need for institutionalization of a patient. (2) The term “eligible organization” means a public or private entity, organized under the laws of any State, which meets the following requirements: (A) The entity (or a division or part of such entity) is primarily engaged in the direct provision of community nursing and ambulatory care. (B) The entity provides directly, or through arrangements with other qualified personnel, the services described in paragraph (1). (C) The entity provides that all nursing care (including services of home health aids) is furnished by or under the supervision of a registered nurse. (D) The entity provides that all services are furnished by qualified staff and are coordinated by a registered professional nurse. (E) The entity has policies governing the furnishing of community nursing and ambulatory care that are developed by registered professional nurses in cooperation with (as appropriate) other professionals. (F) The entity maintains clinical records on all patients. (G) The entity has protocols and procedures to assure, when appropriate, timely referral to or consultation with other health care providers or professionals. (H) The entity complies with applicable State and local laws governing the provision of community nursing and ambulatory care to patients. (I) The requirements of subparagraphs (B), (D), and (E) of section 1876(b)(2) of the Social Security Act. (c) Agreements with Eligible Organizations to4242Copy read “with eligible organizations to”. Conduct Demonstration Projects.— (1) The Secretary may not enter into an agreement with an eligible organization to conduct a demonstration project under this section unless the organization meets the requirements of this subsection and subsection (d) with respect to members enrolled with the organization under this section. (2) The organization shall have an open enrollment period for the enrollment of individuals under this section. The duration of such period of enrollment and any other requirement pertaining to enrollment or termination of enrollment shall be specified in the agreement with the organization. (3) The organization must provide to members enrolled with the organization under this section, through providers and other persons that meet the applicable requirements of titles XVIII and XIX of the Social Security Act, community nursing and ambulatory care (as defined in subsection (b)(1)) which is generally available to individuals residing in the geographic area served by the organization, except that the organization may provide such members with such additional health care services as the members may elect, at their option, to have covered. (4) The organization must make community nursing and ambulatory care (and such other health care services as such individuals have contracted for) available and accessible to each individual enrolled with the organization under this section, within the area served by the organization, with reasonable promptness and in a manner which assures continuity. (5) Section 1876(c)(5) of the Social Security Act shall apply to organizations under this section in the same manner as it applies to organizations under section 1876 of such Act. (6) The organization must have arrangements, established in accordance with regulations of the Secretary, for an ongoing quality assurance program for health care services it provides to such individuals under the demonstration project conducted under this section, which program (A) stresses health outcomes and (B) provides review by health care professionals of the process followed in the provision of such health care services. (7) Under a demonstration project under this section— (A) the Secretary could require the organization to provide financial or other assurances (including financial risk-sharing) that minimize the inappropriate substitution of other services under title XVIII of such Act for community nursing services; and (B) if the Secretary determines that the organization has failed to perform in accordance with the requirements of the project (including meeting financial responsibility requirements under the project, any pattern of disproportionate or inappropriate institutionalization) the Secretory shall, after notice, terminate the project. (d) Determination of Per Capita Payment Rates.— (1) The Secretary shall determine for each 12-month period in which a demonstration project is conducted under this section, and shall announce (in a manner intended to provide notice to interested parties) not later than three months before the beginning of such period, with respect to each eligible organization conducting a demonstration project under this section, a per capita rate of payment for each class of individuals who are enrolled with such organization who are entitled to benefits under part A and enrolled under part B of title XVIII of the Social Security Act. (2) (A) Except as provided in paragraph (3), the per capita rate a of payment under paragraph (1) shall be determined in accordance with this paragraph. (B) The Secretary shall define appropriate classes of members, based on age, disability status, and such other factors as the Secretary determines to be appropriate, so as to ensure actuarial equivalence. The Secretary may add to, modify, or substitute for such classes, if such changes will improve the determination of actuarial equivalence. (C) The per capita rate of pa5mient under paragraph (1) for each such class shall be equal to 95 percent of the adjusted average per capita cost (as defined in subparagraph (D)) for that class. (D) For purposes of subparagraph (C), the term ‘adjusted average per capita cost’ means the average per capita amount that the Secretary estimates in advance (on the basis of actual s experience, or retrospective actuarial equivalent based upon an adequate sample and other information and data, in a geographic area served by an eligible organization or in a similar area, with appropriate adjustments to assure actuarial equivalence) would be payable in any contract year for those services covered under parts A and B of title XVIII of the Social Security Act and types of expenses otherwise reimbursable under such parts A and B which are described in subparagraphs (A) through (G) of subsection (b)(1) (including administrative costs incurred by organizations described in sections 1816 and 1842 of such Act), if the services were to be furnished by other than an eligible organization. (3) The Secretary shall, in consultation with providers, health policy experts, and consumer groups develop capitation-based reimbursement rates for such classes of individuals entitled to benefits under part A and enrolled under part B of the Social Security Act as the Secretary shall determine. Such rates shall be applied in determining per capita rates of payment under paragraph (1) with respect to at least one eligible organization conducting a demonstration project under this section. (4) (A) In the case of an eligible organization conducting a demonstration project under this section, the Secretary shall make monthly payments in advance and in accordance with the rate determined under paragraph (2) or (3), except as provided in subsection (e)(3)(B), to the organization for each individual enrolled with the organization. (B) The amount of payment under paragraph (2) or (3) may be retroactively adjusted to take into account any difference between the actual number of individuals enrolled in the plan under this section and the number of such individuals estimated to be so enrolled in determining the amount of the advance payment. (5) The payment to an eligible organization under this section for individuals enrolled under this section with the organization and entitled to benefits under part A and enrolled under part B of the Social Security Act shall be made from the Federal Hospital Insurance Trust Fund and the Federal Supplementary Medical Insurance Trust Fund established under such Act in such proportions from each such trust fund as the Secretary deems to be fair and equitable taking into consideration benefits attributable to such parts A and B, respectively. (6) During any period in which an individual is enrolled with an eligible organization conducting a demonstration project under this section, only the eligible organization (and no other individual or person) shall be entitled to receive payments from the Secretary under this title for community nursing and ambulatory care (as defined in subsection (b)(1)) furnished to the individual. (e) Restriction on Premiums, Deductibles, Copayments, and Coinsurance.— (1) In no case may the portion of an eligible organization’s premium rate and the actuarial value of its deductibles, coinsurance, and copayments charged (with respect to community nursing and ambulatory care) to individuals who are enrolled under this section with the organization, exceed the actuarial value of the coinsurance and deductibles that would be applicable on the average to individuals enrolled under this section with the organization (or, if the Secretary finds that adequate data are not available to determine that actuarial value, the actuarial value of the coinsurance and deductibles applicable on the average to individuals in the area, in the State, or in the United States, eligible to enroll under this section with the organization, or other appropriate data) and entitled to benefits under part A and enrolled under part B of the Social Security Act, if they were not members of an eligible organization. (2) If the eligible organization provides to its members enrolled under this section services in addition to community nursing and ambulatory care, election of coverage for such additional services shall be optional for such members and such organization shall furnish such members with information on the portion of its premium rate or other charges applicable to such additional services. In no case may the sum of— (A) the portion of such organization’s premium rate charged, with respect to such additional services, to members enrolled under this section, and (B) the actuarial value of its deductibles, coinsurance, and copayments charged, with respect to such services to such members exceed the adjusted community rate for such services (as defined in section 1876(e)(3) of the Social Security Act). (3) (A) Subject to subparagraphs (B) and (C), each agreement to conduct a demonstration project under this section shall provide that if— (i) the adjusted community rate, referred to in paragraph (2), for community nursing and ambulatory care covered under parts A and B of title XVIII of the Social Security Act (as reduced for the actuarial value of the coinsurance and deductibles under those parts) for members enrolled under this section with the organization, is less than (ii) the average of the per capita rates of payment to be made under subsection (d)(1) at the beginning of the 12-month period (as determined on such basis as the Secretary determines appropriate) described in such subsection for members enrolled under this section with the organization, the eligible organization shall provide to such members the additional benefits described in section 1876(g)(3) of the Social Security Act which are selected by the eligible organization and which the Secretary finds are at least equal in value to the difference between that average per capita payment and the adjusted community rate (as so reduced). (B) Subparagraph (A) shall not apply with respect to any organization which elects to receive a lesser payment to the extent that there is no longer a difference between the average per capita payment and adjusted community rate (as so reduced). (C) An organization conducting a demonstration project under this section may provide (with the approval of the Secretary) that a part of the value of such additional benefits under subparagraph (A) be withheld and reserved by the Secretary as provided in section 1876(g)(5) of the Social Security Act. (4) The provisions of paragraphs (3), (5), and (6) of section Contracts. 1876(g) of the Social Security Act shall apply in the same manner to agreements under this section as they apply to risk-sharing contracts under section 1876 of such Act, and, for this purpose, any reference in such paragraphs to paragraph (2) is deemed a reference to paragraph (3) of this subsection. (5) Section 1876(e)(4) of the Social Security Act shall apply to eligible organizations under this section in the same manner as it applies to eligible organizations under section 1876 of such Act. (f) Commencement and Duration of Projects.— Each demonstration project under this section shall begin not later than July 1, 1989, and shall be conducted for a period of three years. (g) Report.— Not later than January 1, 1992, the Secretary shall submit to the Congress a report on the results of the demonstration projects conducted under this section. SEC. 4080. PART B PREMIUM. Section 1839 of the Social Security Act (42 U.S.C. 1395r) is amended— (1) in subsection (e), by striking “1989” each place it appears and inserting in lieu thereof “1990”; (2) in subsection (f)(1), by striking “or 1987” and inserting in lieu thereof “1987, or 1988”; and (3) in subsection (f)(2), by striking “or 1988” and inserting in lieu thereof “1988, or 1989”. Subpart D— Other Provisions SEC. 4081. SUBMISSION OF CLAIMS TO SUPPLEMENTAL INSURANCE CARRIERS. (a) In General.— Section 1842(h)(3) of the Social Security Act (42 U.S.C. 1395u(h)(3)) is amended by inserting “(A)” after “(3)” and by adding at the end the following new subparagraph: “(B) The Secretary shall establish a procedure whereby an individual enrolled under this part may assign, in an appropriate manner on the form claiming a benefit under this part for an item or service furnished by a participating physician or supplier, the individual’s rights of payment under a medicare supplemental policy (described in section 1882(g)(1)) in which the individual is enrolled. In the case such an assignment is properly executed and a claims determination is made by a carrier with a contract under this section, the carrier shall transmit to the private entity issuing the medicare supplemental policy notice of such fact and including such information as the Secretary determines is generally provided to enable the entity to decide whether (and the amount of) any payment is due under the policy. The Secretary may enter into arrangements for the transmittal of such information to entities electronically. The Secretary shall impose user fees for the transmittal of information under this subparagraph, whether electronically or otherwise.”. (b) Medigap Policy Standards.— Section 1882 of such Act (42 U.S.C. 1395ss) is amended— (1) in subsection (b)(1)— (A) by amending subparagraph (B) to read as follows: “(B) includes requirements equal to or more stringent than the requirements described in paragraphs (2) and (3) of subsection (c);”, 4343Paragraphs (B) and (C) were indented wrong. (B) by adding “and” at the end of subparagraph (C), and 4343Paragraphs (B) and (C) were indented wrong. (C) by inserting after subparagraph (C) the following new subparagraph: provides the Secretary periodically (but at least annually) with a list containing the name and address of the issuer of each such policy and the name and number of each such policy (including an indication of policies that have been previously approved, newly approved, or withdrawn from approval since the previous list was provided),”; (2) in subsection (c)— (A) by striking “and” at the end of paragraph (1), (B) by striking the period at the end of paragraph (2) and inserting “; and”, and (C) by inserting after paragraph (2) the following new paragraph: “(3) (A) accepts a notice under section 1842(h)(3)(B) as a claims form for benefits under such policy in lieu of any claims form otherwise required and agrees to make a payment determination on the basis of the information contained in such claims form; “(B) where such a notice is received— “(i) provides notice to such physician or supplier and the beneficiary of the payment determination, and “(ii) provides any appropriate payment directly to the participating physician or supplier involved; “(C) provides each enrollee at the time of enrollment a card listing the policy name and number and a single mailing address to which notices under section 1842(h)(3)(B) respecting the policy are to be sent; “(D) agrees to pay any user fees established under section 1842(h)(3)(B) with respect to information transmitted to the issuer of the policy; and “(E) provides to the Secretary at least annually, for transmittal to carriers, a single mailing address to which notices under section 1842(h)(3)(B) respecting the policy are to be sent.”. (c) Effective Dates.— (1) The amendment made by subsection (a) Contracts. 42 USC 1395u note. shall apply to contracts with carriers for claims for items and services furnished by participating physicians and suppliers on or after January 1, 1989. (2) (A) The amendments made by subsection (b) shall apply to 42 USC 1395ss note. medicare supplemental policies as of January 1, 1989 (or, if applicable, the date established under subparagraph (B)). (B) In the case of a State which the Secretary of Health and Human Services identifies as— (i) requiring State legislation (other than legislation appropriating funds) in order for medical supplemental policies to be changed to meet the requirements of section 1882(c)(3) of the Social Security Act, and (ii) having a legislature which is not scheduled to meet in 1988 in a legislative session in which such legislation may be considered, the date specified in this subparagraph is the first day of the first calendar quarter beginning after the close of the first legislative session of the State legislature that begins on or after January 1, 1989, and in which legislation described in clause (i) may be considered. SEC. 4082. REVISION OF PART B HEARINGS. (a) Clarification of OBRA Amendment.— Section 1869(b)(3)(B) of the Social Security Act (42 U.S.C. 1395ff(b)(3)(B)) is amended 43a43aCopy read “is amended is amended”. by striking “chapter 5” and inserting “section 553”. (b) Expedited Administrative Hearing Where Only Issues of Law.— Section 1869(b) of such Act (42 U.S.C. 1395ffrb)) is amended by adding at the end the following new paragraph: “(5) In an administrative hearing pursuant to paragraph (1), where the moving party alleges that there are no material issues of fact in dispute, the administrative law judge shall make an expedited determination as to whether any such facts are in dispute and, if not, shall determine the case expeditiously.”. (c) Timely Carrier Hearings on Part B Appeals.— Section 1842(b)(5) of such Act (42 U.S.C. 1395u(b)(5)) is amended— (1) by inserting “(A)” after “(5)”, and (2) by adding at the end the following new subparagraph: “(B) The Secretary shall establish standards for evaluating carriers’ performance of reviews of initial carrier determinations and of fair hearings under paragraph (3)(C), under which a carrier is expected— “(i) to complete such reviews, within 45 days after the date of a request by an individual enrolled under this part for such a review, in 95 percent of such requests, and “(ii) to make a final determination, within 120 days after the date of receipt of a request by an individual enrolled under this part for a fair hearing under paragraph (3)(C), in 90 percent of such cases.”. (d) GAO Study.— The Comptroller General shall conduct a study 42 USC 1395u note. concerning the cost effectiveness of requiring hearings with a carrier under part B of title XVIII of the Social Security Act before having a hearing before an administrative law judge respecting carrier determinations under that part. The Comptroller General Reports. shall report to the Congress on the results of such study by not later than June 30, 1989. (e) Effective Dates.— (1) The amendment made by subsection (a) 42 USC 1395ff note. shall take effect on the date of the enactment of this Act. (2) The amendment made by subsection (b) shall apply to requests for hearings filed after the end of the 60-day period beginning on the date of the enactment of this Act. (3) The amendments made by subsection (c) shall apply to evaluation 42 USC 1395u note. of performance of carriers under contracts entered into or renewed on or after October 1, 1988. SEC. 4083. PROVISIONS RELATING TO PHYSICIAN PAYMENT REVIEW COMMISSION. (a) Revision of Appointment Process for the Physician Payment Review Commission.— (1) In general.— Section 1845(a) of the Social 43b43bCopy read “of Social”. Security Act (42 U.S.C. 1395w–l(a)(3)) is amended— (A) in paragraph (1), by striking “with expertise in the provision and financing of physicians’ services” and inserting “with national recognition for their expertise in health economics, physician reimbursement, medical practice, and other related fields”; and (B) in paragraph (3), by striking the last sentence. (2) Effective date.— The amendment made by paragraph (1) 42 USC 1395W–1 note. shall apply to appointments made after the date of the enactment of this Act. (b) Treatment of Employees for Certain Purposes.— (1) In 4444Copy read “General.”. general.— Section 1886(e)(6)(D) of the Social Security Act (42 U.S.C. 1395ww(e)(6)(D)) is amended by adding at the end the following: “For purposes of pay (other than pay of members of the Commission) and employment benefits, rights, and privileges, all personnel of the Commission shall be treated as if they were employees of the United States Senate.”. (2) Effective date.— The amendments made by paragraph (1) 42 USC 1395ww note. shall take effect on the date of the enactment of this Act. (c) Change in Date for Annual Report of Physician Payment Review Commission.— (1) Section 1845(b)(l) of such Act (42 U.S.C. 1395w–l(b)(1)) is amended by striking “March 1” and inserting “March 31”. (2) The amendment made by paragraph (1) shall apply with 42 USC 1395w–1 note. respect to reports for years after 1987. SEC. 4084. TECHNICAL AMENDMENTS RELATED TO CERTIFIED REGISTERED NURSE ANESTHETISTS. (a) In general.— Section 1833(1) of the Social Security Act (42 U.S.C. 13951(1)), as added by section 9320(e) of the Omnibus Budget Reconciliation Act of 1986, is amended— (1) in paragraph (2), by striking “1985” and inserting “1985 and such other data as the Secretary determines necessary”; and (2) in paragraph (5)(A), by striking “or group practice” each place it appears and inserting “group practice, or ambulatory surgical center”. (b) Effective Date.— The amendments made by subsection (a) 42 USC 1395l note. shall apply as if included in the amendment made by section 9320(e)(2) of the Omnibus Budget Reconciliation Act of 1986. SEC. 4085. MISCELLANEOUS AND TECHNICAL PROVISIONS. (a) Prompt Submittal of Data By Secretary.— Section 1845 of the Social Security Act (42 U.S.C. 1395w–l) is amended by adding at the end the following new subsection: “(f) (1) Not later than October 1st of each year (beginning with 1988), the Secretary shall transmit to the Physician Payment Review Commission, to the Congressional Budget Office, and to the Congressional Research Service of the Library of Congress national data (known as the Part B Medicare Annual Data System) for the previous year respecting part B of this title. “(2) In order to ensure that the data are available for transmittal under paragraph (1) on a timely basis, the Secretary shall require, in the standards and criteria established under section 1842(b)(2), that carriers submit data for a year under the system referred to in paragraph (1) not later than July 1st of the following year. “(3) The Secretary, in consultation with the Physician Payment Review Commission, the Congressional Budget Office, and the Congressional Research Service of the Library of Congress, shall establish and annually revise standards for the data reporting system described in paragraph (1). “(4) The Secretary shall also provide to the entities described in paragraph (1) additional data respecting the program under this part as may be reasonably requested by them on an agreed-upon schedule. “(5) The Secretary shall develop, in consultation with the Physician Payment Review Commission, the Congressional Budget Office, and the Congressional Research Service of the Library of Congress, a system for providing to each of such entities on a quarterly basis summary data on aggregate expenditures under this part by type of service and by type of provider. Such data shall be provided not later than 90 days after the end of each quarter (for quarters beginning with the calendar quarter ending on March 31, 1989).”. (b) Clarification of Penalties for Unassigned Laboratory Services.— (1) In general.— Section 1833(h)(5) of the Social Security Act (42 U.S.C. 13951(h)(5)) is amended by adding at the end the following new subparagraph: “(D) If a person knowingly and willfully and on a repeated basis bills an individual enrolled under this part for charges for a clinical diagnostic laboratory test for which payment may only be made on an assignment-related basis under subparagraph (C), the Secretary may apply sanctions against the person in the same manner as the Secretary may apply sanctions against a physician in accordance with section 1842(j)(2).”. (2) Effective date.— The amendment made by paragraph (1) 42 USC 1395l note. shall apply to procedures performed on or after January 1, 1988. (c) Extension of Moratorium on Laboratory Payment Demonstration.— Section 9204(a) of the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended by section 9339(e) of the Omnibus Budget Reconciliation Act of 1986, is amended by striking 42 USC 1395ww note. “January 1, 1988” and inserting “January 1, 1989”. (d) Prompt Payment for Comprehensive Outpatient Rehabilitation Facilities.— (1) Section 1816(c)(2)(C) of the Social Security Act (42 U.S.C. 1395h(c)(2)(C)) is amended by striking “or hospice program” and inserting “hospice program, comprehensive outpatient rehabilitation facility, or rehabilitation agency”. (2) (A) The amendment made by paragraph (1) shall apply to 42 USC 1395h note. claims received on or after the date of enactment of this Act. (B) The Secretary of Health and Human Services shall provide for such timely amendments to agreements under section 1816, and regulations, to such extent as may be necessary to implement the amendment made by paragraph (1). (e) Capacity to 4545Copy read “to”. Set Geographic Payment Limits.— The Secretary 42 USC 1395u note. of Health and Human Services shall develop the capability to implement (for services furnished on or after January 1, 1989) geographic limits on charges and payments under part B of title XVIII of the Social Security Act for physicians’ services based on statewide, regional, or national average (or percentile in a distribution) of prevailing charges or payment amounts (weighted by frequency of services). Any such limits shall take into account adjustments for geographic differences in cost of practice and cost of living. (f) Delay in Effective Date for Establishing Physician Identifier System.— Section 9202(g) of the Consolidated Omnibus Budget Reconciliation Act of 1985 is amended by striking “July 1, 1987” and 42 USC 1395ww note. inserting “October 1, 1988”. (g) Date for Applying Civil Penalities for Improper Use of Assistants in Performing Cataract Surgery.— (1) Section 1842(k) of the Social Security Act (42 U.S.C. 1395u(k)) is amended in paragraphs (1) and (2) by striking “(j)(2)” each place it appears and inserting “(j)(2) in the case of surgery performed on or after March 1, 1987”. (2) The amendment made by paragraph (1) shall be effective 42 USC 1395u note. as if included in section 9307(c) of the Consolidated Omnibus Budget Reconciliation Act of 1985. (h) Utilization Screens for Physician Services Provided to Patients in Rehabiutation Hospitals.— (1) The Secretary of Health and Human Services shall establish (in consultation with appropriate physician groups, including those representing rehabilitative medicine) a separate utilization screen for physician visits to patients in rehabilitation hospitals and rehabilitative units (and patients in long-term care hospitals receiving rehabilitation services) to be used by carriers under section 1842 of the Social Security Act in performing functions under subsection (a) of such section related to the utilization practices of physicians in such hospitals and units. (2) Not later than 12 months after the date of enactment of this Act, the Secretary of Health and Human Services shall take appropriate steps to implement the utilization screen established under paragraph (1). (i) Technical Amendments.— (1) Section 1833(a) of the Social Security Act (42 U.S.C. 13951(a)) is amended— (A) in paragraphs d)(D)(i) and (2)(D)(i), by striking, “on the basis of an assignment described in section 1842(b)(3)(B)(ii), under the procedure described in section 1870(f)(1),” and inserting “on an assignment-related basis”; (B) in paragraph (1), by striking “and” before “(G)”; and (C) in subsection (b)(3)(A), by striking “on the basis of an assignment described in section 1842(b)(3)(B)(ii), under the procedure described in section 1870(f)(1)" and inserting "on an assignment-related basis”. (2) Section 1833(h)(1)(C) of such Act (42 U.S.C. 13951(h)(1)(C)) is amended by inserting before the period the following: “, and ending on December 31, 1989. For such tests furnished on or after January 1, 1990, the fee schedule shall be established on a nationwide basis”. (3) Section 1833(h)(5)(A) of such Act (42 U.S.C. 13951(h)(5)(A)) is amended by striking “and” at the end of clause (i), by striking the period at the end of clause (ii) and inserting “, and”, and by adding at the end the following new clause: “(iii) in the case of a clinical diagnostic laboratory test provided under an arrangement (as defined in section 1861(w)(1)) made by a hospital, payment shall be made to the hospital.”. (4) Section 1835(a)(2)(C) of such Act (42 U.S.C. 1395n(a)(2)(C)) is amended by striking the second comma at the end of clause (i). (5) Section 1842(b)(3)(C) of such Act (42 U.S.C. 1395u(b)(3)(C)) is amended by striking “not more than” and inserting “less than”. (6) Section 1842(h)(5) of such Act (42 U.S.C. 1395u(h)(5)) is amended by striking “the” before “participation”. (7) Effective as if included in the enactment of the Omnibus Budget Reconciliation Act of 1986, section 1842(j)(1) of the Social Security Act (42 U.S.C. 1395u(j)(1)) is amended— (A) in subparagraph (C)(i), by inserting “maximum allowable” after “If the physician’s”, (B) in subparagraph (C)(v), by striking “1987” and inserting 4646Copy read “insert”. “1986”, and (C) by adding at the end of subparagraph (C) the following new clause: “(vii) In the case of a nonparticipating physician who was a participating physician during a previous period, for the purpose of computing the physician’s maximum allowable actual charge during the physician’s period of nonparticipation, the physician shall be deemed to have had a maximum allowable actual charge during the period of participation, and such deemed maximum allowable actual charge shall be determined accordingly to clauses (i) through (vi).”. (8) Paragraph (4) of section 1845(e) of the Social Security Act (42 U.S.C. 1395w–l(e)) is amended by moving the alignment of each of its provisions (including any clauses therein) 2 ems to the left. (9) Section 1861(b)(4) of such Act (42 U.S.C. 1395x(b)(4)) is amended by striking the comma before “anesthesia” and inserting “and” and by striking “certified” the second place it appears. (10) The heading of subsection (g) of section 1861 of such Act (42 U.S.C. 1395x) is amended to read as follows: “Outpatient Occupational Therapy Services”. (11) Section 1861(s) of such Act (42 U.S.C. 1395x(s)), as amended by section 9367(a) of this Act, is amended by striking “which—” before paragraph (15) and all that follows through the end of paragraph (16) and inserting the following: “which would not be included under subsection (b) if it were furnished to an inpatient of a hospital.”. (12) Section 1861(v)(5)(A) of such Act (42 U.S.C. 1395x(v)(5)(A)) is amended by striking “section 1861(p)” and “section 1861(g)” and inserting “subsection (p)” and “subsection (g)”, respectively. (13) The heading of subsection (bb) of section 1861 of such Act (42 U.S.C. 1395x) is amended to read as follows: “Services of a Certified Registered Nurse Anesthetist”. (14) The heading of subsection (ee) of section 1861 of such Act (42 U.S.C. 1395x) is amended to read as follows: “Discharge Planning Process”. (15) Section 1862(a)(1)(A) of such Act (42 U.S.C. 1395y(a)(1)(A)) is amended by striking “or (D)” and inserting “(D), or (E)”. (16) Section 1862(a)(14) of such Act (42 U.S.C. 1395y(a)(14)) is amended by striking “an patient” and inserting “a patient”. (17) Effective as if included in the enactment of the Omnibus Budget Reconciliation Act of 1986, section 1866(g) of the Social Security Act (42 U.S.C. 1395cc(g)) is amended by striking “for a hospital outpatient service” and all that follows through “subsection (a)(1)(H)” and inserting “inconsistent with an arrangement under subsection (a)(1)(H) or in violation of the requirement for such an arrangement”. (18) Section 1869(a) of the Social Security Act (42 U.S.C. 1395ff(a)) is amended by inserting “or a claim for benefits with respect to home health services under part B” before “shall”. (19) Section 1869(b)(2) of such Act (42 U.S.C. 1395ff(b)(2)) is amended by inserting “and (1)(D)” after “paragraph (1)(C)” each place it appears. (20) Section 1875(c)(3)(B) of such Act (42 U.S.C. 139511(c)(3)(B)) is amended by striking “years 1987” and inserting “year 1987”. (21) Effective as if included in the enactment of the Omnibus Budget Reconciliation Act of 1986— (A) section 9313(d)(3) of such Act is amended by striking 42 USC 1395ll note. “2 years after the date of the enactment of this Act” and inserting “January 1, 1990”; (B) section 9332(a)(3) of such Act is amended by inserting 42 USC 1395u note. before the period at the end the following: “or in increasing the proportion of total payments for physicians’ services which are payments for such services rendered by participating physicians”; (C) section 9335(j)(2) of such Act is amended by inserting 42 USC 1395rr note. before the period at the end the following: “except that, until network administrative organizations are established under section 1881(c)(1)(A) of the Social Security Act (as amended by subsection (d)(1) of this section), the distribution of payments described in the last sentence of section 1881(b)(7) of such Act shall be made based on the distribution of payments under section 1881 of such Act to network administrative organizations for fiscal year 1986”; and (D) section 9343 of such Act is amended— (i) amending subparagraph (A) of subsection (e)(2) to read as follows: “(2) (A) Section 1833 (42 U.S.C. 13951) is amended— “(i) in subsection (a)(1)(F), by striking ‘(i)(3)’ and inserting ‘(i)(4)’, and “(ii) in subsection (b)(3), by striking ‘or under subsection (i)(2) or (i)(4)’.”; (ii) in subsection (h)(2), by striking “(d)” and inserting 42 USC 1395l note. “(c)” and by adding at the end the following: “The amendments made by subsection (c) shall apply to services furnished after June 30, 1987.”; and (iii) in subsection (h)(4), by striking “(c)” and inserting 42 USC 1395l note. “(d)”. PART 4— PEER REVIEW ORGANIZATIONS SEC. 4091. CONTRACT PROVISIONS. (a) Extensions of Peer Review Contract Period.— (1) One-time extensions to permit staggering of expiration dates.— (A) In general.— In order to permit the Secretary of Health and Human Services an adequate time to complete contract renewal negotiations with utilization and quality control peer review organizations under part B of title XI of the Social Security Act and to provide for a staggered period of contract expiration dates, notwithstanding section 1153(c) of such Act, the Secretary may provide for extensions of existing contracts, but the total of such extensions may not exceed 24 months for any contract. (B) Effective date.— The amendment made by subparagraph (A) shall apply to renewals occurring on or after the date of the enactment of this Act. (2) 3-year contract period.— (A) Section 1153(c)(3) of such Act (42 U.S.C. 1320c–2(c)(3)) is amended by striking “two” and “biennial” and inserting “three” and “triennial”, respectively. (B) The amendment made by subparagraph (A) shall 42 USC 1320C–2 note. apply with respect to contracts entered into or renewed on or after the date of the enactment of this Act. (b) Contract Requirements.— (1) Section 1153 of the Social Security Act (42 U.S.C. 1320c–2) is amended by adding at the end the following new subsection: “(h) (1) The Secretary shall publish in the Federal Register any Federal Register, publication. new policy or procedure adopted by the Secretary that affects substantially the performance of contract obligations under this section not less than 30 days before the date on which such policy or procedure is to take effect. This paragraph shall not apply to the extent it is inconsistent with a statutory deadline. “(2) The Secretary shall publish in the Federal Register the Federal Register, publication. general criteria and standards used for evaluating the efficient and effective performance of contract obligations under this section and shall provide opportunity for public comment with respect to such criteria and standards. “(3) The Secretary shall regularly furnish each peer review Reports. organization with a contract under this section with a report that documents the performance of the organization in relation to the performance of other such organizations.”. (2) Section 1153(e) of such Act (42 U.S.C. 1320c–2(e)) is amended— (A) by inserting “(1)” after “(e)”; (B) by striking “Contracting” and inserting “Except as provided in paragraph (2), contracting”; and (C) by adding at the end the following new paragraph: If a peer review organization with a contract under this section is required to carry out a review function in addition to any function required to be carried out at the time the Secretary entered into or renewed the contract with the organization, the Secretary shall, before requiring such organization to carry out such additional function, negotiate the necessary contractual modifications, including modifications that provide for an appropriate adjustment (in light of the cost of such additional function) to the amount of reimbursement made to the organization.”. (3) The amendments made by paragraphs (1) and (2) shall 42 USC 1320C–2 note. become effective on the date of enactment of this Act. SEC. 4092. PREFERENCE IN CONTRACTING WITH IN-STATE ORGANIZATIONS. (a) In General.— Section 1153 of the Social Security Act (42 U.S.C. 1320C–2), as amended by section 4091(b)(1) of this part, is further amended by adding at the end the following new subsection: “(i) (1) Notwithstanding any other provision of this section, the Secretary shall not renew a contract with any organization that is not an in-State organization (as defined in paragraph (3)) unless the Secretary has first complied with the requirements of paragraph (2). “(2) (A) Not later than six months before the date on which a Federal Register, publication. contract period ends with respect to an organization that is not an in-State organization, the Secretary shall publish in the Federal Register— “(i) the date on which such period ends; and “(ii) the period of time in which an in-State organization may submit a proposal for the contract ending on such date. “(B) If one or more qualified in-State organizations submits a proposal within the period of time specified under subparagraph (A)(ii), the Secretary shall not automatically renew the current contract on a noncompetitive basis, but shall provide for competition for the contract in the same manner as a new contract under subsection (b). “(3) For purposes of this subsection, an in-State organization is an organization that has its primary place of business in the State in which review will be conducted (or, which is owned by a parent corporation the headquarters of which is located in such State).”. (b) Effective Date.— The amendment made by subsection (a) 42 USC 1320C–2 note. shall apply with respect to contracts scheduled to be renewed on or after the first day of the eighth month to begin after the date of enactment of this Act. SEC. 4093. REQUIRING REASONABLE NOTICE AND OPPORTUNITY FOR DISCUSSION PRIOR TO DENIAL OF CLAIM. (a) In General.— Section 1154(a)(3) of the Social Security Act (42 U.S.C. 1320c–3(a)(3)) is amended to read as follows: “(3) (A) Subject to subparagraph (B), whenever the organization makes a determination that any health care services or items furnished or to be furnished to a patient by any practitioner or provider are disapproved, the organization shall promptly notify such patient and the agency or organization responsible for the payment of claims under title XVIII of this Act of such determination. “(B) The notification under subparagraph (A) shall not occur until 20 days after the date that the organization has— “(i) made a preliminary notification to such practitioner or provider of such proposed determination, and “(ii) provided such practitioner or provider an opportunity for discussion and review of the proposed determination. The discussion and review conducted under subparagraph (B)(ii) shall not affect the rights of a practitioner or provider to a formal reconsideration of a determination under this part (as provided under section 1155).”. (b) Effective Date.— The amendment made by subsection (a) 42 USC 1320C–3 note. shall apply with respect to determinations made on or after April 1, 1988. SEC. 4094. PEER REVIEW NORMS AND EDUCATION. (a) Standards Applied by Pros.— Section 1154(a)(6) of the Social Security Act (42 U.S.C. 1320c–3(a)(6)) is amended by adding after and below subparagraph (B) thereof the following: “As a component of the norms described in clause (i) or (ii), the organization shall take into account the special problems associated with delivering care in remote rural areas, the availability of service alternatives to inpatient hospitalization, and other appropriate factors (such as the distance from a patient’s residence to the site of care, family support, availability of proximate alternative sites of care, and the patient’s ability to carry out necessary or prescribed self-care regimens) that could adversely affect the safety or effectiveness of treatment provided on an outpatient basis.” (b) On-Site Review.— Section 1154(a) of such Act (42 U.S.C. 1320c–3(a)) is amended by adding at the end the following new paragraph: “(15) During each year of the contract entered into under Contracts. section 1153(b), the organization shall perform significant onsite review activities, including on-site review at at least 20 percent of the rural hospitals in the organization’s area.”. (c) Reports to Providers and Educational Activities.— (1) (A) Section 1154(a)(6) of such Act4747Copy read “1154(a)(6) such Act”. (42 U.S.C. 1320c–3(a)(6)) is amended— (i) by redesignating subparagraphs (A) and (B) as clauses (i) and (ii), respectively, (ii) by inserting “(A)” after “(6)”, and (iii) by adding at the end the following: “(B) The organization shall— “(i) offer to provide, several times each year, for a physician representing the organization to meet (at a hospital or at a regional meeting) with medical and administrative staff of each hospital (the services of which are reviewed by g the organization) respecting the organization’s review of the hospital’s services for which payment may be made under title XVIII, and “(ii) publish (not less often than annually) and distribute to providers and practitioners whose services are subject to review a report that describes the organization’s findings with respect to the types of cases in which the organization has frequently determined that (I) inappropriate or unnecessary care has been provided, (II) services were rendered in an inappropriate setting, or (III) services did not meet professionally recognized standards of health care.”. (B) The amendments made by subparagraph (A) shall apply to Contracts. 42 USC 1320C–3 note. contracts under part B of title XI of the Social Security Act entered into or renewed more than 6 months after the date of the enactment of this Act. (2) (A) Section 1154(a)(4)(B) of the Social Security Act (42 U.S.C. 1320c–3(a)(4)(B)) is amended— (i) by inserting before the period at the end of the first sentence the following: “and whether individuals enrolled with an eligible organization have adequate access to health care services provided by or through such organization (as determined, in part, by a survey of individuals enrolled with the organization who have not yet used the organization to receive such services). The contract of each organization shall also provide that with respect to health care provided by a health maintenance organization or competitive medical plan under section 1876, the organization shall maintain a beneficiary outreach program designed to apprise individuals receiving care under such section of the role of the peer review system, of the rights of the individual under such system, and of the method and purposes for contacting the organization”; and (ii) by striking “previous sentence” and inserting “previous two sentences”. (B) Section 1154(a)(7)(A) of such Act (42 U.S.C. 1320c–3(a)(7)(A)) is amended— (i) by inserting “(i)” after “(A)”, (ii) by striking the semicolon and inserting “; and”, and (iii) by adding at the end thereof the following new clause: “(ii) in the case of psychiatric and physical rehabilitation services, make arrangements to ensure that (to the extent possible) initial review of such services be made by a physician who is trained in psychiatry or physical rehabilitation (as appropriate).”. (C) The amendments made by this paragraph shall apply with Contracts. 42 USC 1320C–3 note. respect to contracts entered into or renewed on or after the date of enactment of this Act. (d) Peer Review Emphasis on Educational Activities.— (1) Section 1153(c) of such Act (42 U.S.C. 1320c–2(c)) is amended by adding after and below paragraph (8) the following: “In evaluating the performance of utilization and quality control peer review organizations under contracts under this part, the Secretary shall place emphasis on the performance of such organizations in educating providers and practitioners (particularly those in rural areas) concerning the review process and criteria being applied by the organization.”. (2) The amendment made by paragraph (1) shall apply to Contracts. 42 USC 1320C–2 note. contracts under part B of title XI of the Social Security Act as of January 1, 1988. (e) Telecommunications Demonstration Projects.— The Secretary Contracts. 42 USC 1320C–5 note. of Health and Human Services shall enter into agreements with entities submitting applications under this subsection (in such form as the Secretary may provide) to establish demonstration projects to examine the feasability of requiring instruction and oversight of rural physicians, in lieu of imposing sanctions, through use of video communication between rural hospitals and teaching hospitals under this title. Under such demonstration projects, the Secretary may provide for payments to physicians consulted via video communication systems. No funds may be expended under the demonstration projects for the acquisition of capital items including computer hardware. SEC. 4095. PREEXCLUSION HEARINGS. (a) In General.— Section 1156(b) of the Social Security Act (42 U.S.C. 1320c–5(b)) is amended by adding at the end the following new paragraph: “(5) Before the Secretary may effect an exclusion under paragraph (2) in the case of a provider or practitioner located in a rural health manpower shortage area (HMSA) or in a county with a population of less than 70,000, the provider or practitioner adversely affected by the determination is entitled to a hearing before an administrative law judge (described in section 205(b)) respecting whether the provider or practitioner should be able to continue furnishing services to individuals entitled to benefits under this Act, pending completion of the administrative review procedure under paragraph (4). If the judge does not determine, by a preponderance of the evidence, that the provider or practitioner will pose a serious risk to such individuals if permitted to continue furnishing such services, the Secretary shall not effect the exclusion under paragraph (2) until the provider or practitioner has been provided reasonable notice and opportunity for an administrative hearing thereon under paragraph (4).”. (b) Effective Date.— The amendment made by subsection (a) 42 USC 1320C–5 note. shall apply to determinations made by the Secretary of Health and Human Services under section 1156(b) of the Social Security Act on or after the date of the enactment of this Act. (c) Transition for Current Cases.— In the case of a practitioner 42 USC 1320C–5 note. or person— (1) for whom a notice of determination under section 1156(b) of the Social Security Act has been provided within 365 days before the date of the enactment of this Act, (2) who has not exhausted the administrative remedies available under section 1156(b)(4) of such Act for review of the determination, and (3) who requests, within 90 days after the date of the enactment of this Act, a hearing established under this subsection, the Secretary of Health and Human Services shall provide for a hearing described in section 1156(b)(5) of the Social Security Act (as amended by subsection (a) of this section). (d) Redeterminations in Certain Cases.— If, in hearing under 42 USC 1320C–5 note. subsection (c), the judge does not determine, by a preponderance of the evidence, that the provider or practitioner will pose a serious risk to individuals entitled to benefits under title XVIII of the Social Security Act if permitted to continue or resume furnishing such services, the Secretary shall not effect the exclusion (or shall suspend the exclusion, if previously effected) under paragraph (2) of section 1156(b) of such Act until the provider or practitioner has been provided an administrative hearing thereon under paragraph (4) of such section, notwithstanding any failure by the provider or practitioner to request the hearing on a timely basis. (e) Report on Improvements in Procedures for Imposing Sanctions.— Not later than one year after the date of enactment of this Act, the Secretary of Health and Human Services shall report to Congress on the improved procedures for imposing sanctions against a practitioner or person under section 1156 of the Social Security Act established through agreement by the Health Care Financing Administration, the American Association of Retired Persons, the American Medical Association, and the Office of the Inspector General in the Department of Health and Human Services. The report shall set forth such improved procedures, describe the response of physicians and providers to the procedures, assess whether the procedures effect an appropriate balance between procedural fairness and the need for ensuring quality medical care, comment on the alternative provider-patient notification procedure contained in the agreement, and recommend whether such procedures should apply to institutional providers of health care services. SEC. 4096. LIMITATION OF BENEFICIARY LIABILITY FOR SERVICES DISALLOWED BY PEER REVIEW ORGANIZATIONS. (a) Part B Services— (1) Section 1842 of the Social Security Act (42 U.S.C 1395u) is amended— (A) in subsection (b)(3)(ii), by inserting “(and to refund amounts already collected)” after “agrees not to charge”, and by striking “and (II)” and inserting “, (II) the physician or other person furnishing such service agrees not to charge (and to refund amounts already collected) for services for which payment under this title is denied under section 1154(a)(2) by reason of a determination under section 1154(a)(1)(B), and (III)”; (B) in subsection (1)(1)(A)(iii), by inserting “(I)” after “(iii)” and by inserting before the comma the following: “or (II) payment under this title for such services is denied under section 1154(a)(2) by reason of a determination under section 1154(a)(1)(B)”; and (C) in subsection (1)(1)(C), by inserting “in the case described in subparagraph (A)(iii)(I)” after “to an individual”. (2) Section 1870(f) of such Act (42 U.S.C. 1395gg(f)) is amended by striking “that the reasonable charge is the full charge for the services” each place it appears and inserting “to the terms specified in subclauses (I) and (II) of section 1842(b)(3)(B)(ii) with respect to the services”. (b) Indemnification.— Section 1879(b) of such Act (42 U.S.C. 1395pp(b)) is amended— (1) in the first sentence, by striking “, subject to the deductible and coinsurance provisions of this title,”, and (2) by adding at the end the following: “No item or service for which an individual is indemnified under this subsection shall be taken into account in applying any limitation on the amount of items and services for which payment may be made to or on behalf of the individual under this title.”. (c) Patient Liability for Hospital Charges During Appeal of Discharge Notice.— (1) Section 1154(e)(2) of such Act (42 U.S.C. 1320c–3(e)(2)) is amended by adding at the end thereof the following: “If the hospital requests such a review, it shall also notify the patient that the review has been requested.”. (2) Sections 1154(e)(3)(A)(i) (42 U.S.C. 1320c–3(e)(3)(A)(i)) and 1154(e)(3)(B) (42 U.S.C. 1320c–3(e)(3)(B)) of such Act are each amended by inserting “or (2)” after “paragraph (1)”. (d) Effective Date.— The amendments made by this section shall 42 USC 1320C–3 note. apply to services furnished on or after January 1, 1988. SEC. 4097. SEPARATE FUNDING LEVELS. (a) Aggregate Funding.— Section 1866(a)(1)(F)(i)(III) of the Social Security Act (42 U.S.C. 1395cc(a)(1)(F)(i)(III)) is amended— (1) by striking “1986” and inserting “1988”; and (2) inserting “and for any direct or administrative costs incurred as a result of review functions added with respect to a subsequent fiscal year” after “inflation”. (b) Payment.— Section 1866(a)(4)(C)(ii) of such Act (42 U.S.C. 1395cc(a)(4)(C)(ii)) is amended to read as follows: “(ii) shall not be less in the aggregate for a fiscal year— “(I) in the case of hospitals, than the amount specified in paragraph (1)(F)(i)(III), and “(II) in the case of facilities and agencies, than the amounts the Secretary determines to be sufficient to cover the costs of such organizations’ conducting the activities described in subparagraph (A) with respect to such facilities or agencies under part B of title XL”. (c) Effective Date.— The amendments made by this section 42 USC 1395CC note. shall apply with respect to fiscal years beginning on or after October 1, 1988. Subtitle B— Medicaid PART 1— ELIGIBILITY AND BENEFITS SEC. 4101. MEDICAID BENEFITS FOR POOR CHILDREN AND PREGNANT WOMEN. (a) Medicaid Optional Coverage for Additional Low-Income Pregnant Women and Children.— (1) Section 1902(1) of the Social Security Act (42 U.S.C. 1396a(l)) is amended— (A) in paragraph (2)— (i) striking “(2) For purposes of paragraph (1)” and inserting “(2)(A) For purposes of paragraph (1) with respect to individuals described in subparagraph (A) or (B) of that paragraph”, (ii) by striking “100 percent” and inserting “185 percent”, and (iii) by adding at the end the following new subparagraph: “(B) If a State elects, under subsection (a)(10)(A)(ii)(IX), to cover individuals not described in subparagraph (A) or (B) of paragraph (1), for purposes of that paragraph and with respect to individuals not described in such subparagraphs the State shall establish an income level which is a percentage (not more than 100 percent, or, ifless, the percentage established under subparagraph (A)) of the income official poverty line described in subparagraph (A).“; and (B) in paragraph (3)(D), by inserting “appropriate” after “applied is the”. (2) Section 1902(e)(4) of such Act (42 U.S.C. 1396a(e)(4)) is amended by adding at the end the following new sentence: “During the period in which a child is deemed under the preceding sentence to be eligible for medical assistance, the medical assistance eligibility identification number of the mother shall also serve as the identification number of the child, and all claims shall be submitted and paid under such number (unless the State issues a separate identification number for the child before such period expires).”. (3) The amendments made by this subsection shall apply to Effective date. 42 USC 1396a note. medical assistance furnished on or after July 1, 1988. (b) Allowing Accelerated Coverage of Children Up 4848Copy read “up”. to Age 5.— (1) Section 1902(1)(1) of such Act (42 U.S.C. 1396a(1)(1)) is amended— (A) by inserting “and” at the end of subparagraph (B), and (B) by striking subparagraphs (C) through (F) and inserting the following: “(C) children born after September 30, 1983, and who have attained one year of age but have not attained 2, 3, 4, or 5 years of age (as selected by the State),”. (2) (A) Section 1902(1) of such Act is further amended— (i) in paragraph (3)(C), by striking “, (C), (D), (E), or (F)” and inserting “or (C)”, and (ii) in paragraph (4)(B)(ii), by striking “, (D), (E), or (F)”. (B) Section 1902(e)(7) of such Act (42 U.S.C. 1396a(e)(7)) is amended by striking “, (C), (D), (E), or (F)” and inserting “or (C)”. (C) Section 9401(f)(2) of the Omnibus Budget Reconciliation Act of 1986 is amended by striking “(A)” after “(2)” and by 42 USC 1396a note. striking subparagraphs (B) through (D). (3) The amendments made by this subsection shall apply with Effective date. 42 USC 1396a note. respect to medical assistance furnished on or after July 1, 1988. (c) Coverage of Children Up 4949Copy read “up”. to Age 8.— (1) Section 1905(n)(2) of such Act (42 U.S.C. 1396d(n)(2)) is amended by striking “is under 5 years of age” and inserting “has not attained the age of 7 (or any age designated by the State that exceeds 7 but does not exceed 8)”. (2) Section 1902(1)(1)(C) of such Act, as amended by subsection (n)(1)(B), is further amended by striking “or 5 years” and inserting “5, 6, 7, or 8 years”. (3) (A) The amendments made by this subsection shall apply to Effective date. 42 USC 1396d note. medical assistance furnished on or after October 1, 1988. (B) For purposes of section 1905(n)(2) of the Social Security Act (as amended by subsection (a)) for medical assistance furnished during fiscal year 1989, any reference to “age of 7” is deemed to be a reference to “age of 6”. (d) Premium.— (1) Section 1916 of the Social Security Act (42 U.S.C. 1396o) is amended— (A) in subsection (a)(1), by inserting “(except for a premium imposed under subsection (c))” before the semicolon; (B) by redesignating subsections (c) and (d) as subsections (d) and (e), respectively; and (C) by inserting after subsection (b) the following new subsection: “(c) (1) The State plan of a State may at the option of the State provide for imposing a monthly premium (in an amount that does not exceed the limit established under paragraph (2)) with respect to an individual described in subparagraph (A) or (B) of section 1902(1)(1) who is receiving medical assistance on the basis of section 1902(a)(10)(A)(ii)(IX) and whose family income (as determined in accordance with the methodology specified in section 1902(1)(3)) equals or exceeds 150 percent of the nonfarm 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) In no case may the amount of any premium imposed under paragraph (1) exceed 10 percent of the amount by which the family income (less expenses for the care of a dependent child) of an individual exceeds 150 percent of the line described in paragraph (1). “(3) A State shall not require prepayment of a premium imposed pursuant to paragraph (1) and shall not terminate eligibility of an individual 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. 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. “(4) A State may permit State or local funds available under other programs to be used for payment of a premium imposed under paragraph (1). Payment of a premium with such funds shall not be counted as income to the individual with respect to whom such payment is made.”. (2) The amendments made by paragraph (1) shall become Effective date. 42 USC 13960 note. effective on July 1, 1988. (e) Miscellaneous Provisions Relating to Services for Pregnant Women and Children.— (1) Section 1902(a)(10) of such Act (42 U.S.C. 1396a(a)(10)) is amended, in subdivision (VII) of the matter following subparagraph (E), by striking “and postpartum” and inserting “postpartum, and family planning”. (2) Section 1902(e)(5) of such Act (42 U.S.C. 1396a(e)(5)) is amended by striking “until the end of the 60-day period beginning on the last day of her pregnancy” and inserting “through the end of the month in which the 60-day period (beginning on the last day of her pregnancy) ends”. (3) Section 1902(1)(3)(E) of such Act (42 U.S.C. 1396a(1)(3)(E)) is amended by inserting after “title IV” the following: “(except to the extent such methodology is inconsistent with clause (D) of subsection (a)(17))”. (4) Section 1902(1)(4)(A) of such Act (42 U.S.C. 1396a(1)(4)(A)) is amended by striking “April 17, 1986” and inserting “July 1, 1987”. (5) Section 1902(1)(4) of such Act (42 U.S.C. 1396a(1)(4)) is amended by adding at the end the following new subparagraph: “(C) A State plan may not provide, in its election of the option of furnishing medical assistance to individuals described in paragraph (1), that such individuals must apply for benefits under part A of title IV as a condition of applying for, or receiving, medical assistance under this title.”. (6) (A) The amendment made by paragraph 5050Copy read “paragraphs”. (1) shall become Effective dates. 42 USC 1396a note. effective on the date of enactment of this Act. (B) The amendments made by paragraphs (2) and (3) shall be effective as if they had been included in the enactment of the Consolidated Omnibus Budget Reconciliation Act of 1985. (C) The amendment made by paragraph (4) shall apply to elections made on or after the enactment of this Act. (D) The amendment made by paragraph (5) shall apply as if included in the enactment of section 9401 of the Omnibus Budget Reconciliation Act of 1986. SEC. 4102. HOME AND COMMUNITY-BASED SERVICES FOR THE ELDERLY. (a) In General.— (1) Section 1915 of the Social Security Act (42 U.S.C. 1396n) is amended— (A) by transferring subsection (d) to the end of such section and redesignating it as subsection (h), and (B) by inserting after subsection (c) the following new subsection: “(d) (1) Subject to paragraph (2), the Secretary shall grant a waiver to provide that a State plan approved under this title shall include as ‘medical assistance’ under such plan payment for part or all of the cost of home or community-based services (other than room and board) which are provided pursuant to a written plan of care to individuals 65 years of age or older with respect to whom there has been a determination that but for the provision of such services the individuals would be likely to require the level of care provided in a skilled nursing facility or intermediate care facility the cost of which could be reimbursed under the State plan. “(2) A waiver shall not be granted under this subsection unless the State provides assurances satisfactory to the Secretary that— “(A) necessary safeguards (including adequate standards for provider participation) have been taken to protect the health and welfare of individuals provided services under the waiver and to assure financial accountability for funds expended with respect to such services; “(B) with respect to individuals 65 years of age or older who— “(i) are entitled to medical assistance for skilled nursing or intermediate care facility services under the State plan, “(ii) may require such services, and “(iii) may be eligible for such home or community-based services under such waiver, the State will provide for an evaluation of the need for such skilled nursing facility or intermediate care facility services; and “(C) such individuals who are determined to be likely to require the level of care provided in a skilled nursing facility or intermediate care facility are informed of the feasible alter-natives to the provision of skilled nursing facility or intermediate care facility services, which such individuals may choose if available under the waiver. Each State with a waiver under this subsection shall provide to the Secretary annually, consistent with a reasonable data collection plan designed by the Secretary, information on the impact of the waiver granted under this subsection on the type and amount of medical assistance provided under the State plan and on the health and welfare of recipients. “(3) A waiver granted under this subsection may include a waiver of the requirements of section 1902(a)(1) (relating to statewideness), section 1902(a)(10)(B) (relating to comparability), and section 1902(a)(10)(C)(i)(III) (relating to income and resource rules applicable in the community). Subject to a termination by the State (with notice to the Secretary) at any time, a waiver under this subsection shall be for an initial term of 3 years and, upon the request of a State, shall be extended for additional 5-year periods unless the Secretary determines that for the previous waiver period the assurances provided under paragraph (2) have not been met. A waiver may provide, with respect to post-eligibility treatment of income of all individuals receiving services under the waiver, that the maximum amount of the individual’s income which may be disregarded for any month is equal to the amount that may be allowed for that purpose under a waiver under subsection (c). “(4) A waiver under this subsection may, consistent with paragraph (2), provide medical assistance to individuals for case management services, homemaker/home health aide services and personal care services, adult day health services, respite care, and other medical and social services that can contribute to the health and well-being of individuals and their ability to reside in a community-based care setting. “(5) (A) In the case of a State having a waiver approved under this subsection, notwithstanding any other provision of section 1903 to the contrary, the total amount expended by the State for medical assistance with respect to skilled nursing facility services, intermediate care facility services, and home and community-based services under the State plan for individuals 65 years of age or older during a waiver year under this subsection may not exceed the projected amount determined under subparagraph (B). “(B) For purposes of subparagraph (A), the projected amount under this subparagraph is the sum of the following: “(i) The aggregate amount of the State’s medical assistance under this title for skilled nursing facility services and intermediate care facility services furnished to individuals who have attained the age of 65 for the base year increased by a percentage which is equal to the lesser of 7 percent times the number of years beginning after the base year and ending before the waiver year involved or the sum of— “(I) the percentage increase (based on an appropriate market-basket index representing the costs of elements of such services) between the base year and the waiver year involved, plus “(II) the percentage increase between the base year and the waiver year involved in the number of residents in the State who have attained the age of 65, plus “(III) 2 percent for each year beginning after the base year and ending before the waiver year. “(ii) The aggregate amount of the State’s medical assistance under this title for home and community-based services for individuals who have attained the age of 65 for the base year increased by a percentage which is equal to the lesser of 7 percent times the number of years beginning after the base year and ending before the waiver year involved or the sum of— “(I) the percentage increase (based on an appropriate market-basket index representing the costs of elements of such services) between the base year and the waiver year involved, plus “(II) the percentage increase between the base year and the waiver year involved in the number of residents in the State who have attained the age of 65, plus “(III) 2 percent for each year beginning after the base year and ending before the waiver year, “(iii) The Secretary shall develop and promulgate by regulation Regulations. (by not later than October 1, 1989)— “(I) a method, based on an index of appropriately weighted indicators of changes in the wages and prices of the mix of goods and services which comprise both skilled nursing facility services and intermediate care facility services (regardless of the source of payment for such services), for projecting the percentage increase for purposes of clause (i)(I); “(II) a method, based on an index of appropriately weighted indicators of changes in the wages and prices of the mix of goods and services which comprise home and community-based services (regardless of the source of payment for such services), for projecting the percentage increase for purposes of clause (ii)(I); and “(III) a method for projecting, on a State specific basis, the percentage increase in the number of residents in each State who are over 75 years of age for any period. Effective on and after the date the Secretary promulgates the regulation under clause (iii), any reference in this subparagraph to the ‘lesser of 7 percent’ shall be deemed to be a reference to the ‘greater of 7 percent’. “(C) In this paragraph: “(i) The term ‘home and community-based services’ includes services described in sections 1905(a)(7) and 1905(a)(8), services described in subsection (c)(4)(B), services described in paragraph (4)(B), personal care services, and services furnished pursuant to a waiver under subsection (c). “(ii) (I) Subject to subclause (II), the term ‘base year’ means the most recent year (ending before the date of the enactment of this subsection) for which actual final expenditures under this title have been reported to, and accepted by, the Secretary. “(II) For purposes of subparagraph (C), in the case of a State that does not report expenditures on the basis of the age categories described in such subparagraph for a year ending before the date of the enactment of this subsection, the term ‘base year’ means fiscal year 1989. “(iii) The term ‘intermediate care facility services’ does not include services furnished in an institution certified in accordance with section 1905(d). “(6) (A) A determination by the Secretary to deny a request for a waiver (or extension of waiver) under this subsection shall be subject to review to the extent provided under section 1116(b). “(B) Notwithstanding any other provision of this Act, if the Secretary denies a request of the State for an extension of a waiver under this subsection, any waiver under this subsection in effect on the date such request is made shall remain in effect for a period of not less than 90 days after the date on which the Secretary denies such request (or, if the State seeks review of such determination in accordance with subparagraph (A), the date on which a final determination is made with respect to such review).”. (2) The amendments made by paragraph (1) shall become Effective date. 42 USC 1396n note. effective on January 1, 1988. (b) Conforming Amendments.— (1) Section 1902(a)(10)(A)(ii)(VI) of such Act (42 U.S.C. 1396a(a)(10)(A)(ii)(VI)) is amended by striking “section 1915(c)” each place it appears and inserting “subsection (c) or (d) of section 1915”. (2) Section 1915(h) of such Act, as redesignated by subsection (a), is amended by striking “(c)” and inserting in lieu thereof “(c) or (d)”. (c) Extension of Waiver.— In the case of a State which, as of 42 USC 1396n note. December 1, 1987, has a waiver approved with respect to elderly individuals under section 1915(c) of the Social Security Act, which waiver is scheduled to expire before July 1, 1988, if the State notifies the Secretary of Health and Human Services of the State’s intention to file an application for a waiver under section 1915(d) of such Act (as amended by subsection (a) of this section), the Secretary shall extend approval of the State’s waiver, under section 1915(c) of such Act, on the same terms and conditions through September 30, 1988. SEC. 4103. PHYSICIANS’ SERVICES FURNISHED BY DENTISTS. (a) Clarifying Coverage.— Section 1905(a)(5) of the Social Security Act (42 U.S.C. 1396d(a)(5)) is amended by inserting “(A)” after “(5)” and by inserting before the semicolon at the end the following: “, and (B) medical and surgical services furnished by a dentist (described in section 1861(r)(2)) to the extent such services may be performed under State law either by a doctor of medicine or by a doctor of dental surgery or dental medicine and would be described in subparagraph (A) if furnished by a physician (as defined in section 1861(r)(1))”. (b) Effective Date.— (1) The amendment made by subsection (a) applies (except as provided under paragraph (2)) to payments under title XIX of the Social Security Act for calendar quarters beginning on or after January 1, 1988, without regard to whether or not final regulations to carry out such amendment have been promulgated by such date. (2) In the case of a State plan for medical assistance under title XIX of the Social Security Act which the Secretary of Health and Human Services determines requires State legislation (other than legislation appropriating funds) in order for the plan to meet the additional requirement imposed by the amendment made by subsection (a), the State plan shall not be regarded as failing to comply with the requirements of such title solely on the basis of its failure to meet this additional requirement before the first day of the first calendar quarter beginning after the close of the first regular session of the State legislature that begins after the date of enactment of this Act. SEC. 4104. OPTIONAL MEDICAID COVERAGE OF INDIVIDUALS IN CERTAIN STATES RECEIVING ONLY OPTIONAL STATE SUPPLEMENTARY PAYMENTS. Section 1902(a)(10)(A){ii) of the Social Security Act (42 U.S.C. 1396a(a)(10)(A)(ii)) is amended— (1) by striking “or” at the end of subclause (IX) and inserting “or” at the end of subclause (X); and (2) by adding at the end the following new subclause: “(XI) who receive only an optional State supplementary payment based on need and paid on a regular basis, equal to the difference between the individual’s countable income and the income standard used to determine eligibility for such supplementary payment (with countable income being the income remaining after deductions as established by the State pursuant to standards that are more restrictive than the standards for supplementary security income benefits under title XVI), which are available to all individuals in the State (but which may be based on different income standards by political subdivision according to cost of living differences), and which are paid by a State that does not have an agreement with the Secretary under section 1616 or 1634.”. SEC. 4105. CLARIFICATION OF COVERAGE OF CLINIC SERVICES FURNISHED TO HOMELESS OUTSIDE FACILITY. (a) In General.— Section 1905(a)(9) of the Social Security Act (42 U.S.C. 1396d(a)(9)) is amended by inserting before the semicolon at the end the following: “, including such services furnished outside the clinic by clinic personnel to an eligible individual who does not reside in a permanent dwelling or does not have a fixed home or mailing address”. (b) Effective Date.— The amendment made by subsection (a) 42 USC 1396d note. shall apply to services furnished on or after January 1, 1988, without regard to whether regulations to implement such amendment are promulgated by such date. SEC. 4106. MEDICALLY NEEDY INCOME LEVELS FOR CERTAIN 2-MEMBER COUPLES IN CALIFORNIA. For purposes of section 1903(f)(1)(B) of the Social Security Act, for payments made to California on or after July 1, 1983, in the case of a family consisting only of two individuals both of whom are adults and at least one of whom is aged, blind, or disabled, the "highest amount which would ordinarily be paid to a family of the same size" under the State’s plan approved under part A of title IV of such Act shall, at California’s option, be the amount determined by the State agency to be the amount of the aid which would ordinarily be payable under such plan to a family which consists of one adult and two children and which is without any income or resources. Section 1902(a)(10)(C)(i)(III) of the Social Security Act shall not prevent California from establishing (under the previous sentence) an applicable income limitation for families described in that sentence which is greater than the income limitation applicable to other families, if California has an applicable income limitation under section 1903(f) of such Act which is equal to the maximum applicable income limitation permitted consistent with paragraph (1)(B) of such section for families other than those described in the previous sentence. PART 2— OTHER PROVISIONS SEC. 4111. INCREASING THE MAXIMUM ANNUAL MEDICAID PAYMENTS THAT MAY BE MADE TO THE COMMONWEALTHS AND TERRITORIES. (a) In General.— Subsection (c) of section 1108 of the Social Security Act (42 U.S.C. 1308) is amended to read as follows: “(c) The total amount certified by the Secretary under title XIX with respect to a fiscal year for payment to— “(1) Puerto Rico shall not exceed (A) $73,400,000 for fiscal year 1988, (B) $76,200,000 for fiscal year 1989, and (C) $79,000,000 for fiscal year 1990 (and each succeeding fiscal year); “(2) the Virgin Islands shall not exceed (A) $2,430,000 for fiscal year 1988, (B) $2,515,000 for fiscal year 1989, and (C) $2,600,000 for fiscal year 1990 (and each succeeding fiscal year); “(3) Guam shall not exceed (A) $2,320,000 for fiscal year 1988, (B) $2,410,000 for fiscal year 1989, and (C) $2,500,000 for fiscal year 1990 (and each succeeding fiscal year); “(4) the Northern Mariana Islands shall not exceed (A) $636,700 for fiscal year 1988, (B) $693,350 for fiscal year 1989, and (C) $750,000 for fiscal year 1990 (and each succeeding fiscal year); and “(5) American Samoa shall not exceed (A) $1,330,000 for fiscal year 1988, (B) $1,390,000 for fiscal year 1989, and (C) $1,450,000 for fiscal year 1990 (and each succeeding fiscal year).”. (b) Effective Date.— The amendment made by subsection (a) 42 USC 1308 note. shall apply to payments for fiscal years beginning with fiscal year 1988. SEC. 4112. ADJUSTMENT IN MEDICAID PAYMENT FOR INPATIENT HOSPITAL SERVICES FURNISHED BY DISPROPORTIONATE SHARE HOSPITALS. (a) Implementation of Requirement.— (1) A State’s plan under title XIX of the Social Security Act shall not be considered to meet the requirement of section 1902(a)(13)(A) of such Act (insofar as it requires payments to hospitals to take into account the situation of hospitals which serve a disproportionate number of low income patients with special needs), as of July 1, 1988, unless the State has submitted to the Secretary of Health and Human Services, by not later than such date, an amendment to such plan that— (A) specifically defines the hospitals so described (and includes in such definition any disproportionate share hospital described in subsection (b)(1) which meets the requirement of subsection (d)), and (B) provides, effective for inpatient hospital services provided not later than July 1, 1988, for an appropriate increase in the rate or amount of payment for such services provided by such hospitals, consistent with subsection (c). (2) (A) In order to be considered to have met such requirement of section 1902(a)(13)(A) as of July 1, 1989, the State must submit to the Secretary of Health and Human Services by not later than such date, the State plan amendment described in paragraph (1), consistent with subsection (c). (B) In order to be considered to have met such requirement of section 1902(a)(13)(A) as of July 1, 1990, the State must submit to the Secretary of Health and Human Services by not later than such date, the State plan amendment described in paragraph (1), consistent with subsection (c). The Secretary shall, not later than June 30 of each year in which the State is required to submit an amendment under this subsection, review each such amendment for compliance with such requirement and by such date shall approve or disapprove each such amendment. If the Secretary disapproves such an amendment, the State shall immediately submit a revised amendment which meets such requirement. The requirement of this subsection may not be waived under section 1915(b)(4) of the Social Security Act. (b) Hospitals Deemed Disproportionate Share.— (1) For purposes of subsection (a)(1), a hospital which meets the requirement of subsection (d) is deemed to be a disproportionate share hospital if— (A) the hospital’s medicaid inpatient utilization rate (as defined in paragraph (2)) is at least one standard deviation above the mean medicaid inpatient utilization rate for hospitals receiving medicaid payments in the State; or (B) the hospital’s low-income utilization rate (as defined in paragraph (3)) exceeds 25 percent. (2) For purposes of paragraph (1)(A), the term “medicaid inpatient utilization rate” means, for a hospital, a fraction (expressed as a percentage), the numerator of which is the hospital’s number of inpatient days attributable to patients who (for such days) were eligible for medical assistance under the State plan approved under title XIX of the Social Security Act in a period, and the denominator of which is the total number of the hospital’s inpatient days in that period. (3) For purposes of paragraph (1)(B), the term “low-income utilization rate” means, for a hospital, the sum of— (A) the fraction (expressed as a percentage)— (i) the numerator of which is the sum (for a period) of (I) the total revenues paid the hospital for patient services under a State plan under title XIX of the Social Security Act and (II) the amount of the cash subsidies for patient services received directly from State and local governments, and (ii) the denominator of which is the total amount of revenues of the hospital for patient services (including the amount of such cash subsidies) in the period; and (B) a fraction (expressed as a percentage)— (i) the numerator of which is the total amount of the hospital’s charges for inpatient hospital services which are attributable to charity care in a period, and (ii) the denominator of which is the total amount of the hospital’s charges for inpatient hospital services in the hospital in the period. The numerator under subparagraph (B)(i) shall not include contractual allowances and discounts (other than for indigent patients not eligible for medical assistance under a State plan approved under title XIX of the Social Security Act). (c) Payment Adjustment.— In order to be consistent with this subsection, a payment adjustment for a disproportionate share hospital must either— (1) be in an amount equal to the product of (A) the amount paid under the State plan to the hospital for operating costs for inpatient hospital services (of the kind described in section 1886(a)(4)), and (B) the hospital’s disproportionate share adjustment percentage (established under section 1886(d)(5)(F)(iv)); or (2) provide for a minimum specified additional payment amount (or increased percentage payment) and for an increase in such a payment amount (or percentage payment) in proportion to the percentage by which the hospital’s medicaid utilization rate (as defined in subsection (b)(2)) exceeds one standard deviation above the mean medicaid inpatient utilization rate for hospitals receiving medicaid payments in the State; except that, for purposes of paragraphs (2)(A) and (2)(B), the payment adjustment for a disproportionate share hospital is consistent with this subsection if the appropriate increase in the rate or amount of payment is equal to one-third of the increase otherwise applicable under subsection (c) (in the case of paragraph (2)(A)) and two-thirds of such increase (in the case of paragraph (2)(B)). (d) Requirement to 5151Copy read “to”. Qualify as Disproportionate Share Hospital.— (1) Except as provided in paragraph (2), no hospital may be defined or deemed as a disproportionate share hospital under a State plan under title XIX of the Social Security Act or under subsection (b) of this section unless the hospital has at least 2 obstetricians who have staff privileges at the hospital and who have agreed to provide obstetric services to individuals who are entitled to medical assistance for such services under such State plan. (2) (A) Paragraph (1) shall not apply to a hospital— (i) the inpatients of which are predominantly individuals under 18 years of age; or (ii) which does not offer nonemergency obstetric services to the general population as of the date of the enactment of this Act. (B) In the case of a hospital located in a rural area (as defined for purposes of section 1886 of the Social Security Act), in paragraph (1) the term “obstetrician” includes any physician with staff privileges at the hospital to perform nonemergency obstetric procedures. (e) Special Rule.— A State plan shall be considered to meet the requirement of section 1902(a)(13)(A) (insofar as it requires payments to hospitals to take into account the situation of hospitals which serve a disproportionate number of low income patients with special needs) without regard to the requirement of subsection (a) if the plan provided for payment adjustments for disproportionate share hospitals as of January 1, 1984, and if the aggregate amount of the payment adjustments under the plan for such hospitals is not less than the aggregate amount of such adjustments otherwise required to be made under such subsection. SEC. 4113. HMO-RELATED PROVISIONS. (a) Treatment of Garden State Health Plan.— (1) Section 1903(m) of the Social Security Act (42 U.S.C. 42 USC 1396b. 1396(m)) is amended— (A) by adding at the end the following new paragraph: “(6) (A) For purposes of this subsection and section 1902(eX2KA), in Contracts. the case of the State of New Jersey, the term ‘contract’ shall be deemed to include an undertaking by the State agency, in the State plan under this title, to operate a program meeting all requirements of this subsection. “(B) The undertaking described in subparagraph (A) must provide— “(i) for the establishment of a separate entity responsible for the operation of a program meeting the requirements of this subsection, which entity may be a subdivision of the State agency administering the State plan under this title; “(ii) for separate accounting for the funds used to operate such program; “(iii) for setting the capitation rates and any other payment rates for services provided in accordance with this subsection using a methodology satisfactory to the Secretary designed to ensure that total Federal matching payments under this title for such services will be lower than the matching payments that would be made for the same services, if provided under the State plan on a fee for service basis to an actuarially equivalent population; and “(iv) that the State agency will contract, for purposes of Contracts. meeting the requirement under section 1902(a)(30)(C), with an organization or entity that under section 1154 reviews services provided by an eligible organization pursuant to a contract under section 1876 for the purpose of determining whether the quality of services meets professionally recognized standards of health care. “(C) The undertaking described in subparagraph (A) shall be Contracts. subject to approval (and annual re-approval) by the Secretary in the same manner as a contract under this subsection. “(D) The undertaking described in subparagraph (A) shall not be eligible for a waiver under section 1915(b).”; and (B) in paragraph (2)(F), by striking all that precedes “a State plan may restrict” and inserting the following: 5252Copy read “ ‘(F)”.“(E) In the case of— 5353Copy read “(i)”. “(i) a contract with an entity described in subparagraph (G) Contracts. or with a qualified health maintenance organization (as defined in section 1310(d) of the Public Health Service Act) which meets the requirement of subparagraph (A)(ii), or “(ii) a program pursuant to an undertaking described in paragraph (6) in which at least 25 percent of the membership enrolled on a prepaid basis are individuals who (I) are not insured for benefits under part B of title XVIII or eligible for benefits under this title, and (II) (in the case of such individuals whose prepayments are made in whole or in part by any government entity) had the opportunity at the time of enrollment in the program to elect other coverage of health care costs that would have been paid in whole or in part by any governmental entity,”. (2) Section 1902(e)(2)(A) of such Act (42 U.S.C. 1396a(e)(2)(A)) is amended by striking “section 1903(m)(2)(G)” and inserting “paragraph (2)(G) or (6) of section 1903(m)”. (b) Medicaid Matching Rate for Quality Review of HMO Services.— (1) Section 1902(a)(30)(C) of such Act (42 U.S.C. 1396a(a)(30)(C)) is amended by inserting “, an entity which meets the requirements of section 1152, as determined by the Secretary,” after “title XI)”. (2) Section 1902(d) of such Act (42 U.S.C. 1396a(d)) is amended— (i) by inserting after “contracts with” the following: “an Contracts. entity which meets the requirements of section 1152, as determined by the Secretary, for the performance of the quality review functions described in subsection (a)(30)(C), or”, and (ii) by striking “organization (or organizations)” each place it appears and inserting “such an entity or organization”. (3) Section 1903(a)(3)(C) of such Act (42 U.S.C. 1396b(a)(3)(C)) is amended by inserting “or by an entity which meets the requirements of section 1152, as determined by the Secretary,” after “utilization and quality control peer review organization”. (c) Freedom of Choice.— (1) Section 1902(a)(23) of such Act (42 U.S.C. 1396a(a)(23)) is amended— (A) by inserting “(A)” after “Guam, provide that”, and (B) by inserting before the semicolon at the end the following: “, and (B) an enrollment of an individual eligible for medical assistance in a primary care case-management system (described in section 1915(b)(1)), a health maintenance organization, or a similar entity shall not restrict the choice of the qualified person from whom the individual may receive services under section 1905(a)(4)(C)”. (2) Section 1902(e)(2)(A) of such Act (42 U.S.C. 1396a(e)(2)(A)) is amended by striking “but only” and inserting “but, except for benefits furnished under section 1905(a)(4)(C), only”. (3) The amendments made by this subsection shall apply to Effective date. 42 USC 1396a note . services furnished on and after July 1, 1988. (d) Technical Amendments.— (1) Section 1903(m)(2)(F) of such Act (42 U.S.C. 1396b(m)(2)(F)) is amended by striking “subparagraph (G)” and inserting “subparagraphs (E) or (G)”. (2) Section 1902(e)(2)(A) of such Act (42 U.S.C. 1396a(e)(2)(A)) is amended by striking “section 1903(m)(2)(G)” and inserting “subparagraph (B)(iii), (E), or (G) of section 1903(m)(2)”. (e) Continued Eligibility and Restriction on Disenrollment Without Cause for Metropolitan Health Plan HMO.— For purposes of sections 1902(e)(2)(A) and 1903(m)(2)(F) of the Social Security Act, the Metropolitan Health Plan HMO operated by the New York City public hospitals shall be treated in the same manner as a qualified health maintenance organization (as defined in section 1310(d) of the Public Health Service Act). SEC. 4114. MEDICAID WAIVER FOR HOSPICE CARE FOR AIDS PATIENTS. Section 1905(o)(1) of the Social Security Act (42 U.S.C. 1396d(o)(1)) is amended— (1) by inserting “(A)” after “(1)”; (2) by striking “The” and inserting “Subject to subparagraph (B), the”; and (3) by adding at the end the following new subparagraph: “(B) For purposes of this title only, with respect to the definition of hospice program under section 1861(dd)(2), the Secretary may allow an agency or organization to make the assurance under subparagraph (A)(iii) of such section without taking into account any individual who is afflicted with acquired immunodeficiency syndrome.”. SEC. 4115. STATE DEMONSTRATION PROJECTS. (a) Extension of Arizona Health Care Demonstration Project.— (1) Notwithstanding any limitations contained in section 1115 of the Social Security Act, but subject to paragraphs (2) and (3) of this subsection, the Secretary of Health and Human Services (in this subsection referred to as the “Secretary”) upon application shall renew until September 30, 1989, approval of demonstration project number 11-P-98239/9–05 (“Arizona Health Care Cost Containment System—AHCCCS—A statewide approach to cost effective health care financing”), including all waivers granted by the Secretary under such section 1115 as of September 30, 1987. (2) The Secretary’s renewed approval of the project under paragraph (1) shall— (A) subject to paragraph (3) be on the same terms and conditions that existed between the applicant and the Secretary as of September 30, 1987; and (B) remain in effect through September 30, 1989, unless the Secretary finds that the applicant no longer complies with such terms and conditions. (3) Nothing in this subsection shall be construed to prohibit or require the Secretary from granting additional waivers to the applicant— (A) for coverage of additional optional groups, and (B) for coverage of long-term care and other services which were not covered as of September 30, 1987. (b) New York State Pilot Program for Prenatal, Maternity, and Newborn Care.— (1) Upon application by the State of New York and approval by the Secretary of Health and Human Services (in this subsection referred to as the “Secretary”), the State of New York (in this subsection referred to as the “State”) may conduct a demonstration project in accordance with this subsection for the purpose of testing its Prenatal/Maternity/Newborn Care Pilot Program (in this subsection referred to as the “Program”), as the Program is set forth in the Prenatal Care Act of 1987 (enacted by the State in February 1987), as an alternative to existing Federal programs. (2) Under the demonstration project conducted under this subsection— (A) any individual who receives benefits under the Program shall not receive any of such benefits under the plan of the State under title XIX of the Social Security Act; and (B) the Secretary shall make payments to the State with respect to individuals receiving benefits under the Program in the same amounts as would be payable for such benefits under title XIX of the Social Security Act if such individ-uals were receiving such benefits under such title (as determined by the Secretary). (3) The Secretary may (with respect to the demonstration project under this subsection) waive compliance with any requirement contained in section 1902(a)(1), 1902(a)(10)(B), 1902(a)(17)(D), 1902(a)(23), 1902(a)(30), or 1903(f) of the Social Security Act which (if applied) would prevent the State from carrying out the project, effectively achieving its purpose, or receiving payments in accordance with paragraph (2)(B). (4) As a condition of approval of the demonstration project under this subsection, the State shall provide assurances satisfactory to the Secretary that— (A) the State will continue to make benefits available under title XIX of the Social Security Act to all pregnant women entitled to receive benefits under such title to the extent such benefits are not provided under the Program; and (B) the State has in effect a quality assurance mechanism to ensure the quality and accessibility of the services furnished under the program. (5) (A) The demonstration project under this subsection shall be conducted for a period not to exceed three years. (B) The Secretary shall conduct an evaluation of the demonstration Reports. project under this subsection and shall report the results of such evaluation to the Congress not later than one year after completion of the project. (c) Waivers for Family Independence Program.— Upon approval of the demonstration project relating to the Family Independence Program in the State of Washington and with respect to such project, the Secretary of Health and Human Services shall waive compliance with any requirements of sections 1902(a)(1), 1916, and 1924 of the Social Security Act, but only to the extent necessary to enable the State to carry out the project as enacted by the State of Washington in May 1987. SEC. 4116. WAIVER AUTHORITY UNDER THE MEDICAID PROGRAM FOR THE NORTHERN MARIANA ISLANDS. Section 1902(j) of the Social Security Act (42 U.S.C. 1396a(j)) is amended— (1) by inserting “and the Northern Mariana Islands” after “American Samoa” the first place it appears; and (2) by inserting “or the Northern Mariana Islands” after “American Samoa” the second place it appears. SEC. 4118. TECHNICAL AND MISCELLANEOUS AMENDMENTS. (a) Section 2176 Waiver Technicals.— (1) Section 1915(c)(3) of the Social Security Act (42 U.S.C. 1396n(c)(3)) is amended by striking “and section 1902(a)(10)(B) (relating to comparability)” and inserting “, section 1902(a)(10)(B) (relating to comparability), and section 1902(a)(10)(C)(i)(III) (relating to income and resource rules applicable in the community)”. (2) The amendment made by paragraph (1) shall be effective 42 USC 1396n note. as if included in the enactment of the Omnibus Budget Reconciliation Act of 1986. (b) Increase in Number of Individuals Who May 5454Copy read “who may”. be Served Under Model Home and Community-Based Services Waivers.— Section 1915(c) of the Social Security Act (42 U.S.C. 1396n(c)) is amended by adding at the end the following new paragraph: “(10) No waiver under this subsection shall limit by an amount less than 200 the number of individuals in the State who may receive home and community-based services under such waiver.”. (c) Katie Beckett Technical.— (1) Section 1902(e)(3)(C) of such Act (42 U.S.C. 1396a(e)(3)(C)) is amended by striking “to have a supplemental security income (or State supplemental) payment made with respect to him under title XVI” and inserting “for medical assistance under the State plan under this title”. (2) The amendment made by paragraph (1) shall be effective 42 USC 1396a note. as if it were included in section 134 of the Tax Equity and Fiscal Responsibility Act of 1982. (d) Organ Transplant Technical.— (1) Section 1903(i) of the Social Security Act (42 U.S.C. 1396b(i)) is amended— (A) in paragraph (1), by striking the period at the end and inserting “; or”, and (B) by adding at the end the following new sentence: “Nothing in paragraph (1) shall be construed as permitting a State to provide services under its plan under this title that are not reasonable in amount, duration, and scope to achieve their purpose.”. (2) The amendments made by paragraph (1) shall be effective Effective date. 42 USC 1396b note. as if included in the enactment of section 9507 of the Consolidated Omnibus Budget Reconciliation Act of 1985. (e) Civil Money Penalty and Exclusion Clarifications.— (1) Section 1128A(a)(1) of the Social Security Act (42 U.S.C. 1320a–7(a)(1)), as amended by section 3(a)(1) of the Medicare and Medicaid Patient and Program Protection Act of 1987 (Public Law 100–93), is amended by striking “or has reason to know” 42 USC 1320a–7a. each place it appears and inserting “or should know”. (2) Section 1128(d)(3)(B) of the such Act (42 U.S.C. 1320a–6(d)(3)(B)), as amended by section 2 of the Medicare and Medicaid Patient and Program Protection Act of 1987 (Public Law 100–93), is amended— (A) by inserting “(i)” after “(B)”, and 42 USC 1320a–7. (B) by adding at the end the following new clause: “(ii) A State health care program may provide for a period of exclusion which is longer than the period of exclusion under a program under title XVIII.”. (3) The amendment made by paragraph (1) shall apply to Effective date. 42 USC 1320a–7a note. activities occurring before, on, or after the date of the enactment of this Act. (f) Incorporation of Certain Provisions Relating to Indian Health Service Facilities.— (1) Section 1911 of the Social Security Act (42 U.S.C. 1396j), as amended by section 4111(g)(8) of this title, is amended— (A) by striking “or nursing facility” each place it appears and inserting “, nursing facility, or any other type of facility which provides services of a type otherwise covered under the State plan”; and (B) by adding at the end the following new subsection: “(c) The Secretary is authorized to enter into agreements with the State agency for the purpose of reimbursing such agency for health care and services provided in Indian Health Service facilities to Indians who are eligible for medical assistance under the State plan.”. 5555Subparagraph “ “(c)” indented incorrectly. (2) The amendments made by paragraph (1) shall apply to Effective date. 42 USC 1396j note. health care services performed on or after the date of the enactment of this Act. (g) Frail Elderly Demonstration Project Waivers.— (1) Section 9412(b)(2) of the Omnibus Budget Reconciliation Act of 1986 is amended— 100 Stat. 2063. (A) in subparagraph (A), by inserting before the period at the end the following: “, including permitting the organization to assume progressively (over the initial 3-year period of the waiver) the full financial risk”, and (B) in subparagraph (B), by striking “be awarded a grant from the Robert Wood Johnson Foundation” and insert “participate in an organized initiative to replicate the findings of the On Lok long-term care demonstration project (described in section 603(c)(1) of the Social Security Amendments of 1983)”. (2) The amendments made by paragraph (1) shall take effect Effective date. as though it were included in the Omnibus Budget Reconciliation Act of 1986. (h) Medically Needy Incurred Expenses. (1) Section 1902(a)(17) of the Social Security Act (42 U.S.C. 1396a(a)(17)) is amended by striking “(whether in the form of insurance premiums or otherwise)” and inserting “(whether in the form of insurance premiums or otherwise and regardless of whether such costs are reimbursed under another public program of the State or political subdivision thereof)”. (2) The amendment made by paragraph (1) shall apply to costs Effective date. 42 USC 1396a note. incurred after the date of the enactment of this Act. (i) Qualifications for Case Managers for Individuals With Development Disabilities and Chronic Mental Illness.— (1) Section 1915(g)(1) of such Act (42 U.S.C. 1396n(g)(l)) is amended by adding at the end the following new sentence: “The State may limit the case managers available with respect to case management services for eligible individuals with developmental disabilities or with chronic mental illness in order to ensure that the case managers for such individuals are capable of ensuring that such individuals receive needed services.”. (2) The amendment made by paragraph (1) shall take effect as Effective date. 42 USC 1396n note. though it were included in the enactment of the Consolidated Omnibus Budget Reconciliation Act of 1985. (j) Habilitation Services Effective Date.— Effective as if included 42 USC 1396n note. in the enactment of section 9502 of the Consolidated Omni-bus Budget Reconciliation Act of 1985, subsection (j)(1) of such section is amended by inserting before the period at the end the following: “to individuals eligible for services under a waiver granted under section 1915(c) of the Social Security Act, without regard to whether such individuals were receiving institutional services before their participation in the waiver”. (k) Section 2176 Waiver for Institutionalized Developmentally Disabled.— Section 1915(c)(7) of the Social Security Act (42 U.S.C. 1396n(c)(7)) is amended by inserting “(A)” after “(7)” and adding at the end the following new subparagraph: “(B) In making estimates under paragraph (2)(D) in the case of a waiver that applies only to individuals with developmental disabilities who are inpatients in a skilled nursing facility or intermediate care facility and whom the State has determined, on the basis of an evaluation under paragraph (2)(B), to need the level of services provided by an intermediate care facility for the mentally retarded, the State may determine the average per capita expenditures that would have been made in a fiscal year for those individuals under the State plan on the basis of the average per capita expenditures under the State plan for services to individuals who are inpatients in an intermediate care facility for the mentally retarded.”. (l) Renewal of Freedom-Of-Choice Waivers.— (1) Section 1915(h) of such Act (42 U.S.C. 1396n(h)) is amended by striking “denies such request in writing within 90 days after the date of its submission to the Secretary.” and inserting “, within 90 days after the date of its submission to the Secretary, either denies such request in writing or informs the State agency in writing with respect to any additional information which is needed in order to make a final determination with respect to the request. After the date the Secretary receives such additional information, the request shall be deemed granted unless the Secretary, within 90 day of such date, denies such request.”. (2) The amendment made by paragraph (1) shall apply to Effective date. 42 USC 1396n note. requests for continuation of waivers received after the date of the enactment of this Act. (m) Repeal of Coordinated Audit Requirement.— (1) (A) Section 1129 of such Act (42 U.S.C. 1320a–8) is repealed. (B) Section 1902(a)(42) of such Act (42 U.S.C. 1396a(a)(42)) is amended— (i) by striking “(A)”, and (ii) by striking “, (B)” and all that follows up to the semicolon at the end. (2) The amendments made by paragraph (1) shall apply to Effective date. 42 USC 1396a note. audits conducted after the date of the enactment of this Act. (n) Temporary Technical Error Definition.— For purposes of 42 USC 1396b note. section 1903(u)(1)(E)(ii) of the Social Security Act, effective for the period beginning on the date of enactment of this Act and ending December 31, 1988, a “technical error” 5656Copy read “ ‘technical error’ ”. is an error in eligibility condition (such as assignment of social security numbers and assignment of rights to third-party benefits as a condition of eligibility) that, if corrected, would not result in a difference in the amount of medical assistance paid. (o) Technical Amendments Relating to New Jersey Respite Care Pilot Project.— (1) Section 9414(b) of the Omnibus Budget Reconciliation Act of 1986 is amended— 100 Stat. 2064. (A) by redesignating paragraphs (2), (3), and (4), as paragraphs (3), (4), and (5), respectively, (B) by inserting after paragraph (1) the following new paragraph: “(2) provide that the State may submit a detailed proposal describing the project (in lieu of a formal request for the waiver of applicable provisions of title XIX of the Social Security Act) and that submission of such a description by the State will be treated as such a request for purposes of subsection (g),”, and (C) in paragraph (3), as redesignated by 56a56aCopy read “by by”. paragraph (1) of this subsection, by striking “if the project” and all that follows through “Act” the second place it appears and inserting “the State shall utilize a post-eligibility cost-sharing formula based on the available income of participants with income in excess of the nonfarm 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)”. (2) (A) Section 9414(a) of the Omnibus Budget Reconciliation Act of 1986 is amended by striking “elderly and disabled individuals” and inserting “eligible individuals”. (B) Section 941(c) of the Omnibus Budget Reconciliation Act of 1986 is amended to read as follows: “(C) Definitions.— For purposes of this section— “(1) the term ‘eligible individual’ means an individual— “(A) who is elderly or disabled, “(B) (i) whose income (not including the income of the spouse or family of the individual) does not exceed 300 percent of the amount in effect under section 1611(a)(1)(A) of the Social Security Act (as increased pursuant to section 1617 of such Act), or “(ii) in the case of an individual and spouse who are both dependent on a caregiver, whose combined incomes do not exceed such amount, “(C) whose liquid resources (as declared by the individual) do not exceed $40,000, “(D) who is at risk of institutionalization unless the individual’s caregiver is provided with respite care, and “(E) who has been determined to meet the requirements of subparagraphs (A) through (D) in accordance with an application process designed by the State; and “(2) the term ‘respite care services’ shall include— “(A) short-term and intermittent— “(i) companion or sitter services (paid as well as volunteer), “(ii) homemaker and personal care-services, “(iii) adult day care, and “(iv) inpatient care in a hospital, a skilled nursing facility, or an intermediate care facility (not to exceed a total of 14 days for any individual), and “(B) peer support and training for family caregivers (using informal support groups and organized counseling).”. (3) Section 9414(g) of the Omnibus Budget Reconciliation Act of 1986 is amended by inserting “section 1902(a)(10)(C)(i)(III),” 100 Stat. 2064. after “section 1902(a)(10)(B),”. (4) The amendments made by this subsection shall be effective Effective date. as if included in the enactment of the Omnibus Budget Reconciliation Act of 1986. (p) Miscellaneous Technical Corrections.— (1) Subclause (IX) of section 1902(a)(10)(A)(ii) of the Social Security Act (42 U.S.C. 1396a(a)(10)(A)(ii)) is amended by moving it 4 ems to the right so as to align its left margin with that of subclause (VIII) of that section. (2) Subclause (X) of section 1902(a)(10)(A)(ii) of such Act (42 U.S.C. 1396a(a)(10)(A)(ii)) is amended by moving it 2 ems to the right so as to align its left margin with that of subclause (VIII) of that section. (3) Section 1902(a)(17) of such Act (42 U.S.C. 1396a(a)(17)) is amended by striking “subsection (1)(3)” and inserting “subsections (1)(3), (m)(4), and (m)(5)”. (4) Section 1902(a)(30)(C) of such Act (42 U.S.C. 1396(a)(30)(C)) 42 USC 1396a. is amended by striking “provide” and inserting “use”. (5) Section 1903(f)(4) of such Act (42 U.S.C. 1396b(f)(4)) is amended by inserting “, 1902(a)(10)(A)(ii)(X), or 1905(p)(1)” after “1902(a)(10)(A)(ii)(IX)”. (6) Paragraph (9) of section 1902(e) of such Act (42 U.S.C. 1396a(e)) is amended by moving the paragraph 2 ems to the left so as to align the left margin of subparagraph (A) (before clause (i)) and subparagraphs (B) and (C) with the left margin of paragraph (8). (7) Section 1902(1)(1) of such Act (42 U.S.C. 1396a(1)(1)) is amended— (A) by striking “(1)(1) Individuals” and inserting “(1)(1) Individuals”, (B) by moving the matter before subparagraph (A) 2 ems to the left so it is indented only once, and (C) by striking “, whose” and inserting “and whose”. (8) Sections 1902(1)(2), 1902(m)(2)(A), 1905(p)(2)(A), and 501(b)(2) of such Act (42 U.S.C. 1396a(1)(2), 1396a(m)(2)(A), 1396d(p)(2)(A), 701(b)(2)) are each amended by striking “nonfarm”. (9) Paragraphs (1) and (2) of section 1925(a), as redesignated by section (4111(a)) of this title, are amended to read as follows: 42 USC 1396s. “(1) AFDC.— (A) Section 402(a)(32) of this Act (relating to individuals who are deemed recipients of aid but for whom a payment is not made). “(B) Section 402(a)(37) of this Act (relating to individuals who lose AFDC eligibility due to increased earnings). “(C) Section 406(h) of this Act (relating to individuals who lose AFDC eligibility due to increased collection of child or spousal support). “(D) Section 414(g) of this Act (relating to certain individuals participating in work supplementation programs). “(2) SSI.— (A) Section 1611(e) of this Act (relating to treatment of couples sharing an accommodation in a facility). “(B) Section 1619 of this Act (relating to benefits for individuals who perform substantial gainful activity despite severe medical impairment). “(C) Section 1634(b) of this Act (relating to preservation of benefit status for disabled widows and widowers who lost SSI benefits because of 1983 changes in actuarial reduction formula). “(D) Section 1634(c) of this Act (relating to individuals who lose eligibility for SSI benefits due to entitlement to child’s insurance benefits under section 202(d) of this Act).”. (10) Effective as if included in the enactment of the Omnibus Effective date. 42 USC 1396n. Budget Reconciliation Act of 1986, section 9411(a)(2)(B) of such Act is amended by inserting “such” after “need for”. Subtitle C— Nursing Home Reform PART 1— MEDICARE PROGRAM SEC. 4201. REQUIREMENTS FOR SKILLED NURSING FACILITIES. (a) Specification of Facility Requirements.— Title XVIII of the Social Security Act is amended— (1) by amending subsection (j) of section 1861 (42 U.S.C. 1395x) to read as follows: “Skilled Nursing Facility “(j) The term ‘skilled nursing facility’ has the meaning given such term in section 1819(a).”; (2) by adding at the end of section 1864 (42 U.S.C. 1395aa) the following new subsection: “(d) The Secretary may not enter an agreement under this section Contracts. with a State with respect to determining whether an institution therein is a skilled nursing facility unless the State meets the requirements specified in section 1819(e).”; and (3) by adding at the end of part A the following new section: “requirements for, and assuring quality of care in, skilled nursing facilities “Sec. 1819. (a) Skilled Nursing Facility Defined.— In this title, 42 USC 1395i–3. the term ‘skilled nursing facility’ means an institution (or a distinct part of an institution) which— “(1) is primarily engaged in providing to residents— “(A) skilled nursing care and related services for residents who require medical or nursing care, or “(B) rehabilitation services for the rehabilitation of injured, disabled, or sick persons, and is not primarily for the care and treatment of mental diseases; “(2) has in effect a transfer agreement (meeting the requirements of section 1861(1)) with one or more hospitals having agreements in effect under section 1866; and “(3) meets the requirements for a skilled nursing facility described in subsections (b), (c), and (d) of this section. “(b) Requirements Relating to Provision of Services.— “(1) Quality of life.— “(A) In general.— A skilled nursing facility must care for its residents in such a manner and in such an environment as will promote maintenance or enhancement of the quality of life of each resident, “(B) Quality assessment and assurance.— A skilled nursing facility must maintain a quality assessment and assurance committee, consisting of the director of nursing services, a physician designated by the facility, and at least 3 other members of the facility’s staff, which (i) meets at least quarterly to identify issues with respect to which quality assessment and assurance activities are necessary and (ii) develops and implements appropriate plans of action to correct identified quality deficiencies. “(2) Scope of services and activities under plan of care.— A skilled nursing facility must provide services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, in accordance with a written plan of care which— “(A) describes the medical, nursing, and psychosocial needs of the resident and how such needs will be met; “(B) is initially prepared, with the participation to the extent practicable of the resident or the resident’s family or legal representative, by a team which includes the resident’s attending physician and a registered professional nurse with responsibility for the resident; and “(C) is periodically reviewed and revised by such team after each assessment under paragraph (3). “(3) Residents’ assessment.— “(A) Requirement.— A skilled nursing facility must conduct a comprehensive, accurate, standardized, reproducible assessment of each resident’s functional capacity, which assessment— “(i) describes the resident’s capability to perform daily life functions and significant impairments in functional capacity; “(ii) is based on a uniform minimum data set specified by the Secretary under subsection (f)(6)(A); “(iii) in the case of a resident eligible for benefits under title XIX, uses an instrument which is specified by the State under subsection (e)(5); and “(iv) in the case of a resident eligible for benefits under part A of this title, includes the identification of medical problems. “(B) Certification.— “(i) In general.— Each such assessment must be conducted or coordinated (with the appropriate participation of health professionals) by a registered professional nurse who signs and certifies the completion of the assessment. Each individual who completes a portion of such an assessment shall sign and certify as to the accuracy of that portion of the assessment. “(ii) Penalty for falsification.— “(I) An individual who willfully and knowingly certifies under clause (i) a material and false statement in a resident assessment is subject to a civil money penalty of not more than $1,000 with respect to each assessment. “(II) An individual who willfully and knowingly causes another individual to certify under clause (i) a material and false statement in a resident assess-ment is subject to a civil money penalty of not more than $5,000 with respect to each assessment. “(III) The Secretary shall provide for imposition of civil money penalties under this clause in a manner similar to that for the imposition of civil money penalties under section 1128A. “(iii) Use of independent assessors.— If a State determines, under a survey under subsection (g) or otherwise, that there has been a knowing and willful certification of false assessments under this paragraph, the State may require (for a period specified by the State) that resident assessments under this paragraph be conducted and certified by individuals who are independent of the facility and who are approved by the State. “(C) Frequency.— “(i) In general.— Such an assessment must be conducted— “(I) promptly upon (but no later than 4 days after the date of) admission for each individual admitted on or after October 1, 1990, and by not later than October 1, 1990, for each resident of the facility on that date; “(II) promptly after a significant change in the resident’s physical or mental condition; and “(III) in no case less often than once every 12 months. “(ii) Resident review.— The skilled nursing facility must examine each resident no less frequently than once every 3 months and, as appropriate, revise the resident’s assessment to assure the continuing accuracy of the assessment. “(D) Use.— The results of such an assessment shall be used in developing, reviewing, and revising the resident’s plan of care under paragraph (2). “(E) Coordination.— Such assessments shall be coordinated with any State-required pre-admission screening program to the maximum extent practicable in order to avoid duplicative testing and effort. “(4) Provision of services and activities.— “(A) In general.— To the extent needed to fulfill all plans of care described in paragraph (2), a skilled nursing facility must provide, directly or under arrangements (or, with respect to dental services, under agreements) with others for the provision of— “(i) nursing services and specialized rehabilitative services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident; “(ii) medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident; “(iii) pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident; “(iv) dietary services that assure that the meals meet the daily nutritional and special dietary needs of each resident; “(v) an on-going program, directed by a qualified professional, of activities designed to meet the interests and the physical, mental, and psychosocial well-being of each resident; and “(vi) routine and emergency dental services to meet the needs of each resident. The services provided or arranged by the facility must meet professional standards of quality. Nothing in clause (vi) shall be construed as requiring a facility to provide or arrange for dental services described in that clause without additional charge. “(B) Qualified persons providing services.— Services described in clauses (i), (ii), (iii), (iv), and (vi) of subparagraph (A) must be provided by qualified persons in accordance with each resident’s written plan of care. “(C) Required nursing care.— “(i) In general.— Except as provided in clause (ii), a skilled nursing facility must provide 24-hour nursing service which is sufficient to meet nursing needs of its residents and must employ the services of a registered professional nurse at least during the day tour of duty (of at least 8 hours a day) 7 days a week. “(ii) Exception.— To the extent that clause (i) may be deemed to require that a skilled nursing facility engage the services of a registered professional nurse for more than 40 hours a week, the Secretary is authorized to waive such requirement if the Secretary finds that— “(I) the facility is located in a rural area and the supply of skilled nursing facility services in such area is not sufficient to meet the needs of individuals residing therein, “(II) the facility has one full-time registered professional nurse who is regularly on duty at such facility 40 hours a week, and “(III) the facility either has only patients whose physicians have indicated (through physicians’ orders or admission notes) that each such patient does not require the services of a registered nurse or a physician for a 48-hour period, or has made arrangements for a registered professional nurse or a physician to spend such time at such facility as may be indicated as necessary by the physician to provide necessary skilled nursing services on days when the regular full-time registered professional nurse is not on duty. A waiver under this subparagraph shall be subject to annual renewal. “(5) Required training of nurse aides.— “(A) In general.— A skilled nursing facility must not use (on a full-time, temporary, per diem, or other basis) any individual, who is not a licensed health professional (as defined in subparagraph (E)), as a nurse aide in the facility on or after October 1, 1989, (or January 1, 1990, in the case of an individual used by the facility as a nurse aide before July 1, 1989) for more than 4 months unless the individual— “(i) has completed a training and competency evaluation program, or a competency evaluation program, approved by the State under subsection (e)(1)(A), and “(ii) is competent to provide such services. “(B) Offering competency evaluation programs for current employees.— A skilled nursing facility must provide, for individuals used as a nurse aide by the facility as of July 1, 1989, for a competency evaluation program approved by the State under subsection (e)(1) and such preparation as may be necessary for the individual to complete such a program by January 1, 1990. “(C) Competency.— The skilled nursing facility must not permit an individual, other than in a training and competency evaluation program approved by the State, to serve as a nurse aide or provide services of a type for which the individual has not demonstrated competency and must not use such an individual as a nurse aide unless the facility has inquired of the State registry established under subsection (e)(2)(A) as to information in the registry concerning the individual. “(D) Re-training required.— For purposes of subpagraph (A), if, since an individual’s most recent completion of a training and competency evaluation program, there has been a continuous period of 24 consecutive months during none of which the individual performed nursing or nursing-related services for monetary compensation, such individual shall complete a new training and competency evaluation program. “(E) Regular in-service education.— The skilled nursing facility must provide such regular performance review and regular in-service education as assures that individuals used as nurse aides are competent to perform services as nurse aides, including training for individuals providing nursing and nursing-related services to residents with cognitive impairments. “(F) Nurse aide defined.— In this paragraph, the term ‘nurse aide’ means any individual providing nursing or nursing-related services to residents in a skilled nursing facility, but does not include an individual— “(i) who is a licensed health professional (as defined in subparagraph (G)), or “(ii) who volunteers to provide such services without monetary compensation. “(G) Licensed health professional defined.— In this paragraph, the term ‘licensed health professional’ means a physician, physician assistant, nurse practitioner, physical, speech, or occupational therapist, registered professional nurse, licensed practical nurse, or licensed or certified social worker. “(6) Physician supervision and clinical records.— A skilled nursing facility must— “(A) require that the medical care of every resident be provided under the supervision of a physician; “(B) provide for having a physician available to furnish necessary medical care in case of emergency; and “(C) maintain clinical records on all residents, which records include the plans of care (described in paragraph (2)) and the residents’ assessments (described in paragraph (3)). “(7) Required social services.— In the case of a skilled nursing facility with more than 120 beds, the facility must have at least one social worker (with at least a bachelor’s degree in social work or similar professional qualifications) employed fulltime to provide or assure the provision of social services. “(c) Requirements Relating to Residents’ Rights.— “(1) General rights.— “(A) Specified rights.— A skilled nursing facility must protect and promote the rights of each resident, including each of the following rights: “(i) Free choice.— The right to choose a personal attending physician, to be fully informed in advance about care and treatment, to be fully informed in advance of any changes in care or treatment that may affect the resident’s well-being, and (except with respect to a resident adjudged incompetent) to participate in planning care and treatment or changes in care and treatment. “(ii) Free from restraints.— The right to be free from physical or mental abuse, corporal punishment, involuntary seclusion, and any physical or chemical restraints imposed for purposes of discipline or convenience and not required to treat the resident’s medical symptoms. Restraints may only be imposed— “(I) to ensure the physical safety of the resident or other residents, and “(II) only upon the written order of a physician that specifies the duration and circumstances under which the restraints are to be used (except in emergency circumstances specified by the Secretary) until such an order could reasonably be obtained. “(iii) Privacy.— The right to privacy with regard to accommodations, medical treatment, written and telephonic communications, visits, and meetings of family and of resident groups. “(iv) Confidentiality.— The right to confidentiality of personal and clinical records. “(v) Accommodation of needs.— The right— “(I) to reside and receive services with reasonable accommodations of individual needs and preferences, except where the health or safety of the individual or other residents would be endangered, and “(II) to receive notice before the room or room-mate of the resident in the facility is changed, “(vi) Grievances.— The right to voice grievances with respect to treatment or care that is (or fails to be) furnished, without discrimination or reprisal for voicing the grievances and the right to prompt efforts by the facility to resolve grievances the resident may have, including those with respect to the behavior of other residents. “(vii) Participation in resident and family groups.— The right of the resident to organize and participate in resident groups in the facility and the right of the resident’s family to meet in the facility with the families of other residents in the facility. 5757Copy read “ “(ix)”.“(viii) Participation in other activities.— The right of the resident to participate in social, religious, and community activities that do not interfere with the rights of other residents in the facility. 5858Copy read “ “(x)”.“(ix) Examination of survey results.— The right to examine, upon reasonable request, the results of the most recent survey of the facility conducted by the Secretary or a State with respect to the facility and any plan of correction in effect with respect to the facility. 5959Copy read “ “(xi)”.“(x) Other rights.— Any other right established by the Secretary. Clause (iii) shall not be construed as requiring the provision of a private room. “(B) Notice of rights and services.— A skilled nursing facility must— “(i) inform each resident, orally and in writing at the time of admission to the facility, of the resident’s legal rights during the stay at the facility; “(ii) make available to each resident, upon reasonable request, a written statement of such rights (which statement is updated upon changes in such rights); and “(iii) inform each other resident, in writing before or at the time of admission and periodically during the resident’s stay, of services available in the facility and of related charges for such services, including any charges for services not covered under this title or by the facility’s basic per diem charge. The written description of legal rights under this subparagraph shall include a description of the protection of personal funds under paragraph (6) and a statement that a resident may file a complaint with a State survey and certification agency respecting resident abuse and neglect and misappropriation of resident property in the facility. “(C) Rights of incompetent residents.— In the case of a resident adjudged incompetent under the laws of a State, the rights of the resident under this title shall devolve upon, and, to the extent judged necessary by a court of competent jurisdiction, be exercised by, the person appointed under State law to act on the resident’s behalf. “(2) Transfer and discharge rights.— “(A) In general.— A skilled nursing facility must permit each resident to remain in the facility and must not transfer or discharge the resident from the facility unless— “(i) the transfer or discharge is necessary to meet the resident’s welfare and the resident’s welfare cannot be met in the facility; “(ii) the transfer or discharge is appropriate because the resident’s health has improved sufficiently so the resident no longer needs the services provided by the facility; “(iii) the safety of individuals in the facility is endangered; “(iv) the health of individuals in the facility would otherwise be endangered; “(v) the resident has failed, after reasonable and appropriate notice, to pay (or to have paid under this title or title XIX on the resident’s behalf) an allowable charge imposed by the facility for an item or service requested by the resident and for which a charge may be imposed consistent with this title and title XIX; or “(vi) the facility ceases to operate. In each of the cases described in clauses (i) through (v), the basis for the transfer or discharge must be documented in the resident’s clinical record. In the cases described in clauses (i) and (ii), the documentation must be made by the resident’s physician, and in the cases described in clauses (iii) and (iv) the documentation must be made by a physician. “(B) Pre-transfer and pre-discharge notice.— “(i) In general.— Before effecting a transfer or discharge of a resident, a skilled nursing facility must— “(I) notify the resident (and, if known, a family member of the resident or legal representative) of the transfer or discharge and the reasons therefor, “(II) record the reasons in the resident’s clinical record (including any documentation required under subparagraph (A)), and “(III) include in the notice the items described in clause (iii). “(ii) Timing of notice.— The notice under clause (i)(I) must be made at least 30 days in advance of the resident’s transfer or discharge except— “(I) in a case described in clause (iii) or (iv) of subparagraph (A); “(II) in a case described in clause (ii) of subparagraph (A), where the resident’s health improves sufficiently to allow a more immediate transfer or discharge; “(III) in a case described in clause (i) of subparagraph (A), where a more immediate transfer or discharge is necessitated by the resident’s urgent medical needs; or “(IV) in a case where a resident has not resided in the facility for 30 days. In the case of such exceptions, notice must be given as many days before the date of the transfer or discharge as is practicable. “(iii) Items included in notice.— Each notice under clause (i) must include— “(I) for transfers or discharges effected on or after October 1, 1990, notice of the resident’s right to appeal the transfer or discharge under the State process established under subsection (e)(3); and “(II) the name, mailing address, and telephone number of the State long-term care ombudsman(established under section 307(a)(12) of the Older Americans Act of 1965). “(C) Orientation.— A skilled nursing facility must provide sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility. “(3) Access and visitation rights.— A skilled nursing facility must— “(A) permit immediate access to any resident by any representative of the Secretary, by any representative of the State, by an ombudsman described in paragraph (2)(B)(iii)(II), or by the resident’s individual physician; “(B) permit immediate access to a resident, subject to the resident’s right to deny or withdraw consent at any time, by immediate family or other relatives of the resident; “(C) permit immediate access to a resident, subject to reasonable restrictions and the resident’s right to deny or withdraw consent at any time, by others who are visiting with the consent of the resident; “(D) permit reasonable access to a resident by any entity or individual that provides health, social, legal, or other services to the resident, subject to the resident’s right to deny or withdraw consent at any time; and “(E) permit representatives of the State ombudsman (described in paragraph (2)(B)(iii)(II)), with the permission of the resident (or the resident’s legal representative) and consistent with State law, to examine a resident’s clinical records. “(4) Equal access to quality care.— A skilled nursing facility must establish and maintain identical policies and practices regarding transfer, discharge, and covered services under this title for all individuals regardless of source of payment. “(5) Admissions policy.— “(A) Admissions.— With respect to admissions practices, a skilled nursing facility must— “(i) (I) not require individuals applying to reside or residing in the facility to waive their rights to benefits under this title or under a State plan under title XIX, (II) not require oral or written assurance that such individuals are not eligible for, or will not apply for, benefits under this title or such a State plan, and (III) prominently display in the facility and provide to such individuals written information about how to apply for and use such benefits and how to receive refunds for previous payments covered by such benefits; and “(ii) not require a third party guarantee of payment to the facility as a condition of admission (or expedited admission) to, or continued stay in, the facility. “(B) Construction.— “(i) No preemption of stricter standards.— Subparagraph (A) shall not be construed as preventing States or political subdivisions therein from prohibiting, under State or local law, the discrimination against individuals who are entitled to medical assistance under this title with respect to admissions practices of skilled nursing facilities. “(ii) Contracts with legal representatives.— Subparagraph (A)(ii) shall not be construed as preventing a facility from requiring an individual, who has legal access to a resident’s income or resources available to pay for care in the facility, to sign a contract (without incurring personal financial liability) to provide payment from the resident’s income or resources for such care. “(6) Protection op resident funds.— “(A) In general.— The skilled nursing facility— “(i) may not require residents to deposit their personal funds with the facility, and “(ii) once the facility accepts the written authorization of the resident, must hold, safeguard, and account for such personal funds under a system established and maintained by the facility in accordance with this paragraph. “(B) Management of personal funds.— Upon a facility’s acceptance of written authorization of a resident under subparagraph (A)(ii), the facility must manage and account for the personal funds of the resident deposited with the facility as follows: “(i) Deposit.— The facility must deposit any amount of personal funds in excess of $50 with respect to a resident in an interest bearing account (or accounts) that is separate from any of the facility’s operating accounts and credits all interest earned on such separate account to such account. With respect to any other personal funds, the facility must maintain such funds in a non-interest bearing account or petty cash fund. “(ii) Accounting and records.— The facility must assure a full and complete separate accounting of each such resident’s personal funds, maintain a written record of all financial transactions involving the personal funds of a resident deposited with the facility, and afford the resident (or a legal representative of the resident) reasonable access to such record. “(iii) Conveyance upon death.— Upon the death of a resident with such an account, the facility must convey promptly the resident’s personal funds (and a final accounting of such funds) to the individual administering the resident’s estate. “(C) Assurance of financial security.— The facility must purchase a surety bond, or otherwise provide assurance satisfactory to the Secretary, to assure the security of all personal funds of residents deposited with the facility. “(D) Limitation on charges to personal funds.— The facility may not impose a charge against the personal funds of a resident for any item or service for which payment is made under this title or title XIX. “(d) Requirements Relating to Administration and Other Matters.— “(1) Administration.— “(A) In general.— A skilled nursing facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical mental, and psychosocial well-being of each resident (consistent with requirements established under subsection (f)(5)). “(B) Required notices.— If a change occurs in— “(i) the persons with an ownership or control interest (as defined in section 1124(a)(3)) in the facility, “(ii) the persons who are officers, directors, agents, or managing employees (as defined in section 1126(b)) of the facility, “(iii) the corporation, association, or other company responsible for the management of the facility, or “(iv) the individual who is the administrator or director of nursing of the facility, the skilled nursing facility must provide notice to the State agency responsible for the licensing of the facility, at the time of the change, of the change and of the identity of each new person, company, or individual described in the respective clause. “(C) Skilled nursing facility administrator.— The administrator of a skilled nursing facility must meet standards established by the Secretary under subsection (f)(4). “(2) Licensing and life safety code.— “(A) Licensing.— A skilled nursing facility must be licensed under applicable State and local law. “(B) Life safety code.— A skilled nursing facility must meet such provisions of such edition (as specified by the Secretary in regulation) of the Life Safety Code of the National Fire Protection Association as are applicable to nursing homes; except that— “(i) the Secretary may waive, for such periods as he deems appropriate, specific provisions of such Code which if rigidly applied would result in unreasonable hardship upon a facility, but only if such waiver would not adversely affect the health and safety of residents or personnel, and “(ii) the provisions of such Code shall not apply in any State if the Secretary finds that in such State there is in effect a fire and safety code, imposed by State law, which adequately protects residents of and personnel in skilled nursing facilities. “(3) Sanitary and infection control and physical environment.— A skilled nursing facility must— “(A) establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment in which residents reside and to help prevent the development and transmission of disease and infection, and “(B) be designed, constructed, equipped, and maintained in a manner to protect the health and safety of residents, personnel, and the general public. “(4) Miscellaneous.— “(A) Compliance with federal, state, and local laws and professional standards.— A skilled nursing facility must operate and provide services in compliance with all applicable Federal, State, and local laws and regulations (including the requirements of section 59a59aCopy read “sections”. 1124) and with accepted professional standards and principles which apply to professionals providing services in such a facility. “(B) Other.— A skilled nursing facility must meet such other requirements relating to the health, safety, and wellbeing of residents or relating to the physical facilities thereof as the Secretary may find necessary. “(e) State Requirements Relating to Skilled Nursing Facility Requirements.— The requirements, referred to in section 1864(d), with respect to a State are as follows: “(1) Specification and review of nurse aide training and competency evaluation programs and of nurse aide competency evaluation programs.— The State must— “(A) by not later than March 1, 1989, specify those training and competency evaluation programs, and those competency evaluation programs, that the State approves for purposes of subsection (b)(5) and that meet the requirements established under clause (i) or (ii) of subsection (f)(2)(A), and “(B) by not later than March 1, 1990, provide for the review and reapproval of such programs, at a frequency and using a methodology consistent with the requirements established under subsection (f)(2)(A)(iii). The failure of the Secretary to establish requirements under subsection (f)(2) shall not relieve any State of its responsibility under this paragraph. “(2) Nurse aide registry.— “(A) In general.— By not later than March 1, 1989, the State shall establish and maintain a registry of all individuals who have satisfactorily completed a nurse aide training and competency evaluation program, or a nurse aide competency evaluation program, approved under paragraph (1) in the State. “(B) Information in registry.— The registry under subparagraph (A) shall provide (in accordance with regulations of the Secretary) for the inclusion of specific documented findings by a State under subsection (g)(1)(C) of resident neglect or abuse or misappropriation of resident property involving an individual listed in the registry, as well as any brief statement of the individual disputing the findings. In the case of inquiries to the registry concerning an individual listed in the registry, any information disclosed concerning such a finding shall also include disclosure of any such statement in the registry relating to the finding or a clear and accurate summary of such a statement. “(3) State appeals process for transfers.— The State, for transfers from skilled nursing facilities effected on or after October 1, 1990, must provide for a fair mechanism for hearing appeals on transfers of residents of such facilities. Such mechanism must meet the guidelines established by the Secretary under subsection (f)(3); but the failure of the Secretary to establish such guidelines shall not relieve any State of its responsibility to provide for such a fair mechanism. “(4) Skilled nursing facility administrator standards.— By not later than January 1, 1990, the State must have implemented and enforced the skilled nursing facility administrator standards developed under subsection (f)(4) respecting the qualification of administrators of skilled nursing facilities. “(5) Specification of resident assessment instrument.— Effective July 1, 1989, the State shall specify the instrument to be used by nursing facilities in the State in complying with the requirement of subsection (b)(3)(A)(iii). Such instrument shall be— “(A) one of the instruments designated under subsection (f)(6)(B), or “(B) an instrument which the Secretary has approved as being consistent with the minimum data set of core elements, common definitions, and utilization guidelines specified by the Secretary under subsection (f)(6)(A). “(f) Responsibiuties of Secretary Relating to Skilled Nursing Facility Requirements.— “(1) General responsibility.— It is the duty and responsibility of the Secretary to assure that requirements which govern the provision of care in skilled nursing facilities under this title, and the enforcement of such requirements, are adequate to protect the health, safety, welfare, and rights of residents and to promote the effective and efficient use of public moneys. “(2) Requirements for nurse aide training and competency evaluation programs and for nurse aide competency evaluation programs.— “(A) In general.— For purposes of subsections (b)(5) and (e)(1)(A), the Secretary shall establish, by not later than September 1, 1988— “(i) requirements for the approval of nurse aide training and competency evaluation programs, including requirements relating to (I) the areas to be covered in such a program (including at least basic nursing skills, personal care skills, cognitive, behavioral and social care, basic restorative services, and residents’ rights), content of the curriculum, (II) minimum hours of initial and ongoing training and retraining (including not less than 75 hours in the case of initial training), (III) qualifications of instructors, and (IV) procedures for determination of competency; “(ii) requirements for the approval of nurse aide competency evaluation programs, including requirement relating to the areas to be covered in such a program, including at least basic nursing skills, personal care skills, cognitive, behavioral and social care, basic restorative services, residents’ rights, and procedures for determination of competency; and “(iii) requirements respecting the minimum frequency and methodology to be used by a State in reviewing such programs compliance with the requirements for such programs. “(B) Approval of certain programs.— Such requirements— “(i) may permit approval of programs offered by or in facilities, as well as outside facilities (including employee organizations), and of programs in effect on the date of the enactment of this section; “(ii) shall permit a State to find that an individual who has completed (before July 1, 1989) a nurse aide training and competency evaluation program shall be deemed to have completed such a program approved under subsection (b)(5) if the State determines that, at the time the program was offered, the program met the requirements for approval under such paragraph; and “(iii) shall prohibit approval of such a program— “(I) offered by or in a skilled nursing facility which has been determined to be out of compliance with the requirements of subsection (b), (c), or (d), within the previous 2 years, or “(II) offered by or in a skilled nursing facility unless the State makes the determination, upon an individual’s completion of the program, that the individual is competent to provide nursing and nursing-related services in skilled nursing facilities. A State may not delegate its responsibility under clause (iii)(II) to the skilled nursing facility. “(3) Federal guidelines for state appeals process for transfers.— For purposes of subsections (c)(2)(B)(iii)(I) and (e)(3), by not later than October 1, 1989, the Secretary shall establish guidelines for minimum standards which State appeals processes under subsection (e)(3) must meet to provide a fair mechanism for hearing appeals on transfers of residents from skilled nursing facilities. “(4) Secretarial standards for qualification of administrators.— For purposes of subsections (d)(1)(C) and (e)(4), the Secretary shall develop, by not later than March 1, 1989, standards to be applied in assuring the qualifications of administrators of skilled nursing facilities. “(5) Criteria for administration.— The Secretary shall establish criteria for assessing a skilled nursing facility’s compliance with the requirement of subsection (d)(1) with respect to— “(A) its governing body and management, “(B) agreements with hospitals regarding transfers of residents to and from the hospitals and to and from other skilled nursing facilities, “(C) disaster preparedness, “(D) direction of medical care by a physician, “(E) laboratory and radiological services, “(F) clinical records, and “(G) resident and advocate participation. “(6) Specification of resident assessment data set and instruments.— The Secretary shall— “(A) not later than July 1, 1989, specify a minimum data set of core elements and common definitions for use by nursing facilities in conducting the assessments required under subsection (b)(3), and establish guidelines for utilization of the data set; and “(B) by not later than October 1, 1990, designate one or more instruments which are consistent with the specification made under subparagraph (A) and which a State may specify under subsection (e)(5)(A) for use by nursing facilities in complying with the requirements of subsection (b)(3)(A)(iii). “(7) List of items and services furnished in skilled nursing facilities not chargeable to the personal funds of a resident.— “(A) Regulations required.— Pursuant to the requirement of section 21(b) of the Medicare-Medicaid Anti-Fraud and Abuse Amendments of 1977, the Secretary shall issue regulations, on or before the first day of the seventh month to begin after the date of enactment of this section, that define those costs which may be charged to the personal funds of patients in skilled nursing facilities who are individuals receiving benefits under this part and those costs which are to be included in the reasonable cost (or other payment amount) under this title for extended care services. “(B) Rule if failure to publish regulations.— If the Secretary does not issue the regulations under subparagraph (A) on or before the date required in such subparagraph, in the case of a resident of a skilled nursing facility who is eligible to receive benefits under this part, the costs which may not be charged to the personal funds of such resident (and for which payment is considered to be made under this title) shall not include, at a minimum, the costs for routine personal hygiene items and services furnished by the facility.”. (b) Costs of Meeting Requirements.— (1) Under reasonable cost.— Section 1861(v)(1)(E) of such Act 42 USC 1395x. (42 U.S.C. 1395s(v)(1)(E)) is amended by adding at the end the following new sentence: “Notwithstanding the previous sentence, such regulations with respect to skilled nursing facilities shall take into account (in a manner consistent with subparagraph (A) and based on patient-days of services furnished) the costs of such facilities complying with the requirements of subsections (b), (c), and (d) of section 1819 (including the costs of conducting nurse aide training and competency evaluation programs and competency evaluation programs).”. (2) Adjustment in prospective payments.— Section 1888(d) of such Act (42 U.S.C. 1395yy(d)) is amended by adding at the end the following new paragraph: “(7) In computing the rates of payment to be made under this subsection, there shall be taken into account the costs described in the last sentence of section 1861(v)(1)(E) (relating to compliance with nursing facility requirements and of conducting nurse aide training and competency evaluation programs and competency evaluation programs).”. (c) Evaluation.— The Secretary of Health and Human Services Reports. 42 USC 1395i–3 note. shall evaluate, and report to Congress by not later than January 1, 1992, on the implementation of the resident assessment process for residents of skilled nursing facilities under the amendments made by this section. (d) Conforming Amendment.— Section 1861(a)(2) of the Social Security Act (42 U.S.C. 1395x(a)(2)) is amended by striking “skilled nursing facility” and inserting “facility described in section 1919(a)(2) or subsection (y)(1)”. SEC. 4202. SURVEY AND CERTIFICATION PROCESS. (a) State Requirement for Process.— Title XVIII of the Social Security Act is amended— (1) in section 1864(d) (42 U.S.C. 1395aa(d)), as added by section 4201(a)(2) of this Act, by inserting before the period “and section 1819(g)”, and (2) in section 1819, as added by section 4201(a)(3) of this Act, by adding at the end the following new subsection: “(g) Survey and Certification Process.— “(1) State and federal responsibility.— “(A) In general.— Pursuant to an agreement under section 1864, each State shall be responsible for certifying, in accordance with surveys conducted under paragraph (2), the compliance of skilled nursing facilities (other than facilities of the State) with the requirements of subsections (b), (c), and (d). The Secretary shall be responsible for certifying, in accordance with surveys conducted under paragraph (2), the compliance of State skilled nursing facilities with the requirements of such subsections. “(B) Educational program.— Each State shall conduct periodic educational programs for the staff and residents (and their representatives) of skilled nursing facilities in order to present current regulations, procedures, and policies under this section. “(C) Investigation of allegations of resident neglect and abuse and misappropriation of resident property.— The State shall provide, through the agency responsible for surveys and certification of nursing facilities under this subsection, for a process for the receipt, review, and investigation of allegations of neglect and abuse and misappropriation of resident property by a nurse aide of a resident in a nursing facility. If the State finds, after notice to the nurse aide involved and a reasonable opportunity for a hearing for the nurse aide to rebut allegations, that a nurse aide whose name is contained in a nurse aide registry has neglected or abused a resident or misappropriated resident property in a facility, the State shall notify the nurse aide and the registry of such finding. “(D) Construction.— The failure of the Secretary to establish standards under subsection (f) shall not relieve a State of its responsibility under this subsection. “(2) Surveys.— “(A) Standard survey.— “(i) In general.— Each skilled nursing facility shall be subject to a standard survey, to be conducted without any prior notice to the facility. Any individual who notifies (or causes to be notified) a skilled nursing facility of the time or date on which such a survey is scheduled to be conducted is subject to a civil money penalty of not to exceed $2,000. The Secretary shall provide for imposition of civil money penalties under this clause in a manner similar to that for the imposition of civil money penalties under section 1128A. The Secretary shall review each State’s procedures for the scheduling and conduct of standard surveys to assure that the State has taken all reasonable steps to avoid giving notice of such a survey through the scheduling procedures and the conduct of the surveys themselves, “(ii) Contents.— Each standard survey shall include, for a case-mix stratified sample of residents— “(I) a survey of the quality of care furnished, as measured by indicators of medical, nursing, and rehabilitative care, dietary and nutrition services, activities and social participation, and sanitation, infection control, and the physical environment, “(II) written plans of care provided under subsection (b)(2) and an audit of the residents’ assessments under subsection (b)(3) to determine the accuracy of such assessments and the adequacy of such plans of care, and “(III) a review of compliance with residents’ rights under subsection (c). “(iii) Frequency.— “(I) In general.— Each skilled nursing facility shall be subject to a standard survey not later than 15 months after the date of the previous standard survey conducted under this subparagraph. The Statewide average interval between standard surveys of skilled nursing facilities under this subsection shall not exceed 12 months. “(II) Special surveys.— If not otherwise conducted under subclause (I), a standard survey (or an abbreviated standard survey) may be conducted within 2 months of any change of ownership, administration, management of a skilled nursing facility, or the director of nursing in order to determine whether the change has resulted in any decline in the quality of care furnished in the facility. “(B) Extended surveys.— “(i) In general.— Each skilled nursing facility which is found, under a standard survey, to have provided substandard quality of care shall be subject to an extended survey. Any other facility may, at the Secretary’s or State’s discretion, be subject to such an extended survey (or a partial extended survey). “(ii) Timing.— The extended survey shall be conducted immediately after the standard survey (or, if not practical, not later than 2 weeks after the date of completion of the standard survey). “(iii) Contents.— In such an extended survey, the survey team shall review and identify the policies and procedures which produced such substandard quality of care and shall determine whether the facility has complied with all the requirements described in subsections (b), (c), and (d). Such review shall include an expansion Contracts. of the size of the sample of residents’ assessments reviewed and a review of the staffing, of in-service training, and, if appropriate, of contracts with consultants. “(iv) Construction.— Nothing in this paragraph shall be construed as requiring an extended or partial extended survey as a prerequisite to imposing a sanction against a facility under subsection (h) on the basis of findings in a standard survey. “(C) Survey protocol.— Standard and extended surveys shall be conducted— “(i) based upon a protocol which the Secretary has developed, tested, and validated by not later than October 1, 1990, and “(ii) by individuals, of a survey team, who meet such minimum qualifications as the Secretary establishes by not later than such date. The failure of the Secretary to develop, test, or validate such protocols or to establish such minimum qualifications shall not relieve any State of its responsibility (or the Secretary of the Secretary’s responsibility) to conduct surveys under this subsection. “(D) Consistency of surveys.— Each State and the Secretary shall implement programs to measure and reduce inconsistency in the application of survey results among surveyors. “(E) Survey teams.— “(i) In general.— Surveys under this subsection shall be conducted by a multidisciplinary team of professionals (including a registered professional nurse). “(ii) Prohibition of conflicts of interest.— A State may not use as a member of a survey team under this subsection an individual who is serving (or has served within the previous 2 years) as a member of the staff of, or as a consultant to, the facility surveyed respecting compliance with the requirements of subsections (b), (c), and (d), or who has a personal or familial financial interest in the facility being surveyed. “(iii) Training.— The Secretary shall provide for the comprehensive training of State and Federal surveyors in the conduct of standard and extended surveys under this subsection, including the auditing of resident assessments and plans of care. No individual shall serve as a member of a survey team unless the individual has successfully completed a training and testing program in survey and certification techniques that has been approved by the Secretary. “(3) Validation surveys.— “(A) In general.— The Secretary shall conduct onsite surveys of a representative sample of skilled nursing facilities in each State, within 2 months of the date of surveys conducted under paragraph (2) by the State, in a sufficient number to allow inferences about the adequacies of each State’s surveys conducted under paragraph (2). In conducting such surveys, the Secretary shall use the same survey protocols as the State is required to use under paragraph (2). If the State has determined that an individual skilled nursing facility meets the requirements of subsections (b), (c), and (d), but the Secretary determines that the facility does not meet such requirements, the Secretary’s determination as to the facility’s noncompliance with such requirements is binding and supersedes that of the State survey. “(B) Scope.— With respect to each State, the Secretary shall conduct surveys under subparagraph (A) each year with respect to at least 5 percent of the number of skilled nursing facilities surveyed by the State in the year, but in no case less than 5 skilled nursing facilities in the State. “(C) Remedies for substandard performance.— If the Secretary finds, on the basis of such surveys, that a State has failed to perform surveys as required under paragraph (2) or that a State’s survey and certification performance otherwise is not adequate, the Secretary shall provide for an appropriate remedy, which may include the training of survey teams in the State. 6060Copy read ““(C)”.“(D) Special surveys of compliance.— Where the Secretary has reason to question the compliance of a skilled nursing facility with any of the requirements of subsections (b), (c), and (d), the Secretary may conduct a survey of the facility and, on that basis, make independent and binding determinations concerning the extent to which the skilled nursing facility meets such requirements. “(4) Investigation of complaints and monitoring compliance.— Each State shall maintain procedures and adequate staff to— “(A) investigate complaints of violations of requirements by skilled nursing facilities, and “(B) monitor, on-site, on a regular, GS needed basis, a skilled nursing facility’s compliance with the requirements of subsections (b), (c), and (d), if— “(i) the facility has been found not to be in compliance with such requirements and is in the process of correcting deficiencies to achieve such compliance; “(ii) the facility was previously found not to be in compliance with such requirements, has corrected deficiencies to achieve such compliance, and verification of continued compliance is indicated; or “(iii) the State has reason to question the compliance of the facility with such requirements. A State may maintain and utilize a specialized team (including an attorney, an auditor, and appropriate health care professionals) for the purpose of identifying, surveying, gathering and preserving evidence, and carrying out appropriate enforcement actions against chronically substandard skilled nursing facilities. “(5) Disclosure of results of inspections and activities.— “(A) Public information.— Each State, and the Secretary, shall make available to the public— “(i) information respecting all surveys and certifications made respecting skilled nursing facilities, including statements of deficiencies and plans of correction. “(ii) copies of cost reports of such facilities filed under Reports. this title or title XIX, “(iii) copies of statements of ownership under section 1124, and “(iv) information disclosed under section 1126. “(B) Notice to ombudsman.— Each State shall notify the State long-term care ombudsman (established under section 307(a)(12) of the Older Americans Act of 1965) of the State’s findings of noncompliance with any of the requirements of subsections (b), (c), and (d), with respect to a skilled nursing facility in the State. “(C) Notice to physicians and skilled nursing facility administrator licensing board.— If a State finds that a skilled nursing facility has provided substandard quality of care, the State shall notify— “(i) the attending physician of each resident with respect to which such finding is made, and “(ii) the State board responsible for the licensing of the skilled nursing facility administrator at the facility. “(D) 60a60aCopy read ““(C)”. Access to fraud control units.— Each State shall provide its State medicaid fraud and abuse control unit (established under section 1903(q)) with access to all information of the State agency responsible for surveys and certifications under this subsection.”. (c) Posting Survey Results.— Section 1864(a) of such Act (42 U.S.C. 1395aa(a)) is amended by inserting, after “readily available form and place” in the fifth sentence, the following: “, and require (in the case of skilled nursing facilities) the posting in a place readily accessible to patients (and patients’ representatives),”. SEC. 4203. ENFORCEMENT PROCESS. (a) State Requirement.— Title XVIII of the Social Security Act is amended— (1) in section 1864(d) (42 U.S.C. 1395aa(d)), as added by section 4201(a)(2) and as amended by section 4202(a)(1) of this Act, by inserting before the period at the end the following: “and the establishment of remedies under sections 1819(h)(2)(B) and 1819(h)(2)(C) (relating to establishment and application of remedies)”; and (2) by adding at the end of section 1819 of such Act, as added by section 4201(a)(3) and as amended by section 4202(a)(2), the end the following new subsection: “(h) Enforcement process.— “(1) In general.— If a State finds, on the basis of a standard, extended, or partial extended survey under subsection (g)(2) or otherwise, that a skilled nursing facility no longer meets a requirement of subsection (b), (c), or (d), and further finds that the facility’s deficiencies— “(A) immediately jeopardize the health or safety of its residents, the State shall recommend to the Secretary that the Secretary take such action as described in paragraph (2)(A)(i); or “(B) do not immediately jeopardize the health or safety of its residents, the State may recommend to the Secretary that the Secretary take such action as described in paragraph (2)(A)(ii). If a State finds that a skilled nursing facility meets the requirements of subsections (b), (c), and (d), but, as of a previous period, did not meet such requirements, the State may recommend a civil money penalty under paragraph (2)(B)(ii) for the days in which it finds that the facility was not in compliance with such requirements. “(2) Secretarial authority.— “(A) In general.— With respect to any skilled nursing facility in a State, if the Secretary finds, or pursuant to a recommendation of the State under paragraph (1) finds, that a skilled nursing facility no longer meets a requirement of subsection (b), (c), (d), or (e), and further finds that the facility’s deficiencies— “(i) immediately jeopardize the health or safety of its residents, the Secretary shall take immediate action to remove the jeopardy and correct the deficiencies through the remedy specified in subparagraph (B)(iii), or terminate the facility’s participation under this title and may provide, in addition, for one or more of the other remedies described in subparagraph (B); or “(ii) do not immediately jeopardize the health or safety of its residents, the Secretary may impose any of the remedies described in subparagraph (B). Nothing in this subparagraph shall be construed as restricting the remedies available to the Secretary to remedy a skilled nursing facility’s deficiencies. If the Secretary finds, or pursuant to the recommendation of the State under paragraph (1) finds, that a skilled nursing facility meets such requirements but, as of a previous period, did not meet such requirements, the Secretary may provide for a civil money penalty under subparagraph (B)(ii) for the days on which he finds that the facility was not in compliance with such requirements. “(B) Specified remedies.— The Secretary may take the following actions with respect to a finding that a facility has not met an applicable requirement: “(i) Denial of payment.— The Secretary may deny any further payments under this title with respect to all individuals entitled to benefits under this title in the facility or with respect to such individuals admitted to the facility after the effective date of the finding. “(ii) Authority with respect to civil money penalties.— The Secretary may impose a civil money penalty in an amount not to exceed $10,000 for each day of noncompliance and the Secretary shall impose and collect such a penalty in the same manner as civil money penalties are imposed and collected under section 1128 A. “(iii) Appointment of temporary management.— In consultation with the State, the Secretary may appoint temporary management to oversee the operation of the facility and to assure the health and safety of the facility’s residents, where there is a need for temporary management while— “(I) there is an orderly closure of the facility, or “(II) improvements are made in order to bring the facility into compliance with all the requirements of subsections (b), (c), and (d). The temporary management under this clause shall not be terminated under subclause (II) until the Secretary has determined that the facility has the management capability to ensure continued compliance with all the requirements of subsections (b), (c), and (d). The Secretary shall specify criteria, as to when and how each of such remedies is to be applied, the amounts of any fines, and the severity of each of these remedies, to be used in the imposition of such remedies. Such criteria shall be designed so as to minimize the time between the identification of violations and final imposition of the remedies and shall provide for the imposition of incrementally moresevere fines for repeated or uncorrected deficiencies. In addition, the Secretary may provide for other specified remedies, such as directed plans of correction. “(C) Continuation of payments pending remediation.— The Secretary may continue payments, over a period of not longer than 6 months, under this title with respect to a skilled nursing facility not in compliance with a requirement of subsection (b), (c), or (d), if— “(i) the State survey agency finds that it is more appropriate to take alternative action to assure compliance of the facility with the requirements than to terminate the certification of the facility, “(ii) the State has submitted a plan and timetable for corrective action to the Secretary for approval and the Secretary approves the plan of corrective action, and “(iii) the facility agrees to repay to the Federal Government payments received under this subparagraph if the corrective action is not taken in accordance with the approved plan and timetable. The Secretary shall establish guidelines for approval of corrective actions requested by States under this subparagraph. “(D) Assuring prompt compliance.— If a skilled nursing facility has not complied with any of the requirements of subsections (b), (c), and (d), within 3 months after the date the facility is found to be out of compliance with such requirements, the Secretary shall impose the remedy described in subparagraph (B)(i) for all individuals who are admitted to the facility after such date. “(E) Repeated noncompliance.— In the case of a skilled nursing facility which, on 3 consecutive standard surveys conducted under subsection (g)(2), has been found to have provided substandard quality of care, the Secretary shall (regardless of what other remedies are provided)— “(i) impose the remedy described in subparagraph (B)(i), and “(ii) monitor the facility under subsection (g)(4)(B), until the facility has demonstrated, to the satisfaction of the Secretary, that it is in compliance with the requirements of subsections (b), (c), and (d), and that it will remain in compliance with such requirements. “(3) Effective period of denial of payment.— A finding to deny payment under this subsection shall terminate when the Secretary finds that the facility is in substantial compliance with all the requirements of subsections (b), (c), and (d). “(4) Immediate termination of participation for facility where secretary finds noncompliance and immediate jeopardy.— If the Secretary finds that a skilled nursing facility has not met a requirement of subsection (b), (c), or (d), and finds that the failure immediately jeopardizes the health or safety of its residents, the Secretary shall take immediate action to remove the jeopardy and correct the deficiencies through the remedy specified in paragraph (2)(B)(iii), or the Secretary shall terminate the facility’s participation under this title. If the facility’s participation under this title is terminated, the State shall provide for the safe and orderly transfer of the residents eligibleunder this title consistent with the requirements of subsection (c)(2). “(5) Construction.— The remedies provided under this subsection are in addition to those otherwise available under State or Federal law and shall not be construed as limiting such other remedies, including any remedy available to an individual at common law. The remedies described in clauses (i), (iii), and (iv) of paragraph (2)(A) may be imposed during the pendency of any hearing. “(6) Sharing of information.— Notwithstanding any other provision of law, all information concerning skilled nursing facilities required by this section to be filed with the Secretary or a State agency shall be made available to Federal or State employees for purposes consistent with the effective administration of programs established under this title and title XIX, including investigations by State medicaid fraud control units.”. SEC. 4204. EFFECTIVE DATES. (a) New Requirements and Survey and Certification Process.— Except as otherwise specifically provided in section 1819 of the Social Security Act, the amendments made by this part shall apply to extended care services furnished on or after October 1, 1990, without regard to whether regulations to implement such amendments are promulgated by such date. (b) Waiver of Paperwork Reduction.— Chapter 35 of title 44, United States Code, shall not apply to information required for purposes of carrying out this part and implementing the amendments made by this part. SEC. 4205. ANNUAL REPORT. The Secretary of Health and Human Services shall report to the Congress annually on the extent to which skilled nursing facilities are complying with the requirements of subsections (b), (c), and (d) of section 1819 of the Social Security Act (as added by the amendments made by this part) and the number and type of enforcement actions taken by States and the Secretary under section 1819(h) of such Act (as added by section 4203 of this Act). SEC. 4206. CONSTRUCTION. Section 1819 of the Social Security Act is amended by adding at 42 USC 1395i–3. the end the following new subsection: “(i) Construction.— Where requirements or obligations under this section are identical to those provided under section 1919 of this Act, the fulfillment of those requirements or obligations under section 1919 shall be considered to be the fulfillment of the corresponding requirements or obligations under this section.”. PART 2— MEDICAID PROGRAM SEC. 4211. REQUIREMENTS FOR NURSING FACILITIES. (a) Specification of Facility Requirements.— Title XIX of the Social Security Act is amended— (1) by redesignating section 1922 as section 1923, 42 USC 1396s. (2) by redesignating section 1919 as section 1922 and by 42 USC 1396r, 1396r–3. transferring and inserting such section after section 1921, and (3) by inserting after section 1918 the following new section: “requirements for nursing facilities “Sec. 1919. (a) Nursing Facility Defined.— In this title, the term 42 USC 1396r. ‘nursing facility’ means an institution (or a distinct part of an institution) which— “(1) is primarily engaged in providing to residents— “(A) skilled nursing care and related services for residents who require medical or nursing care, “(B) rehabilitation services for the rehabilitation of injured, disabled, or sick persons, or “(C) on a regular basis, health-related care and services to individuals who because of their mental or physical condition require care and services (above the level of room and board) which can be made available to them only through institutional facilities, and is not primarily for the care and treatment of mental diseases; “(2) has in effect a transfer agreement (meeting the requirements of section 1861(1)) with one or more hospitals having agreements in effect under section 1866; and “(3) meets the requirements for a nursing facility described in subsections (b), (c), and (d) of this section. Such term also includes any facility which is located in a State on an Indian reservation and is certified by the Secretary as meeting the requirements of paragraph (1) and subsections (b), (c), and (d). “(b) Requirements Relating to Provision of Services.— “(1) Quality of life.— “(A) In general.— A nursing facility must care for its residents in such a manner and in such an environment as will promote maintenance or enhancement of the quality of life of each resident. “(B) Quality assessment and assurance.— A nursing facility must maintain a quality assessment and assurance committee, consisting of the director of nursing services, a physician designated by the facility, and at least 3 other members of the facility’s staff, which (i) meets at least quarterly to identify issues with respect to which quality assessment and assurance activities are necessary and (ii) develops and implements appropriate plans of action to correct identified quality deficiencies. “(2) Scope of services and activities under plan of care.— A nursing facility must provide services and activities to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in accordance with a written plan of care which— “(A) describes the medical, nursing, and psychosocial needs of the resident and how such needs will be met; “(B) is initially prepared, with the participation to the extent practicable of the resident or the resident’s family or legal representative, by a team which includes the resident’s attending physician and a registered professional nurse with responsibility for the resident; and “(C) is periodically reviewed and revised by such team after each assessment under paragraph (3). “(3) Residents’ assessment.— “(A) Requirement.— A nursing facility must conduct a comprehensive, accurate, standardized, reproducible assess—ment of each resident’s functional capacity, which assessment— “(i) describes the resident’s capability to perform daily life functions and significant impairments in functional capacity; “(ii) is based on a uniform minimum data set specified by the Secretary under subsection (f)(6)(A); “(iii) in the case of a resident eligible for benefits under this title, uses an instrument which is specified by the State under subsection (e)(5); and “(iv) in the case of a resident eligible for benefits under part A of title XVIII, includes the identification of medical problems. “(B) Certification.— “(i) In general.— Each such assessment must be conducted or coordinated (with the appropriate participation of health professionals) by a registered professional nurse who signs and certifies the completion of the assessment. Each individual who completes a portion of such an assessment shall sign and certify as to the accuracy of that portion of the assessment. “(ii) Penalty for falsification.— “(I) An individual who willfully and knowingly certifies under clause (i) a material and false statement in a resident assessment is subject to a civil money penalty of not more than $1,000 with respect to each assessment. “(II) An individual who willfully and knowingly causes another individual to certify under clause (i) a material and false statement in a resident assessment is subject to a civil money penalty of not more than $5,000 with respect to each assessment. “(III) The Secretary shall provide for imposition of civil money penalties under this clause in a manner similar to that for the imposition of civil money penalties under section 1128A. “(iii) Use of independent assessors.— If a State determines, under a survey under subsection (g) or otherwise, that there has been a knowing and willful certification of false assessments under this paragraph, the State may require (for a period specified by the State) that resident assessments under this paragraph be conducted and certified by individuals who are independent of the facility and who are approved by the State. “(C) Frequency.— “(i) In general.— Such an assessment must be conducted— “(I) promptly upon (but no later than 4 days after the date of) admission for each individual admitted on or after October 1, 1990, and by not later than October 1, 1991, for each resident of the facility on that date; “(II) promptly after a significant change in the resident’s physical or mental condition; and “(III) in no case less often than once every 12 months. “(ii) Resident review.— The nursing facility must examine each resident no less frequently than once every 3 months and, as appropriate, revise the resident assessment to assure the continuing accuracy of the assessment. “(D) Use.— The results of such an assessment shall be used in developing, reviewing, and revising the resident’s plan of care under paragraph (2). “(E) Coordination.— Such assessments shall be coordinated with any State-required pre-admission screening program to the maximum extent practicable in order to avoid duplicative testing and effort. “(F) Requirements relating to pre-admission screening for mentally ill and mentally retarded individuals.— A nursing facility must not admit, on or after January 1, 1989, any new resident who— “(i) is mentally ill (as defined in subsection (e)(7)(G)(i)) unless the State mental health authority has determined (based on an independent physical and mental evaluation performed by a person or entity other than the State mental health authority) prior to admission that, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility, and, if the individual requires such level of services, whether the individual requires active treatment for mental illness, or “(ii) is mentally retarded (as defined in subsection (e)(7)(G)(ii)) unless the State mental retardation or developmental disability authority has determined prior to admission that, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility, and, if the individual requires such level of services, whether the individual requires active treatment for mental retardation. “(4) Provision of services and activities.— “(A) In general.— To the extent needed to fulfill all plans of care described in paragraph (2), a nursing facility must provide (or arrange for the provision of)— “(i) nursing and related services and specialized rehabilitative services to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident; “(ii) medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident; “(iii) pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident; “(iv) dietary services that assure that the meals meet the daily nutritional and special dietary needs of each resident; “(v) an on-going program, directed by a qualified professional, of activities designed to meet the interests and the physical, mental, and psychosocial well-being of each resident; and “(vi) routine dental services (to the extent covered under the State plan) and emergency dental services to meet the needs of each resident. The services provided or arranged by the facility must meet professional standards of quality. “(B) Qualified persons providing services.— Services described in clauses (i), (ii), (iii), (iv), and (vi) of subparagraph (A) must be provided by qualified persons in accordance with each resident’s written plan of care. “(C) Required nursing care; facility waivers.— “(i) General requirements.— With respect to nursing facility services provided on or after October 1, 1990, a nursing facility— “(I) except as provided in clause (ii), must provide 24-hour licensed nursing services which are sufficient to meet the nursing needs of its residents, and “(II) except as provided in clause (ii), must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week, “(ii) Facility waivers.— “(i) Waiver by state.— A State may waive the requirement of subclause (I) or (II) of clause (i) with respect to a facility if— “(I) the facility demonstrates to the satisfaction of the State that the facility has been unable, despite diligent efforts (including offering wages at the community prevailing rate for nursing facilities), to recruit appropriate personnel, “(II) the State determines that a waiver of the requirement will not endanger the health or safety of individuals staying in the facility, and “(III) the State finds that, for any such periods in which licensed nursing services are not available, a registered nurse or a physician is obligated to respond immediately to telephone calls from the facility. A waiver under this clause shall be subject to annual review and to the review of the Secretary and subject to clause (ii) shall be accepted by the Secretary for purposes of this title to the same extent as is the State’s certification of the facility. In granting or renewing a waiver, a State may require the facility to employ other qualified, licensed personnel. “(ii) Assumption of waiver authority by secretary.— If the Secretary determines that a State has shown a clear pattern and practice of allowing waivers in the absence of diligent efforts by facilities to meet the staffing requirements, the Secretary shall assume and excercise the authority of the State to grant waivers. “(5) Required training of nurse aides.— “(A) In general.— A nursing facility must not use (on a full-time, temporary, per diem, or other basis) any individual, who is not a licensed health professional (as defined in subparagraph (E)), as a nurse aide in the facility on or after January 1, 1990, for more than 4 months unless the individual— “(i) has completed a training and competency evaluation program, or a competency evaluation program, approved by the State under subsection (e)(1)(A), and “(ii) is competent to provide such services. “(B) Offering competency evaluation programs for current employees.— A nursing facility must provide, for individuals used as a nurse aide by the facility as of July 1, 1989, for a competency evaluation program approved by the State under subsection (e)(1) and such preparation as may be necessary for the individual to complete such a program by January 1, 1990. “(C) Competency.— The nursing facility must not permit an individual, other than in a training and competency evaluation program approved by the State, to serve as a nurse aide or provide services of a type for which the individual has not demonstrated competency and must not use such an individual as a nurse aide unless the facility has inquired of the State registry established under subsection (e)(2)(A) as to information in the registry concerning the individual. “(D) Re-training required.— For purposes of subparagraph (A), if, since an individual’s most recent completion of a training and competency evaluation program, there has been a continuous period of 24 consecutive months during none of which the individual performed nursing or nursing-related services for monetary compensation, such individual shall complete a new training and competency evaluation program. “(E) Regular in-service education.— The nursing facility must provide such regular performance review and regular in-service education as assures that individuals used as nurse aides are competent to perform services as nurse aides, including training for individuals providing nursing and nursing-related services to residents with cognitive impairments. “(F) Nurse aide defined.— In this paragraph, the term ‘nurse aide’ means any individual providing nursing or nursing-related services to residents in a nursing facility, but does not include an individual— “(i) who is a licensed health professional (as defined in subparagraph (G)), or “(ii) who volunteers to provide such services without monetary compensation. “(G) Licensed health professional defined.— In this paragraph, the term ‘licensed health professional’ means a physician, physician assistant, nurse practitioner, physical, speech, or occupational therapist, registered professional nurse, licensed practical nurse, or licensed or certified social worker. “(6) Physician supervision and clinical records.— A nursing facility must— “(A) require that the health care of every resident be provided under the supervision of a physician; “(B) provide for having a physician available to furnish necessary medical care in case of emergency; and “(C) maintain clinical records on all residents, which records include the plans of care (described in paragraph (2)) and the residents’ assessments (described in paragraph (3)), as well as the results of any pre-admission screening conducted under subsection (e)(7). “(7) Required social services.— In the case of a nursing facility with more than 120 beds, the facility must have at least one social worker (with at least a bachelor’s degree in social work or similar professional qualifications) employed full-time to provide or assure the provision of social services. “(c) Requirements relating to residents’ rights.— “(1) General rights.— “(A) Specified rights.— A nursing facility must protect and promote the rights of each resident, including each of the following rights: “(i) Free choice.— The right to choose a personal attending physician, to be fully informed in advance about care and treatment, to be fully informed in advance of any changes in care or treatment that may affect the resident’s well-being, and (except with respect to a resident adjudged incompetent) to participate in planning care and treatment or changes in care and treatment. “(ii) Free from restraints.— The right to be free from physical or mental abuse, corporal punishment, involuntary seclusion, and any physical or chemical restraints imposed for purposes of discipline or convenience and not required to treat the resident’s medical symptoms. Restraints may only be imposed— “(I) to ensure the physical safety of the resident or other residents, and “(II) only upon the written order of a physician that specifies the duration and circumstances under which the restraints are to be used (except in emergency circumstances specified by the Secretary) until such an order could reasonably be obtained, “(iii) Privacy.— The right to privacy with regard to accommodations, medical treatment, written and telephonic communications, visits, and meetings of family and of resident groups. “(iv) Confidentiality.— The right to confidentiality of personal and clinical records. “(v) Accommodation of needs.— The right— “(I) to reside and receive services with reasonable accommodations of individual needs and preferences, except where the health or safety of the individual or other residents would be endangered, and “(II) to receive notice before the room or roommate of the resident in the facility is changed, “(vi) Grievances.— The right to voice grievances with respect to treatment or care that is (or fails to be) furnished, without discrimination or reprisal for voicing the grievances and the right to prompt efforts by the facility to resolve grievances the resident may have, including those with respect to the behavior of other residents. “(vii) Participation in resident and family groups.— The right of the resident to organize and participate in resident groups in the facility and the right of the resident’s family to meet in the facility with the families of other residents in the facility. 6161Copy read “ “(ix)”.“(viii) Participation in other activities.— The right of the resident to participate in social, religious, and community activities that do not interfere with the rights of other residents in the facility. 6262Copy read “ “(x)”.“(ix) Examination of survey results.— The right to examine, upon reasonable request, the results of the most recent survey of the facility conducted by the Secretary or a State with respect to the facility and any plan of correction in effect with respect to the facility. 6363Copy read “ “(xi)”.“(x) Other rights.— Any other right established by the Secretary. Clause (iii) shall not be construed as requiring the provision of a private room. “(B) Notice of rights.— A nursing facility must— “(i) inform each resident, orally and in writing at the time of admission to the facility, of the resident’s legal rights during the stay at the facility; “(ii) make available to each resident, upon reasonable request, a written statement of such rights (which statement is updated upon changes in such rights); “(iii) inform each resident who is entitled to medical assistance under this title— “(I) at the time of admission to the facility or, if later, at the time the resident becomes eligible for such assistance, of the items and services (including those specified under section 1902(a)(28)(B)) that are included in nursing facility services under the State plan and for which the resident may not be charged (except as permitted in section 1916), and of those other items and services that the facility offers and for which the resident may be charged and the amount of the charges for such items and services, and “(II) of changes in the items and services described in subclause (I) and of changes in the charges imposed for items and services described in that subclause; and “(iv) inform each other resident, in writing before or at the time of admission and periodically during the resident’s stay, of services available in the facility and of related charges for such services, including any charges for services not covered under title XVIII or by the facility’s basic per diem charge. The written description of legal rights under this subparagraph shall include a description of the protection of personal funds under paragraph (6) and a statement that a resident may file a complaint with a State survey and certification agency respecting resident abuse and neglect and misappropriation of resident property in the facility. “(C) Rights of incompetent residents.— In the case of a resident adjudged incompetent under the laws of a State, the rights of the resident under this title shall devolve upon, and, to the extent judged necessary by a court of competent jurisdiction, be exercised by, the person appointed under State law to act on the resident’s behalf. “(D) Use of psychopharmacologic drugs.— Psychopharmacologic drugs may be administered only on the orders of a physician and only as part of a plan (included in the written plan of care described in paragraph (2)) designed to eliminate or modify the symptoms for which the drugs are prescribed and only if, at least annually an independent, external consultant reviews the appropriateness of the drug plan of each resident receiving such drugs. “(2) Transfer and discharge rights.— “(A) In general.— A nursing facility must permit each resident to remain in the facility and must not transfer or discharge the resident from the facility unless— “(i) the transfer or discharge is necessary to meet the resident’s welfare and the resident’s welfare cannot be met in the facility; “(ii) the transfer or discharge is appropriate because the resident’s health has improved sufficiently so the resident no longer needs the services provided by the facility; “(iii) the safety of individuals in the facility is endangered; “(iv) the health of individuals in the facility would otherwise be endangered; “(v) the resident has failed, after reasonable and appropriate notice, to pay (or to have paid under this title or title XVIII on the resident’s behalf) an allowable charge imposed by the facility for an item or service requested by the resident and for which a charge may be imposed consistent with this title and title XVIII; or “(vi) the facility ceases to operate. In each 6464Copy read “In the each”. of the cases described in clauses (i) through (iv), the basis for the transfer or discharge must be documented in the resident’s clinical record. In the cases described in clauses (i) and (ii), the documentation must be made by the resident’s physician, and in the case described in clause (iv) the documentation must be made by a physician. For purposes of clause (v), in the case of a resident who becomes eligible for assistance under this title after admission to the facility, only charges which may be imposed under this title shall be considered to be allowable. “(B) Pre-transfer and pre-discharge notice.— “(i) In general.— Before effecting a transfer or discharge of a resident, a nursing facility must— “(I) notify the resident (and, if known, an immediate family member of the resident or legal representative) of the transfer or discharge and the reasons therefor, “(II) record the reasons in the resident’s clinical record (including any documentation required under subparagraph (A)), and “(III) include in the notice the items described in clause (iii). “(ii) Timing of notice.— The notice under clause (i)(I) must be made at least 30 days in advance of the resident’s transfer or discharge except— “(I) in a case described in clause (iii) or (iv) of subparagraph (A); “(II) in a case described in clause (ii) of subparagraph (A), where the resident’s health improves sufficiently to allow a more immediate transfer or discharge; “(III) in a case described in clause (i) of subparagraph (A), where a more immediate transfer or discharge is necessitated by the resident’s urgent medical needs; or “(IV) in a case where a resident has not resided in the facility for 30 days. In the case of such exceptions, notice must be given as many days before the date of the transfer or discharge as is practicable. “(iii) Items included in notice.— Each notice under clause (i) must include— “(I) for transfers or discharges effected on or after October 1, 1989, notice of the resident’s right to appeal the transfer or discharge under the State process established under subsection (e)(3); “(II) the name, mailing address, and telephone number of the State long-term care ombudsman (established under section 307(a)(12) of the Older Americans Act of 1965); “(III) in the case of residents with developmental disabilities, the mailing address and telephone number of the agency responsible for the protection and advocacy system for developmentally disabled individuals established under part C of the Developmental Disabilities Assistance and Bill of Rights Act; and “(IV) in the case of mentally ill residents (as defined in subsection (e)(7)(G)(i)), the mailing address and telephone number of the agency responsible for the protection and advocacy system for mentally ill individuals established under the Protection and Advocacy for Mentally 111 Individuals Act. “(C) Orientation.— A nursing facility must provide sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility. “(D) Notice on bed-hold policy and readmission.— “(i) Notice before transfer.— Before a resident of a nursing facility is transferred for hospitalization or therapeutic leave, a nursing facility must provide written information to the resident and an immediate family member or legal representative concerning— “(I) the provisions of the State plan under this title regarding the period (if any) during which the resident will be permitted under the State plan to return and resume residence in the facility, and “(II) the policies of the facility regarding such a period, which policies must be consistent with clause (iii). “(ii) Notice upon transfer.— At the time of transfer of a resident to a hospital or for therapeutic leave, a nursing facility must provide written notice to the resident and an immediate family member or legal representative of the duration of any period described in clause (i). “(iii) Permitting resident to return.— A nursing facility must establish and follow a written policy under which a resident— “(I) who is eligible for medical assistance for nursing facility services under a State plan, “(II) who is transferred from the facility for hospitalization or therapeutic leave, and “(III) whose hospitalization or therapeutic leave exceeds a period paid for under the State plan for the holding of a bed in the facility for the resident, will be permitted to be readmitted to the facility immediately upon the first availability of a bed in a semiprivate room in the facility if, at the time of readmission, the resident requires the services provided by the facility. “(3) Access and visitation rights.— A nursing facility must— “(A) permit immediate access to any resident by any representative of the Secretary, by any representative of the State, by an ombudsman or agency described in subclause (II), (III), or (IV) of paragraph (2)(B)(iii), or by the resident’s individual physician; “(B) permit immediate access to a resident, subject to the resident’s right to deny or withdraw consent at any time, by immediate family or other relatives of the resident; “(C) permit immediate access to a resident, subject to reasonable restrictions and the resident’s right to deny or withdraw consent at any time, by others who are visiting with the consent of the resident; “(D) permit reasonable access to a resident by any entity or individual that provides health, social, legal, or other services to the resident, subject to the resident’s right to deny or withdraw consent at any time; and “(E) permit representatives of the State ombudsman (described in paragraph (2)(B)(iii)(II)), with the permission of the resident (or the resident’s legal representative) and consistent with State law, to examine a resident’s clinical records. “(4) Equal access to quauty care.— “(A) In general.— A nursing facility must establish and maintain identical policies and practices regarding trans-fer, discharge, and the provision of services required under the State plan for all individuals regardless of source of payment. “(B) Construction.— “(i) Nothing prohibiting any charges for non-medicaid patients.— Subparagraph (A) shall not be construed as prohibiting a nursing facility from charging any amount for services furnished, consistent with the notice in paragraph (1)(B) describing such charges, “(ii) No additional services required.— Subparagraph (A) shall not be construed as requiring a State to offer additional services on behalf of a resident than are otherwise provided under the State plan. “(5) Admissions policy.— “(A) Admissions.— With respect to admissions practices, a nursing facility must— “(i) (I) not require individuals applying to reside or residing in the facility to waive their rights to benefits under this title or title XVIII, (II) not require oral or written assurance that such individuals are not eligible for, or will not apply for, benefits under this title or title XVIII, and (III) prominently display in the facility written information, and provide to such individuals oral and written information, about how to apply for and use such benefits and how to receive refunds for previous payments covered by such benefits; “(ii) not require a third party guarantee of payment to the facility as a condition of admission (or expedited admission) to, or continued stay in, the facility; and “(iii) in the case of an individual who is entitled to medical assistance for nursing facility services, not charge, solicit, accept, or receive, in addition to any amount otherwise required to be paid under the State plan under this title, any gift, money, donation, or other consideration as a precondition of admitting (or expediting the admission of) the individual to the facility or as a requirement for the individual’s continued stay in the facility. “(B) Construction.— “(i) No preemption of stricter standards.— Subparagraph (A) shall not be construed as preventing States or political subdivisions therein from prohibiting, under State or local law, the discrimination against individuals who are entitled to medical assistance under the State plan with respect to admissions practices of nursing facilities. “(ii) Contracts with legal representatives.— Subparagraph (A)(ii) shall not be construed as preventing a facility from requiring an individual, who has legal access to a resident’s income or resources available to pay for care in the facility, to sign a contract (without incurring personal financial liability) to provide payment from the resident’s income or resources for such care. “(iii) Charges for additional services requested.— Subparagraph (A)(iii) shall not be construed as preventing a facility from charging a resident, eligible for medical assistance under the State plan, for items or services the resident has requested and received and that are not specified in the State plan as included in the term ‘nursing facility services’. “(iv) Bona fide contributions.— Subparagraph (A)(iii) shall not be construed as prohibiting a nursing facility from soliciting, accepting, or receiving a charitable, religious, or philanthropic contribution from an organization or from a person unrelated to the resident (or potential resident), but only to the extent that such contribution is not a condition of admission, expediting admission, or continued stay in the facility. “(6) Protection of resident funds.— “(A) In general.— The nursing facility— “(i) may not require residents to deposit their personal funds with the facility, and “(ii) once the facility accepts the written authorization of the resident, must hold, safeguard, and account for such personal funds under a system established and maintained by the facility in accordance with this paragraph. “(B) Management of personal funds.— Upon a facility’s acceptance of written authorization of a resident under subparagraph (A)(ii), the facility must manage and account for the personal funds of the resident deposited with the facility as follows: “(i) Deposit.— The facility must deposit any amount of personal funds in excess of $50 with respect to a resident in an interest bearing account (or accounts) that is separate from any of the facility’s operating accounts and credits all interest earned on such separate account to such account. With respect to any other personal funds, the facility must maintain such funds in a non-interest bearing account or petty cash fund. “(ii) Accounting and records.— The facility must assure a full and complete separate accounting of each such resident’s personal funds, maintain a written record of all financial transactions involving the personal funds of a resident deposited with the facility, and afford the resident (or a legal representative of the resident) reasonable access to such record. “(iii) Notice of certain balances.— The facility must notify each resident receiving medical assistance under the State plan under title XIX when the amount in the resident’s account reaches $200 less than the dollar amount determined under section 1611(a)(3)(B) and the fact that if the amount in the account (in addition to the value of the resident’s other nonexempt resources) reaches the amount determined under such section the resident may lose eligibility for such medical assistance or for benefits under title XVI. “(iv) Conveyance upon death.— Upon the death of a resident with such an account, the facility must convey promptly the resident’s personal funds (and a final accounting of such funds) to the individual administering the resident’s estate. “(C) Assurance of financial security.— The facility must purchase a surety bond, or otherwise provide assurance satisfactory to the Secretary, to assure the security of all personal funds of residents deposited with the facility. “(D) Limitation on charges to personal funds.— The facility may not impose a charge against the personal funds of a resident for any item or service for which payment is made under this title or title XVIII. “(d) Requirements relating to administration and other matters.— “(1) Administration.— “(A) In general.— A nursing facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident (consistent with requirements established under subsection (f)(5)). “(B) Required notices.— If a change occurs in— “(i) the persons with an ownership or control interest (as defined in section 1124(a)(3)) in the facility, “(ii) the persons who are officers, directors, agents, or managing employees (as defined in section 1126(b)) of the facility, “(iii) the corporation, association, or other company responsible for the management of the facility, or “(iv) the individual who is the administrator or director of nursing of the facility, the nursing facility must provide notice to the State agency responsible for the licensing of the facility, at the time of the change, of the change and of the identity of each new person, company, or individual described in the respective clause. “(C) Nursing facility administrator.— The administrator of a nursing facility must meet standards established by the Secretary under subsection (f)(4). “(2) Licensing and life safety code.— “(A) Licensing.— A nursing facility must be licensed under applicable State and local law. “(B) Life safety code.— A nursing facility must meet such provisions of such edition (as specified by the Secretary in regulation) of the Life Safety Code of the National Fire Protection Association as are applicable to nursing homes; except that— “(i) the Secretary may waive, for such periods as he deems appropriate, specific provisions of such Code which if rigidly applied would result in unreasonable hardship upon a facility, but only if such waiver would not adversely affect the health and safety of residents or personnel, and “(ii) the provisions of such Code shall not apply in any State if the Secretary finds that in such State there is in effect a fire and safety code, imposed by State law, which adequately protects residents of and personnel in nursing facilities. “(3) Sanitary and infection control and physical environment.— A nursing facility must— “(A) establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment in which residents reside and to help prevent the development and transmission of disease and infection, and “(B) be designed, constructed, equipped, and maintained in a manner to protect the health and safety of residents, personnel, and the general public. “(4) Miscellaneous.— “(A) Compliance with federal, state, and local laws and professional standards.— A nursing facility must operate and provide services in compliance with all applicable Federal, State, and local laws and regulations (including the requirements of section 1124 and with accepted professional standards and principles which apply to professionals providing services in such a facility. “(B) Other.— A nursing facility must meet such other requirements relating to the health and safety of residents or relating to the physical facilities thereof as the Secretary may find necessary.”. (c) State Requirements Relating to Nursing Facility Requirements.— Section 1919 of such Act is further amended by adding at the end the following new subsection: “(e) State Requirements Relating to Nursing Facility Requirements.— As a condition of approval of 6565Copy read “approval its”. its plan under this title, a State must provide for the following: “(1) Specification and review of nurse aide training and competency evaluation programs and of nurse aide competency evaluation programs.— The State must— “(A) by not later than September 1, 1988, specify those training and competency evaluation programs, and those competency evaluation programs, that the State approves for purposes of subsection (b)(5) and that meet the requirements established under clause (i) or (ii) of subsection (f)(2)(A), and “(B) by not later than September 1, 1990, provide for the review and reapproval of such programs, at a frequency and using a methodology consistent with the requirements established under subsection (f)(2)(A)(iii). The failure of the Secretary to establish requirements under subsection (f)(2) shall not relieve any State of its responsibility under this paragraph. “(2) Nurse aide registry.— “(A) In general.— By not later than January 1, 1989, the State shall establish and maintain a registry of all individuals who have satisfactorily completed a nurse aide training and competency evaluation program, or a nurse aide competency evaluation program, approved under paragraph (1) in the State. “(B) Information in registry.— The registry under subparagraph (A) shall provide (in accordance with regulations of the Secretary) for the inclusion of specific documented findings by a State under subsection (g)(1)(C) of resident neglect or abuse or misappropriation of resident property involving an individual listed in the registry, as well as any brief statement of the individual disputing the findings. In the case of inquiries to the registry concerning an individual listed in the registry, any information disclosed concerning such a finding shall also include disclosure of any such statement in the registry relating to the finding or a clear and accurate summary of such a statement. “(3) State appeals process for transfers.— The State, for transfers from nursing facilities effected on or after October 1, 1989, must provide for a fair mechanism, meeting the guidelines established under subsection (f)(3), for hearing appeals on transfers of residents of such facilities; but the failure of the Secretary to establish such guidelines under such subsection shall not relieve any State of its responsibility under this paragraph. “(4) Nursing facility administrator standards.— By not later than July 1, 1989, the State must have implemented and enforced the nursing facility administrator standards developed under subsection (f)(4) respecting the qualification of administrators of nursing facilities. “(5) Specification of resident assessment instrument.— Effective July 1, 1990, the State shall specify the instrument to be used by nursing facilities in the State in complying with the requirement of subsection (b)(3)(A)(iii). Such instrument shall be— “(A) one of the instruments designated under subsection (f)(6)(B), or “(B) an instrument which the Secretary has approved as being consistent with the minimum data set of core elements, common definitions, and utilization guidelines specified by the Secretary under subsection (f)(6)(A). “(6) Notice of medicaid rights.— Each State, as a condition of approval of its plan under this title, effective April 1, 1988, must develop (and periodically update) a written notice of the rights and obligations of residents of nursing facilities (and spouses of such residents) under this title. “(7) State requirements for pre-admission screening and resident review.— “(A) Pre-admission screening.— Effective January 1, 1989, the State must have in effect a pre-admission screening program, for making determinations (using any criteria developed under subsection (f)(8)) described in subsection (b)(3)(F) for mentally ill and mentally retarded individuals (as defined in subparagraph (G)) who are admitted to nursing facilities on or after January 1, 1989. The failure of the Secretary to develop minimum criteria under subsection (f)(8) shall not relieve any State of its responsibility to have a pre-admission screening program under this subparagraph or to perform resident reviews under subparagraph (B). “(B) State requirement for annual resident review.— “(i) For mentally ill residents.— As of April 1, 1990, in the case of each resident of a nursing facility who is mentally ill, the State mental health authority must review and determine (using any criteria developed under subsection (f)(8) and based on an independent physical and mental evaluation performed by a person or entity other than the State mental health authority)— “(I) whether or not the resident, because of the resident’s physical and mental condition, requires the level of services provided by a nursing facility or requires the level of services of an inpatient psychiatric hospital for individuals under age 21 (as described in section 1905(h)) or of an institution for mental diseases providing medical assistance to individuals 65 years of age or older; and “(II) whether or not the resident requires active treatment for mental illness, “(ii) For mentally retarded residents.— As of April 1, 1990, in the case of each resident of a nursing facility who is mentally retarded, the State mental retardation or developmental disability authority must review and determine (using any criteria developed under subsection (f)(8))— “(I) whether or not the resident, because of the resident’s physical and mental condition, requires the level of services provided by a nursing facility or requires the level of services of an intermediate care facility described under section 1905(d); and “(II) whether or not the resident requires active treatment for mental retardation, “(iii) Frequency of reviews.— “(I) Annual.— Except as provided in subclauses (II) and (III), the reviews and determinations under clauses (i) and (ii) must be conducted with respect to each mentally ill or mentally retarded resident not less often than annually. “(II) Pre-admission review cases.— In the case of a resident subject to a pre-admission review under subsection (b)(3)(F), the review and determination under clause (i) or (ii) need not be done until the resident has resided in the nursing facility for 1 year. “(III) Initial review.— The reviews and determinations under clauses (i) and (ii) must first be conducted (for each resident not subject to pre-admission review under subsection (b)(3)(F)) by not later than April 1, 1990. “(C) Response to pre-admission screening and resident review.— AS of April 1, 1990, the State must meet the following requirements: “(i) Long-term residents not requiring nursing facility services, but requiring active treatment.— In the case of a resident who is determined, under subparagraph (B), not to require the level of services provided by a nursing facility, but to require active treatment for mental illness or mental retardation, and who has continuously resided in a nursing facility for at least 30 months before the date of the determination, the State must, in consultation with the resident’s family or legal representative and care-givers— “(I) inform the resident of the institutional and noninstitutional alternatives covered under the State plan for the resident, “(II) offer the resident the choice of remaining in the facility or of receiving covered services in an alternative appropriate institutional or noninstitutional setting, “(III) clarify the effect on eligibility for services under the State plan if the resident chooses to leave the facility (including its effect on readmission to the facility), and “(IV) regardless of the resident’s choice, provide for (or arrange for the provision of) such active treatment for the mental illness or mental retardation. A State shall not be denied payment under this title for nursing facility services for a resident described in this clause because the resident does not require the level of services provided by such a facility, if the resident chooses to remain in such a facility. “(ii) Other residents not requiring nursing facility services, but requiring active treatment.— In the case of a resident who is determined, under subparagraph (B), not to require the level of services provided by a nursing facility, but to require active treatment for mental illness or mental retardation, and who has not continuously resided in a nursing facility for at least 30 months before the date of the determination, the State must, in consultation with the resident’s family or legal representative and care-givers— “(I) arrange for the safe and orderly discharge of the resident from the facility, consistent with the requirements of subsection (c)(2), “(II) prepare and orient the resident for such discharge, and “(III) provide for (or arrange for the provision of) such active treatment for the mental illness or mental retardation, “(iii) Residents not requiring nursing facility services and not requiring active treatment.— In the case of a resident who is determined, under subparagraph (B), not to require the level of services provided by a nursing facility and not to require active treatment for mental illness or mental retardation, the State must— “(I) arrange for the safe and orderly discharge of the resident from the facility, consistent with the requirements of subsection (c)(2), and “(II) prepare and orient the resident for such discharge. “(D) Denial of payment where failure to conduct pre-admission screening.— No payment may be made under section 1903(a) with respect to nursing facility services furnished to an individual for whom a determination is required under subsection (b)(3)(F) or subparagraph (B) but for whom the determination is not made. “(E) Permitting alternative disposition plans.— With Contracts. respect to residents of a nursing facility who are mentally retarded or mentally ill and who are determined under subparagraph (B) not to require the level of services of such a facility, but who require active treatment for mental illness or mental retardation, a State and the nursing facility shall be considered to be in compliance with the requirement of this paragraph if, before October 1, 1988, the State and the Secretary have entered into an agreement relating to the disposition of such residents of the facility and the State is in compliance with such agreement. Such an agreement may provide for the disposition of the residents after the date specified in subparagraph (C). “(F) Appeals procedures.— Each State, as a condition of approval of its plan under this title, effective January 1, 1989, must have in effect an appeals process for individuals adversely affected by determinations under subparagraph (A) or (B). “(G) Definitions.— In this paragraph and in subsection (b)(3)(F): “(i) An individual is considered to be ‘mentally ill’ if the individual has a primary or secondary diagnosis of mental disorder (as defined in the Diagnostic and Statistical Manual of Mental Disorders, 3rd edition) and does not have a primary diagnosis of dementia (including Alzheimer’s disease or a related disorder), “(ii) An individual is considered to be ‘mentally retarded’ if the individual is mentally retarded or a person with a related condition (as described in section 1905(d)). “(iii) The term ‘active treatment’ has the meaning given such term by the Secretary in regulations, but does not include, in the case of a resident of a nursing facility, services within the scope of services which the facility must provide or arrange for its residents under subsection (b)(4). “(f) Responsibilities of Secretary Relating to Nursing Facility Requirements.— “(1) General responsibility.— It is the duty and responsibility of the Secretary to assure that requirements which govern the provision of care in nursing facilities under State plans approved under this title, and the enforcement of such requirements, are adequate to protect the health, safety, welfare, and rights of residents and to promote the effective and efficient use of public moneys. “(2) Requirements for nurse aide training and competency evaluation programs and for nurse aide competency evaluation programs.— “(A) In general.— For purposes of subsections (b)(5) and (e)(1)(A), the Secretary shall establish, by not later than July 1, 1988— “(i) requirements for the approval of nurse aide training and competency evaluation programs, including requirements relating to (I) the areas to be covered in such a program (including at least basic nursing skills, personal care skills, cognitive, behavioral and social care, basic restorative services, and residents’ rights), content of the curriculum, (II) minimum hours of initial and ongoing training and retraining (including not less than 75 hours in the case of initial training), (III) qualifications of instructors, and (IV) procedures for determination of competency; “(ii) requirements for the approval of nurse aide competency evaluation programs, including requirement relating to the areas to be covered in such a program, including at least basic nursing skills, personal care skills, cognitive, behavioral and social care, basic restorative services, and residents’ rights, and procedures for determination of competency; “(iii) requirements respecting the minimum frequency and methodology to be used by a State in reviewing such programs’ compliance with the requirements for such programs. “(B) Approval of certain programs.— Such requirements— “(i) may permit approval of programs offered by or in facilities, as well as outside facilities (including employee organizations), and of programs in effect on the date of the enactment of this section; “(ii) shall permit a State to find that an individual who has completed (before January 1, 1989) a nurse aide training and competency evaluation program shall be deemed to have completed such a program approved under subsection (b)(5) if the State determines that, at the time the program was offered, the program met the requirements for approval under such paragraph; and “(iii) shall prohibit approval of such a program— “(I) offered by or in a nursing facility which has been determined to be out of compliance with the requirements of subsection (b), (c), or (d), within the previous 2 years, or “(II) offered by or in a nursing facility unless the State makes the determination, upon an individual’s completion of the program, that the individual is competent to provide nursing and nursing-related services in nursing facilities. A State may not delegate its responsibility under clause (iii)(II) to the nursing facility. “(3) Federal guidelines for state appeals process for transfers.— For purposes of subsections (c)(2)(B)(iii) and (e)(3), by not later than October 1, 1988, the Secretary shall establish guidelines for minimum standards which State appeals processes under subsection (e)(3) must meet to provide a fair mechanism for hearing appeals on transfers of residents from nursing facilities. “(4) Secretarial standards qualification of administrators.— For purposes of subsections (d)(1)(C) and (e)(4), the Secretary shall develop, by not later than March 1, 1988, standards to be applied in assuring the qualifications of administrators of nursing facilities. “(5) Criteria for administration.— The Secretary shall establish criteria for assessing a nursing facility’s compliance with the requirement of subsection (d)(1) with respect to— “(A) its governing body and management, “(B) agreements with hospitals regarding transfers of residents to and from the hospitals and to and from other nursing facilities, “(C) disaster preparedness, “(D) direction of medical care by a physician, “(E) laboratory and radiological services, “(F) clinical records, and “(G) resident and advocate participation. “(6) Specification of resident assessment data set and instruments.— The Secretary shall— “(A) not later than January 1, 1989, specify a minimum data set of core elements and common definitions for use by nursing facilities in conducting the assessments required under subsection (b)(3), and establish guidelines for utilization of the data set; and “(B) by not later than April 1, 1990, designate one or more instruments which are consistent with the specification made under subparagraph (A) and which a State may specify under subsection (e)(5)(A) for use by nursing facilities in complying with the requirements of subsection (b)(3)(A)(iii). “(7) List of items and services furnished in nursing facilities not chargeable to the personal funds of a resident.— “(A) Regulations required.— Pursuant to the requirement of section 21(b) of the Medicare-Medicaid Anti-Fraud and Abuse Amendments of 1977, the Secretary shall issue regulations, on or before the first day of the seventh month to begin after the date of enactment of this section, that define those costs which may be charged to the personal funds of patients in nursing facilities who are individuals receiving medical assistance with respect to nursing facility services under this title and those costs which are to be included in the payment amount under this title for nursing facility services. “(B) Rule if failure to publish regulations.— If the Secretary does not issue the regulations under subparagraph (A) on or before the date required in that subparagraph, in the case of a resident of a nursing facility who is eligible to receive benefits for nursing facility services under this title, for purposes of section 1902(a)(28)(B), the Secretary shall be deemed to have promulgated regulations under this paragraph which provide that the costs which may not be charged to the personal funds of such resident (and for which payment is considered to be made under this title) do not include, at a minimum, the costs for routine personal hygiene items and services furnished by the facility. “(8) Federal minimum criteria and monitoring for pre-admission screening and resident review.— “(A) Minimum criteria.— The Secretary shall develop, by not later than October 1, 1988, minimum criteria for States to use in making determinations under subsections (b)(3)(F) and (e)(7)(B) and in permitting individuals adversely affected to appeal such determinations, and shall notify the States of such criteria. “(B) Monitoring compliance.— The Secretary shall review, in a sufficient number of cases to allow reasonable inferences, each State’s compliance with the requirements of subsection (e)(7)(C)(ii) (relating to discharge and placement for active treatment of certain residents). “(9) 6666Copy read “ “(8)”. Criteria for monitoring state waivers.— The Secretary shall develop, by not later than October 1, 1988, criteria and procedures for monitoring State performances in granting waivers pursuant to subsection (b)(4)(C)(ii).”. (b) Incorporating Requirements into State Plan.— (1) In general.— Section 1902(a) of such Act (42 U.S.C. 1396a(a)) is amended— (A) in paragraph (13)(A), by inserting “which, in the case of nursing facilities, take into account the costs of complying with subsections (b) (other than paragraph (3)(F) thereof), (c), and (d) of section 1919 and provide (in the case of a nursing facility with a waiver under section 1919(b)(4)(C)(ii)) for an appropriate reduction to take into account the lower costs (if any) of the facility for nursing care,” after “State” the second place it appears; and (B) by amending paragraph (28) to read as follows: “(28) provide— “(A) that any nursing facility receiving payments under such plan must satisfy all the requirements of subsections (b) through (d) of section 1919 as they apply to such facilities; “(B) for including in ‘nursing facility services’ at least the items and services specified (or deemed to be specified) by the Secretary under section 1919(f)(7) and making available upon request a description of the items and services so included; “(C) for procedures to make available to the public the data and methodology used in establishing payment rates for nursing facilities under this title; and “(D) for compliance (by the date specified in the respective sections) with the requirements of— “(i) section 1919(f) (relating to implementation of, nursing facility requirements, including paragraph (6)(B), relating to specification of resident assessment instrument); “(ii) section 1919(g) (relating to responsibility for survey and certification of nursing facilities); and “(iii) sections 1919(h)(2)(B) and 1919(h)(2)(D) (relating to establishment and application of remedies);”. (2) State plan amendment required.— A plan of a State 42 USC 1396a note. under title XIX of the Social Security Act shall not be considered to have met the requirement of section 1902(a)(13)(A) of the Social Security Act (as amended by paragraph (1)(A) of this subsection), as of the first day of a Federal fiscal year (beginning on or after October 1, 1990), unless the State has submitted to the Secretary of Health and Human Services, as of April 1 before the fiscal year, an amendment to such State plan to provide for an appropriate adjustment in payment amounts for nursing facility services furnished during the Federal fiscal year. The Secretary shall, not later than September 80 before the fiscal year concerned, review each such plan amendment for compliance with such requirement and by such date shall approve or disapprove each such amendment. If the Secretary disapproves such an amendment, the State shall immediately submit a revised amendment which meets such requirement. The absence of approval of such a plan amendment does not relieve the State or any nursing facility of any obligation or requirement under title XIX of the Social Security Act (as amended by this Act). (c) Evaluation.— The Secretary of Health and Human Services Reports. 42 USC 1396r note. shall evaluate, and report to Congress by not later than January 1, 1993, on the implementation of the resident assessment process for residents of nursing facilities under the amendments made by this section. (d) Funding.— (1) In general.— Section 1903(a)(2) of such Act (42 U.S.C. 1396b(a)(2)) is amended— (A) by inserting “(A)” after “(2)”, and (B) by adding at the end the following new subparagraphs: “(B) notwithstanding paragraph (1) or subparagraph (A), with respect to amounts expended for nursing aide training and competency evaluation programs, and competency evaluation programs, described in section 1919(e)(1), regardless of whether the programs are provided in or outside nursing facilities or of the skill of the personnel involved in such programs, an amount equal to 50 percent of so much of the sums expended during such quarter (as found necessary by the Secretary for the proper and efficient administration of the State plan) as are attributable to such programs; plus “(C) an amount equal to 75 percent of so much of the sums expended during such quarter (as found necessary by the Secretary for the proper and efficient administration of the State plan) as are attributable to pre-admission screening and resident review activities conducted by the State under section 1919(e)(7); plus”. (2) Enhanced funding for nurse aide training.— For Calendar 42 USC 1396b note. quarters during fiscal years 1988 and 1989, with respect to payment under section 1903(a)(2)(B) of the Social Security Act to a State for additional amounts expended by the State under its plan approved under title XIX of such Act for nursing aide training and competency evaluation programs, and competency evaluation programs, described in section 1919(e)(1) of such title, any reference to “50 percent” is deemed a reference to the sum of the Federal medical assistance percentage (determined under section 1905(b) of such Act) plus 25 percentage points, but not to exceed 90 percent. (e) Revision of Previous Definitions.— Section 1905 of such Act (42 U.S.C. 1396d) is amended— (1) by amending subsection (c) to read as follows: “(c) For definition of the term ‘nursing facility’, see section 1919(a).”; (2) in subsection (d)— (A) by striking “intermediate care facility services” and inserting “intermediate care facility for the mentally retarded”, (B) by striking “may include services in a public” and inserting “means an”, (C) in paragraph (3), by inserting “in the case of a public institution,” after “(3)”; (3) in subsection (f), by striking “skilled” each place it appears; and (4) by striking subsection (i). (f) Making Coverage of Nursing Facility Services Mandatory for Adults.— Section 1905(a)(4)(A) of such Act (42 U.S.C. 1396d(a)(4)(A)) is amended by striking “skilled”. (g) Elimination of Payment Differential.— Section 1903 of such Act (42 U.S.C. 1396b) is amended— (1) by striking subsection (h), and (2) in subsection (a)(1), by striking “, (h), and” and inserting “and”. (h) Clarifying Terminology.— (1) Section 1902(a)(10) of such Act (42 U.S.C. 1396a(a)(10)) is amended— (A) in subparagraph (A)(ii)(VI), by striking “skilled” and by inserting “for the mentally retarded” after “intermediate care facility”; (B) in subparagraph (C)(iv), by striking “intermediate care facility services” and inserting “in an intermediate care facility”; and (C) in subparagraph (D), by striking “skilled”. (2) Section 1902(a)(13) of such Act (42 U.S.C. 1396a(a)(13)) is amended— (A) in subparagraph (A), by striking “, skilled nursing facility, and intermediate care facility services” and inserting “services, nursing facility services, and services in an intermediate care facility for the mentally retarded”;6767Copy read “retarded”,”. (B) in subparagraph (A), by striking “, skilled nursing facility, and intermediate care facility and” and inserting “nursing facility, and intermediate care facility for the mentally retarded and”; (C) in subparagraph (C), by striking “skilled nursing facilities and intermediate care facilities” and inserting “nursing facilities”; and (D) in subparagraph (D)— (i) by striking “skilled nursing facility or intermediate care facility” and inserting “nursing facility”, and (ii) by striking “skilled nursing facility services or intermediate care facility services” and inserting “nursing facility services” (3) Section 1902(a)(30)(B) of such Act (42 U.S.C. 1396a(a)(30)(B)) is amended by striking “skilled nursing facility, intermediate care facility,” each place it appears and inserting “intermediate care facility for the mentally retarded,”. (4) Section 1902(e)(3)(B)(i) of such Act (42 U.S.C. 1396a(e)(3)(B)(i)) is amended by striking “skilled nursing facility, or intermediate care facility” and inserting “nursing facility, or intermediate care facility for the mentally retarded”. (5) Section 1902(e)(9) of such Act (42 U.S.C. 1396a(e)(9)) is amended— (A) in subparagraph (A)(iii), by striking “skilled nursing facility, or intermediate care facility,” and inserting “nursing facility, or intermediate care facility for the mentally retarded” and (B) in subparagraph (B), by striking “skilled nursing facilities, or intermediate care facilities” and inserting “nursing facilities, or intermediate care facilities for the mentally retarded”. (6) Section 1905(a) of such Act (42 U.S.C. 1396d(a)) is amended— (A) in paragraph (5), by striking “skilled”, (B) in paragraph (14), by striking “, skilled nursing facility services, and intermediate care facility services” and inserting “and nursing facility services”, and (C) in paragraph (15), by striking “intermediate care facility services (other than such services” and inserting “services in an intermediate care facility for the mentally retarded (other than”. (7) Section 1128B of such Act (42 U.S.C. 1320a–7b) is amended— (A) in subsection (c), by striking “intermediate care facility” and inserting “nursing facility, intermediate care facility for the mentally retarded”, and (B) in subsection (d)(2)(A), by striking “skilled nursing facility, or intermediate care facility” and inserting “nursing facility, or intermediate care facility for the mentally retarded”. (8) Section 1911 of such Act (42 U.S.C. 1396j) is amended by striking “, intermediate care facility, or skilled nursing facility” each place it appears and inserting “or nursing facility”. (9) Section 1913 of such Act (42 U.S.C. 13961) is amended— (A) in the heading, by striking “skilled nursing and intermediate care services” and inserting “nursing facility services”; (B) in subsection (a)— (i) by striking “skilled nursing facility services and intermediate care facility services” and inserting “nursing facility services”, and (ii) by inserting before the period at the end the following: “and which, with respect to the provision of such services, meets the requirements of subsections (b) through (d) of section 1919”; (C) in subsection (b)(1)— (i) by striking “skilled nursing or intermediate care facility services” and inserting “nursing facility services”, and (ii) by striking “skilled nursing and intermediate care facilities” and inserting “nursing facilities”; and (D) in subsection (b)(3), by striking “skilled nursing or intermediate care facility services” and inserting “nursing facility services”. (10) Section 1915(c) of such Act (42 U.S.C. 1396n(c)) is amended— (A) in paragraph (1), by striking “skilled nursing facility or intermediate care facility” and inserting “nursing facility or intermediate care facility for the mentally retarded”; (B) in paragraph (2)(B)(i), by striking “, skilled nursing facility, or intermediate care facility services” and inserting “services, nursing facility services, or services in an intermediate care facility for the mentally retarded”; (C) in paragraph (2)(B), by striking “need” and all that follows up to the semicolon and inserting “need for inpatient hospital services, nursing facility services, or services in an intermediate care facility for the mentally retarded”; (D) in paragraph (2)(C), by striking “or skilled nursing facility or intermediate care facility” and inserting “, nursing facility, or intermediate care facility for the mentally retarded”; (E) in paragraph (2)(C), by striking “or skilled nursing facility or intermediate care facility services” and inserting “, nursing facility services, or services in an intermediate care facility for the mentally retarded”; (F) in paragraph (5), by striking “skilled nursing facility or intermediate care facility” and inserting “nursing facility or intermediate care facility for the mentally retarded”; and (G) in paragraph (7), by striking “or in skilled nursing or intermediate care facilities” and inserting “, nursing facilities, or intermediate care facilities for the mentally retarded”. (11) Section 1916 of such Act (42 U.S.C. 1396m) is amended, in 42 USC 1396o. subsections (a)(2)(C) and (b)(2)(C), by striking “skilled nursing facility, intermediate care facility” and inserting “nursing facility, intermediate care facility for the mentally retarded”. (12) Section 1917 of such Act (42 U.S.C. 1396p), as amended by this title, is further amended— (A) in subsections (a)(1)(B)(i) and (c)(2)(B)(i), by striking “skilled nursing facility, intermediate care facility” and inserting “nursing facility, intermediate care facility for the mentally retarded”, and (B) in subsection (c)(3)(A), by striking “skilled”. (i) Utilization Review.— Section 1903(i)(4) of such Act (42 U.S.C. 1396b(i)(4)) is amended by striking “or skilled nursing facility” each place it appears. (j) Technical Assistance.— The Secretary of Health and Human 42 USC 1396a note. Services shall, upon request by a State, furnish technical assistance with respect to the development and implementation of reimbursement methods for nursing facilities that take into account the case mix of residents in the different facilities. (k) Report on Staffing Requirements.— The Secretary of Health 42 USC 1396r note. and Human Services shall report to Congress, by not later than January 1, 1993, on the progress made in implementing the nursing facility staffing requirements of subparagraph (C) of section 1919(b)(4) of the Social Security Act (as amended by subsection (a) of this section), including the number and types of waivers approved under subparagraph (C)(ii) of such section and the number of facilities which have received waivers. (l) Conforming Amendment.— Section 9516(c) of the Consolidated Omnibus Budget Reconciliation Act of 1985 is amended by striking 42 USC 1396r–3 note. “section 1919” and inserting “section 1922”. SEC. 4212. SURVEY AND CERTIFICATION PROCESS. (a) In general.— Section 1919 of the Social Security Act, as inserted by section 4211, is amended by adding at the end the following new subsection: “(g) Survey and Certification Process.— “(1) State and federal responsibility.— “(A) In general.— Under each State plan under this title, the State shall be responsible for certifying, in accordance with surveys conducted under paragraph (2), the compliance of nursing facilities (other than facilities of the State) with the requirements of subsections (b), (c), and (d). The Secretary shall be responsible for certifying, in accordance with surveys conducted under paragraph (2), the compliance of State nursing facilities with the requirements of such subsections. “(B) Educational program.— Each State shall conduct periodic educational programs for the staff and residents (and their representatives) of nursing facilities in order to present current regulations, procedures, and policies under this section. “(C) Investigation of allegations of resident neglect and abuse and misappropriation of resident property.— The State shall provide, through the agency responsible for surveys and certification of nursing facilities under this subsection, for a process for the receipt, review, and investigation of allegations of neglect and abuse and misappropriation of resident property by a nurse aide of a resident in a nursing facility. If the State finds, after notice to the nurse aide involved and a reasonable opportunity for a hearing for the nurse aide to rebut allegations, that a nurse aide whose name is contained in a nurse aide registry has neglected or abused a resident or misappropriated resident property in a facility, the State shall notify the nurse aide and the registry of such finding. “(D) Construction.— The failure of the Secretary to establish standards under subsection (f) shall not relieve a State of its responsibility under this subsection. “(2) Surveys.— “(A) Annual standard survey.— “(i) In general.— Each nursing facility shall be subject to a 6868Copy read “to an standard”. standard survey, to be conducted without any prior notice to the facility. Any individual who notifies (or causes to be notified) a nursing facility of the time or date on which such a survey is scheduled to be conducted is subject to a civil money penalty of not to exceed $2,000. The Secretary shall provide for imposition of civil money penalties under this clause in a manner similar to that for the imposition of civil money penalties under section 1128A. The Secretary shall review each State’s procedures for scheduling and conduct of standard surveys to assure that the State has taken all reasonable steps to avoid giving notice of such a survey through the scheduling procedures and the conduct of the surveys themselves. “(ii) Contents.— Each standard survey shall include, for a case-mix stratified sample of residents— “(I) a survey of the quality of care furnished, as measured by indicators of medical, nursing, and rehabilitative care, dietary and nutrition services, activities and social participation, and sanitation, infection control, and the physical environment, “(II) written plans of care provided under subsection (b)(2) and an audit of the residents’ assessments under subsection (b)(3) to determine the accuracy of such assessments and the adequacy of such plans of care, and “(III) a review of compliance with residents’ rights under subsection (c). “(iii) Frequency.— “(I) In general.— Each nursing facility shall be subject to a standard survey not later than 15 months after the date of the previous standard survey conducted under this subparagraph. The statewide 6969Copy read “Statewide”. average interval between standard surveys of a nursing facility shall not exceed 12 months. “(II) Special surveys.— If not otherwise conducted under subclause (I), a standard survey (or an abbreviated standard survey) may be conducted within 2 months of any change of ownership, administration, management of a nursing facility, or director of nursing in order to determine whether the change has resulted in any decline in the quality of care furnished in the facility. “(B) Extended surveys.— “(i) In general.— Each nursing facility which is found, under a standard survey, to have provided substandard quality of care shall be subject to an extended survey. Any other facility may, at the Secretary’s or State’s discretion, be subject to such an extended survey (or a partial extended survey). “(ii) Timing.— The extended survey shall be conducted immediately after the standard survey (or, if not practical, not later than 2 weeks after the date of completion of the standard survey). “(iii) Contents.— In such an extended survey, the survey team shall review and identify the policies and procedures which produced such substandard quality of care and shall determine whether the facility has complied with all the requirements described in subsections (b), (c), and (d). Such review shall include an expansion of the size of the sample of residents’ assessments reviewed and a review of the staffing, of in-service training, and, if appropriate, of contracts with consultants. “(iv) Construction.— Nothing in this paragraph shall be construed as requiring an extended or partial extended survey as a prerequisite to imposing a sanction against a facility under subsection (h) on the basis of findings in a standard survey. “(C) Survey protocol.— Standard and extended surveys shall be conducted— “(i) based upon a protocol which the Secretary has developed, tested, and validated by not later than January 1, 1990, and “(ii) by individuals, of a survey team, who meet such minimum qualifications as the Secretary establishes by not later than such date. The failure of the Secretary to develop, test, or validate such protocols or to establish such minimum qualifications shall not relieve any State of its responsibility (or the Secretary of the Secretary’s responsibility) to conduct surveys under this subsection. “(D) Consistency of surveys.— Each State shall implement programs to measure and reduce inconsistency in the application of survey results among surveyors. “(E) Survey teams.— “(i) In general.— Surveys under this subsection shall be conducted by a multidisciplinary team of professionals (including a registered professional nurse). “(ii) Prohibition of conflicts of interest.— A State may not use as a member of a survey team under this subsection an individual who is serving (or has served within the previous 2 years) as a member of the staff of, or as a consultant to, the facility surveyed respecting compliance with the requirements of subsections (b), (c), and (d), or who has a personal or familial financial interest in the facility being surveyed. “(iii) Training.— The Secretary shall provide for the comprehensive training of State and Federal surveyors in the conduct of standard and extended surveys under this subsection, including the auditing of resident assessments and plans of care. No individual shall serve as a member of a survey team unless the individual has successfully completed a training and testing program in survey and certification techniques that has been approved by the Secretary. “(3) Validation surveys.— “(A) In general.— The Secretary shall conduct onsite surveys of a representative sample of nursing facilities in each State, within 2 months of the date of surveys conducted under paragraph (2) by the State, in a sufficient number to allow inferences about the adequacies of each State’s surveys conducted under paragraph (2). In conducting such surveys, the Secretary shall use the same survey protocols as the State is required to use under paragraph (2). If the State has determined that an individual nursing facility meets the requirements of subsections (b), (c), and (d), but the Secretary determines that the facility does not meet such requirements, the Secretary’s determination as to the facility s noncompliance with such requirements is binding and supersedes that of the State survey. “(B) Scope.— With respect to each State, the Secretary shall conduct surveys under subparagraph (A) each year with respect to at least 5 percent of the number of nursing facilities surveyed by the State in the year, but in no case less than 5 nursing facilities in the State. “(C) Reduction in administrative costs for substandard performance.— If the Secretary finds, on the basis of such surveys, that a State has failed to perform surveys as required under paragraph (2) or that a State’s survey and certification performance otherwise is not adequate, the Secretary may provide for the training of survey teams in the State and shall provide for a reduction of the payment otherwise made to the State under section 1903(a)(2)(D) with respect to a quarter equal to 33 percent multiplied by a fraction, the denominator of which is equal to the total number of residents in nursing facilities surveyed by the Secretary that quarter and the numerator of which is equal to the total number of residents in nursingfacilities which were found pursuant to such surveys to be not in compliance with any of the requirements of subsections (b), (c), and (d). A State that is dissatisfied with the Secretary’s findings under this subparagraph may obtain reconsideration and review of the findings under section 1116 in the same manner as a State may seek reconsideration and review under that section of the Secretary’s determination under section 1116(a)(1). “(C) Special surveys of compliance.— Where the Secretary has reason to question the compliance of a nursing facility with any of the requirements of subsections (b), (c), and (d), the Secretary may conduct a survey of the facility and, on that basis, make independent and binding determinations concerning the extent to which the nursing facility meets such requirements. “(4) Investigation of complaints and monitoring nursing facility compliance.— Each State shall maintain procedures and adequate staff to— “(A) investigate complaints of violations of requirements by nursing facilities, and “(B) monitor, on-site, on a regular, as needed basis, a nursing facility’s compliance with the requirements of subsections (b), (c), and (d), if— “(i) the facility has been found not to be in compliance with such requirements and is in the process of correcting deficiencies to achieve such compliance; “(ii) the facility was previously found not to be in compliance with such requirements, has corrected deficiencies to achieve such compliance, and verification of continued compliance is indicated; or “(iii) the State has reason to question the compliance of the facility with such requirements. A State may maintain and utilize a specialized team (including an attorney, an auditor, and appropriate health care professionals) for the purpose of identifying, surveying, gathering and preserving evidence, and carrying out appropriate enforcement actions against chronically substandard nursing facilities. “(5) Disclosure of results of inspections and activities.— “(A) Public information.— Each State, and the Secretary, shall make available to the public— “(i) information respecting all surveys and certifications made respecting nursing facilities, including statements of deficiencies and plans of correction, “(ii) copies of cost reports of such facilities filed under this title or under title XVIII, “(iii) copies of statements of ownership under section 1124, and “(iv) information disclosed under section 1126. “(B) Notice to ombudsman.— Each State shall notify the State long-term care ombudsman (established under section 307(a)(12) of the Older Americans Act of 1965) of the State’s findings of noncompliance with any of the requirements of subsections (b), (c), and (d), with respect to a nursing facility in the State. “(C) Notice to physicians and nursing facility administrator licensing board.— If a State finds that a nursing facility has provided substandard quality of care, the State shall notify— “(i) the attending physician of each resident with respect to which such finding is made, and “(ii) any State board responsible for the licensing of the nursing facility administrator of the facility. “(D) Access to fraud control units.— Each State shall provide its State medicaid fraud and abuse control unit (established under section 1903(q)) with access to all information of the State agency responsible for surveys and certifications under this subsection.”. (b) Posting Survey Results.— Section 1864(a) of such Act (42 U.S.C. 1395aa(a)) is amended by inserting, after “readily available form and place” in the fifth sentence, the following: “, and require (in the case of skilled nursing facilities) the posting in a place readily accessible to patients (and patients’ representatives),”. (c) Increasing Matching Percentage for Nursing Home Survey and Certification Activities.— (1) Section 1903(a)(2) of such Act (42 U.S.C. 1396b(a)(2)), as amended by this title, is further amended by adding at the end the following new subparagraph: “(D) for each calendar quarter during— “(i) fiscal year 1991, an amount equal to 90 percent, “(ii) fiscal year 1992, an amount equal to 85 percent, “(iii) fiscal year 1993, an amount equal to 80 percent, and “(iv) fiscal year 1994 and thereafter, an amount equal to 75 percent, of so much of the sums expended during such quarter (as found necessary by the Secretary for the proper and efficient administration of the State plan) as are attributable to State activities under section 1919(g); plus”. (2) Section 1903(r) of such Act (42 U.S.C. 1396b(r)) is amended by striking “paragraphs (2)” each place it appears and inserting “paragraphs (2)(A)”. (3) For purposes of section 1903(a) of the Social Security Act, 42 USC 1396b note. proper expenses incurred by a State for medical review by independent professionals of the care provided to residents of nursing facilities who are entitled to medical assistance under title XIX of such Act shall be reimbursable as expenses necessary for the proper and efficient administration of the State plan under that title. (d) Revision of Penalty Provisions.— (1) Section 1903(g) of such Act (42 U.S.C. 1396b(g)) is amended— (A) in paragraph (1)— (i) by striking “or intermediate care facility services” the first place it appears and inserting “or services in an intermediate care facility for the mentally retarded”, (ii) by striking “, skilled nursing facility services for 30 days,”, (iii) by striking “, skilled nursing facility services, or intermediate care facility services” and inserting “or services in an intermediate care facility for the mentally retarded”, (iv) by striking “, skilled nursing facilities, and intermediate care facilities” and inserting “and intermediate care facilities for the mentally retarded”; (B) in paragraph (4)(B), by striking “, skilled nursing facilities, and intermediate care facilities” and inserting “and intermediate care facilities for the mentally retarded”; (C) in paragraph (6)— (i) by striking subparagraph (B), (ii) in subparagraph (C), by striking “intermediate care facility services” and inserting “services in an intermediate care facility for the mentally retarded”, and (iii) by redesignating subparagraphs (C) and (D) as subparagraphs (B) and (C), respectively; and (D) by striking paragraph (7). (2) Section 1902(a)(31) of such Act (42 U.S.C. 1396a(a)(31)) is amended— (A) in the matter before subparagraph (A), by striking “skilled nursing facility services” and all that follows through “where” and inserting “services in an intermediate care facility for the mentally retarded (where”, and (B) in subparagraph (B), by striking “skilled nursing or intermediate care facility” and inserting “intermediate care facility for the mentally retarded”. (3) Section 1902(a)(33)(B) of such Act (42 U.S.C. 1396a(a)(33)(B)) is amended by inserting “, except as provided in section 1919(d),” after “(B) that”. (4) The amendments made by this subsection shall not apply to a Effective date. 42 USC 1396a note. State until such date (not earlier than October 1, 1990) as of which the Secretary determines that— (A) the State has specified the resident assessment instrument under section 1919(e)(5) of the Social Security Act, and (B) the State has begun conducting surveys under section 1919(g)(2) of such Act. (e) Miscellaneous Conforming Amendments.— (1) Section 1902(a)(44) of such Act (42 U.S.C. 1396a(a)(44)) is amended— (A) in the matter before subparagraph (A), by striking “skilled nursing facility services, intermediate care facility services” and inserting “services in an intermediate care facility for the mentally retarded”, and (B) in subparagraph (A), by striking “that are intermediate care facility services in an institution for the mentally retarded” and inserting “that are services in an intermediate care facility for the mentally retarded”. (2) Section 1903(a)(7) of such Act (42 U.S.C. 1396b(a)(7)) is amended by inserting “subject to section 1919(g)(3)(B),” after “(7)”. (3) Section 1910 of such Act (42 U.S.C. 13961) is amended— (A) by striking “skilled nursing facilities and” in the heading, (B) by striking subsection (a), and (C) by redesignating subsections (b) and (c) as subsections (a) and (b) respectively. (4) Section 1866(c) of such Act (42 U.S.C. 1395cc(c)) is amended by striking paragraph (2) and by redesignating paragraph (3) as paragraph (2). SEC. 4213. ENFORCEMENT PROCESS. (a) In general.— Section 1919 of the Social Security Act, as inserted by section 4201 and amended by section 4202, is further amended by adding at the end the following new subsection: “(h) Enforcement Process.— “(1) In general.— If a State finds, on the basis of a standard, extended, or partial extended survey under subsection (g)(2) or otherwise, that a nursing facility no longer meets a requirement of subsection 0)), (c), or (d), and further finds that the facility’s deficiencies— “(A) immediately jeopardize the health or safety of its residents, the State shall take immediate action to remove the jeopardy and correct the deficiencies through the remedy specified in paragraph (2)(A)(iii), or terminate the facility’s participation under the State plan and may provide, in addition, for one or more of the other remedies described in paragraph (2); or “(B) do not immediately jeopardize the health or safety of its residents, the State may— “(i) terminate the facility’s participation under the State plan, “(ii) provide for one or more of the remedies described in paragraph (2), or “(iii) do both. Nothing in this paragraph shall be construed as restricting the remedies available to a State to remedy a nursing facility’s deficiencies. If a State finds that a nursing facility meets the requirements of subsections (b), (c), and (d), but, as of a previous period, did not meet such requirements, the State may provide for a civil money penalty under paragraph (2)(A)(i) for the days in which it finds that the facility was not in compliance with such requirements. “(2) Specified remedies.— “(A) Listing.— Except as provided in subparagraph (B)(ii), each State shall establish by law (whether statute or regulation) at least the following remedies: “(i) Denial of payment under the State plan with respect to any individual admitted to the nursing facility involved after such notice to the public and to the facility as may be provided for by the State. “(ii) A civil money penalty assessed and collected, with interest, for each day in which the facility is or was out of compliance with a requirement of subsection (b), (c), or (d). Funds collected by a State as a result of imposition of such a penalty (or as a result of the imposition by the State of a civil money penalty for activities described in subsections (b)(3)(B)(ii)(I), (b)(3)(B)(ii)(II), or (g)(2)(A)(i)) shall be applied to the protection of the health or property of residents of nursing facilities that the State or the Secretary finds deficient, including payment for the costs of relocation of residents to other facilities, maintenance of operation of a facility pending correction of deficiencies or closure, and reimbursement of residents for personal funds lost. “(iii) The appointment of temporary management to oversee the operation of the facility and to assure the health and safety of the facility s residents, where there is a need for temporary management while— “(I) there is an orderly closure of the facility, or “(II) improvements are made in order to bring the facility into compliance with all the requirements of subsections (b), (c), and (d). The temporary management under this clause shall not be terminated under subclause (II) until the State has determined that the facility has the management capability to ensure continued compliance with all the requirements of subsections (b), (c), and (d). “(iv) The authority, in the case of an emergency, to close the facility, to transfer residents in that facility to other facilities, or both. The State also shall specify criteria, as to when and how each of such remedies is to be applied, the amounts of any fines, and the severity of each of these remedies, to be used in the imposition of such remedies. Such criteria shall be designed so as to minimize the time between the identification of violations and final imposition of the remedies and shall provide for the imposition of incrementally more severe fines for repeated or uncorrected deficiencies. In addition, the State may provide for other specified remedies, such as directed plans of correction. “(B) Deadline and guidance.— (i) Except as provided in clause (ii), as a condition for approval of a State plan for calendar quarters beginning on or after October 1, 1989, each State shall establish the remedies described in clauses (i) through (iv) of subparagraph (A) by not later than October 1, 1989. The Secretary shall provide, through regulations Regulations. or otherwise by not later than October 1, 1988, guidance to States in establishing such remedies; but the failure of the Secretary to provide such guidance shall not relieve a State of the responsibility for establishing such remedies. “(ii) A State may establish alternative remedies (other than termination of participation) other than those described in clauses (i) through (iv) of subparagraph (A), if the State demonstrates to the Secretary’s satisfaction that the alternative remedies are as effective in deterring noncompliance and correcting deficiencies as those described in subparagraph (A). “(C) Assuring prompt compliance.— If a nursing facility has not complied with any of the requirements of subsections (b), (c), and (d), within 3 months after the date the facility is found to be out of compliance with such requirements, the State shall impose the remedy described in subparagraph (A)(i) for all individuals who are admitted to the facility after such date. “(D) Repeated noncompliance.— In the case of a nursing facility which, on 3 consecutive standard surveys conducted under subsection (g)(2), has been found to have provided substandard quality of care, the State shall (regardless of what other remedies are provided)— “(i) impose the remedy described in subparagraph (A)(i), and “(ii) monitor the facility under subsection (g)(4)(B), until the facility has demonstrated, to the satisfaction of the State, that it is in compliance with the requirements of subsections (b), (c), and (d), and that it will remain in compliance with such requirements. “(E) Funding.— The reasonable expenditures of a State to provide for temporary management and other expenses associated with implementing the remedies described in clauses (iii) and (iv) of subparagraph (A) shall be considered, for purposes of section 1903(a)(7), to be necessary for the proper and efficient administration of the State plan. “(F) Incentives for high quality care.— In addition to the remedies specified in this paragraph, a State may establish a program to reward, through public recognition, incentive payments, or both, nursing facilities that provide the highest quality care to residents who are entitled to medical assistance under this title. For purposes of section 1903(a)(7), proper expenses incurred by a State in carrying out such a program shall be considered to be expenses necessary for the proper and efficient administration of the State plan under this title. “(3) Secretarial authority.— “(A) For state nursing facilities.— With respect to a State nursing facility, the Secretary shall have the authority and duties of a State under this subsection, including the authority to impose remedies described in clauses (i), (ii), and (iii) of paragraph (2)(A). “(B) Other nursing facilities.— With respect to any other nursing facility in a State, if the Secretary finds that a nursing facility no longer meets a requirement of subsection (b), (c), (d), or (e), and further finds that the facility’s deficiencies— “(i) immediately jeopardize the health or safety of its residents, the Secretary shall take immediate action to remove the jeopardy and correct the deficiencies through the remedy specified in subparagraph (C)(iii), or terminate the facility’s participation under the State plan and may provide, in addition, for one or more of the other remedies described in subparagraph (C); or “(ii) do not immediately jeopardize the health or safety of its residents, the Secretary may impose any of the remedies described in subparagraph (C). Nothing in this subparagraph shall be construed as restricting the remedies available to the Secretary to remedy a nursing facility’s deficiencies. If the Secretary finds that a nursing facility meets such requirements but, as of a previous period, did not meet such requirements, the Secretary may provide for a civil money penalty under subparagraph (C)(ii) for the days on which he finds that the facility was not in compliance with such requirements. “(C) Specified remedies.— The Secretary may take the following actions with respect to a finding that a facility has not met an applicable requirement: “(i) Denial of payment.— The Secretary may deny any further payments to the State for medical assistance furnished by the facility to all individuals in the facility or to individuals admitted to the facility after the effective date of the finding. “(ii) Authority with respect to civil money penalties.— The Secretary may impose a civil money penalty in an amount not to exceed $10,000 for each day of noncompliance and the Secretary shall impose and collect such a penalty in the same manner as civil money penalties are imposed and collected under section 1128A. “(iii) Appointment of temporary management.— In consultation with the State, the Secretary may appoint temporary management to oversee the operation of the facility and to assure the health and safety of the facility’s residents, where there is a need for temporary management while— “(I) there is an orderly closure of the facility, or “(II) improvements are made in order to bring the facility into compliance with all the requirements of subsections (b), (c), and (d). The temporary management under this clause shall not be terminated under subclause (II) until the Secretary has determined that the facility has the management capability to ensure continued compliance with all the requirements of subsections (b), (c), and (d). The Secretary shall specify criteria, as to when and how each of such remedies is to be applied, the amounts of any fines, and the severity of each of these remedies, to be used in the imposition of such remedies. Such criteria shall be designed so as to minimize the time between the identification of violations and final imposition of the remedies and shall provide for the imposition of incrementally more severe fines for repeated or uncorrected deficiencies. In addition, the Secretary may provide for other specified remedies, such as directed plans of correction. “(D) Continuation of payments pending remediation.— The Secretary may continue payments, over a period of not longer than 6 months, under this title with respect to a nursing facility not in compliance with a requirement of subsection (b), (c), or (d), if— “(i) the State survey agency finds that it is more appropriate to take alternative action to assure compliance of the facility with the requirements than to terminate the certification of the facility, “(ii) the State has submitted a plan and timetable for corrective action to the Secretary for approval and the Secretary approves the plan of corrective action, and “(iii) the State agrees to repay to the Federal Government payments received under this subparagraph if the corrective action is not taken in accordance with the approved plan and timetable. The Secretary shall establish guidelines for approval of corrective actions requested by States under this subparagraph. “(4) Effective period of denial of payment.— A finding to deny payment under this subsection shall terminate when the State or Secretary (or both, as the case may be) finds that the facility is in substantial compliance with all the requirements of subsections (b), (c), and (d). “(5) Immediate termination of participation for facility where state or secretary finds noncompliance and immediate jeopardy.— If either the State or the Secretary finds that a nursing facility has not met a requirement of subsection (b), (c), or (d), and finds that the failure immediately jeopardizes the health or safety of its residents, the State and the Secretary shall notify the other of such finding, and the State or the Secretary, respectively, shall take immediate action to remove the jeopardy and correct the deficiencies through the remedy specified in paragraph (2)(A)(iii) or (3)(C)(iii), or terminate the facility’s participation under the State plan. If the facility’s participation in the State plan is terminated by either the State or the Secretary, the State shall provide for the safe and orderly transfer of the residents eligible under the State plan consistent with the requirements of subsection (c)(2). “(6) Special rules where state and secretary do not agree on finding of noncompliance.— “(A) State finding of noncompliance and no secretarial finding of noncompliance.— If the Secretary finds that a nursing facility has met all the requirements of subsections (b), (c), and (d), but a State finds that the facility has not met such requirements and the failure does not immediately jeopardize the health or safety of its residents, the State’s findings shall control and the remedies imposed by the State shall be applied. “(B) Secretarial finding of noncompliance and no state finding of noncompliance.— If the Secretary finds that a nursing facility has not met all the requirements of subsections (b), (c), and (d), and that the failure does not immediately jeopardize the health or safety of its residents, but the State has not made such a finding, the Secretary— “(i) may impose any remedies specified in paragraph (3)(C) with respect to the facility, and “(ii) shall (pending any termination by the Secretary) permit continuation of payments in accordance with paragraph (3)(D). “(7) Special rules for timing of termination of participation where remedies overlap.— If both the Secretary and the State find that a nursing facility has not met all the requirements of subsections (b), (c), and (d), and neither finds that the failure immediately jeopardizes the health or safety of its residents— “(A) (i) if both find that the facility’s participation under the State plan should be terminated, the State’s timing of any termination shall control so long as the termination date does not occur later than 6 months after the date of the finding to terminate; “(ii) if the Secretary, but not the State, finds that the facility’s participation under the State plan should be terminated, the Secretary shall (pending any termination by the Secretary) permit continuation of payments in accordance with paragraph (3)(D); or “(iii) if the State, but not the Secretary, finds that the facility’s participation under the State plan should be terminated, the State’s decision to terminate, and timing of such termination, shall control; and “(B) (i) if the Secretary or the State, but not both, establishes one or more remedies which are additional or alternative to the remedy of terminating the facility’s participation under the State plan, such additional or alternative remedies shall also be applied, or “(ii) if both the Secretary and the State establish one or more remedies which are additional or alternative to the remedy of terminating the facility’s participation under the the Secretary shall apply. “(8) Construction.— The remedies provided under this subsection are in addition to those otherwise available under State or Federal law and shall not be construed as limiting such other remedies, including any remedy available to an individual at common law. The remedies described in clauses (i), (iii), and (iv) of paragraph (2)(A) may be imposed during the pendency of any hearing. “(9) Sharing of information.— Notwithstanding any other provision of law, all information concerning nursing facilities required by this section to be filed with the Secretary or a State agency shall be made available to Federal or State employees for purposes consistent with the effective administration of programs established under this title and title XVIII, including investigations by State medicaid fraud control units.”, (b) Conforming Amendments.— (1) Section 1902 of such Act (42 U.S.C. 1396a) is amended by striking subsection (i). (2) Section 1903(i) of such Act (42 U.S.C. 1396b(i)) is amended by striking the period at the end of paragraph (7) and inserting “; or” and by adding at the end the following new paragraph: “(8) with respect to any amount expended for medical assistance for nursing facility services to reimburse (or otherwise compensate) a nursing facility for payment of a civil money penalty imposed under section 1919(h).”. SEC. 4214. EFFECTIVE DATES. (a) New Requirements and Survey and Certification Process.— Except as otherwise specifically provided in section 1919 of the Social Security Act, the amendments made by sections 4211 and 4212 (relating to nursing facility requirements and survey and certification requirements) shall apply to nursing facility services furnished on or after October 1, 1990, without regard to whether regulations to implement such amendments are promulgated by such date; except that section 1902(a)(28)(B) of the Social Security Act (as amended by section 4211(b) of this Act), relating to requiring State medical assistance plans to specify the services included in nursing facility services, shall apply to calendar quarters beginning more than 6 months after the date of the enactment of this Act, without regard to whether regulations to implement such section are promulgated by such date. (b) Enforcement.— (1) Except as otherwise specifically provided in section 1919 of the Social Security Act, the amendments made by section 4213 of this Act apply to payments under title XIX of the Social Security Act for calendar quarters beginning on or after the date of the enactment of this Act, without regard to whether regulations to implement such amendments are promulgated by such date. (c) Transitional Rule.— In applying the amendments made by this part for services furnished before October 1, 1990— (A) any reference to a nursing facility is deemed a reference to a skilled nursing facility or intermediate care facility (other than an intermediate care facility for the mentally retarded), and (B) with respect to such a skilled nursing facility or intermediate care facility, any reference to a requirement of subsection (b), (c), or (d), is deemed a reference to the provisions of section 186l(j) or section 1905(c), respectively, of the Social Security Act. (d) Waiver Of Paperwork Reduction.— Chapter 35 of title 44, United States Code, shall not apply to information required for purposes of carrying out this part and implementing the amendments made by this part. SEC. 4215. ANNUAL REPORT. The Secretary of Health and Human Services shall report to the Congress annually on the extent to which nursing facilities are complying with the requirements of subsections (b), (c), and (d) of section 1919 of the Social Security Act (as added by the amendments made by this part) and the number and type of enforcement actions taken by States and the Secretary under section 1919(h) of such Act (as added by section 4213 of this Act). SEC. 4216. CONSTRUCTION. Section 1919 of the Social Security Act is amended by adding at the end the following new subsection: “(i) Construction.— Where requirements or obligations under this section are identical to those provided under section 1819 of this Act, the fulfillment of those requirements or obligations under section 1819 shall be considered to be the fulfillment of the corresponding requirements or obligations under this section.”. SEC. 4217. FINAL REGULATIONS WITH RESPECT TO PLANS OF CORRECTION OR REDUCTION. (a) In General.— Not later than 30 days after the date of enactment of this Act, the Secretary of Health and Human Services shall promulgate final regulations to implement the amendments made by section 9516 of the Consolidated Omnibus Budget Reconciliation Act of 1985. (b) The regulations promulgated under paragraph (1) shall be 100 Stat. 82. effective as if promulgated on the date of enactment of the Consolidated Omnibus Budget Reconciliation Act of 1985. SEC. 4218. MEDICAID CERTIFICATIONS AND RECERTIFICATIONS FOR CERTAIN SERVICES. (a) In General.— Section 1902(a)(44) of the Social Security Act (42 U.S.C. 1396a(a)(44)) is amended— (1) in subparagraph (A)— (A) by striking “physician certifies” and inserting “physician (or, in the case of skilled nursing facility services or intermediate care facility services, a physician, or a nurse practitioner or clinical nurse specialist who is not an employee of the facility but is working in collaboration with a physician) certifies”, and (B) by striking “the physician, or a physician assistant or nurse practitioner under the supervision of a physician,” and inserting “a physician, a physician assistant under the supervision of a physician, or, in the case of skilled nursing facility services or intermediate care facility services, a physician, or a nurse practitioner or clinical nurse specialist who is not an employee of the facility but is working in collaboration with a physician,”; and (2) in subparagraph (B), by striking “a physician;” and inserting “a physician, or, in the case of skilled nursing facility services or intermediate care facility services, a physician, or a nurse practitioner or clinical nurse specialist who is not an employee of the facility but is working in collaboration with a physician;”. (b) Effective Date.— The amendments made by subsection (a) 42 USC 1396a note. shall apply with respect to certifications or recertifications during the period beginning on July 1, 1988, and ending on October 1, 1990. Subtitle D— Vaccine Compensation SEC. 4301. SHORT TITLE, REFERENCE. (a) Short Title.— This subtitle may be cited as the “Vaccine 42 USC 201 note. Compensation Amendments of 1987”. (b) Reference.— Whenever in this subtitle (other than in section 4302(a)) an amendment or repeal 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 a section or other provision of the Public Health Service Act. SEC. 4302. EFFECTIVE DATE. (a) In General.— Section 323(a) of the National Childhood Vaccine Injury Act of 1986 (42 U.S.C. 300aa–l note) is amended by striking out “Subtitle 2 of such title and this title shall take effect on the effective date of a tax” and all that follows in that section and inserting in lieu thereof “parts A and B of subtitle 2 of such title shall take effect on October 1, 1988 and parts C and D of such title and this title shall take effect on the date of the enactment of the Vaccine Compensation Amendments of 1987.”. (b) References.— (1) Sections 2111, 2115, 2119(a), 2122, 2123, 2125, 2126, 2127, 42 USC 300aa–i9. and 2128 (42 U.S.C. 300aa–ll, 300aa–15, 300aa–199a), 300aa–22, 300aa–23, 300aa–25, 300aa–26, 300aa–27, 300aa–28) are each amended by striking out “effective date of this subtitle” each place it appears and inserting in lieu thereof “effective date of this part”. (2) Sections 2111(a)(5)(A), 2115(e)(2) and 2116 (42 U.S.C. 300aa–11(a)(5)(A), 42 USC 300aa–16. 300aa–15(e)(2), 300a–16) are each amended by striking out “effective date of this title” each place it appears and inserting in lieu thereof “effective date of this part”. SEC. 4303. COMPENSATION. (a) Source.— Section 2115 (42 U.S.C. 300aa–15) is amended by adding at the end the following: “(i) Source of compensation.— “(1) Payment of compensation under the Program to a petitioner for a vaccine-related injury or death associated with the administration of a vaccine before the effective date of this part shall be made from appropriations under subsection (i). “(2) Payment of compensation under the Program to a petitioner for a vaccine-related injury or death associated with the administration of a vaccine on or after the effective date of this part shall be made from the Vaccine Injury Compensation Trust Fund established under section 9510 of the Internal Revenue Code of 1986.”. (b) Authorization.— Section 2115 (42 U.S.C. 300aa–15) (as amended by subsection (a)) is amended by adding at the end the following: “(j) Authorization.— For the payment of compensation under the Program to a petitioner for a vaccine-related injury or death associated with the administration of a vaccine before the effective date of this part there are authorized to be appropriated $80,000,000 for fiscal year 1989, $80,000,000 for fiscal year 1990, $80,000,000 for fiscal year 1991, and $80,000,000 for fiscal year 1992. Amounts appropriated under this subsection shall remain available until expended.”. (c) Minimum.— Section 2115(a)(1) (42 U.S.C. 300a–15(a)(1)) is 42 USC 300aa–15. amended by striking out the last sentence of subparagraphs (A)and(B). (d) Lump Sum.— (1) Section 2115 (42 U.S.C. 300aa–15) is amended— (A) by striking out the last two sentences after paragraph (4) in subsection (a), and (B) by adding at the end of the first subsection (f) the following: (A) Except as provided in subparagraph (B), payment of compensation under the Program shall be made in a lump sum determined on the basis of the net present value of the elements of the compensation. “(B) In the case of a payment of compensation under the Program to a petitioner for a vaccine-related injury or death associated with the administration of a vaccine before the effective date of this part the compensation shall be paid in 4 equal annual installments. If the appropriations under subsection (i) are insufficient to make a payment of an annual installment, section 2111(a) shall not apply to a civil action for damages brought by the petitioner entitled to the payment.”. (2) (A) Subsections (e) and (f) of section 2112 (42 U.S.C. 300a–12) 42 USC 300aa–12. are repealed and subsection (g) of such section is redesignated as subsection (e). (B) Section 2118 (42 U.S.C. 300aa–18) is repealed. (e) Limit.— Section 2115(b) (42 U.S.C. 300aa–15(b)) is amended by striking out “shall only include the compensation described in paragraphs (1)(A) and (2) of subsection (a)” and inserting in lieu thereof the following: “may not include the compensation described in paragraph (1)(B) of subsection (a) and may include attorneys’ fees and other costs included in a judgment under subsection (e), except that the total amount that may be paid as compensation under paragraphs (3) and (4) of subsection (a) and included as attorneys’ fees and other costs under subsection (e) may not exceed $30,000”. (f) Termination of Program.— Part D of title XXI is amended by adding at the end the following: “termination of program “Sec. 2134. (a) Reviews.— The Secretary shall review the number 42 USC 300aa–34. of awards of compensation made under the program to petitioners under section 2111 for vaccine-related injuries and deaths associated with the administration of vaccines on or after the effective date of this part as follows: “(1) The Secretary shall review the number of such awards made in the 12-month period beginning on the effective date of this part. “(2) At the end of each 3-month period beginning after the expiration of the 12-month period referred to in paragraph (1) the Secretary shall review the number of such awards made in the 3-month period. “(b) Report.— “(1) If in conducting a review under subsection (a) the Secretary determines that at the end of the period reviewed the total number of awards made by the end of that period and accepted under section 2121(a) exceeds the number of awards listed next to the period reviewed in the table in paragraph (2)— “(A) the Secretary shall notify the Congress of such determination, and “(B) beginning 180 days after the receipt by Congress of a notification under paragraph (1), no petition for a vaccine-related injury or death associated with the administration of a vaccine on or after the effective date of this part may be filed under section 2111. Section 2111(a) and part B shall not apply to civil actions for damages for a vaccine-related injury or death for which a petition may not be filed because of subparagraph (B). “(2) The table referred to in paragraph (1) is as follows: 10Copy read “Period reviewed:”. “Period reviewed Total number of awards by the end of the period reviewed 12 months after the effective date of part ......................... 150 13th through the 15th month after such date ......................... 188 16th through the 18th month after such date ......................... 225 19th through the 21st month after such date ......................... 263 22nd through the 24th month after such date ......................... 300 25th through the 27th month after such date ......................... 338 28th through the 30th month after such date ......................... 375 31st through the 33rd month after such date ......................... 413 34th through the 36th month after such date ......................... 450 37th through the 39th month after such date ......................... 488 40th through the 42nd month after such date ......................... 525 43rd through the 45th month after such date ......................... 563 46th through the 48th month after such date ......................... 600.”. (g) Technical.— Section 2115 (42 U.S.C. 300a–15) is amended by 42 USC 300aa–15. redesignating the second subsection (f) and subsection (g) as subsections (g) and (h), respectively. SEC. 4304. PETITIONS. (a) Application of Limits.— Section 2111(a) (42 U.S.C. 300aa–11) is amended by adding at the end the following: “(8) This subsection applies only to a person who has sustained a vaccine-related injury or death and who is qualified to file a petition for compensation under the Program.”. (b) Qualification.— (1) Section 2111(b)(1) (42 U.S.C. 300a–l 1(b)(1)(A)) is amended by 42 USC 300aa–11. striking out “may file” and inserting in lieu thereof “may, if the person meets the requirements of subsection (c)(1), file”. (2) Section 2111(c)(1)(D) (42 U.S.C. 300a–11(c)(1)(D)) is amended (A) by striking out “for more than 1 year” and inserting in lieu thereof “for more than 6 months”, (B) by striking out “, (ii)” and inserting in lieu thereof “and”, and (C) by striking out “(iii)” and inserting in lieu thereof “(ii)”. (c) Withdrawal.— Section 2121 (42 U.S.C. 300a–21) is amended by 42 USC 300aa–21. redesignating subsection (b) as subsection (c) and by inserting after subsection (a) the following: “(b) Withdrawal of Petition.— If the United States Claims Court fails to enter a judgment under section 2112 on a petition filed under section 2111 within 365 days after the date on which the petition was filed, the petitioner may submit to the court a notice in writing withdrawing the petition. Such a notice shall be filed not later than 90 days after the expiration of such 365-day period. A person who has submitted a notice under this subsection may, notwithstanding section 2111(a)(2), thereafter maintain a civil action for damages in a State or Federal court without regard to part B and consistent with otherwise applicable law.”. SEC. 4305. CITIZEN’S ACTIONS. Section 2131(c) (42 U.S.C. 300a–31(c)) 7171Copy read “300a–31(c)”. is amended by striking out 42 USC 300aa–31. “to any party, whenever the court determines that such award is appropriate” and inserting in lieu thereof “to any plaintiff who substantially prevails on one or more significant issues in the action”. SEC. 4306. VACCINE ADMINISTRATORS. Section 2111(a) (42 U.S.C. 300a–ll) is amended by striking out “vaccine manufacturer” each place it appears and inserting in lieu thereof “vaccine administrator or manufacturer”. SEC. 4307. COURT JURISDICTION. Subtitle 2 of title XXI is amended as follows: (1) Section 2111(a)(1) (42 U.S.C. 300aa–11(a)(1)) is amended by striking out “with the United States district court for the district in which the petitioner resides or the injury or death occurred” and inserting in lieu thereof “with the United States Claims Court”. (2) Section 2111(a)(2)(A)(ii) (42 U.S.C. 300aa–11(a)(2)(A)(ii)) is amended by striking out “a district court of the United States” and inserting in lieu thereof “the United States Claims Court”. (3) Section 2112 (42 U.S.C. 300aa–12) is amended— (A) in subsection (a), by striking out “district courts of the United States” and inserting in lieu thereof “United States Claims Court” and by striking out “the courts” and inserting in lieu thereof “the court”, (B) in subsection (c)(1), by striking out “the district court of the United States in which the petition is filed” and inserting in lieu thereof “the United States Claims Court”, and (C) in subsection (g), by striking out “a district court of the United States” and inserting in lieu thereof “the United States Claims Court” and by striking out “for the circuit in which the court is located” and inserting in lieu thereof “for the Federal Circuit”. (4) Section 2113(c) (42 U.S.C. 300aa–13(c)) is amended by striking out “a district court of the United States” and inserting in lieu thereof “the United States Claims Court”. (5) Section 2115(e)(1) (42 U.S.C. 300aa–15(e)(1)) is amended by striking out “of a court” and inserting in lieu thereof “of the United States Claims Court”. (6) Paragraph (2) of subsection (f) of section 2115 (42 U.S.C. 300aa–15) is amended by striking out “district court of the United States” and inserting in lieu thereof “United States Claims Court”. (7) Section 2117(a) (42 U.S.C. 300aa–17(a)) is amended by striking out “(1)”, by running in the text of paragraph (1) into the subsection heading, and by striking out paragraph (2). (8) Section 2121(a) (42 U.S.C. 300aa–21(a)) is amended by striking out “a district court of the United States” and inserting in lieu thereof “the United States Claims Court” and by striking out “a court” each place it occurs and inserting in lieu thereof “the court”. (9) Section 2123(e) (42 U.S.C. 300aa–23(e)) is amended by striking out “a district court of the United States” and inserting in lieu thereof “the United States Claims Court”. Subtitle E— Rural Health SEC. 4401. OFFICE OF RURAL HEALTH POLICY. Title VII of the Social Security Act is amended by adding at the end thereof the following new section: “office of rural health policy “Sec. 711. (a) There shall be established in the Department of Establishment. 42 USC 912. Health and Human Services (in this section referred to as the ‘Department’) 7272Copy read “ “Department”)”. an Office of Rural Health Policy (in this section referred to as the ‘Office’). The Office shall be headed by a Director, who shall advise the Secretary on the effects of current policies and proposed statutory, regulatory, administrative, and budgetary changes in the programs established under titles XVIII and XIX on the financial viability of small rural hospitals, the ability of rural areas (and rural hospitals in particular) to attract and retain physicians and other health professionals, and access to (and the quality of) health care in rural areas. “(b) In addition to advising the Secretary with respect to the matters specified in subsection (a), the Director, through the Office, shall— “(1) oversee compliance with the requirements of section 1102(b) of this Act and section 4083 of the Omnibus Budget Reconciliation Act of 1987, “(2) establish and maintain a clearinghouse for collecting and disseminating information on— “(A) rural health care issues, “(B) research findings relating to rural health care, and “(C) innovative approaches to the delivery of health care in rural areas, “(3) coordinate the activities within the Department that relate to rural health care, and “(4) provide information to the Secretary and others in the Department with respect to the activities, of other Federal departments and agencies, that relate to rural health care.”. SEC. 4402. IMPACT ANALYSES OF MEDICARE AND MEDICAID RULES AND REGULATIONS ON SMALL RURAL HOSPITALS. (a) In General.— Section 1102 of the Social Security Act (42 U.S.C. 1302) is amended— (1) by inserting “(a)” after “Sec. 1102.”, and (2) by adding at the end thereof the following new subsection: “(b) (1) Whenever the Secretary publishes a general notice of proposed rulemaking for any rule or regulation proposed under title XVIII, title XIX, or part B of this title that may have a significant impact on the operations of a substantial number of small rural hospitals, the Secretary shall prepare and make available for public comment an initial regulatory impact analysis. Such analysis shall describe the impact of the proposed rule or regulation on such hospitals and shall set forth, with respect to small rural hospitals, the matters required under section 603 of title 5, United States Code, to be set forth with respect to small entities. The initial regulatory Federal Register, publication. impact analysis (or a summary) shall be published in the Federal Register at the time of the publication of general notice of proposed rulemaking for the rule or regulation. “(2) Whenever the Secretary promulgates a final version of a rule or regulation with respect to which an initial regulatory impact analysis is required by paragraph (1), the Secretary shall prepare a final regulatory impact analysis with respect to the final version of such rule or regulation. Such analysis shall set forth, with respect to small rural hospitals, the matters required under section 604 of title 5, United States Code, to be set forth with respect to small entities. The Secretary shall make copies of the final regulatory impact Federal Register, publication. analysis available to the public and shall publish, in the Federal Register at the time of publication of the final version of the rule or regulation, a statement describing how a member of the public may obtain a copy of such analysis. “(3) If a regulatory flexibility analysis is required by chapter 6 of title 5, United States Code, for a rule or regulation to which this subsection applies, such analysis shall specifically address the impact of the rule or regulation on small rural hospitals.”. (b) Effective Date.— The amendments made by paragraph (1) 42 USC 1302 note. shall apply to regulations proposed more than 30 days after the date of the enactment of this Act. SEC. 4403. SET ASIDE FOR EXPERIMENTS AND DEMONSTRATION PROJECTS RELATING TO RURAL HEALTH CARE ISSUES. (a) Set Aside.— Not less than ten percent of the total amounts expended in each fiscal year by the Secretary of Health and Human Services (in this section referred to as the “Secretary”) after October 1, 1988, with respect to experiments and demonstration projects authorized by section 402 of the Social Security Amendments of 1967 and the experiments and demonstration projects authorized by the Social Security Amendments of 1972 shall be expended for experiments and demonstration projects relating exclusively or substantially to rural health issues, including (but not limited to) the impact of the payment methodology under section 1886(d) of the Social Security Act on the financial viability of small rural hospitals, the effect of medicare payment policies on the ability of rural areas (and rural hospitals in particular) to attract and retain physicians and other health professionals, the appropriateness of medicare conditions of participation and staffing requirements for small rural hospitals, and the impact of medicare policies on access to (and the quality of) health care in rural areas, (b) Agenda.— The Secretary of Health and Human Services shall establish an agenda of experiments and demonstration projects, relating exclusively or substantially to rural health issues, that are in progress or have been proposed, and shall include such agenda in the annual report submitted pursuant to section 1875(b) of the Social Security Act. The agenda shall be accompanied by a statement setting forth the amounts that have been obligated and expended with respect to such experiments and projects in the current and most recently completed fiscal years.

2. 1987

   Pub. L. 100–203 § 4022(a) · 101 Stat. 1330

   Added · 42 U.S.C. § 1395bbb(c); 42 U.S.C. § 1395bbb(d)

   Pub. L. 100–203, § 4022(a), added subsecs. (c) and (d)

   Source evidence

   Code amendment note
   Subsecs. (c), (d). Pub. L. 100–203, § 4022(a), added subsecs. (c) and (d).

   Enacted provision · exact public law section
   (a) In General.— Section 1891 of the Social Security Act (as added by section 4021) is amended by adding at the end the following new subsections: “(c) (1) Any agreement entered into or renewed by the Secretary pursuant to section 1864 relating to home health agencies shall provide that the appropriate State or local agency shall conduct, without any prior notice, a standard survey of each home health agency. Any individual who notifies (or causes to be notified) a home health agency of the time or date on which such a survey is scheduled to be conducted is subject to a civil money penalty of not to exceed $2,000. The Secretary shall provide for imposition of civil money penalties under this clause in a manner similar to that for the imposition of civil money penalties under section 1128A. The Secretary shall review each State’s or local agency’s procedures for scheduling and conduct of standard surveys to assure that the State or agency has taken all reasonable steps to avoid giving notice of such a survey through the scheduling procedures and the conduct of the surveys themselves. “(2) (A) Except as provided in subparagraph (B), each home health agency shall be subject to a standard survey not later than 15 months after the date of the previous standard survey conducted under this paragraph. The statewide 27a27aCopy read “Statewide”. average interval between standard surveys of any home health agency shall not exceed 12 months. “(B) If not otherwise conducted under subparagraph (A), a standard survey (or an abbreviated standard survey) of an agency— “(i) may be conducted within 2 months of any change of a ownership, administration, or management of the agency to determine whether the change has resulted in any decline in the quality of care furnished by the agency, and “(ii) shall be conducted within 2 months of when a significant number of complaints have been reported with respect to the agency to the Secretary, the State, the entity responsible for the licensing of the agency, the State or local agency responsible for maintaining a toll-free hotline and investigative unit (under section 1864(a)), or any other appropriate Federal, State, or local agency. “(C) A standard survey conducted under this paragraph with respect to a home health agency— “(i) shall include (to the extent practicable), for a case-mix stratified sample of individuals furnished items or services by the agency— “(I) visits to the homes of such individuals, but only with the consent of such individuals, for the purpose of evaluating (in accordance with a standardized reproducible assessment instrument (or instruments) approved by the Secretary under subsection (d)) the extent to which the quality and scope of items and services furnished by the agency attained and maintained the highest practicable functional capacity of each such individual as reflected in such individual’s written plan of care required under section 1861(m) and clinical records required under section 1861(o)(3); and “(II) a survey of the quality of care and services furnished by the agency as measured by indicators of medical, nursing, and rehabilitative care; “(ii) shall be based upon a protocol that is developed, tested, and validated by the Secretary not later than January 1, 1989; and “(iii) shall be conducted by an individual— “(I) who meets minimum qualifications established by the Secretary not later than July 1, 1989, “(II) who is not serving (or has not served within the previous 2 years) as a member of the staff of, or as a consultant to, the home health agency surveyed respecting compliance with the conditions of participation specified in or pursuant to section 1861(o) or subsection (a) of this section, and “(III) who has no personal or familial financial interest in the home health agency surveyed. “(D) Each home health agency that is found, under a standard survey, to have provided substandard care shall be subject to an extended survey to review and identify the policies and procedures which produced such substandard care and to determine whether the agency has complied with the conditions of participation specified in or pursuant to section 1861(o) or subsection (a) of this section. Any other agency may, at the Secretary’s or State’s discretion, be subject to such an extended survey (or a partial extended survey). The extended survey shall be conducted immediately after the standard survey (or, if not practical, not later than 2 weeks after the date of completion of the standard survey). “(E) Nothing in this paragraph shall be construed as requiring an extended (or partial extended) survey as a prerequisite to imposing a sanction against an agency under subsection (e) on the basis of the findings of a standard survey. “(d) (1) Not later than January 1, 1989, the Secretary shall designate an assessment instrument (or instruments) for use by an agency in complying with subsection (c)(2)(C)(I). “(2) (A) Not later than January 1, 1991, the Secretary shall— “(i) evaluate the assessment process, “(ii) report to Congress on the results of such evaluation, and Reports. “(iii) based on such evaluation, make such modifications in the assessment process as the Secretary determines are appropriate. “(B) The Secretary shall periodically update the evaluation conducted Reports. under subparagraph (A), report the results of such update to Congress, and, based on such update, make such modifications in the assessment process as the Secretary determines are appropriate. “(3) The Secretary shall provide for the comprehensive training of State and Federal surveyors in matters relating to the performance of standard and extended surveys under this section, including the use of any assessment instrument (or instruments) designated under paragraph (1).”.

3. 1987

   Pub. L. 100–203 § 4023(a) · 101 Stat. 1330

   1. Amended · 42 U.S.C. § 1395bbb(e); 42 U.S.C. § 1395bbb(f)

      Pub. L. 100–203, § 4023(a), as amended by Pub. L. 100–360, § 411(d)(3)(A)

   2. Added · 42 U.S.C. § 1395bbb(e); 42 U.S.C. § 1395bbb(f)

      Pub. L. 100–203, § 4023(a), as added subsecs. (e) and (f)

   Source evidence

   Code amendment note
   Subsecs. (e), (f). Pub. L. 100–203, § 4023(a), as amended by Pub. L. 100–360, § 411(d)(3)(A), added subsecs. (e) and (f).

   Enacted provision · exact public law section
   SEC. 4023. ENFORCEMENT. Section 1891 of the Social Security Act (as added by section 4021 and amended by section 4022) is further amended by adding at the end the following new subsections: “(e) (1) If the Secretary determines on the basis of a standard, extended, or partial extended survey or otherwise, that a home health agency that is certified for participation under this title is no longer in compliance with the requirements specified in or pursuant to section 1861(o) or subsection (a) and determines that the deficiencies involved immediately jeopardize the health and safety of the individuals to whom the agency furnishes items and services, the Secretary shall take immediate action to remove the jeopardy and correct the deficiencies through the remedy specified in subsection (f)(2)(A)(iii) or terminate the certification of the agency, and may provide, in addition, for 1 or more of the other remedies described in subsection (f)(2)(A). “(2) If the Secretary determines on the basis of a standard, extended, or partial extended survey or otherwise, that a home health agency that is certified for participation under this title is no longer in compliance with the requirements specified in or pursuant to section 1861(o) or subsection (a) and determines that the deficiencies involved do not immediately jeopardize the health and safety of the individuals to whom the agency furnishes items and services, the Secretary may (for a period not to exceed 6 months) impose intermediate sanctions developed pursuant to subsection (f), in lieu of terminating the certification of the agency. If, after such a period of intermediate sanctions, the agency is still no longer in compliance with the requirements specified in or pursuant to section 1861(o) or subsection (a), the Secretary shall terminate the certification of the agency. “(3) If the Secretary determines that a home health agency that is certified for participation under this title is in compliance with the requirements specified in or pursuant to section 1861(o) or subsection (a) but, as of a previous period, did not meet such requirements, the Secretary may provide for a civil money penalty under subsection (f)(2)(A)(i) for the days in which it finds that the agency was not in compliance with such requirements. “(4) The Secretary may continue payments under this title with respect to a home health agency not in compliance with the requirements specified in or pursuant to section 1861(o) or subsection (a) over a period of not longer than 6 months, if— “(A) the State or local survey agency finds that it is more appropriate to take alternative action to assure compliance of the agency with the requirements than to terminate the certification of the agency, “(B) the agency has submitted a plan and timetable for corrective action to the Secretary for approval and the Secretary approves the plan of corrective action, and “(C) the agency agrees to repay to the Federal Government payments received under this subparagraph if the corrective action is not taken in accordance with the approved plan and timetable. The Secretary shall establish guidelines for approval of corrective actions requested by home health agencies under this subparagraph. “(f) (1) The Secretary shall develop and implement, by not later than April 1, 1989— “(A) a range of intermediate sanctions to apply to home health agencies under the conditions described in subsection (e), and “(B) appropriate procedures for appealing determinations relating to the imposition of such sanctions. “(2) (A) The intermediate sanctions developed under paragraph (1) shall include— “(i) civil money penalties for each day of noncompliance, “(ii) suspension of all or part of the payments to which a home health agency would otherwise be entitled under this title with respect to items and services furnished by a home health agency on or after the date on which the Secretary determines that intermediate sanctions should be imposed pursuant to subsection (e)(2), and “(iii) the appointment of temporary management to oversee the operation of the home health agency and to protect and assure the health and safety of the individuals under the care of the agency while improvements are made in order to bring the agency into compliance with all the requirements specified in or pursuant to section 1861(o) or subsection (a). The temporary management under clause (iii) shall not be terminated until the Secretary has determined that the agency has the management capability to ensure continued compliance with all the requirements referred to in that clause. “(B) The sanctions specified in subparagraph (A) are in addition to sanctions otherwise available under State or Federal law and shall not be construed as limiting other remedies, including any remedy available to an individual at common law. “(C) A finding to suspend payment under subparagraph (A)(ii) shall terminate when the Secretary finds that the home health agency is in substantial compliance with all the requirements specified in or pursuant to section 1861(o) and subsection (a). “(3) The Secretary shall develop and implement, by not later than April 1, 1989, specific procedures with respect to the conditions under which each of the intermediate sanctions developed under paragraph (1) is to be applied, including the amount of any fines and the severity of each of these sanctions. Such procedures shall be designed so as to minimize the time between identification of deficiencies and imposition of these sanctions and shall provide for the imposition of incrementally more severe fines for repeated or uncorrected deficiencies.”.

4. 1988

   Medicare Catastrophic Coverage Act of 1988

   Pub. L. 100–360 § 411(d)(1)(A)(i) · 102 Stat. 683

   Struck · 42 U.S.C. § 1395bbb(a)(3)(A)

   Pub. L. 100–360, § 411(d)(1)(A)(i), struck out “who is not a licensed health care professional (as defined in subparagraph (F))” after “any individual” in introductory provisions

   Source evidence

   Code amendment note
   Subsec. (a)(3)(A). Pub. L. 100–360, § 411(d)(1)(A)(i), struck out “who is not a licensed health care professional (as defined in subparagraph (F))” after “any individual” in introductory provisions.

   Enacted provision · exact public law section
   (i) in paragraph (3)(A), by striking “who is not a licensed health care professional (as defined in subparagraph (F))”,

5. 1988

   Medicare Catastrophic Coverage Act of 1988

   Pub. L. 100–360 § 411(d)(1)(A)(ii) · 102 Stat. 683

   Inserted · 42 U.S.C. § 1395bbb(a)(3)(F)

   Pub. L. 100–360, § 411(d)(1)(A)(ii), inserted “physical or occupational therapy assistant,” after “occupational therapist”

   Source evidence

   Code amendment note
   Subsec. (a)(3)(F). Pub. L. 100–360, § 411(d)(1)(A)(ii), inserted “physical or occupational therapy assistant,” after “occupational therapist”.

   Enacted provision · exact public law section
   (ii) in paragraph (3)(F), by inserting “physical or occupational Health care professionals. therapy assistant,” after “occupational therapist,”, and

6. 1988

   Medicare Catastrophic Coverage Act of 1988

   Pub. L. 100–360 § 411(d)(1)(A)(iii) · 102 Stat. 683

   1. Redesignated · 42 U.S.C. § 1395bbb(a)(4)(6)

      Pub. L. 100–360, § 411(d)(1)(A)(iii), redesignated pars. (5) and (6) as (4) and (5), respectively

   2. Struck · 42 U.S.C. § 1395bbb(a)(4)(6)

      Pub. L. 100–360, § 411(d)(1)(A)(iii), struck out former par. (4) which read as follows: “With respect to durable medical equipment furnished to individuals for whom the agency provides items and services, suppliers of such equipment do not use (on a full-time, temporary, per diem, or other basis) any individual who does not meet minimum training standards (established by the Secretary by October 1, 1988) for the demonstration and use of any such equipment furnished to individuals with respect to whom payments may be made under this subchapter.”

   Source evidence

   Code amendment note
   Subsec. (a)(4) to (6). Pub. L. 100–360, § 411(d)(1)(A)(iii), redesignated pars. (5) and (6) as (4) and (5), respectively, and struck out former par. (4) which read as follows: “With respect to durable medical equipment furnished to individuals for whom the agency provides items and services, suppliers of such equipment do not use (on a full-time, temporary, per diem, or other basis) any individual who does not meet minimum training standards (established by the Secretary by October 1, 1988) for the demonstration and use of any such equipment furnished to individuals with respect to whom payments may be made under this subchapter.”

   Enacted provision · exact public law section
   (iii) by striking paragraph (4) and by redesignating paragraphs (5) and (6) as paragraphs (4) and (5), respectively.

7. 1988

   Medicare Catastrophic Coverage Act of 1988

   Pub. L. 100–360 § 411(d)(2)(A) · 102 Stat. 683

   1. Amended · 42 U.S.C. § 1395bbb(c)(1)

      Pub. L. 100–360, § 411(d)(2)(A), as amended by Pub. L. 100–485, § 608(d)(20)(A)

   2. Amended · 42 U.S.C. § 1395bbb(c)(1)

      Pub. L. 100–360, § 411(d)(2)(A), as amended third sentence generally. Prior to amendment, third sentence read as follows: “The Secretary shall provide for imposition of civil money penalties under this clause in a manner similar to that for the imposition of civil money penalties under section 1320a–7a of this title.”

   Source evidence

   Code amendment note
   Subsec. (c)(1). Pub. L. 100–360, § 411(d)(2)(A), as amended by Pub. L. 100–485, § 608(d)(20)(A), amended third sentence generally. Prior to amendment, third sentence read as follows: “The Secretary shall provide for imposition of civil money penalties under this clause in a manner similar to that for the imposition of civil money penalties under section 1320a–7a of this title.”

   Enacted provision · exact public law section
   (A) The third sentence of section 1891(c)(1) of the Social Security Act, as added by section 4022(a) of OBRA, is amended by inserting “(other than subsections (a) and (b))” after “1128A”.

8. 1988

   Medicare Catastrophic Coverage Act of 1988

   Pub. L. 100–360 § 411(d)(2)(B) · 102 Stat. 683

   Substituted · 42 U.S.C. § 1395bbb(d)(2)(A)

   Pub. L. 100–360, § 411(d)(2)(B), substituted “1992” for “1991” in introductory provisions

   Source evidence

   Code amendment note
   Subsec. (d)(2)(A). Pub. L. 100–360, § 411(d)(2)(B), substituted “1992” for “1991” in introductory provisions.

   Enacted provision · exact public law section
   (B) Section 1891(d)(2)(A) of the Social Security Act, as added 42 USC 1395bbb. by section 4022(a) of OBRA, is amended by striking “1991” and inserting “1992”.

9. 1988

   Medicare Catastrophic Coverage Act of 1988

   Pub. L. 100–360 § 411(d)(3)(A) · 102 Stat. 683

   Changed · 42 U.S.C. § 1395bbb(e); 42 U.S.C. § 1395bbb(f)

   Pub. L. 100–360, § 411(d)(3)(A), made technical amendment to Pub. L. 100–203, § 4023(a), see 1987 Amendment note below

   Source evidence

   Code amendment note
   Subsecs. (e), (f). Pub. L. 100–360, § 411(d)(3)(A), made technical amendment to Pub. L. 100–203, § 4023(a), see 1987 Amendment note below.

   Enacted provision · exact public law section
   (A) Section 4023 of OBRA is amended by inserting “(a) In General.—” before “Section 1891”.

10. 1988

    Medicare Catastrophic Coverage Act of 1988

    Pub. L. 100–360 § 411(d)(3)(B)(iii) · 102 Stat. 683

    Inserted · 42 U.S.C. § 1395bbb(f)(2)(A)

    Pub. L. 100–360, § 411(d)(3)(B)(iii), inserted before last sentence “The provisions of section 1320a–7a of this title (other than subsections (a) and (b)) shall apply to a civil money penalty under clause (i) in the same manner as such provisions apply to a penalty or proceeding under section 1320a–7a(a) of this title.”

    Source evidence

    Code amendment note
    Subsec. (f)(2)(A). Pub. L. 100–360, § 411(d)(3)(B)(iii), inserted before last sentence “The provisions of section 1320a–7a of this title (other than subsections (a) and (b)) shall apply to a civil money penalty under clause (i) in the same manner as such provisions apply to a penalty or proceeding under section 1320a–7a(a) of this title.”

    Enacted provision · exact public law section
    (iii) by inserting after and below clause (iii), the following: “The provisions of section 1128A (other than subsections (a) and (b)) shall apply to a civil money penalty under clause (i) in the same manner as such provisions apply to a penalty or proceeding under section 1128A(a).”.

11. 1988

    Medicare Catastrophic Coverage Act of 1988

    Pub. L. 100–360 § 411(d)(3)(B)(i) · 102 Stat. 683

    Changed · 42 U.S.C. § 1395bbb(f)(2)(A)

    Pub. L. 100–360, § 411(d)(3)(B)(i), realigned the margins of cls. (i) to (iii) and concluding provisions

    Target inherited from the preceding amendment note.

    Source evidence

    Code amendment note
    Pub. L. 100–360, § 411(d)(3)(B)(i), realigned the margins of cls. (i) to (iii) and concluding provisions.

    Enacted provision · exact public law section
    (i) by moving the indentation of clauses (i) through (iii) (and the sentence following clause (iii)) 2 ems to the left, (ii) in clause (i), by striking “for each day of noncompliance” and inserting “in an amount not to exceed $10,000 for each day of noncompliance”, and

12. 1988

    Medicare Catastrophic Coverage Act of 1988

    Pub. L. 100–360 § 411(d)(3)(B)(ii) · 102 Stat. 683

    Substituted · 42 U.S.C. § 1395bbb(f)(2)(A)(i)

    Pub. L. 100–360, § 411(d)(3)(B)(ii), substituted “in an amount not to exceed $10,000 for each day of noncompliance” for “for each day of noncompliance”

    Source evidence

    Code amendment note
    Subsec. (f)(2)(A)(i). Pub. L. 100–360, § 411(d)(3)(B)(ii), substituted “in an amount not to exceed $10,000 for each day of noncompliance” for “for each day of noncompliance”.

    Enacted provision · exact public law section
    (B) Section 1891(f)(2)(A) of the Social Security Act, as added by section 4023 of OBRA, is amended— (i) by moving the indentation of clauses (i) through (iii) (and the sentence following clause (iii)) 2 ems to the left, (ii) in clause (i), by striking “for each day of noncompliance” and inserting “in an amount not to exceed $10,000 for each day of noncompliance”, and (iii) by inserting after and below clause (iii), the following: “The provisions of section 1128A (other than subsections (a) and (b)) shall apply to a civil money penalty under clause (i) in the same manner as such provisions apply to a penalty or proceeding under section 1128A(a).”.

13. 1990

    Omnibus Budget Reconciliation Act of 1990

    Pub. L. 101–508 § 4207(i)(1) · 104 Stat. 1388

    Substituted · 42 U.S.C. § 1395bbb(a)(3)(D)(iii)

    Pub. L. 101–508, § 4207(i)(1), formerly § 4027(i)(1), as renumbered by Pub. L. 103–432, substituted “which, within the previous 2 years—” and subcls. (I) to (IV) for “which has been determined to be out of compliance with the requirements specified in or pursuant to section 1395x(o) of this title or subsection (a) of this section within the previous 2 years.”

    Target inherited from the preceding amendment note.

    Source evidence

    Code amendment note
    Subsec. (a)(3)(D)(iii). Pub. L. 101–508, § 4207(i)(1), formerly § 4027(i)(1), as renumbered by Pub. L. 103–432, substituted “which, within the previous 2 years—” and subcls. (I) to (IV) for “which has been determined to be out of compliance with the requirements specified in or pursuant to section 1395x(o) of this title or subsection (a) of this section within the previous 2 years.”

    Enacted provision · exact public law section
    (1) In general.— Effective as if included in the enactment of the Omnibus Budget Reconciliation Act of 1987, section 1891(a)(3)(D)(iii) of the Social Security Act (42 U.S.C. 1395bbb(a)(3)(D)(iii)) is amended by striking “which has been determined” and all that follows and inserting the following: “which, within the previous 2 years— “(I) has been determined to he out of compliance with subparagraph (A), (B), or (C); “(II) has been subject to an extended (or partial extended) survey under subsection (c)(2)(D); “(III) has been assessed a civil money penalty described in subsection (f)(2)(A)(i) of not less than $5,000; or “(IV) has been subject to the remedies described in subsection (e)(1) or in clauses (ii) or (iii) of subsection (1)(2)(A).”.

14. 1990

    Omnibus Budget Reconciliation Act of 1990

    Pub. L. 101–508 § 4206(d)(2) · 104 Stat. 1388

    Added · 42 U.S.C. § 1395bbb(a)(6)

    Pub. L. 101–508, § 4206(d)(2), added par. (6)

    Source evidence

    Code amendment note
    Subsec. (a)(6). Pub. L. 101–508, § 4206(d)(2), added par. (6).

    Enacted provision · exact public law section
    (2) Section 1891(a) of such Act (42 U.S.C. 1395bbb(a)) is amended by adding at the end the following: (6) The agency complies with the requirement of section 1866(f) (relating to maintaining written policies and procedures respecting advance directives).”.

15. 1996

    Pub. L. 104–134 title I § 101(d)(tV)(s516)(a) · 110 Stat. 1321

    1. Substituted · 42 U.S.C. § 1395bbb(c)(2)(A)

       Pub. L. 104–134 substituted “36 months” for “15 months” in first sentence

    2. Amended · 42 U.S.C. § 1395bbb(c)(2)(A)

       Pub. L. 104–134 amended last sentence generally. Prior to amendment, last sentence read as follows: “The statewide average interval between standard surveys of any home health agency shall not exceed 12 months.”

    Source evidence

    Code amendment note
    Subsec. (c)(2)(A). Pub. L. 104–134 substituted “36 months” for “15 months” in first sentence and amended last sentence generally. Prior to amendment, last sentence read as follows: “The statewide average interval between standard surveys of any home health agency shall not exceed 12 months.”

    Enacted provision · exact public law section
    Section 101. For programs, projects or activities in the Departments of Commerce, Justice, and State, the Judiciary, and Related Agencies Appropriations Act, 1996, provided as follows, to be effective as if it had been enacted into law as the regular appropriations Act:

16. 1997

    Balanced Budget Act of 1997

    Pub. L. 105–33 title IV § 4604(a) · 111 Stat. 251

    Added · 42 U.S.C. § 1395bbb(g)

    Pub. L. 105–33 added subsec. (g)

    Source evidence

    Code amendment note
    Subsec. (g). Pub. L. 105–33 added subsec. (g).

    Enacted provision · exact public law section
    (a) Conditions of Participation.— Section 1891 (42 U.S.C. 1395bbb) is amended by adding at the end the following: “(g) Payment on Basis of Location of Service.— A home health agency shall submit claims for payment for home health services under this title only on the basis of the geographic location at which the service is furnished, as determined by the Secretary.”.

    Effective date note
    Amendment by Pub. L. 105–33 applicable to cost reporting periods beginning on or after Oct. 1, 1997, see section 4604(c) of Pub. L. 105–33, set out as a note under section 1395x of this title.

17. 2003

    Medicare Prescription Drug, Improvement, and Modernization Act of 2003

    Pub. L. 108–173 title VII § 736(c)(3) · 117 Stat. 2066

    Substituted · 42 U.S.C. § 1395bbb(d)(1)

    Pub. L. 108–173 substituted “subsection (c)(2)(C)(i)(I)” for “subsection (c)(2)(C)(I)”

    Source evidence

    Code amendment note
    Subsec. (d)(1). Pub. L. 108–173 substituted “subsection (c)(2)(C)(i)(I)” for “subsection (c)(2)(C)(I)”.

    Enacted provision · exact public law section
    (3) Section 1891(d)(1) (42 U.S.C. 1395bbb(d)(1)) is amended by striking “subsection (c)(2)(C)(I)” and inserting “subsection (c)(2)(C)(i)(I)”.

20 of 21 references resolved to an enrolled provision · 1 partial