§ 1395xx. Payment of provider-based physicians and payment under certain percentage arrangements

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. 97–248 title I · 96 Stat. 324

   Enacted · 42 U.S.C. § 1395xx

   Aug. 14, 1935, ch. 531, title XVIII, § 1887, as added and amended Pub. L. 97–248, title I, §§ 108(a)[(1)], 109(a), Sept. 3, 1982, 96 Stat. 337, 338

   Source evidence

   Code source credit
   Aug. 14, 1935, ch. 531, title XVIII, § 1887, as added and amended Pub. L. 97–248, title I, §§ 108(a)[(1)], 109(a), Sept. 3, 1982, 96 Stat. 337, 338

   Enacted provision · exact public law
   TITLE I— PROVISIONS RELATING TO SAVINGS IN HEALTH AND INCOME SECURITY PROGRAMS Subtitle A— Medicare PART I— CHANGES IN PAYMENTS FOR SERVICES Subpart A— Amount of Payment for Institutional Services payment for inpatient hospital services Sec. 101. (a) (1) Title XVIII of the Social Security Act is amended by adding at the end thereof the following new section: “payment to hospitals for inpatient hospital services “Sec. 1886. (a) (1) (A) (i) The Secretary, in determining the amount 42 USC 1395ww. of the payments that may be made under this title with respect to operating costs of inpatient hospital services (as defined in paragraph (4)) shall not recognize as reasonable (in the efficient delivery of health services) costs for the provision of such services by a hospital for a cost reporting period to the extent such costs exceed the applicable percentage (as determined under clause (ii)) of the average of such costs for all hospitals in the same grouping as such hospital for comparable time periods. “(ii) For purposes of clause (i), the applicable percentage for hospital cost reporting periods beginning— “(I) on or after October 1, 1982, and before October 1, 1983, is 120 percent; “(II) on or after October 1, 1983, and before October 1, 1984, is 115 percent; and “(III) on or after October 1, 1984, is 110 percent. “(B) (i) For purposes of subparagraph (A) the Secretary shall establish case mix indexes for all short-term hospitals, and shall set limits for each hospital based upon the general mix of types of medical cases with respect to which such, hospital provides services for which payment may be made under this title. “(ii) The Secretary shall set such limits for a cost reporting period Cost reporting period, limitation. of a hospital— “(I) by updating available data for a previous period to the immediate preceding cost reporting period by the estimated average rate of change of hospital costs industry-wide, and “(II) by projecting for the cost reporting period by the applicable percentage increase (as defined in subsection (b)(3)(B)). “(C) The limitation established under subparagraph (A) for any hospital shall in no event be lower than the allowable operating costs of inpatient hospital services (as defined in paragraph (4)) recognized under this title for such hospital for such hospital’s last cost reporting period prior to the hospital’s first cost reporting period for which this section is in effect. “(2) The Secretary shall provide for such exemptions from, and exceptions and adjustments to, the limitation established under paragraph (1)(A) as he deems appropriate, including those which he deems necessary to take into account— “(A) the special needs of sole community hospitals, of new hospitals, of risk based health maintenance organizations, and of hospitals which provide atypical services or essential community services, and to take into account extraordinary circumstances beyond the hospital’s control, medical and paramedical education costs, significantly fluctuating population in the service area of the hospital, and unusual labor costs, “(B) the special needs of psychiatric hospitals and of public or other hospitals that serve a significantly disportionate number of patients who have low income or are entitled to benefits under part A of this title, and “(C) a decrease in the inpatient hospital services that a hospital provides and that are customarily provided directly by similar hospitals which results in a significant distortion in the operating costs of inpatient hospital services. “(3) The limitation established under paragraph (1)(A) shall not apply with respect to any hospital which— “(A) is located outside of a standard metropolitan statistical area, and “(B) (i) has less than 50 beds, and “(ii) was in operation and had less than 50 beds on the date of the enactment of this section. “(4) For purposes of this section, the term ‘‘operating costs of inpatient hospital services’ includes all routine operating costs, ancillary service operating costs, and special care unit operating costs with respect to inpatient hospital services and such costs are determined on an average per admission or per discharge basis (as determined by the Secretary). “(b) (1) Notwithstanding sections 1814(b) but subject to the provisions 42 USC 1395f. 42 USC 1395e. of sections 1813, if the operating costs of inpatient hospital services (as defined in subsection (a)(4)) of a hospital for a cost reporting period subject to this paragraph— “(A) are less than or equal to the target amount (as defined in paragraph (3)) for that hospital for that period, the amount of the payment with respect to such operating costs payable under part A on a per discharge or per admission basis (as the case may be) shall be equal to the amount of such operating costs, plus— “(i) 50 percent of the amount by which the target amount exceeds the amount of the operating costs, or “(ii) 5 percent of the target amount, whichever is less; or “(B) are greater than the target amount, the amount of the payment with respect to such operating costs payable under part A on a per discharge or per admission basis (as the case may be) shall be equal to (i) the target amount, plus (ii) in the case of cost reporting periods beginning on or after October 1, 1982, and before October 1, 1984, 25 percent of the amount by which the amount of the operating costs exceeds the target amount; except that in no case may the amount payable under this title with respect to operating costs of inpatient hospital services exceed the maximum amount payable with respect to such costs pursuant to subsection (a). “(2) Paragraph (1) shall not apply to cost reporting periods of hospitals beginning on or after October 1, 1985. “(3) (A) For purposes of this subsection, the term ‘target amount’ “Target amount.’ means, with respect to a hospital for a particular 12-month cost reporting period— “(i) in the case of the first such reporting period for which this subsection is in effect, the allowable operating costs of inpatient hospital services (as defined in subsection (a)(4)) recognized under this title for such hospital for the preceding 12-month cost reporting period, and “(ii) in the case a later reporting period, the target amount for the preceding 12-month cost reporting period, increased by the applicable percentage increase under subparagraph (B) for that particular cost reporting period. “(B) For purposes of subparagraph (A), the ‘applicable percentage “Applicable percentage increase.” increase’ for any 12-month cost reporting period shall be equal to 1 percentage point plus the percentage, estimated by the Secretary, by which the cost of the mix of goods and services (including personnel costs but excluding non-operating costs) comprising routine, ancillary, and special care unit inpatient hospital services, based on an index of appropriately weighted indicators of changes in wages and prices which are representative of the mix of goods and services included in such inpatient hospital services, for such cost reporting period exceeds the cost of such mix of goods and services for the preceding 12-month cost reporting period. “(4) (A) The Secretary shall provide for an exemption from, or an exception and adjustment to, the method under this subsection for determining the amount of payment to a hospital where events beyond the hospital’s control or extraordinary circumstances, including changes in the case mix of such hospital, create a distortion in the increase in costs for a cost reporting period (including any distortion in the costs for the base period against which such increase is measured). The Secretary may provide for such other exemptions from, and exceptions and adjustments to, such method as the Secretary deems appropriate, including those which he deems necessary to take into account a decrease in the inpatient hospital services that a hospital provides and that are customarily provided directly by similar hospitals which results in a significant distortion in the operating costs of inpatient hospital services. “(B) Paragraph (1) shall not apply to payment of hospitals which is otherwise determined under paragraph (3) of section 1814(b). 42 USC 1395f. “(5) In the case of any hospital having any cost reporting period of other than a 12-month period, the Secretary shall determine the 12-month period which shall be used for purposes of this section. “(6) (A) The Secretary shall provide for an adjustment under this paragraph in the amount of payment otherwise provided a hospital under this subsection in the case of a hospital which, as of August 15, 1982, was subject to the taxes (hereinafter in this paragraph referred to as the TICA taxes’) imposed by section 3111 of the Internal Revenue Code of 1954 and which is not subject to such 26 USC 3111. taxes for part or all of a cost reporting period beginning on or after October 1, 1982. “(B) In making such adjustment for a cost reporting period the Operating costs, estimate. Secretary shall estimate the amount of the operating costs of inpatient hospital services that would have resulted if the hospital was subject to the FICA taxes during that period. In making such estimate the Secretary shall reduce the amount of such FICA taxes that would have been paid (but not below zero) by the amount of costs which the hospital demonstrates to the satisfaction of the Secretary were incurred in the period for pensions, health, and other fringe benefits for employees (and former employees and family members) comparable to, and in lieu of, the benefits provided under title II and this title of the Social Security Act. 42 USC 401. “(C) If a hospital’s operating costs of inpatient hospital services estimated under subparagraph (B) is greater than the hospital’s operating costs of inpatient hospital services determined without regard to this paragraph for a cost reporting period, then the Secretary shall reduce the amount otherwise paid the hospital (respecting operating costs of inpatient hospital services) under this subsection for the period by the amount by which— “(i) the amount that would have been paid the hospital if (I) the amount of the operating costs of inpatient hospital services estimated under subparagraph (B) were treated as the amount of the operating costs of inpatient hospital services and (II) subsection (a) did not apply to the determination, exceeds— “(ii) the amount that would otherwise have been paid the hospital if subsection (a) (and this paragraph) did not apply; except that, in making such determination for cost reporting periods beginning on or after October 1, 1984, clause (ii) of paragraph (1)(B) shall continue to apply. “(c) (1) The Secretary may provide, in his discretion, that payment with respect to services provided by a hospital in a State may be made in accordance with a hospital reimbursement control system in a State, rather than in accordance with the other provisions of this title, if the chief executive officer of the State requests such treatment and if— “(A) the Secretary determines that the system, if approved under this subsection, will apply (i) to substantially all non-Federal acute care hospitals (as defined by the Secretary) in the State and (ii) to the review of at least 75 percent of all revenues or expenses in the State for inpatient hospital services and of revenues or expenses for inpatient hospital services provided under the State’s plan approved under title XIX; 42 USC 1396. “(B) the Secretary has been provided satisfactory assurances as to the equitable treatment under the system of all entities (including Federal and State programs) that pay hospitals for inpatient hospital services, of hospital employees, and of hospital patients; and “(C) the Secretary has been provided satisfactory assurances that under the system, over 36-month periods (the first such period beginning with the first month in which this subsection applies to that system in the State), the amount of payments made under this title under such system will not exceed the amount of payments which would otherwise have been made under this title not using such system. “(2) In determining under paragraph (1)(C) the amount of payment which would otherwise have been made under this title for a State, the Secretary may provide for appropriate adjustment of such amount to take into account previous reductions effected in the amount of payments made under this title in the State due to the operation of the hospital reimbursement control system in the State if the system has resulted in an aggregate rate of increase in operating costs of inpatient hospital services (as defined in subsection (a)(4)) under this title for hospitals in the State which is less than the aggregate rate of increase in such costs under this title for hospitals in the United States. “(3) The Secretary shall discontinue payments under a system described in paragraph (1) if the Secretary— “(A) determines that the system no longer meets the requirement of paragraph (1)(A) or “(B) has reason to believe that the assurances described in subparagraph (B) or (C) of paragraph (1) are not being (or will not be) met.”. (2) Section 1861(v)(l)(L) of such Act is amended by striking out 95 Stat. 798. 42 USC 1395x. “(i)” and all that follows through “(ii)”. (b) (1) The amendments made by subsection (a) shall apply to cost 42 USC 1395ww note. reporting periods beginning on or after October 1, 1982. (2) (A) The Secretary of Health and Human Services shall first Regulations. issue such final regulations (whether on an interim or other basis) before October 1, 1982, as may be necessary to implement such amendments on a timely basis. If such regulations are promulgated on an interim final basis, the Secretary shall take such steps as may be necessary to provide opportunity for public comment, and appropriate revision based thereon, so as to provide that such regulations are not on an interim basis later than March 31, 1983. (B) Chapter 35 of title 5, United States Code, shall not apply, until 5 USC 3501 et seq. January 1, 1984, to collection of information and information collection requests which the Secretary of Health and Human Services determines to be necessary to carry out the amendments made by this section. (3) Section 1135 of the Social Security Act is amended by adding at 95 Stat. 809. 42 USC 1320b-5. the end the following new subsection: “(c) The Secretary shall develop, in consultation with the Senate Committee on Finance and the Committee on Ways and Means of the House of Representatives, proposals for legislation which would provide that hospitals, skilled nursing facilities, and, to the extent feasible, other providers, would be reimbursed under title XVIII of this Act on a prospective basis. The Secretary shall report such 42 USC 1395. Report to congressional committees. proposals to such committees not later than December 31, 1982.”. (c) (1) Section 1814(b) of the Social Security Act is amended— (A) by striking out “section 1813” in the matter before paragraph 42 USC 1395f. (1) and inserting in lieu thereof “sections 1813 and 1886”; and (B) by striking out “until the Secretary determines” in the second sentence and inserting in lieu thereof “until the first day of the seventh month beginning after the date the Secretary determines and notifies the Governor of the State”. (2) Section 1833(a)(2)(B) of such Act is amended by inserting “and 42 USC 1395l. except as may be provided in section 1886” after “except those described in subparagraph (C) of this paragraph”. (d) Section 1861(v)(7) of such Act is amended by inserting “(A)” 42 USC 1395x. after “(7)” and by adding at the end thereof the following new subparagraph: “(B) For further limitations on reasonable cost and determination of payment amounts for operating costs of inpatient hospital services and waivers for certain States, see section 1886.”. Ante, p. 331. single reimbursement limit for skilled nursing facilities Sec. 102. (a) Section 1861(v)(l) of the Social Security Act is 42 USC 1395x. amended— (1) in subparagraph (E), by striking out “; except that” and all that follows and inserting in lieu thereof a period; (2) in subparagraph (E), by striking out “(E)” and inserting in lieu thereof “(ii)”; and (3) by inserting after subparagraph (D) the following: “(E) (i) Such regulations shall provide that any determination of reasonable cost with respect to services provided by hospital-based skilled nursing facilities shall be made on the basis of a single standard based on the reasonableness of costs incurred by free standing skilled nursing facilities, subject to such adjustments as the Secretary may deem appropriate.”. (b) The amendment made by subsection (a) shall be effective with Effective date. 42 USC 1395x note. respect to cost reporting periods beginning on or after October 1, 1982. elimination of inpatient routine nursing salary cost differential Sec. 103. (a) Subparagraph (J) of section 1861(v)(1) of the Social Security Act is amended to read as follows: 95 Stat. 797. 42 USC 1395x. “(J) Such regulations may not provide for any inpatient routine salary cost differential as a reimbursable cost for hospitals and skilled nursing facilities.”. (b) The amendment made by subsection (a) shall be effective with Effective date. 42 USC 1395x note. respect to cost reporting periods ending after September 30, 1982, but in the case of any cost reporting period beginning before October 1, 1982, any reduction in payments under title XVIII of the Social Security Act to a hospital or skilled nursing facility resulting from 42 USC 1395. such amendment shall be imposed only in proportion to the part of the period which occurs after September 30, 1982. elimination of duplicate overhead payments for outpatient services Sec. 104. (a) The last sentence of section 1842(b)(3) of the Social Security Act is amended by inserting after “1861(v)(1)(K)” the following: 42 USC 1395u. “, and in determining the reasonable charge for such services, the Secretary may limit such reasonable charge to a percentage of the amount of the prevailing charge for similar services furnished in a physician’s office, taking into account the extent to which overhead costs associated with such outpatient services have been included in the reasonable cost or charge of the facility”. (b) The amendment made by subsection (a) made by this section Effective date. 42 USC 1395u note. shall be effective with respect to services furnished on or after October 1, 1982. single reimbursement limit for home health agencies Sec. 105. (a) Section 1861(v)(l)(L) of the Social Security Act, as 42 USC 1395x. amended by section 101(a)(2) of this subtitle, is amended by inserting “free standing” after “75th percentile of such costs per visit for”. (b) The amendment made by subsection (a) shall be effective with Effective date. 42 USC 1395x note. respect to cost reporting periods beginning on or after the date of the enactment of this Act. prohibiting payment for hill-burton free care Sec. 106. (a) Section 1861(v)(1) of the Social Security Act is 42 USC 1395x. amended by adding at the end the following new subparagraph: “(M) Such regulations shall provide that costs respecting care provided by a provider of services, pursuant to an assurance under title VI or XVI of the Public Health Service Act that the provider 42 USC 291a, 300o. will make available a reasonable volume of services to persons unable to pay therefor, shall not be allowable as reasonable costs.”. (b) The amendment made by subsection (a) shall be effective with Effective date. 42 USC 1395x note. 42 USC 1395. respect to any costs incurred under title XVIII of the Social Security Act, except that it shall not apply to costs which have been allowed prior to the date of the enactment of this Act pursuant to the final court order affirmed by a United States Court of Appeals. prohibiting payment for anti-unionization activities Sec. 107. (a) Section 1861(v)(1) of the Social Security Act, as amended by section 106(a) of this subtitle, is further amended by adding after subparagraph (M) the following new subparagraph: “(N) In determining such reasonable costs, costs incurred for activities directly related to influencing employees respecting unionization may not be included.”. (b) The amendment made by subsection (a) shall be effective with Effective date. 42 USC 1395x note. respect to costs incurred after the date of the enactment of this Act. reimbursement of provider-based physicians Sec. 108. (a) Title XVIII of the Social Security Act is amended by adding after section 1886 of the Social Security Act (as added by section 101(a)(1) of this subtitle) the following new section: “payment of provider-based physicians “Sec. 1887. (a) (1) The Secretary shall by regulation determine 42 USC 1395xx. criteria for distinguishing those services (including inpatient and outpatient services) rendered in hospitals or skilled nursing facilities— “(A) which constitute professional medical services, which are personally rendered for an individual patient by a physician and which contribute to the diagnosis or treatment of an indi-vidual patient, and which may be reimbursed as physicians’ services under part B, and “(B) which constitute professional services which are rendered for the general benefit to patients in a hospital or skilled nursing facility and which may be reimbursed only on a reasonable cost basis. “(2) (A) For purposes of cost reimbursement, the Secretary shall recognize as a reasonable cost of a hospital or skilled nursing facility only that portion of the costs attributable to services rendered by a physician in such hospital or facility which are services described in paragraph (1)(B), apportioned on the basis of the amount of time actually spent by such physician rendering such services. “(B) In determining the amount of the payments which may be made with respect to services described in paragraph (1)(B), after apportioning costs as required by subparagraph (A), the Secretary may not recognize as reasonable (in the efficient delivery of health services) such portion of the provider’s costs for such services to the extent that such costs exceed the reasonable compensation equivalent for such services. The reasonable compensation equivalent for any service shall be established by the Secretary in regulations. “(C) The Secretary may, upon a showing by a hospital or facility that it is unable to recruit or maintain an adequate number of physicians for the hospital or facility on account of the reimbursement limits established under this subsection, grant exceptions to such reimbursement limits as may be necessary to allow such provider to provide a compensation level sufficient to provide adequate physician services in such hospital or facility.”. (2) Section 1861(v)(7) of such Act, as amended by section 101(d) of this subtitle, is further amended by adding at the end the following Ante, p. 336. new subparagraph: “(C) For provisions restricting payment for provider-based physicians’ Services, see section 1887.”. Ante, p. 337. (c) The Secretary of Health and Human Services shall first promulgate Regulations. 42 USC 1395xx note. Ante, p. 337. regulations to carry out section 1887(a) of the Social Security Act not later than October 1, 1982. Such regulations shall become effective on October 1, 1982, and shall be effective with respect to cost reporting periods ending after September 30, 1982, but in the case of any cost reporting period beginning before October 1, 1982, any reduction in payments under title XVIII of the Social Security Act to a hospital or skilled nursing facility resulting from 42 USC 1395. such regulations shall be imposed only in proportion to the part of the period which occurs after September 30, 1982. prohibiting recognition of payments under certain percentage arrangements Sec. 109. (a) Section 1887 of the Social Security Act (as added by section 108(a) of this subtitle) is amended— (1) by inserting “and payment under certain percentage arrangements” at the end of its heading, and (2) by adding at the end the following new subsection: “(b) (1) Except as provided in paragraph (2), in the case of a provider of services which is paid under this title on a reasonable cost basis, or other basis related to costs that are reasonable, and which has entered into a contract for the purpose of having services furnished for or on behalf of it, the Secretary may not include any cost incurred by the provider under the contract if the amount payable under the contract by the provider for that cost is determined on the basis of a percentage (or other proportion) of the provider’s charges, revenues, or claim for reimbursement. “(2) Paragraph (1) shall not apply— “(A) to services furnished by a physician and described in subsection (a)(1)(B) and covered by regulations in effect under subsection (a), and “(B) under regulations established by the Secretary, where the amount involved under the percentage contract is reasonable and the contract— “(i) is a customary commercial business practice, or “(ii) provides incentives for the efficient and economical operation of the provider of services.”. (b) (1) Section 1861(v)(1)(H)(iii) of such Act is amended by striking 42 USC 1395x. out “(I)” and by striking out “, or (II)” and all that follows through “furnished by the agency”. (2) Section 1861(v)(7)(C) of such Act, as added by section 108(b)(2) of this subtitle, is further amended by inserting “and for payments Ante, p. 338. under certain percentage arrangements” after “services”. (c) (1) The amendments made by this section shall become effective Effective date. 42 USC 1395xx note. Ante, p. 338. on the date of the enactment of this Act, except that section 1887(b)(1) of the Social Security Act shall not apply before October 1, 1982, to services furnished by a physician and described in section 1887(a)(1)(B) of such Act. (2) In the case of a contract with a provider of services entered into prior to the date of the enactment of this Act, the amendment made by subsection (a) shall apply to payments under such contract (A) 30 days after the first date (after such date of enactment) the provider of services may unilaterally terminate the contract, or (B) one year after the date of the enactment of this Act, whichever is earlier. (3) The amendment made by subsection (b)(1) shall not apply to 42 USC 1395x note. contracts entered into before the date of the enactment of this Act. elimination of lesser-of-cost-or-charge provision Sec. 110. Section 1886 of the Social Security Act, as added by Ante, p. 331. section 101(a)(1) of this subtitle, is amended by adding at the end the following new subsection: “(d) (1) The lesser-of-cost-or-charges provisions (described in paragraph (2)) will not apply in the case of services provided by a class of provider of services if the Secretary determines and certifies to Congress that the failure of such provisions to apply to the services provided by that class of providers will not result in any increase in the amount of payments made for those services under this title. Such change will take effect with respect to services furnished, or cost reporting periods of providers, on or after such date as the Secretary shall provide in the certification. Such change for a class of provider shall be discontinued if the Secretary determines and notifies Congress that such change has resulted in an increase in the amount of payments made under this title for services provided by that class of provider. “(2) The lesser-of-cost-or-charges provisions referred to in paragraph (1) are as follows: “(A) Clause (B) of paragraph (1) and paragraph (2) of section 1814(b). 42 USC 1395f. “(B) So much of subparagraph (A) of section 1833(a)(2) as 42 USC 1395l. provides for payment other than of the reasonable cost of such services, as determined under section 1861(v). “(C) Subclause (II) of clause (i) and clause (ii) of section 42 USC 1395x. 1833(a)(2)(B).”. elimination of private room subsidy Sec. 111. (a) The Secretary of Health and Human Services shall, 42 USC 1395x note. pursuant to section 1861(v)(2) of the Social Security Act, not allow as a reasonable cost the estimated amount by which the costs incurred by a hospital or skilled nursing facility for nonmedically necessary private accommodations for medicare beneficiaries exceeds the costs which would have been incurred by such hospital or facility for semiprivate accommodations. (b) The Secretary of Health and Human Services shall first issue Regulations. such final regulations (whether on an interim or other basis) as may be necessary to implement subsection (a) by October 1, 1982. If such regulations are promulgated on an interim final basis, the Secretary shall take such steps as may be necessary to provide opportunity for public comment, and appropriate revision based thereon, so as to provide that such regulations are not on an interim basis later than January 31, 1983. Subpart B— Payments for Other Services reimbursement for inpatient radiology and pathology services Sec. 112. (a) Section 1833(a)(1) of the Social Security Act is 42 USC 1395l. amended— (1) by striking out clause (B) and inserting in lieu thereof the following: “(B) with respect to items and services described in section 1861(s)(10), the amounts paid shall be 100 percent of the reasonable charges for such items and services,”; (2) by inserting “and” at the end of clause (F); and (3) by striking out “and (H)” and all that follows through “for such items and services,”. (b) Clause (1) of section 1833(b) of such Act is amended to read as follows: “(1) such total amount shall not include expenses incurred for items and services described in section 1861(s)(10),”. (c) The amendments made by this section shall apply with respect Effective date. 42 USC 1395l note. to items and services furnished on or after October 1, 1982. reimbursement for assistants at surgery Sec. 113. (a) Section 1842(b)(6) of the Social Security Act is 42 USC 1395u. amended by adding at the end thereof the following new subparagraph: “(D) (i) In the case of physicians’ services furnished to a patient in a hospital with a teaching program approved as specified in section 1861(b)(6) but which does not meet the conditions described in 42 USC 1395x. section 1861(b)(7), no payment shall be made under this part for services of assistants at surgery with respect to a surgical procedure if such hospital has a training program relating to the medical specialty required for such surgical procedure and a qualified individual on the staff of the hospital is available to provide such services; except that payment may be made under this part for such services, to the extent that such payment is otherwise allowed under this paragraph, if such services, as determined under regulations of the Secretary— “(I) are required due to exceptional medical circumstances, “(II) are performed by team physicians needed to perform complex medical procedures, or “(III) constitute concurrent medical care relating to a medical condition which requires the presence of, and active care by, a physician of another specialty during surgery, and under such other circumstances as the Secretary determines by regulation to be appropriate. “(ii) For purposes of this subparagraph, the term ’assistant at “Assistant at surgery.” surgery’ means a physician who actively assists the physician in charge of a case in performing a surgical procedure. “(iii) The Secretary shall determine appropriate methods of reimbursement of assistants at surgery where such services are reimbursable under this part.”. (b) (1) The amendment made by subsection (a) is effective with Effective date. 42 USC 1395u note. respect to services performed on or after October 1, 1982. (2) The Secretary of Health and Human Services shall first issue such final regulations (whether on an interim or other basis) before October 1, 1982, as may be necessary to implement the amendment made by subsection (a) on a timely basis. If such regulations are promulgated on an interim final basis, the Secretary shall take such steps as may be necessary to provide opportunity for public comment, and appropriate revision based thereon, so as to provide that such regulations are not on an interim basis later than January 31, 1983. payments to health maintenance organizations and competitive medical plans Sec. 114. (a) Section 1876 of the Social Security Act is amended to 42 USC 1395mm. read as follows: “payments to health maintenance organizations and competitive medical plans “Sec. 1876. (a) (1) (A) The Secretary shall annually determine— “(i) a per capita rate of payment for each class of individuals who are enrolled under this section with an eligible organization which has entered into a risk-sharing contract and who are entitled to benefits under part A and enrolled under part B, and 42 USC 1395c, 1395j. “(ii) a per capita rate of payment for each class of individuals who are so enrolled with such an organization and who are enrolled under part B only. For purposes of this section, the term ‘risk-sharing contract’ means Definitions. a contract entered into under subsection (g) and the term ‘reasonable cost reimbursement contract’ means a contract entered into under subsection (h). “(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 annual per capita rate of payment for each such class shall be equal to 95 percent of the adjusted average per capita cost (as defined in paragraph (4)) for that class. “(D) In the case of an eligible organization with a risk-sharing contract, the Secretary shall make monthly payments in advance and in accordance with the rate determined under subparagraph (C) and except as provided in subsection (g)(2), to the organization for each individual enrolled with the organization under this section. “(E) The amount of payment under this paragraph 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. “(2) With respect to any eligible organization which has entered into a reasonable cost reimbursement contract, payments shall be made to such plan in accordance with subsection (h)(2) rather than paragraph (1). “(3) Payments under a contract to an eligible organization under paragraph (1) or (2) shall be instead of the amounts which (in the absence of the contract) would be otherwise payable, pursuant to sections 1814(b) and 1833(a), for services furnished by or through the Ante, p. 335. 42 USC 1395l. organization to individuals enrolled with the organization under this section. “(4) For purposes of this section, the term ‘adjusted average per “Adjusted average per capita cost.” capita cost’ means the average per capita amount that the Secretary estimates in advance (on the basis of actual 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 services covered under parts A and B, or part B only, and types of expenses otherwise reimbursable under parts A and B, or part B only (including administrative costs incurred by organizations described in sections 1816 and 1842), if the services were to be 42 USC 1395h, 1395u. Post, p. 350. furnished by other than an eligible organization or, in the case of services covered only under section 1861(s)(2)(H), if the services were to be furnished by a physician or as an incident to a physician’s service. “(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 shall be made from the Federal Hospital Insurance Trust Fund and the Federal Supplementary Medical Insurance Trust Fund. The portion of that payment to the organization for a month to be paid by the latter trust fund shall be equal to 200 percent of the sum of— “(A) the product of (i) the number of such individuals for the month who have attained age 65, and (ii) the monthly actuarial rate for supplementary medical insurance for the month as determined under section 1839(c)(1), and 42 USC 1395r. “(B) the product of (i) the number of such individuals for the month who have not attained age 65, and (ii) the monthly actuarial rate for supplementary medical insurance for the month as determined under section 1839(c)(4). The remainder of that payment shall be paid by the former trust fund. “(6) If an individual is enrolled under this section with an eligible organization having a risk-sharing contract, only the eligible organi-zation shall be entitled to receive payments from the Secretary under this title for services furnished to the individual. “(b) For purposes of this section, the term ‘eligible organization’ “Eligible organization.” means a public or private entity (which may be a health maintenance organization or a competitive medical plan), organized under the laws of any State, which— “(1) is a qualified health maintenance organization (as defined in section 1310(d) of the Public Health Service Act), or 42 USC 300e-9. “(2) meets the following requirements: “(A) The entity provides to enrolled members at least the following health care services: “(i) Physicians’ services performed by physicians (as defined in section 1861(r)(l)). 42 USC 1395x. “(ii) Inpatient hospital services, “(iii) Laboratory, X-ray, emergency, and preventive services. “(iv) Out-of-area coverage. “(B) The entity is compensated (except for deductibles, coinsurance, and copayments) for the provision of health care services to enrolled members by a payment which is paid on a periodic basis without regard to the date the health care services are provided and which is fixed without regard to the frequency, extent, or kind of health care service actually provided to a member. “(C) The entity provides physicians’ services primarily (i) directly through physicians who are either employees or partners of such organization, or (ii) through contracts with individual physicians or one or more groups of physicians (organized on a group practice or individual practice basis). “(D) The entity assumes full financial risk on a prospective basis for the provision of the health care services listed in paragraph (1), except that such entity may— “(i) obtain insurance or make other arrangements for the cost of providing to any enrolled member health care services listed in subparagraph (A) the aggregate value of which exceeds $5,000 in any year, “(ii) obtain insurance or make other arrangements for the cost of health care service listed in subparagraph (A) provided to its enrolled members other than through the entity because medical necessity required their provision before they could be secured through the entity, “(iii) obtain insurance or make other arrangements for not more than 90 percent of the amount by which its costs for any of its fiscal years exceed 115 percent of its income for such fiscal year, and “(iv) make arrangements with physicians or other health professionals, health care institutions, or any combination of such individuals or institutions to assume all or part of the financial risk on a prospective basis for the provision of basic health services by the physicians or other health professionals or through the institutions. “(E) The entity has made adequate provision against the risk of insolvency, which provision is satisfactory to the Secretary. Paragraph (2)(A)(ii) shall not apply to an entity which had contracted with a single State agency administering a State plan approved under title XIX for the provision of services (other than 42 USC 1396. inpatient hospital services) to individuals eligible for such services under such State plan on a prepaid risk basis prior to 1970. “(c) (1) The Secretary may not enter into a contract under this section with an eligible organization unless it meets the requirements of this subsection and subsection (e) with respect to members enrolled under this section. “(2) The organization must provide to members enrolled under this section, through providers and other persons that meet the applicable requirements of this title and part A of title XI— 42 USC 1301. “(A) only those services covered under parts A and B of this title, for those members entitled to benefits under part A and 42 USC 1395c, 1395j. enrolled under part B, or “(B) only those services covered under part B, for those members enrolled only under such part, which are available to individuals residing in the geographic area served by the organization, except that (i) the organization may provide such members with such additional health care services as the members may elect, at their option, to have covered, and (ii) in the case of an organization with a risk-sharing contract, the organization may provide such members with such additional health care services as the Secretary may approve. The Secretary shall approve any such additional health care services which the organization proposes to offer to such members, unless the Secretary determines that including such additional services will substantially discourage enrollment by covered individuals with the organization. “(3) (A) Each eligible organization must have an open enrollment period, for the enrollment of individuals under this section, of at least 30 days duration every year, and must provide that at any time during which enrollments are accepted, the organization will accept up to the limits of its capacity (as determined by the Secretary) and without restrictions, except as may be authorized in regulations, individuals who are eligible to enroll under subsection (d) in the order in which they apply for enrollment, unless to do so would result in failure to meet the requirements of subsection (f) or would result in the enrollment of enrollees substantially nonrepresentative, as determined in accordance with regulations of the Secretary, of the population in the geographic area served by the organization. “(B) An individual may enroll under this section with an eligible organization in such manner as may be prescribed in regulations and may terminate his enrollment with the eligible organization as of the beginning of the first calendar month following a full calendar month after the request is made for such termination (or, in the case of financial insolvency of the organization, as may be prescribed by regulations) or, in the case of such an organization with a reasonable cost reimbursement contract, as may be prescribed by regulations. “(C) The Secretary may prescribe the procedures and conditions under which an eligible organization that has entered into a contract with the Secretary under this subsection may inform individuals eligible to enroll under this section with the organization about the organization, or may enroll such individuals with the organization. “(D) The organization must provide assurances to the Secretary that it will not expel or refuse to re-enroll any such individual because of the individual’s health status or requirements for health care services, and that it will notify each such individual of such fact at the time of the individual’s enrollment. “(4) The organization must— “(A) make the services described in paragraph (2) (and such other health care services as such individuals have contracted for) (i) available and accessible to each such individual, within the area served by the organization, promptly as appropriate and in a manner which assures continuity, and (ii) when medically necessary, available and accessible twenty-four hours a day and seven days a week, and “(B) provide for reimbursement with respect to services which are described in subparagraph (A) and which are provided to such an individual other than through the organization, if (i) the services were medically necessary and immediately required because of an unforeseen illness, injury, or condition and (ii) it was not reasonable given the circumstances to obtain the services through the organization. “(5) (A) The organization must provide meaningful procedures for hearing and resolving grievances between the organization (including any entity or individual through which the organization provides health care services) and members enrolled with the organization under this section. “(B) A member enrolled with an eligible organization under this section who is dissatisfied by reason of his failure to receive any health service to which he believes he is entitled and at no greater charge than he believes he is required to pay is entitled, if the amount in controversy is $100 or more, to a hearing before the Secretary to the same extent as is provided in section 205(b), and in 42 USC 405. any such hearing the Secretary shall make the eligible organization a party. If the amount in controversy is $1,000 or more, the individual or eligible organization shall, upon notifying the other party, be entitled to judicial review of the Secretary s final decision as provided in section 205(g), and both the individual and the eligible organization shall be entitled to be parties to that judicial review. “(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, which program (A) stresses health outcomes and (B) provides review by physicians and other health care professionals of the process followed in the provision of such health care services. “(d) Subject to the provisions of subsection (c)(3), every individual entitled to benefits under part A and enrolled under part B or 42 USC 1395c, 1395j. enrolled under part B only (other than an individual medically determined to have end-stage renal disease) shall be eligible to enroll under this section with any eligible organization with which the Secretary has entered into a contract under this section and which serves the geographic area in which the individual resides. “(e) (1) In no case may— “(A) the portion of an eligible organization’s premium rate and the actuarial value of its deductibles, coinsurance, and copayments charged (with respect to services covered under parts A and B) to individuals who are enrolled under this section with the organization and who are entitled to benefits under part A and enrolled under part B, or “(B) the portion of its premium rate and the actuarial value of its deductibles, coinsurance, and copayments charged (with respect to services covered under part B) to individuals who are enrolled under this section with the organization and enrolled under part B only 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 42 USC 1395c, 1395j. enrolled under part B, or enrolled under part B only, respectively, 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 services covered under parts A and B of this title, election of coverage for such additional services (unless such services have been approved by the Secretary under subsection (c)(2)) 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. “(3) For purposes of this section, the term ‘adjusted community “Adjusted community rate.” rate’ for a service or services means, at the election of an eligible organization, either— “(A) the rate of payment for that service or services which the “Community rating system.” Secretary annually determines would apply to a member enrolled under this section with an eligible organization if the rate of payment were determined under a ‘community rating system’ (as defined in section 1302(8) of the Public Health Service Act, other than subparagraph (O), or 95 Stat. 575. “(B) such portion of the weighted aggregate premium, which 42 USC 300e-1. the Secretary annually estimates would apply to a member enrolled under this section with the eligible organization, as the Secretary annually estimates is attributable to that service or services, but adjusted for differences between the utilization characteristics of the members enrolled with the eligible organization under this section and the utilization characteristics of the other members of the organization (or, if the Secretary finds that adequate data are not available to adjust for those differences, the differences between the utilization characteristics of members in other eligible organizations, or individuals in the area, in the State, or in the United States, eligible to enroll under this section with an eligible organization and the utilization characteristics of the rest of the population in the area, in the State, or in the United States, respectively). “(4) Notwithstanding any other provision of law, the eligible organization may (in the case of the provision of services to a member enrolled under this section for an illness or injury for which the member is entitled to benefits under a workmen’s compensation law or plan of the United States or a State, under an automobile or liability insurance policy or plan, including a self-insured plan, or under no fault insurance) charge or authorize the provider of such services to charge, in accordance with the charges allowed under such law or policy— “(A) the insurance carrier, employer, or other entity which under such law, plan, or policy is to pay for the provision of such services, or “(B) such member to the extent that the member has been paid under such law, plan, or policy for such services. “(f) (1) Each eligible organization with which the Secretary enters into a contract under this section shall have, for the duration of such contract, an enrolled membership at least one-half of which consists of individuals who are not entitled to benefits under this title or under a State plan approved under title XIX. 42 USC 1396. “(2) The Secretary may modify or waive the requirement imposed Waiver. by paragraph (1) only if the Secretary determines that— “(A) special circumstances warrant such modification or waiver, and “(B) the eligible organization has taken and is making reasonable efforts to enroll individuals who are not entitled to benefits under this title or under a State plan approved under title XIX. “(g) (1) The Secretary may enter a risk-sharing contract with any Risk-sharing contract. eligible organization, as defined in subsection (b)(1), which has at least 5,000 members, except that the Secretary may enter into such a contract with an eligible organization that has fewer members if the organization primarily serves members residing outside of urbanized areas. “(2) Each risk-sharing contract shall provide that— Provisions. “(A) if the adjusted community rate, as defined in subsection (e)(3), for services under parts A and B (as reduced for the 42 USC 1395c, 1395j. actuarial value of the coinsurance and deductibles under those parts) for members enrolled under this section with the organization and entitled to benefits under part A and enrolled in part B, or “(B) if the adjusted community rate for services under part B (as reduced for the actuarial value of the coinsurance and deductibles under that part) for members enrolled under this section with the organization and entitled to benefits under part B only is less than the average of the per capita rates of payment to be made under subsection (a)(1) at the beginning of an annual contract period for members enrolled under this section with the organization and entitled to benefits under part A and enrolled in part B, or enrolled in part B only, respectively, the eligible organization shall provide to members enrolled under a risk-sharing contract under this section with the organization and entitled to benefits under part A and enrolled in part B, or enrolled in part B only, respectively, the additional benefits described in paragraph (3) 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); except that this paragraph 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). If the Secretary finds that there is insufficient enrollment experience to determine an average of the per capita rates of payment to be made under subsection (a)(1) at the beginning of a contract period, the Secretary may determine such an average based on the enrollment experience of other contracts entered into under this section. “(3) The additional benefits referred to in paragraph (2) are— “(A) the reduction of the premium rate or other charges made with respect to services furnished by the organization to members enrolled under this section, or “(B) the provision of additional health benefits, or both. “(h) (1) If— “(A) the Secretary is not satisfied that an eligible organization has the capacity to bear the risk of potential losses under a risk-sharing contract under this section, or “(B) the eligible organization so elects or has an insufficient number of members to be eligible to enter into a risk-sharing contract under subsection (g)(1), the Secretary may, if he is otherwise satisfied that the eligible organization is able to perform its contractual obligations effectively and efficiently, enter into a contract with such organization pursuant to which such organization is reimbursed on the basis of its reasonable cost (as defined in section 1861(v)) in the manner prescribed 42 USC 1395x. in paragraph (3). “(2) A reasonable cost reimbursement contract under this subsection may, at the option of such organization, provide that the Secretary— “(A) will reimburse hospitals and skilled nursing facilities either for the reasonable cost (as determined under section 1861(v)) or for payment amounts determined in accordance with section 1886, as applicable, of services furnished to individuals Ante, p. 331. enrolled with such organization pursuant to subsection (d), and “(B) will deduct the amount of such reimbursement from payment which would otherwise be made to such organization. If such an eligible organization pays a hospital or skilled nursing facility directly, the amount paid shall not exceed the reasonable cost of the services (as determined under section 1861(v)) or the amount determined under section 1886, as applicable, unless such organization demonstrates to the satisfaction of the Secretary that such excess payments are justified on the basis of advantages gained by the organization. “(3) Payments made to an organization with a reasonable cost reimbursement contract shall be subject to appropriate retroactive corrective adjustment at the end of each contract year so as to assure that such organization is paid for the reasonable cost actually incurred (excluding any part of incurred cost found to be unnecessary in the efficient delivery of health services) or the amounts otherwise determined under section 1886 for the types of expenses otherwise reimbursable under this title for providing services covered under this title to individuals described in subsection (a)(1). “(4) Any reasonable cost reimbursement contract with an eligible organization under this subsection shall provide that the Secretary shall require, at such time following the expiration of each accounting period of the eligible organization (and in such form and in such detail) as he may prescribe— “(A) that the organization report to him in an independently certified financial statement its per capita incurred cost based on the types of components of expenses otherwise reimbursable under this title for providing services described in subsection (a)(1), including therein, in accordance with accounting procedures prescribed by the Secretary, its methods of allocating costs between individuals enrolled under this section and other individuals enrolled with such organization; “(B) that failure to report such information as may be required may be deemed to constitute evidence of likely overpayment on the basis of which appropriate collection action may be taken; “(C) that in any case in which an eligible organization is Filing of a consolidated financial statement. related to another organization by common ownership or control, a consolidated financial statement shall be filed and that the allowable costs for such organization may not include costs for the types of expense otherwise reimbursable under this title, in excess of those which would be determined to be reasonable in accordance with regulations (providing for limiting reimbursement to costs rather than charges to the eligible organization by related organizations and owners) issued by the Secretary; and “(D) that in any case in which compensation is paid by an Distribution profits. of eligible organization substantially in excess of what is normally paid for similar services by similar practitioners (regardless of method of compensation), such compensation may as appropriate be considered to constitute a distribution of profits. “(i) (1) Each contract under this section shall be for a term of at least one year, as determined by the Secretary, and may be made automatically renewable from term to term in the absence of notice by either party of intention to terminate at the end of the current term; except that the Secretary may terminate any such contract at any time (after such reasonable notice and opportunity for hearing to the eligible organization involved as he may provide in regulations), if he finds that the organization— “(A) has failed substantially to carry out the contract, “(B) is carrying out the contract in a manner inconsistent with the efficient and effective administration of this section, or “(C) no longer substantially meets the applicable conditions of subsections (b), (c), and (e). “(2) The effective date of any contract executed pursuant to this section shall be specified in the contract. “(3) Each contract under this section— “(A) shall provide that the Secretary, or any person or organization designated by him— “(i) shall have the right to inspect or otherwise evaluate (I) the quality, appropriateness, and timeliness of services performed under the contract and (II) the facilities of the organization when there is reasonable evidence of some need for such inspection, and “(ii) shall have the right to audit and inspect any books and records of the eligible organization that pertain (I) to the ability of the organization to bear the risk of potential financial losses, or (II) to services performed or determinations of amounts payable under the contract; “(B) shall require the organization with a risk-sharing contract to provide (and pay for) written notice in advance of the contract’s termination, as well as a description of alternatives for obtaining benefits under this title, to each individual enrolled under this section with the organization; and “(C) shall require the organization to comply with subsections (a) and (c) of section 1318 of the Public Health Service Act 42 USC 300e-17. (relating to disclosure of certain financial information) and with the requirement of section 1301(c)(8) of such Act (relating to 42 USC 300e. liability arrangements to protect members); and “(D) shall contain such other terms and conditions not inconsistent with this section (including requiring the organization to provide the Secretary with such information) as the Secretary may find necessary and appropriate. “(4) The Secretary may not enter into a risk-sharing contract with an eligible organization if a previous risk-sharing contract with that organization under this section was terminated at the request of the organization within the preceding five-year period, except in circumstances which warrant special consideration, as determined by the Secretary. “(5) The authority vested in the Secretary by this section may be performed without regard to such provisions of law or regulations relating to the making, performance, amendment, or modification of contracts of the United States as the Secretary may determine to be inconsistent with the furtherance of the purpose of this title.”. (b) Section 1861(s)(2) of the Social Security Act is amended— 42 USC 1395x. (1) by striking out “and” at the end of subparagraph (F); (2) by inserting “and” after the semicolon in subparagraph (G); and (3) by adding after subparagraph (G) the following new subparagraph: “(H) services furnished pursuant to a contract under section 1876 to a member of an eligible organization by a physician Ante, p. 341. assistant or by a nurse practitioner (as defined in subsection (aa)(3)) and such services and supplies furnished as an incident to his service to such a member as would otherwise be covered under this part if furnished by a physician or as an incident to a physician’s service;”. (c) (1) Subject to paragraph (2), the amendment made by subsection 42 USC 1395mm note. (a) shall apply with respect to services furnished on or after the initial effective date (as defined in paragraph (4)), except that such amendment shall not apply— (A) with respect to services furnished by an eligible organization to any individual who is enrolled with that organization under an existing cost contract (as defined in paragraph (3)(A)) and entitled to benefits under part A, or enrolled in part B, of title XVIII of the Social Security Act at the time the organization 42 USC 1395c, 1395j. first enters into a new risk-sharing contract (as defined in paragraph (3)(D)) unless— (i) the individual requests at any time that the amendment apply, or (ii) the Secretary determines at any time that the amendment should apply to all members of the organization because of administrative costs or other administrative burdens involved and so informs in advance each affected member of the eligible organization; (B) with respect to services furnished by an eligible organization during the five-year period beginning on the initial effective date, if— (i) the organization has an existing risk-sharing contract (as defined in paragraph (3)(B)) on the initial effective date, or (ii) on the date of the enactment of this Act the organization was furnishing services pursuant to an existing demonstration project (as defined in paragraph (3)(C)), such demonstration project is concluded before the initial effective date, and before such initial effective date the organization enters into an existing risk-sharing contract, unless the organization requests that the amendment apply earlier; or (C) with respect to services furnished by an eligible organization during the period of an existing demonstration project if on the initial effective date the organization was furnishing services pursuant to the project and if the project concludes after such date. (2) (A) In the case of an eligible organization which has in effect an existing cost contract (as defined in paragraph (3)(A)) on the initial effective date, the organization may receive payment under a new risk-sharing contract with respect to a current, nonrisk medicare enrollee (as defined in subparagraph (O) only to the extent that the organization enrolls, for each such enrollee, two new medicare enrollees (as defined in subparagraph (D)). The selection of those current nonrisk medicare enrollees with respect to whom payment may be so received under a new risk-sharing contract shall be made in a nonbiased manner. (B) Subparagraph (A) shall not be construed to prevent an eligible organization from providing for enrollment, on a basis described in subsection (a)(6) of section 1876 of the Social Security Act (as amended by this Act, other than under a reasonable cost reimbursement Ante, p. 341. contract), of current, nonrisk medicare enrollees and from providing such enrollees with some or all of the additional benefits described in section 1876(g)(2) of the Social Security Act (as amended by this Act), but (except as provided in subparagraph (A))— (i) payment to the organization with respect to such enrollees shall only be made in accordance with the terms of a reasonable cost reimbursement contract, and (ii) no payment may be made under section 1876 of such Act with respect to such enrollees for any such additional benefits. Individuals enrolled with the organization under this subparagraph shall be considered to be individuals enrolled with the organization for the purpose of meeting the requirement of section 1876(g)(2) of the Social Security Act (as amended by this Act). (C) For purposes of this paragraph, the term “current, nonrisk “Current, nonrisk medicare enrollee.” medicare enrollee” means, with respect to an organization, an individual who on the initial effective date— (i) is enrolled with that organization under an existing cost contract, and (ii) is entitled to benefits under part A, or enrolled in part B, of title XVIII of the Social Security Act. 42 USC 1395c, 1395j. (D) For purposes of this paragraph, the term “new medicare enrollee” means, with respect to an organization, an individual who— (i) is enrolled with the organization after the date the organization first enters into a new risk-sharing contract, (ii) at the time of such enrollment is entitled to benefits under part A, or enrolled in part B, of title XVIII of the Social Security Act, and (iii) was not enrolled with the organization at the time the individual became entitled to benefits under part A, or to enroll in part B, of such title. (3) For purposes of this subsection: Definitions. (A) The term “existing cost contract” means a contract which is entered into under section 1876 of the Social Security Act, as Ante, p. 341. in effect before the initial effective date, or reimbursement on a reasonable cost basis under section 1833(a)(1)(A) of such Act, and 42 USC 1395l. which is not an existing risk-sharing contract or an existing demonstration project. (B) The term “existing risk-sharing contract” means a contract entered into under section 1876(i)(2)(A) of the Social Security Act, as in effect before the initial effective date. (C) The term “existing demonstration project” means a demonstration project under section 402(a) of the Social Security Amendments of 1967 or under section 222(a) of the Social 81 Stat. 930. 86 Stat. 1390. Security Amendments of 1972, relating to the provision of services for which payment may be made under title XVIII of the Social Security Act. 42 USC 1395. (D) The term “new risk-sharing contract” means a contract entered into under section 1876(g) of the Social Security Act, as amended by this Act. (E) The term “reasonable cost reimbursement contract” means a contract entered into under section 1833(a)(1) of the Social Security Act or under section 1876(h) of such Act, as amended by this Act. (4) As used in this section, the term “initial effective date” means— (A) the first day of the thirteenth month which begins after the date of the enactment of this Act, or (B) the first day of the first month after the month in which the Secretary of Health and Human Services notifies the Committee on Finance of the Senate and the Committees on Ways and Means and on Energy and Commerce of the House of Representatives that he is reasonably certain that the methodology to make appropriate adjustments (referred to in section 1876(a)(4) of the Social Security Act, as amended by this Act) has been developed and can be implemented to assure actuarial equivalence in the estimation of adjusted average per capita costs under that section, whichever is later. (d) The Secretary of Health and Human Services shall conduct a Study. 42 USC 1395mm note. study of the additional benefits selected by eligible organizations pursuant to section 1876(g)(2) of the Social Security Act, as amended by subsection (a) of this section. The Secretary shall report to the Report to Congress. Congress within 24 months of the initial effective date (as defined in subsection (c)(4)) with respect to the findings and conclusions made as a result of such study. (e) The Secretary of Health and Human Services shall conduct a Study. 42 USC 1395mm note. study evaluating the extent of, and reasons for, the termination by medicare beneficiaries of their memberships in organizations with contracts under section 1876 of the Social Security Act. Such study may be coordinated with the study provided for under section 2178(d) of the Omnibus Budget Reconciliation Act of 1981. In conducting 95 Stat. 813. 42 USC 1396a note. such study, the Secretary shall place special emphasis on the quantity and quality of medical care provided in such organizations and the quality of such care when provided on a fee-for-service basis. The Secretary shall submit an interim report to the Congress, Report to Congress. within two years after the initial effective date (as defined in subsection (c)(4)), and a final report within five years after such date containing the respective interim and final findings and conclusions made as a result of such study. prohibition of payment for ineffective drugs Sec. 115. (a) Effective September 30, 1982, section 131 of Public Law 97–92 is repealed, and the provisions of such section, and of Repeal. 95 Stat. 1199. section 210 of the Departments of Labor, Health and Human Services, and Education and Related Agencies Appropriation Act, 1982 (H.R. 4560), as passed by the House of Representatives on October 6, 1981, and of section 209 of such Act as reported by the Senate Committee on Appropriations on November 9, 1981, shall not apply to any sums appropriated for fiscal year 1983 or any succeeding fiscal year. (b) No provision of law limiting the use of funds for purposes of 42 USC 1395y note. enforcing or implementing section 1862(c) or section 1903(i)(5) of the Social Security Act, section 2103 of the Omnibus Budget Reconciliation 42 USC 1395y, 1396b. 95 Stat. 787. Act of 1981, or any rule or regulation issued pursuant to any such section (including any provision contained in, or incorporated by reference into, any appropriation Act or resolution making continuing appropriations) shall apply to any period after September 30, 1982, unless such provision of law is enacted after the date of the enactment of this Act and specifically states that such provision is to supersede this section. Subpart C— Other Payment Provisions medicare payments secondary for older workers covered under group health plans Sec. 116. (a) Section 4 of the Age Discrimination in Employment Act of 1967 is amended by adding at the end thereof the following 29 USC 623. new subsection: “(g) (1) For purposes of this section, any employer must provide that any employee aged 65 through 69 shall be entitled to coverage under any group health plan offered to such employees under the same conditions as any employee under age 65. “(2) For purposes of paragraph (1), the term ‘group health plan’ “Group health plan.” 26 USC 162. has the meaning given to such term in section 162(i)(2) of the Internal Revenue Code of 1954.”. (b) Section 1862(b) of the Social Security Act is amended by adding 42 USC 13953, at the end thereof the following new paragraph: “(3) (A) (i) Payment under this title may not be made, except as provided in clause (ii), with respect to any item or service furnished during the period described in clause (iii) to an individual who is over 64 but under 70 years of age (or to the spouse of such individual, if the spouse is over 64 but under 70 years of age) who is employed at the time such item or service is furnished to the extent that payment with respect to expenses for such item or service has been made, or can reasonably be expected to be made, under a group health plan (as defined in clause (iv)) under which such individual is covered by reason of such employment. “(ii) Any payment under this title with respect to any item or service during the period described in clause (iii) shall be condi-tioned on reimbursement to the appropriate Trust Fund established by this title when notice or other information is received that payment for such item or service has been made under a group health plan. The Secretary may waive the provisions of this clause “Waiver.” in the case of an individual claim if he determines that the probability of recovery or amount involved in such claim does not warrant the pursuing of the claim. “(iii) The provisions of clauses (i) and (ii) shall apply to an individual only for the period beginning with the month in which such individual becomes entitled to benefits under this title under section 226(a) and ending with the month in which such individual attains 42 USC 426. the age of 70 and shall not include any month for which the individual would, upon application, be entitled to benefits under section 226A. 42 USC 426–1. “(iv) For purposes of this paragraph, the term ‘group health plan’ “Group health plan.” 26 USC 162. has the meaning given to such term in section 162(i)(2) of the Internal Revenue Code of 1954. “(B) Where payment for an item or service under a group health plan is less than the amount of the charge for such item or service, payment may be made under this title (without regard to deductibles and coinsurance under this title) for the remainder of such charge, but— “(i) such payment under this title may not exceed an amount which would be payable under this title for such item or service in the absence of such group health plan; and “(ii) such payment under this title, when combined with the amount payable under such plan, may not exceed— “(I) in the case of an item or service payment for which is determined under this title on the basis of reasonable cost (or other cost-related basis) or under section 1886, the Ante, p. 331. amount which would be payable under this title on such basis; and “(II) in the case of an item or service for which payment is authorized under this title on another basis, the greater of— “(a) the amount which would be payable under the group health plan (without regard to deductibles and coinsurance under such plan), or “(b) the reasonable charge or other amount which would be payable under this title (without regard to deductibles and coinsurance under this title).”. (c) The amendment made by subsection (a) shall become effective Effective date. 29 USC 623 note. on January 1, 1983, and the amendment made by subsection (b) shall apply with respect to items and services furnished on or after such date. interest charges on overpayments and underpayments Sec. 117. (a) (1) Section 1815 of the Social Security Act is amended 42 USC 1395g. by adding at the end the following new subsection: “(d) Whenever a final determination is made that the amount of payment made under this part to a provider of services was in excess of or less than the amount of payment that is due, and payment of such excess or deficit is not made (or effected by offset) within 30 days of the date of the determination, interest shall accrue on the balance of such excess or deficit not paid or offset (to the extent that the balance is owed by or owing to the provider) at a rate deter- mined in accordance with the regulations of the Secretary of the Treasury applicable to charges for late payments.”. (2) Section 1833 of such Act is amended by adding at the end the 42 USC 1395l. following new subsection: “(j) Whenever a final determination is made that the amount of payment made under this part either to a provider of services or to another person pursuant to an assignment under section 1842(b)(3)(B)(ii) was in excess of or less than the amount of payment 42 USC 1395u. that is due, and payment of such excess or deficit is not made (or effected by offset) within 30 days of the date of the determination, interest shall accrue on the balance of such excess or deficit not paid or offset (to the extent that the balance is owed by or owing to the provider) at a rate determined in accordance with the regulations of the Secretary of the Treasury applicable to charges for late payments.”. (b) The amendments made by subsection (a) apply to final determinations 42 USC 1395g note. made on or after the date of the enactment of this Act. audit and medical claims review Sec. 118. In addition to any funds otherwise provided for fiscal 42 USC 1395h note. years 1983, 1984, and 1985 for payments to intermediaries and carriers under agreements entered into under sections 1816 and 1842 of the Social Security Act, there are transferred from the 42 USC 1395h, 1395u. Federal Hospital Insurance Trust Fund and the Federal Supplementary Medical Insurance Fund in such proportions as the Secretary of Health and Human Services determines to be appropriate, an additional $45,000,000 for each of such fiscal years for payments to such intermediaries and carriers under such agreements to be used exclusively for the purpose of carrying out provider cost audits and reviews of medical necessity, consistent with the provisions of sections 1816 and 1842 of the Social Security Act. private sector review initiative Sec. 119. (a) The Secretary of Health and Human Services shall 42 USC 1395cc note. undertake an initiative to improve medical review by intermediaries and carriers under title XVIII of the Social Security Act and to 42 USC 1395. encourage similar review efforts by private insurers and other private entities. The initiative shall include the development of specific standards for measuring the performance of such intermediaries and carriers with respect to the identification and reduction of unnecessary utilization of health services. (b) Where such review activity results in the denial of payment to providers of services under title XVIII of the Social Security Act, such providers shall be prohibited, in accordance with sections 1866 and 1879 of such title, from collecting any payments from beneficiaries unless otherwise provided under such title. temporary delay in periodic interim payments Sec. 120. Notwithstanding section 1815(a) of the Social Security 42 USC 1395g note. 42 USC 1395g. Act, in the case of a hospital which is paid periodic interim payments under such section, the Secretary of Health and Human Services shall provide that— (1) with respect to the last 21 days for which such payments would otherwise be made during fiscal year 1983, such payments shall be deferred until fiscal year 1984; and (2) with respect to the last 21 days for which such payments would otherwise be made during fiscal year 1984, such payments shall be deferred until fiscal year 1985. PART II— CHANGES IN BENEFITS, PREMIUMS, AND ENROLLMENT medicare coverage of federal employees Sec. 121. For provisions providing certain employees of the United States and instrumentalities thereof with entitlement to hospital insurance benefits under part A of title XVIII of the Social Security Act, see section 278 of this Act. Post, p. 559. hospice care Sec. 122. (a) (1) Section 1811 of the Social Security Act is amended 42 USC 1395c. by striking out “and home health services” and inserting in lieu thereof “home health services, and hospice care”. (2) Section 7(d)(1) of the Railroad Retirement Act of 1974 is 45 USC 231f. amended by inserting “hospice care,” after “home health services,”, (b) (1) Section 1812(a) of the Social Security Act is amended by 42 USC 1395d. striking out “and” at the end of paragraph (2), by striking out the period at the end of paragraph (3) and inserting in lieu thereof “; and”, and by adding after paragraph (3) the following new paragraph: “(4) in lieu of certain other benefits, hospice care with respect to the individual during up to two periods of 90 days each and one subsequent period of 30 days with respect to which the individual makes an election under subsection (d)(1).”. (2) Section 1812 of such Act is further amended by inserting after subsection (c) the following new subsection: “(d) (1) Payment under this part may be made for hospice care provided with respect to an individual only during two periods of 90 days each and one subsequent period of 30 days during the individual’s lifetime and only, with respect to each such period, if the individual makes an election under this paragraph to receive hospice care under this part provided by, or under arrangements made by, a particular hospice program instead of certain other benefits under this title. “(2) (A) Except as provided in subparagraphs (B) and (C) and except in such exceptional and unusual circumstances as the Secretary may provide, if an individual makes such an election for a period with respect to a particular hospice program, the individual shall be deemed to have waived all rights to have payment made under this title with respect to— “(i) hospice care provided by another hospice program (other than under arrangements made by the particular hospice program) during the period, and “(ii) services furnished during the period that are determined (in accordance with guidelines of the Secretary) to be— “(I) related to the treatment of the individual’s condition with respect to which a diagnosis of terminal illness has been made or “(II) equivalent to (or duplicative of) hospice care; except that clause (ii) shall not apply to physicians’ services furnished by the individual’s attending physician (if not an employee of the hospice program) or to other than services provided by (or under arrangements made by) the hospice program. “(B) After an individual makes such an election with respect to a 90- or 30-day period, the individual may revoke the election during the period, in which case— “(i) the revocation shall act as a waiver of the right to have payment made under this part for any hospice care benefits for the remaining time in such period and (for purposes of subsection (a)(4) and subparagraph (A)) the individual shall be deemed to have been provided such benefits during such entire period, and “(ii) the individual may at any time after the revocation execute a new election for a subsequent period, if the individual otherwise is entitled to hospice care benefits with respect to such a period. “(C) An individual may, once in each such period, change the hospice program with respect to which the election is made and such change shall not be considered a revocation of an election under subparagraph (B). “(D) For purposes of this title, an individual’s election with respect to a hospice program shall no longer be considered to be in effect with respect to that hospice program after the date the individual’s revocation or change of election with respect to that election takes effect.”. (c) (1) Section 1814(a) of the Social Security Act is amended by 42 USC 1395f. striking out “and” at the end of paragraph (6), by striking out the period at the end of paragraph (7) and inserting in lieu thereof “; and”, and by inserting after paragraph (7) the following new paragraph: “(8) in the case of hospice care provided an individual— “(A) (i) in the first 90-day period— “(I) the individual’s attending physician (as defined in section 1861(dd)(3)(B)), and Post, p. 359. “(II) the medical director (or physician member of the interdisciplinary group described in section 1861(dd)(2)(B)) of the hospice program providing (or arranging for) the care, each certify, not later than two days after hospice care is initiated, that the individual is terminally ill (as defined in section 1861(dd)(3)(A)), and “(ii) in a subsequent 90- or 30-day period, the medical director or physician described in clause (i)(II) recertifies at the beginning of the period that the individual is terminally ill; “(B) a written plan for providing hospice care with respect to such individual has been established (before such care is provided by, or under arrangements made by, that hospice program) and is periodically reviewed by the individual’s attending physician and by the medical director (and the interdisciplinary group described in section 1861(dd)(2)(B)) of the hospice program; and “(C) such care is being or was provided pursuant to such plan of care.”. (2) (A) Section 1814(b) of such Act is amended by inserting “(other 42 USC 1395f. than a hospice program providing hospice care)” after “The amount paid to any provider of services”. (B) Section 1814 of such Act is further amended by adding at the end the following new subsection: “payment for hospice care “(i) (1) Subject to the limitation under paragraph (2) and the provisions of section 1813(a)(4), the amount paid to a hospice program Post, p. 361. with respect to hospice care for which payment may be made under this part shall be an amount equal to the costs which are reasonable and related to the cost of providing hospice care or which are based on such other tests of reasonableness as the Secretary may prescribe in regulations (including those authorized under section 1861(v)(1)(A)), except that no payment may be for bereavement counseling and no reimbursement may be made for other counseling services (including nutritional and dietary counseling) as separate services. “(2) (A) The amount of payment made under this part for hospice care provided by (or under arrangements made by) a hospice program located in a region (as defined by the Secretary) for an accounting year may not exceed the ‘cap amount’ for the region for the year (computed under subparagraph (B)) multiplied by the number of medicare beneficiaries in the hospice program in that year (determined under subparagraph (C)). “(B) For purposes of subparagraph (A), the ‘cap amount’ for a “Cap amount.” region for a year is computed as follows: “(i) The Secretary, using records of the program under this title, shall identify individuals (or a representative sample of such individuals)— “(I) who died during the base period (as defined in clause (v)), “(II) with respect to whom the primary cause of death was cancer, and “(III) who, during the six-month period preceding death, were provided benefits under this title, “(ii) The Secretary shall determine a national average medicare per capita expenditure amount by (I) determining (or estimating) the amount of payments made under this title with respect to services provided to individuals identified in clause (i) during the six months before death, and (II) dividing such amount of payments by the number of such individuals. “(iii) The Secretary, using the best available data, shall then compute a regional average medicare per capita expenditure amount for each region, by adjusting the national average medicare per capita expenditure amount (computed under clause (ii)) to reflect the relative difference between that region’s average cost of delivering health care and the national average cost of delivering health care. “(iv) The ‘cap amount’ for a region for an accounting year is “Cap amount.” 40 percent of the regional average determined under clause (iii) for that region, increased or decreased by the same percentage as the percentage increase or decrease, respectively, in the medical care expenditure category of the consumer price index for all urban consumers (U.S. city average), published by the Bureau of Labor Statistics, from the fourth month of the base period to the fifth month of the accounting year. “(v) For purposes of this subparagraph, the term ‘base period’ “Base period.” means the most recent period of 12 months (ending before the date proposed regulations are first issued to carry out this paragraph) for which the Secretary determines he has sufficient data to make the determinations required under clauses (i) through (iii). “(C) For purposes of subparagraph (A), the ‘number of medicare “Number of medicare beneficiaries.” beneficiaries’ in a hospice program in an accounting year is equal to the number of individuals who have made an election under subsection (d) with respect to the hospice program and have been provided hospice care by (or under arrangements made by) the hospice program under this part in the accounting year, such number reduced to reflect the proportion of hospice care that each such individual was provided in a previous or subsequent accounting year or under a plan of care established by another hospice program.”. (3) Section 1816(e) of such Act is amended by adding at the end 42 USC 1395h. thereof the following new paragraph: “(5) Notwithstanding any other provision of this title, the Secretary shall designate the agency or organization which has entered into an agreement under this section to perform functions under such an agreement with respect to each hospice program, except that with respect to a hospice program which is a subdivision of a provider of services (and such hospice program and provider of services are under common control) due regard shall be given to the agency or organization which performs the functions under this section for the provider of services.”. (d) (1) Section 1861(u) of the Social Security Act is amended by 42 USC 1395x. inserting “hospice program,” after “home health agency,”. (2) Section 1861(w)(1) of such Act is amended by striking out “or home health agency” and by inserting in lieu thereof “home health agency, or hospice program”. (3) Section 1861 of such Act is further amended by adding at the end the following new subsection: “hospice care; hospice program “(dd) (1) The term ‘hospice care’ means the following items and “Hospice care.” services provided to a terminally ill individual by, or by others under arrangements made by, a hospice program under a written plan (for providing such care to such individual) established and periodically reviewed by the individual’s attending physician and by the medical director (and by the interdisciplinary group described in paragraph (2)(B)) of the program— “(A) nursing care provided by or under the supervision of a registered professional nurse, “(B) physical or occupational therapy or speech-language pathology, “(C) medical social services under the direction of a physician, “(D) (i) services of a home health aide who has successfully completed a training program approved by the Secretary and (ii) homemaker services, “(E) medical supplies (including drugs and biologicals) and the use of medical appliances, while under such a plan, “(F) physicians’ services, “(G) short-term inpatient care (including both respite care and procedures necessary for pain control and acute and chronic symptom management) in an inpatient facility meeting such conditions as the Secretary determines to be appropriate to provide such care, but such respite care may be provided only on an intermittent, nonroutine, and occasional basis and may not be provided consecutively over longer than five days, and “(H) counseling (including dietary counseling) with respect to care of the terminally ill individual and adjustment to his death. The care and services described in subparagraphs (A) and (D) may be provided on a 24-hour, continuous basis only during periods of crisis (meeting criteria established by the Secretary) and only as necessary to maintain the terminally ill individual at home. “(2) The term ‘hospice program’ means a public agency or private “Hospice program.” organization (or a subdivision thereof) which— “(A) (i) is primarily engaged in providing the care and services described in paragraph (1) and makes such services available (as needed) on a 24-hour basis and which also provides bereavement counseling for the immediate family of terminally ill individuals, “(ii) provides for such care and services in individuals’ homes, on an outpatient basis, and on a short-term inpatient basis, directly or under arrangements made by the agency or organization, except that— “(I) the agency or organization must routinely provide directly substantially all of each of the services described in subparagraphs (A), (C), (F), and (H) of paragraph (1), and “(II) in the case of other services described in paragraph (1) which are not provided directly by the agency or organization, the agency or organization must maintain professional management responsibility for all such services furnished to an individual, regardless of the location or facility in which such services are furnished; and “(iii) provides assurances satisfactory to the Secretary that the aggregate number of days of inpatient care described in paragraph (1)(G) provided in any 12-month period to individuals who have an election in effect under section 1812(d) with respect 42 USC 1395d. to that agency or organization does not exceed 20 percent of the aggregate number of days during that period on which such elections for such individuals are in effect; “(B) has an interdisciplinary group of personnel which— “(i) includes at least— “(I) one physician (as defined in subsection (r)(1)), “(II) one registered professional nurse, and “(III) one social worker, employed by the agency or organization, and also includes at least one pastoral or other counselor, “(ii) provides (or supervises the provision of) the care and services described in paragraph (1), and “(iii) establishes the policies governing the provision of such care and services; “(C) maintains central clinical records on all patients; “(D) does not discontinue the hospice care it provides with respect to a patient because of the inability of the patient to pay for such care; “(E) (i) utilizes volunteers in its provision of care and services in accordance with standards set by the Secretary, which standards shall ensure a continuing level of effort to utilize such volunteers, and (ii) maintains records on the use of these volunteers and the cost savings and expansion of care and services achieved through the use of these volunteers; “(F) in the case of an agency or organization in any State in which State or applicable local law provides for the licensing of agencies or organizations of this nature, is licensed pursuant to such law; and “(G) meets such other requirements as the Secretary may find necessary in the interest of the health and safety of the individuals who are provided care and services by such agency or organization. “(3) (A) An individual is considered to be ‘terminally ill’ if the “Terminally ill.” individual has a medical prognosis that the individual’s life expectancy is 6 months or less. “(B) The term ‘attending physician’ means, with respect to an “Attending physician.” individual, the physician (as defined in subsection (r)(l)), who may be employed by a hospice program, whom the individual identifies as having the most significant role in the determination and delivery of medical care to the individual at the time the individual makes an election to receive hospice care. “(4) (A) An entity which is certified as a provider of services other than a hospice program shall be considered, for purposes of certification as a hospice program, to have met any requirements under paragraph (2) which are also the same requirements for certification as such other type of provider. The Secretary shall coordinate surveys for determining certification under this title so as to provide, to the extent feasible, for simultaneous surveys of an entity which seeks to be certified as a hospice program and as a provider of services of another type. “(B) Any entity which is certified as a hospice program and as a provider of another type shall have separate provider agreements under section 1866 and shall file separate cost reports with respect 42 USC 1395cc. to costs incurred in providing hospice care and in providing other services and items under this title.”. (e) Section 1813(a) of such Act is amended by adding at the end the 42 USC 1395e. following new paragraph: “(4) (A) The amount payable for hospice care shall be reduced— “(i) in the case of drugs and biologicals provided on an outpatient basis by (or under arrangements made by) the hospice program, by a coinsurance amount equal to an amount (not to exceed $5 per prescription) determined in accordance with a drug copayment schedule (established by the hospice program) which is related to, and approximates 5 percent of, the cost of the drug or biological to the program, and “(ii) in the case of respite care provided by (or under arrangements made by) the hospice program, by a coinsurance amount equal to 5 percent of the amount estimated by the hospice program (in accordance with regulations of the Secretary) to be equal to the amount of payment under section 1814(i) to that Ante, p. 358. program for respite care; except that the total of the coinsurance required under clause (ii) for an individual may not exceed for a hospice coinsurance period the inpatient hospital deductible applicable for the year in which the period began. For purposes of this subparagraph, the term ‘hospice “Hospice coinsurance period.” coinsurance period’ means, for an individual, a period of consecutive days beginning with the first day for which an election under section 1812(d) is in effect for the individual and ending with the Ante, p. 356. close of the first period of 14 consecutive days on each of which such an election is not in effect for the individual. “(B) During the period of an election by an individual under section 1812(d)(1), no copayments or deductibles other than those under subparagraph (A) shall apply with respect to services furnished to such individual which constitute hospice care, regardless of the setting in which such services are furnished.”. (f) Section 1862(a) of the Social Security Act is amended— 42 USC 1395y. (1) by amending paragraph (1) to read as follows: “(1) (A) which, except for items and services described in subparagraph (B) or (C), are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, “(B) in the case of items and services described in section 1861(s)(10), which are not reasonable and necessary for the 42 USC 1395x. prevention of illness, and “(C) in the case of hospice care, which are not reasonable and necessary for the palliation or management of terminal illness;”; (2) by inserting “(except, in the case of hospice care, as is otherwise permitted under paragraph (1)(C))” in paragraph (6) after “comfort items”; (3) by striking out “paragraph (1)” in paragraph (7) and inserting in lieu thereof “paragraph (1)(B)”; and (4) by inserting “(except, in the case of hospice care, as is otherwise permitted under paragraph (1)(C))” in paragraph (9) after “custodial care”. (g) (1) Section 1862(f) of the Social Security Act is amended by 42 USC 1395y. striking out “paragraph (1)” and inserting in lieu thereof “paragraph (1)(A)”. (2) Section 1863 of the Social Security Act is amended by striking 42 USC 1395z. out “and (cc)(2)(I)” and inserting in lieu thereof “(cc)(2)(I), and (dd)(2)”. (3) Section 1864(a) of such Act is amended— 42 USC 1395aa. (A) by inserting “or whether an agency is a hospice program” in the first sentence after “home health agency,”; and (B) by striking out “or home health agency” in the second sentence and inserting in lieu thereof “home health agency, or hospice program”. (4) Section 1865(a) of such Act is amended by striking out “"or (o)” 42 USC 1395bb. in the last sentence and inserting in lieu thereof “(o), or (dd)”. (5) Section 1866(b)(2)(A) of such Act is amended by striking out “or 42 USC 1395CC. (a)(3)” and inserting in lieu thereof “(a)(3), or (a)(4)”. (6) Section 1866(b)(4)(A) of such Act is amended by inserting “or hospice care” after “home health services”. (h) (1) (A) Subject to subparagraph (B), the amendments made by 42 USC 1395c note. this section apply to hospice care provided on or after November 1, 1983, and before October 1, 1986. (B) An individual who on October 1, 1986, has an election under section 1812(d)(1) of the Social Security Act in effect for a period, is entitled to hospice care benefits after that date during the remainder of that period and any consecutive period to which the individual would have been entitled before such date. (2) In order to provide for the timely implementation of the 42 USC 1395f note. amendments made by this Act, the Secretary of Health and Human Services shall, not later than September 1, 1983, promulgate such final regulations as may be necessary to set forth— (A) a description of the care included in “hospice care” and the standards for qualification of a “hospice program”, under section 1861(dd) of the Social Security Act, and Ante, p. 359. (B) the standards for payment for hospice care under part A of title XVIII of such Act, pursuant to section 1814(i) of such 42 USC 1395; Ante, p. 358. Act. (h) (1) Notwithstanding any provision of law which has the effect of 42 USC 1395b-1 note. restricting the time period of a hospice demonstration project in effect on July 15, 1982, pursuant to section 402(a) of the Social Security Amendments of 1967, the Secretary of Health and Human 81 Stat. 930. Services, upon request of the hospice involved, shall permit continuation of the project until November 1, 1983, or, if later, the date on which payments can first be made to any hospice program under the amendments made by this section. (2) Prior to September 30, 1983, the Secretary shall submit to Report to Congress. Congress a report on the effectiveness of demonstration projects referred to in paragraph (1), including an evaluation of the cost-effectiveness of hospice care, the reasonableness of the 40-percent cap amount for hospice care as provided in section 1814(i) of the Social Security Act (as added by this section), proposed methodology for determining such cap amount, proposed standards for requiring and measuring the maintenance of effort for utilizing volunteers as required under section 1861(dd) of such Act, an evaluation of physician reimbursement for services furnished as a part of hospice care and for services furnished to individuals receiving hospice care but which are not reimbursed as a part of the hospice care, and any proposed legislative changes in the hospice care provisions of title XVIII of such Act. 42 USC 1395. (i) (1) The Secretary of Health and Human Services shall conduct a Study; report to Congress. 42 USC 1395f note. study and, prior to January 1, 1986, report to the Congress on whether or not the reimbursement method and benefit structure (including copayments) for hospice care under title XVIII of the Social Security Act are fair and equitable and promote the most efficient provision of hospice care. Such report shall include the feasibility and advisability of providing for prospective reimbursement for hospice care, an evaluation of the inclusion of payment for outpatient drugs, an evaluation of the need to alter the method of reimbursement for nutritional, dietary, and bereavement counseling as hospice care, and any recommendations for legislative changes in the hospice care reimbursement or benefit structure. (2) The Comptroller General shall monitor and evaluate the study and the preparation of the report under paragraph (1). (j) The Secretary of Health and Human Services shall grant Waivers. 42 USC 1395f note. waivers of the limitations imposed by section 1814(i)(2) of the Social Security Act (relating to the cap amount), section 1861(dd)(1)(G) of such Act (relating to the limitations on the frequency and number of respite care days), and section 1861(dd)(2)(A)(iv) of such Act (relating to the aggregate limit on the number of days of inpatient care), as may be necessary to allow any institution which commenced operations as a hospice prior to January 1, 1975, to participate until October 1, 1986, in a viable manner as a hospice program under title XVIII of the Social Security Act. coverage of extended care services without regard to three-day prior hospitalization requirement Sec. 123. (a) Section 1812(a)(2) of the Social Security Act is 42 USC 1395d. amended by inserting “(A)” after “(2)” and by inserting before the semicolon at the end the following: “, and (B) to the extent provided in subsection (f), extended care services that are not post-hospital extended care services”. (b) Section 1812 of such Act is further amended by redesignating subsection (f) as subsection (g) and by inserting after subsection (e) the following new subsection: “(f) (1) The Secretary shall provide for coverage, under clause (B) of subsection (a)(2), of extended care services which are not post-hospital extended care services at such time and for so long as the Secretary determines, and under such terms and conditions (described in paragraph (2)) as the Secretary finds appropriate, that the inclusion of such services will not result in any increase in the total of payments made under this title and will not alter the acute care nature of the benefit described in subsection (a)(2). “(2) The Secretary may provide— “(A) for such limitations on the scope and extent of services described in subsection (a)(2)(B) and on the categories of individuals who may be eligible to receive such services, and “(B) notwithstanding sections 1814, 1861(v), and 1886, for such 42 USC 1395f, 1395x; Ante, p. 331. restrictions and alternatives on the amounts and methods of payment for services described in such subsection, as may be necessary to carry out paragraph (1).”. provision temporarily holding part b premium at constant percentage of cost Sec. 124. (a) (1) Section 1839(c)(2) of the Social Security Act is 42 USC 1395r. amended by striking out “except as provided in subsection (d)” and inserting in lieu thereof “except as provided in subsections (d) and (g)”. (2) Section 1839(c)(3) of such Act is amended by inserting “(except as otherwise provided in subsection (g))” after “The monthly premium shall”. (b) Section 1839 of such Act is amended by adding at the end thereof the following new subsection: “(g) (1) Notwithstanding the provisions of subsection (c), the monthly premium for each individual enrolled under this part for each month after June 1983 and prior to July 1985 shall be an amount equal to 50 percent of the monthly actuarial rate for enrollees age 65 and over, as determined under subsection (c)(1) and applicable to such month. “(2) Any increases in premium amounts taking effect prior to July 1985 by reason of paragraph (1) shall be taken into account for purposes of determining increases thereafter under subsection (c)(3).”. (c) Section 1844(a)(1) of such Act is amended by striking out 42 USC 1395w. “section 1839(c)(3)” each place it appears in subparagraphs (A)(i) and (B)(i) and inserting in lieu thereof in each instance “section 1839(c)(3) or 1839(g), as the case may be”. Supra. special enrollment provisions for merchant seamen Sec. 125. (a) Any individual who— 42 USC 1395i-2 note. (1) was entitled to medical, surgical, and dental treatment and hospitalization under section 322(a) of the Public Health Service Act (as in effect on September 30, 1981), including such entitlement 95 Stat. 603. 42 USC 249. on the basis of continuing medical care under 42 C.F.R. § 32.17, at any time during the period beginning on March 10, 1981, and ending on October 1, 1981, and (2) as of September 30, 1981, was eligible under section 1818(a) or section 1836 of the Social Security Act to enroll in the 42 USC 1395i-2, 1395o. insurance program established by part A or part B, respectively, of title XVIII of that Act (hereinafter in this section referred to 42 USC 1395c, 1395j. as the “respective program”), may enroll (if not otherwise enrolled) in the respective program during the period beginning on the first day of the first month beginning at least 20 days after the date of the enactment of this Act and ending on December 31, 1982. (b) (1) The coverage period under the respective program of an individual who enrolls under subsection (a) shall begin— (A) on the first day of the month following the month in which the individual enrolls, or (B) on October 1, 1981, if the individual files a request for this subparagraph to apply and pays the monthly premiums for the months so covered. (2) The coverage period under the respective program of an individual described in subsection (a) who enrolled in the respective program before the enrollment period described in that subsection shall be retroactively extended to October 1, 1981, if the individual files a request before January 1, 1983, for such retroactive extension and pays the monthly premiums for the months so covered. (c) (1) For purposes of section 1839(d) of the Social Security Act 42 USC 1395r. with respect to the monthly premium for months after September 1981, if an individual described in subsection (a) has enrolled in the insurance program under part B of title XVIII of the Social Security Act at any time before the end of the enrollment period described in subsection (a), any month (before the end of that enrollment period) in which he was not enrolled in that program shall not be treated as a month in which he could have been enrolled in the program. (2) Paragraph (1) shall not apply to an individual— (A) if the individual has enrolled in the insurance program before March 10, 1981, unless the enrollment was terminated solely because the individual lost eligibility to be so enrolled, or (B) unless the individual applies for the benefit of such paragraph before January 1, 1983. (d) (1) The Secretary of Health and Human Services, beginning as soon as possible but not later than 30 days after the date of the enactment of this Act, shall provide for the dissemination of information— (A) to unions and other associations representing or assisting seamen, (B) to offices enrolling individuals under the respective programs, and (C) to such other entities and in such a manner as will effectively inform individuals eligible for benefits under this section, concerning the special benefits provided under this section. (2) An individual may establish that the individual was entitled at a date to medical, surgical, and dental treatment and hospitalization under section 322(a) of the Public Health Service Act (as in effect 95 Stat. 603. 42 USC 249. before October 1, 1981) by providing— (A) documentation relating to the status under which the individual was provided care in (or under arrangements with) a Public Health Service facility on that date, (B) the individual’s seamen’s papers covering that date, or (C) such other reasonable documentation as the Secretary may require. PART III— MISCELLANEOUS PROVISIONS extending medicare proficiency examination authority Sec. 126. Section 1123(a) of the Social Security Act is amended by 42 USC l320a-2. striking out “December 31, 1981” and inserting in lieu thereof “September 30, 1983”. regulations regarding access to books and records Sec. 127. Section 952 of the Omnibus Reconciliation Act of 1980 (94 Stat. 2646) is amended— (1) by inserting “(a)” after “Sec. 952.”, and (2) by adding at the end the following new subsection: “(b) Unless the Secretary of Health and Human Services first 42 USC 1395x note. publishes final regulations prescribing the criteria and procedures described in the last sentence of section 1861(v)(l)(I) of the Social Security Act by January 1, 1983, after providing a period of not less 94 Stat. 2646. 42 USC 1395x. than 60 days for public comment on proposed regulations, the amendment made by subsection (a) shall only apply to books, documents, and records relating to services furnished (pursuant to contract or subcontract) on or after the date on which final regulations of the Secretary are first published.”. technical corrections to omnibus budget reconciliation act of 1981 Sec. 128. (a) (1) Section 1861(cc)(l) of the Social Security Act is 42 USC 1395x. amended, in the matter following subparagraph (H), by striking out “outpatient” and inserting in lieu thereof “inpatient”. (2) The second sentence of section 1862(b)(1) of such Act is 42 USC 1395y. amended by striking out “or plan”. (3) Section 1862(b)(2)(A) of such Act is amended by striking out 95 Stat. 800. 42 USC 1395y. “section 162(h)(2)” and inserting in lieu thereof “section 162(i)(2)”. (4) The first sentence of section 1862(b)(2)(B) of such Act is amended by inserting “furnished” before “to an individual”. (5) Section 1866(b) of such Act is amended by striking out “(and in 42 USC 1395cc. the case of a skilled nursing facility, prior to the end of the term specified in subsection (a)(1))” in the matter preceding paragraph (1). (6) The second subsection (c) of section 1884 of such Act is redesignated 95 Stat. 785. 42 USC 1395uu. 26 USC 162. as subsection (d). (b) Section 162 of the Internal Revenue Code of 1954 is amended— (1) by redesignating the subsection (i) (relating to cross reference), as redesignated by the Economic Recovery Tax Act of 1981 (Public Law 95–34), as subsection (j), and 95 Stat. 202. (2) by redesignating the subsection (h) (relating to group health plans), as added by section 2146(b) of the Omnibus Budget Reconciliation Act of 1981, as subsection (i). 95 Stat. 800. (c) (1) Section 2143(b)(1) of the Omnibus Budget Reconciliation Act 95 Stat. 798. 42 USC 1395x note. of 1981 is amended by striking out “costs” and inserting in lieu thereof “cost”. (2) Section 2203(f)(3) of such Act is amended by striking out 95 Stat. 835. “August 1982” and inserting in lieu thereof “August 1981”. (d) (1) Sections 1842(b)(3)(B)(ii)(II) and 1870(c) of the Social Security Act are each amended by striking out “1862” and inserting in lieu 42 USC 1395u, 1395gg. thereof “1862(a)”. (2) The final subparagraph (C) of section 1861(e) of such Act is 42 USC 1395x. amended by striking out “may (i),” and inserting in lieu thereof “(i) may”. (3) Section 1865(b) of such Act is amended by striking out “an 42 USC 1395bb. institution” and “such institution” and inserting in lieu thereof “a hospital” and “the hospital”, respectively. (4) Section 1866(a)(1)(B) of such Act is amended by inserting “of 42 USC 1395cc. section 1862(a)” after “(1) or (9)”. (e) (1) Any amendment to the Omnibus Budget Reconciliaton Act Effective date. 42 USC 1395x note. 95 Stat. 357. of 1981 made by this section shall be effective as if it had been originally included in the provision of the Omnibus Budget Reconciliation Act of 1981 to which such amendment relates. (2) Except as otherwise provided in this section, any amendment to the Social Security Act or the Internal Revenue Code of 1954 made by this section (other than subsection (d)) shall be effective as 42 USC 1305; 26 USC 1. if it had been originally included as a part of that provision of the Social Security Act or Internal Revenue Code of 1954 to which it relates, as such provision of such Act or Code was amended by the Omnibus Budget Reconciliaton Act of 1981. (3) The amendments made by subsection (d) shall take effect upon Effective date. enactment. Subtitle B— Medicaid copayments by medicaid recipients Sec. 131. (a) Section 1902(a)(14) of the Social Security Act is 42 USC 1396a. amended to read as follows: “(14) provide that enrollment fees, premiums, or similar charges, and deductions, cost sharing, or similar charges, may be imposed only as provided in section 1916;”. (b) Title XIX of the Social Security Act is amended by adding at 42 USC 1396. the end thereof the following new section: “use of enrollment fees, premiums, deductions, cost sharing, and similar charges “SEC. 1916. (a) The State plan shall provide that in the case of 42 USC 1396a. 95 Stat. 807. individuals described in section 1902(a)(10)(A) who are eligible under the plan— “(1) no enrollment fee, premium, or similar charge will be imposed under the plan; “(2) no deduction, cost sharing or similar charge will be imposed under the plan with respect to— “(A) services furnished to individuals under 18 years of age (and, at the option of the State, individuals under 21, 20, or 19 years of age, or any reasonable category of individuals 18 years of age or over), “(B) services furnished to pregnant women, if such services relate to the pregnancy or to any other medical condition which may complicate the pregnancy (or, at the option of the State, any services furnished to pregnant women), “(C) services furnished to any individual who is an inpatient in a hospital, skilled nursing facility, intermediate care facility, or other medical institution, if such individual is required, as a condition of receiving services in such institution under the State plan, to spend for costs of medical care all but a minimal amount of his income required for personal needs, or “(D) emergency services (as defined by the Secretary), family planning services and supplies described in section 1905(a)(4)(C), or services furnished to such an individual by 42 USC 1396d. a health maintenance organization (as defined in section 1903(m)) in which he is enrolled; and 42 USC 1396b. “(3) any deduction, cost sharing, or similar charge imposed under the plan with respect to other such individuals or other care and services will be nominal in amount (as determined by the Secretary in regulations which shall, if the definition of ‘nominal’ under the regulations in effect on July 1, 1982 is changed, take into account the level of cash assistance provided in such State and such other criteria as the Secretary determines to be appropriate); except that a deduction, cost-sharing, or similar charge of up to twice the nominal amount established for outpatient services may be imposed by a State under a waiver granted by the Secretary for services received at a hospital emergency room if the services are not emergency services (referred to in paragraph (2)(D)) and the State has established to the satisfaction of the Secretary that individuals eligible for services under the plan have actually available and accessible to them alternative sources of nonemergency, outpatient services. “(b) The State plan shall provide that in the case of individuals other than those described in section 1902(a)(10)(A) who are eligible 95 Stat. 807. 42 USC 1396a. under the plan— “(1) there may be imposed an enrollment fee, premium, or similar charge, which (as determined in accordance with standards prescribed by the Secretary) is related to the individual’s income, “(2) no deduction, cost sharing, or similar charge will be imposed under the plan with respect to— “(A) services furnished to individuals under 18 years of age (and, at the option of the State, individuals under 21, 20, or 19 years of age, or any reasonable category of individuals 18 years of age or over), “(B) services furnished to pregnant women, if such services relate to the pregnancy or to any other medical condition which may complicate the pregnancy (or, at the option of the State, any services furnished to pregnant women), “(C) services furnished to any individual who is an inpatient in a hospital, skilled nursing facility, intermediate care facility, or other medical institution, if such individual is required, as a condition of receiving services in such institution under the State plan, to spend for costs of medical care all but a minimal amount of his income required for personal needs, or “(D) emergency services (as defined by the Secretary), family planning services and supplies described in section 1905(a)(4)(C), or (at the option of the State) services furnished 42 USC 1396d. to such an individual by a health maintenance organization (as defined in section 1903(m)) in which he is 42 USC 1396b. enrolled; and “(3) any deduction, cost sharing, or similar charge imposed under the plan with respect to other such individuals or other care and services will be nominal in amount (as determined by the Secretary in regulations which shall, if the definition of ‘nominal’ under the regulations in effect on July 1, 1982 is changed, take into account the level of cash assistance provided in such State and such other criteria as the Secretary determines to be appropriate); except that a deduction, cost-sharing, or similar charge of up to twice the nominal amount established for outpatient services may be imposed by a State under a waiver granted by the Secretary for services received at a hospital emergency room if the services are not emergency services (referred to in paragraph (2)(D)) and the State has established to the satisfaction of the Secretary that individuals eligible for services under the plan have actually available and accessible to them alternative sources of nonemergency, outpatient services. “(c) The State plan shall require that no provider participating under the State plan may deny care or services to an individual eligible for such care or services under the plan on account of such individual’s inability to pay a deduction, cost sharing, or similar charge. The requirements of this subparagraph shall not extinguish the liability of the individual to whom the care or services were furnished for payment of the deduction, cost sharing, or similar charge. “(d) No deduction, cost sharing, or similar charge may be imposed under any waiver authority of the Secretary unless authorized under this section, unless such waiver is for a demonstration project which the Secretary finds after public notice and opportunity for comment— “(1) will test a unique and previously untested use of copayments, “(2) is limited to a period of not more than two years, “(3) will provide benefits to recipients of medical assistance which can reasonably be expected to be equivalent to the risks to the recipients, “(4) is based on a reasonable hypothesis which the demonstration is designed to test in a methodologically sound manner, including the use of control groups of similar recipients of medical assistance in the area, and “(5) in which participation is voluntary, or in which provision is made for assumption of liability for preventable damage to the health of recipients of medical assistance resulting from involuntary participation.”. (b) Section 1902(a)(10) of such Act is amended in the matter 42 USC 1396a. following subparagraph (D)— (1) by striking out “and” before “(III)”; and (2) by inserting before the semicolon at the end thereof the following: “and (IV) the imposition of a deductible, cost sharing, or similar charge for any item or service furnished to an individual not eligible for the exemption under section 1916(a)(2) or (b)(2) shall not require the imposition of a deductible, Ante, p. 367. cost sharing, or similar charge for the same item or service furnished to an individual who is eligible for such exemption”. (c) (1) Except as provided in paragraph (2), the amendments made Effective date. 42 USC 13960 note. 42 USC 1396. by this section shall become effective on October 1, 1982. (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 in order for the plan to meet the additional requirements imposed by the amendments made by this section, 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 these additional requirements 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 the enactment of this Act. modifications in lien provisions Sec. 132. (a) Section 1902(a)(18) of the Social Security Act is 42 USC 1396a. amended to read as follows: “(18) comply with the provisions of section 1917 with respect Infra. to liens, adjustments and recoveries of medical assistance correctly paid, and transfers of assets;”, (b) Title XIX of such Act is amended by adding after section 1916 (added by section 131 of this Act) the following new section: “liens, adjustments and recoveries, and transfers of assets “Sec. 1917. (a) (1) No lien may be imposed against the property of 42 USC 1396p. any individual prior to his death on account of medical assistance paid or to be paid on his behalf under the State plan, except— “(A) pursuant to the judgment of a court on account of benefits incorrectly paid on behalf of such individual, or “(B) in the case of the real property of an individual— “(i) who is an inpatient in a skilled nursing facility, intermediate care facility, or other medical institution, if such individual is required, as a condition of receiving services in such institution under the State plan, to spend for costs of medical care all but a minimal amount of his income required for personal needs, and “(ii) with respect to whom the State determines, after notice and opportunity for a hearing (in accordance with procedures established by the State), that he cannot reasonably be expected to be discharged from the medical institution and to return home, except as provided in paragraph (2). “(2) No lien may be imposed under paragraph (1)(B) on such individual’s home if— “(A) the spouse of such individual, “(B) such individual’s child who is under age 21, or (with respect to States eligible to participate in the State program established under title XVI) is blind or permanently and totally 42 USC 1381. disabled, or (with respect to States which are not eligible to participate in such program) is blind or disabled as defined in section 1614, or 42 USC 1382c. “(C) a sibling of such individual (who has an equity interest in such home and who was residing in such individual’s home for a period of at least one year immediately before the date of the individual’s admission to the medical institution), is lawfully residing in such home. “(3) Any lien imposed with respect to an individual pursuant to paragraph (1)(B) shall dissolve upon that individual’s discharge from the medical institution and return home. “(b) (1) No adjustment or recovery of any medical assistance correctly paid on behalf of an individual under the State plan may be made, except— “(A) in the case of an individual described in subsection (a)(1)(B), from his estate or upon sale of the property subject to a lien imposed on account of medical assistance paid on behalf of such individual, and “(B) in the case of any other individual who was 65 years of age or older when he received such assistance, from his estate. “(2) Any adjustment or recovery under paragraph (1) may be made only after the death of the individual’s surviving spouse, if any, and only at a time— “(A) when he has no surviving child who is under age 21, or (with respect to States eligible to participate in the State program established under title XVI) is blind or permanently and 42 USC c. totally disabled, or (with respect to States which are not eligible to participate in such program) is blind or disabled as defined in section 1614; and “(B) in the case of a lien on an individual’s home under subsection (a)(1)(B), when— “(i) no sibling of the individual (who was residing in the individual’s home for a period of at least one year immediately before the date of the individual’s admission to the medical institution), and “(ii) no son or daughter of the individual (who was residing in the individual’s home for a period of at least two years immediately before the date of the individual’s admission to the medical institution, and who establishes to the satisfaction of the State that he or she provided care to such individual which permitted such individual to reside at home rather than in an institution), is lawfully residing in such home and has lawfully resided in such home on a continuous basis since the date of the individual’s admission to the medical institution. “(c) (1) Notwithstanding any other provision of this title, an individual who would otherwise be eligible for medical assistance under the State plan approved under this title may be denied such assistance if such individual would not be eligible for such medical assistance but for the fact that he disposed of resources for less than fair market value. If the State plan provides for the denial of such assistance by reason of such disposal of resources, the State plan shall specify a procedure for implementing such denial which, except as provided in paragraph (2), is not more restrictive than the procedure specified in section 1613(c) of this Act, and which may 42 USC 1382b. provide for a waiver of denial of such assistance in any instance where the State determines that such denial would work an undue hardship. “(2) (A) In any case where the uncompensated value of disposed of resources exceeds $12,000, the State plan may provide for a period of ineligibility which exceeds 24 months. If a State plan provides for a period of ineligibility exceeding 24 months, such plan shall provide for the period of ineligibility to bear a reasonable relationship to such uncompensated value. “(B) (i) In the case of any individual who is an inpatient in a skilled nursing facility, intermediate care facility, or other medical institution, if such individual is required, as a condition of receiving services in such institution under the State plan, to spend for costs of medical care all but a minimal amount of his income required for personal needs, and, who, at any time during or after the 24-month period immediately prior to application for medical assistance under the State plan, disposed of a home for less than fair market value, the State plan (subject to clause (iii)) may provide for a period of ineligibility for medical assistance in accordance with clause (ii). “(ii) If the State plan provides for a period of ineligibility under clause (i), such plan— “(I) shall provide that such individual shall be ineligible for all medical assistance for a period of 24 months after the date on which he disposed of such home, except that, in the case where the uncompensated value of the home is less than the average amount payable under the State plan as medical assistance for 24 months of care in a skilled nursing facility, the period of ineligibility shall be such shorter time as bears a reasonable relationship (based upon the average amount payable under the State plan as medical assistance for care in a skilled nursing facility) to the uncompensated value of the home, and “(II) may provide (at the option of the State) that, in the case where the uncompensated value of the home is more than the average amount payable under the State plan as medical assistance for 24 months of care in a skilled nursing facility, such individual shall be ineligible for all medical assistance for a period in excess of 24 months after the date on which he disposed of such home which bears a reasonable relationship (based upon the average amount payable under the State plan as medical assistance for care in a skilled nursing facility) to the uncompensated value of the home, “(iii) An individual shall not be ineligible for medical assistance by reason of clause (ii) if— “(I) a satisfactory showing is made to the State (in accordance with any regulations promulgated by the Secretary) that the individual cannot reasonably be expected to be discharged from the medical institution and to return to that home, “(II) title to such home was transferred to the individual’s spouse or child who is under age 21, or (with respect to States eligible to participate in the State program established under title XVI) is blind or permanently and totally disabled, or (with 42 USC 1381. respect to States which are not eligible to participate in such program) is blind or disabled as defined in section 1614, 42 USC 1382c. “(III) a satisfactory showing is made to the State (in accordance with any regulations promulgated by the Secretary) that the individual intended to dispose of the home either at fair market value, or for other valuable consideration, or “(IV) if the State determines that denial of eligibility would work an undue hardship. “(3) In any case where an individual is ineligible for medical assistance under the State plan solely because of the applicability to such individual of the provisions of section 1613(c), the State plan 42 USC 1382b. may provide for the eligibility of such individual for medical assistance under the plan if such individual would be so eligible if the State plan requirements with respect to disposal of resources applicable under paragraphs (1) and (2) of this subsection were applied in lieu of the provisions of section 1613(c).”. (c) Section 1902 of such Act is amended by striking out subsection 42 USC 1396a. (j) thereof. (d) The amendments made by this section shall become effective Effective date. 42 USC 1396p note. Ante, p. 370. on the date of the enactment of this Act, but the provisions of section 1917(c)(2)(B) of the Social Security Act shall not apply with respect to a transfer of assets which took place prior to such date of enactment. limitation of federal financial participation in erroneous medical assistance expenditures Sec. 133. (a) Section 1903 of the Social Security Act is amended by 42 USC 1396b. adding at the end thereof the following new subsection: “(u) (1) (A) Notwithstanding subsection (a)(1), if the ratio of a State’s erroneous excess payments for medical assistance (as defined in subparagraph (D)) to its total expenditures for medical assistance under the State plan approved under this title exceeds 0.03, for the period consisting of the third and fourth quarters of fiscal year 1983, or for any full fiscal year thereafter, then the Secretary shall make no payment for such period or fiscal year with respect to so much of such erroneous excess payments as exceeds such allowable error rate of 0.03. “(B) The Secretary may waive, in certain limited cases, all or part Waiver. of the reduction required under subparagraph (A) with respect to any State if such State is unable to reach the allowable error rate for a period or fiscal year despite a good faith effort by such State. “(C) In estimating the amount to be paid to a State under subsection (d), the Secretary shall take into consideration the limitation on Federal financial participation imposed by subparagraph (A) and shall reduce the estimate he makes under subsection (d)(1), for purposes of payment to the State under subsection (d)(3), in light of any expected erroneous excess payments for medical assistance (estimated in accordance with such criteria, including sampling procedures, as he may prescribe and subject to subsequent adjustment, if necessary, under subsection (d)(2)). “(D) (i) For purposes of this subsection, the term ‘erroneous excess “Erroneous excess payments for medical assistance.” payments for medical assistance’ means the total of— “(I) payments under the State plan with respect to ineligible individuals and families, and “(II) overpayments on behalf of eligible individuals and families by reason of error in determining the amount of expenditures for medical care required of an individual or family as a condition of eligibility. “(ii) In determining the amount of erroneous excess payments for medical assistance to an ineligible individual or family under clause (i)(I), if such ineligibility is the result of an error in determining the amount of the resources of such individual or family, the amount of the erroneous excess payment shall be the smaller of (I) the amount of the payment with respect to such individual or family, or (II) the difference between the actual amount of such resources and the allowable resource level established under the State plan. “(iii) In determining the amount of erroneous excess payments for medical assistance to an individual or family under clause (i)(II), the amount of the erroneous excess payment shall be the smaller of (I) the amount of the payment on behalf of the individual or family, or (II) the difference between the actual amount incurred for medical care by the individual or family and the amount which should have been incurred in order to establish eligibility for medical assistance. “(E) For purposes of subparagraph (D), there shall be excluded, in determining both erroneous excess payments for medical assistance and total expenditures for medical assistance— “(i) payments with respect to any individual whose eligibility therefor was determined exclusively by the Secretary under an agreement pursuant to section 1634 and such other classes of individuals as the Secretary may by regulation prescribe whose eligibility was determined in part under such an agreement; and “(ii) payments made as the result of a technical error. “(2) The State agency administering the plan approved under this title shall, at such times and in such form as the Secretary may specify, provide information on the rates of erroneous excess payments made (or expected, with respect to future periods specified by the Secretary) in connection with its administration of such plan, together with any other data he requests that are reasonably necessary for him to carry out the provisions of this subsection. “(3) (A) If a State fails to cooperate with the Secretary in providing information necessary to carry out this subsection, the Secretary, directly or through contractual or such other arrangements as he may find appropriate, shall establish the error rates for that State on the basis of the best data reasonably available to him and in accordance with such techniques for sampling and estimating as he finds appropriate. “(B) In any case in which it is necessary for the Secretary to exercise his authority under subparagraph (A) to determine a State’s error rates for a fiscal year, the amount that would otherwise be payable to such State under this title for quarters in such year shall be reduced by the costs incurred by the Secretary in making (directly or otherwise) such determination. “(4) This subsection shall not apply with respect to Puerto Rico, Guam, the Virgin Islands, the Northern Mariana Islands, or American Samoa.”. (b) The amendment made by subsection (a) shall become effective Effective date. 42 USC 1396b note. on the date of the enactment of this Act. (c) No provision of law limiting Federal financial participation 42 USC 1396b note. 42 USC 1896. with respect to erroneous payments made by States under a State plan approved under title XIX of the Social Security Act (including any provision contained in, or incorporated by reference into, any appropriation Act or resolution making continuing appropriations), other than the limitations contained in section 1903 of such Act, 42 USC 1396b. shall be effective with respect to payments to States under such section 1903 for quarters beginning on or after October 1, 1982, unless such provision of law is enacted after the date of the date of the enactment of this Act and expressly provides that such limitation is in addition to or in lieu of the limitations contained in section 1903 of the Social Security Act. medicaid coverage of home care for certain disabled children Sec. 134. (a) Section 1902(e) of the Social Security Act is amended 42 USC 1396a. by adding at the end the following new paragraph: “(3) At the option of the State, any individual who— “(A) is 18 years of age or younger and qualifies as a disabled individual under section 1614(a); 42 USC 1382c. “(B) with respect to whom there has been a determination by the State that— “(i) the individual requires a level of care provided in a hospital, skilled nursing facility, or intermediate care facility, “(ii) it is appropriate to provide such care for the individual outside such an institution, and “(iii) the estimated amount which would be expended for medical assistance for the individual for such care outside an institution is not greater than the estimated amount which would otherwise be expended for medical assistance for the individual within an appropriate institution; and “(C) if the individual were in a medical institution, would be eligible to have a supplemental security income (or State supplemental) payment made with respect to him under title XVI, 42 USC 1381. shall be deemed, for purposes of this title only, to be an individual with respect to whom a supplemental security income payment, or State supplemental payment, respectively, is being paid under title XVI.”. (b) The amendment made by subsection (a) shall become effective Effective date. 42 USC 1396a note. on October 1, 1982. six-month moratorium on deregulation of skilled nursing and intermediate care facilities Sec. 135. The Secretary of Health and Human Services may not promulgate any change in the regulations prescribed under— (1) subpart K of part 405 of subchapter B (relating to medicare conditions of participation of skilled nursing facilities), (2) so much of subpart S of part 405 of subchapter B (relating to certification procedure for providers) as relates to certification of skilled nursing facilities, and (3) subparts C, D, and E of part 442 of subchapter C (relating to medicaid certification and requirements for skilled nursing and intermediate care facilities), of chapter IV of title 42 of the Code of Federal Regulations until the first day of the seventh calendar month beginning after the date of the enactment of this Act unless ordered to do so by a court of competent jurisdiction. medicaid program in american samoa Sec. 136. (a) Section 1101(a)(1) of the Social Security Act is 42 USC 1301. amended by inserting “and American Samoa” after “Such term when used in title XIX also includes the Northern Mariana Islands”. (b) Section 1108(c) of such Act is amended— 42 USC 1308. (1) by striking out “and” at the end of paragraph (3); (2) by striking out the period at the end of paragraph (4) and inserting in lieu thereof “, and”; and (3) by adding at the end thereof the following: “(5) American Samoa shall not exceed $750,000.”. (c) Section 1905(b)(2) of such Act is amended by striking out “and 42 USC 1396d. the Northern Mariana Islands” and inserting in lieu thereof “the Northern Mariana Islands, and American Samoa”. (d) Section 1902 of such Act (as amended by section 132(c) of this 42 USC 1396a. Act) is amended by adding at the end thereof the following new subsection: “(j) Notwithstanding any other requirement of this title, the Secretary may waive or modify any requirement of this title with respect to the medical assistance program in American Samoa, other than a waiver of the Federal medical assistance percentage, the limitation in section 1108(c), or the requirement that payment 42 USC 1308. may be made for medical assistance only with respect to amounts expended by American Samoa for care and services described in paragraphs (1) through (18) of section 1905(a).”. 42 USC 1396d. Effective date. 42 USC 1301 note. (e) The amendments made by this section shall become effective on October 1, 1982. technical corrections from omnibus budget reconciliation act of 1981 Sec. 137. (a) (1) Section 2161(b) of the Ominbus Budget Reconciliation 95 Stat. 803. 42 USC 1396b. Act of 1981 is amended by striking out “Section 1902” and inserting in lieu thereof “Section 1903”. (2) Paragraphs (1) and (2) of section 2161(c) of such Act are each amended by striking out “section 1902” and inserting in lieu thereof in each instance “section 1903”. (3) Section 2171(a)(3) of such Act is amended by striking out “by 95 Stat. 807. 42 USC 1396a. striking out paragraph (C)” and inserting in lieu thereof “by striking out ‘(C) if medical assistance’ and all that follows through the semicolon preceding ‘except that’”. (4) Section 2181(b) of such Act is amended by inserting before the 95 Stat. 815. 42 USC 603 note. 42 USC 1396. period at the end thereof the following: “, except that, in the case of a State plan under title XIX of the Social Security Act which the Secretary determines requires State legislation in order to incorporate the provisions required to be included by this section into such State plan, 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 include the provisions required to be included in such State plan by subsection (a)(2) of this section 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, but the requirements previously set forth in paragraphs (1) through (3) of section 403(g) of the Social Security Act 42 USC 603. (prior to its repeal by this section) shall apply under title XIX of such Act to such State on and after October 1, 1981, whether or not the provisions required to be included by this section in the State plan under title XIX have been incorporated into such State plan”. (5) Section 2193(c)(3)(B) of such Act is amended by striking out “or 95 Stat. 826. 42 USC 1320a-1. X’ ” and inserting in lieu thereof “or XIX’ ”. (b) (1) Section 501(b)(1)(D) of the Social Security Act is amended by 95 Stat. 819. 42 USC 701. striking out “title IV” and inserting in lieu thereof “title VI”. (2) Section 501(b)(2) of such Act is amended by striking out “section 624 of the Economic Opportunity Act of 1964” and inserting in lieu thereof “section 673(2) of the Omnibus Budget Reconciliation Act of 1981”. (3) Section 505(2)(B) of such Act is amended by striking out 95 Stat. 822. 42 USC 705. “502(b)(1)” and inserting in lieu thereof “501(b)(1)”. (4) Section 505(2)(D) of such Act is amended by striking out “the State imposes any charges” and inserting in lieu thereof “any charges are imposed”. (5) Section 1134(4) of such Act is amended by striking out “scale” 42 USC 1320b-4. and inserting in lieu thereof “sale”. (6) The heading of title XVI of such Act as such title applies in the 42 USC 1381. case of Puerto Rico, Guam, and the Virgin Islands is amended by striking out “, OR FOR SUCH AID FOR THE AGED”. (7) Section 1902(a)(10)(A) of such Act is amended to read as follows: 95 Stat. 807. 42 USC 1396a. “(A) for making medical assistance available, including at least the care and services listed in paragraphs (1) through (5) and (17) of section 1905(a), to— 42 USC 1396d. “(i) all individuals receiving aid or assistance under any plan of the State approved under title I, X, XIV, or XVI, or part A or part E of title IV (including pregnant women deemed by the State to be receiving such aid as authorized in section 406(g) and individuals considered by the State to 42 USC 606. be receiving such aid as authorized under section 414(g)), or with respect to whom supplemental security income benefits are being paid under title XVI; and “(ii) at the option of the State, to any group or groups of individuals described in section 1905(a) (or, in the case of 42 USC 1396d. individuals described in section 1905(a)(i), to any reasonable categories of such individuals) who are not individuals described in clause (i) of this subparagraph but— “(I) who meet the income and resources requirements of the appropriate State plan described in clause (i) or the supplemental security income program (as the case may be), “(II) who would meet the income and resources requirements of the appropriate State plan described in clause (i) if their work-related child care costs were paid from their earnings rather than by a State agency as a service expenditure, “(III) who would be eligible to receive aid under the appropriate State plan described in clause (i) if coverage under such plan was as broad as allowed under Federal law, “(IV) with respect to whom there is being paid, or who are eligible, or would be eligible if they were not in a medical institution, to have paid with respect to them, aid or assistance under the appropriate State plan described in clause (i), supplemental security income benefits under title XVI, or a State supplementary payment; “(V) who are in a medical institution, who meet the resource requirements of the appropriate State plan described in clause (i) or the supplemental security income program, and whose income does not exceed a separate income standard established by the State which is consistent with the limit established under section 1903(f)(4)(C), or 42 USC 1396b. “(VI) who would be eligible under the State plan under this title if they were in a medical institution, with respect to whom there has been a determination that but for the provision of home or community-based services described in section 1915(c) they would require 95 Stat. 809. 42 USC 1396n. the level of care provided in a hospital, skilled nursing facility or intermediate care facility the cost of which could be reimbursed under the State plan, and who will receive home or community-based services pursuant to a waiver granted by the Secretary under section 1915(c)”. (8) Section 1902(a)(10)(C)(i) of such Act is amended— 95 Stat. 807. 42 USC 1396a. (A) by striking out “and (II)” and inserting in lieu thereof “, (II)”; and (B) by inserting before the semicolon at the end thereof “, and (III) the single standard to be employed in determining income and resource eligibility for all such groups, and the methodology to be employed in determining such eligibility, which shall be the same methodology which would be employed under the supplemental security income program in the case of groups consisting of aged, blind, or disabled individuals in a State in which such program is in effect, and which shall be the same methodology which would be employed under the appropriate State plan (described in subparagraph (A)(i)) to which such group is most closely categorically related in the case of other groups”. (9) Section 1902(a)(10)(C)(ii)(I) of such Act is amended by striking 95 Stat. 807. 42 USC 1396a. out “described in section 1905(a)(i)” and inserting in lieu thereof “under the age of 18 who (but for income and resources) would be eligible for medical assistance as an individual described in subparagraph (A)(i)”. (10) Section 1902(b) of such Act is amended by striking out paragraph 42 USC 1396a. (2) and redesignating paragraphs (3) and (4) as paragraphs (2) and (3), respectively. (11) Section 1903(g)(1) of such Act is amended by inserting “or 42 USC 1396b. which is a qualified health maintenance organization (as defined in section 131()(d) of the Public Health Service Act)” after “as defined in section 1876”. (12) Section 1903(g)(1)(A) of such Act is amended by striking out 95 Stat. 816. 42 USC 1396b. “intermediate care facility services described in section 1905(d)” and inserting in lieu thereof “intermediate care facility services provided in an institution for the mentally retarded”. (13) Section 1903(k) of such Act is amended by striking out “section 1876” and inserting in lieu thereof “subsection (m) of this section”. (14) Section 1903(m)(2)(A) of such Act is amended— 95 Stat. 813. 42 USC 1396b. (A) by striking out “and” before “(II)” in clause (iv) and inserting in lieu thereof “or”; and (B) by striking out “unforseen” in clause (vii) and inserting in lieu thereof “unforeseen”. (15) Section 1903(s) of such Act is amended— 95 Stat. 803. 42 USC 1396b. (A) in paragraph (1)(A), by striking out “made before fiscal year 1981” and inserting in lieu thereof “made before fiscal year 1982”; (B) in paragraph (1)(A), by striking out “without regard to payments under subsection (t) and” and inserting in lieu thereof “without regard to payments under subsections (a)(6) and (t), without regard to payments for claims relating to expenditures made for medical assistance for services received through a facility of the Indian Health Service, and”; (C) in paragraph (1)(C), by inserting “a program in operation under” before “a plan approved under this title”; (D) in paragraph (3)(D)— (i) by striking out “determines that” and inserting in lieu thereof “must determine that”; (ii) by striking out “most recent calendar year” and inserting in lieu thereof “most recent year (which shall consist of a 12-month period determined by the Secretary for this purpose)”; (iii) by striking out “2 or 3 calendar year period” and inserting in lieu thereof “2- or 3-year period”; and (iv) by striking out “calendar” each place it appears; (E) in paragraph (4)(B), by inserting “and paragraph (3)(D)” after “subparagraph (A)”; and (F) in paragraph (5)(A)(i), by inserting “(including amounts saved, to the extent such amounts can be documented to the satisfaction of the Secretary, by reason of the suspension or termination of a provider or other person for fraud or abuse, but only during the period of such suspension or termination or, if shorter, the 1-year period beginning on the date of such termination or suspension)” after “recovered or diverted”. (16) Section 1903(t) of such Act (as added by section 2161(b) of the 95 Stat. 803. 42 USC 1396b. Omnibus Budget Reconciliation Act of 1981 as amended by subsection (a) of this section) is amended— (A) in paragraphs (1)(A) and (2)(A), by striking out “other than interest paid under subsection (d)(5)” each place it appears and inserting in lieu thereof in each instance “other than payments under subsection (a)(6), interest paid under subsection (d)(5), and payments for claims relating to expenditures made for medical assistance for services received through a facility of the Indian Health Service”; (B) in paragraph (1)(B), by striking out “between September 1982 and September 1983” and inserting in lieu thereof “for the 12-month period ending on September 30, 1983”; (C) in paragraph (1)(C), by striking out “between September 1982 and September 1984” and inserting in lieu thereof “for the 24-month period ending on September 30, 1984”; (D) in subparagraphs (B) and (C) of paragraph (1), by striking out “consumer price index for all urban consumers (published by the Bureau of Labor Statistics)” each place it appears and inserting in lieu thereof in each instance “Consumer Price Index for all urban consumers (U.S. city average) published by the Bureau of Labor Statistics”; and (E) by amending paragraph (3) to read as follows: Only for the purpose of computing under this subsection the Federal share of expenditures for a State for fiscal years 1982, 1983, and 1984 (in the case of the payment which may be made for the first quarter of fiscal years 1983, 1984, and 1985, respectively), the Federal medical assistance percentage for fiscal years 1982, 1983, and 1984 shall be the Federal medical assistance percentage for States in effect for fiscal year 1981, disregarding any change in such percentage after fiscal year 1981.”. (17) Section 1905(a)(i) of such Act is amended by striking out “or 95 Stat. 808. 42 USC 1396d. any reasonable category of such individuals,”. (18) Section 1905(a) of such Act is amended by striking out “or” at the end of clause (vi), inserting “or” at the end of clause (vii), and inserting after clause (vii) the following: “(viii) pregnant women,”. (19) (A) Section 1915(b) of such Act is amended by striking out “and 95 Stat. 809. 42 USC 1396n. section 1903(m)”. (B) The amendment made by subparagraph (A) shall not apply 42 USC 1396n note. with respect to any waiver if such waiver was granted, and the arrangement covered by the waiver was in place, prior to August 10, 1982. (20) Section 1915(b)(1) of such Act is amended— (A) by inserting “primary care” before “case-management system”; and (B) by striking out “primary care services” and inserting in lieu thereof “medical care services”. (21) Section 1915(c)(1) of such Act is amended by inserting “payment for part or all of the cost of” after “may include as ‘medical assistance’ under such plan”. (22) Section 1915(c)(2)(B) of such Act is amended to read as follows: “(B) the State will provide, with respect to individuals who— “(i) are entitled to medical assistance for skilled nursing facility 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 care under such waiver, for an evaluation of the need for such services;”. (23) Section 1915(c)(3) of such Act is amended— (A) by striking out “subsection (a)(1)” and inserting in lieu thereof “section 1902(a)(1)”; and (B) by striking out “subsection (a)(10) of section 1902” and inserting in lieu thereof “section 1902(a)(10)”. (24) Section 1915(c)(4) of such Act is amended by striking out “this section” and inserting in lieu thereof “this subsection”. (25) Section 1915(f) of such Act is amended by inserting “approval of” before “a proposed State plan”. (26) Subsection (a) of section 1128A of such Act is amended by 95 Stat. 789. 42 USC 1320a-7a. striking out all that precedes “shall be subject” and inserting in lieu thereof the following: “(a) Any person (including an organization, agency, or other entity) that— “(1) presents or causes to be presented to an officer, employee, or agent of the United States, or of any department or agency thereof, or of any State agency (as defined in subsection (h)(1)), a claim (as defined in subsection (h)(2)) that the Secretary determines is for a medical or other item or service— “(A) that the person knows or has reason to know was not provided as claimed, or “(B) payment for which may not be made under the program under which such claim was made, pursuant to a determination by the Secretary under section 1128, 1160(b), 42 USC 1320a-7, 1820C-9, 1395y. or 1862(d), or pursuant to a determination by the Secretary under section 1866(b)(2) with respect to which the Secretary has initiated termination proceedings; or 42 USC 1395cc. “(2) presents or causes to be presented to any person a request for payment which is in violation of the terms of (A) an assignment under section 1842(b)(3)(B)(ii), or (B) an agreement with a 42 USC 1395u. State agency not to charge a person for an item or service in excess of the amount permitted to be charged,”. (27) Section 1903(s)(5)(B) of such Act is amended by inserting “or 95 Stat. 803. 42 USC 1396b. quarters” after “carried forward to the following quarter”. (c) (1) Section 914(b)(2)(A) of the Omnibus Reconciliation Act of 42 USC 1896a note. 1980 is amended by striking out “medical assistance” and all that follows and inserting in lieu thereof “cost reporting periods, beginning on or after April 1, 1981, of an entity providing services under a State plan approved under title XIX of the Social Security Act.”. 42 USC 1396. (2) Section 914(c)(2) of the Omnibus Reconciliation Act of 1980 is 42 USC 705 note. amended by striking out “services provided” and all that follows and inserting in lieu thereof “cost reporting periods, beginning on or after April 1, 1981, of an entity providing services under a State plan approved under title V of the Social Security Act.”. 42 USC 701. (d) (1) Except as otherwise provided in this section, any amendment 42 USC 1396a note. 95 Stat. 357. to the Omnibus Budget Reconciliation Act of 1981 made by this section shall be effective as if it had been originally included in the provision of the Omnibus Budget Reconciliation Act of 1981 to which such amendment relates. (2) Except as otherwise provided in this section, any amendment to the Social Security Act made by the preceding provisions of this 42 USC 1305. section shall be effective as if it had been originally included as a part of that provision of the Social Security Act to which it relates, as such provision of the Social Security Act was amended by the Omnibus Budget Reconciliation Act of 1981. (e) Section 1902(a) of the Social Security Act is amended in the 95 Stat. 815. 42 USC 1396a. matter following paragraph (44) by inserting “, (26)” after “(9)(A)”. (f) Section 1905(h)(1)(C) of the Social Security Act is amended by 42 USC 1396d. redesignating clauses (i) and (ii) as subclauses (I) and (II) respectively, and by redesignating clauses (A) and (B) as clauses (i) and (ii) respectively. (g) Effective October 1, 1982, section 1903(f)(3) of the Social Security 42 USC 1396b. Act is amended by striking out “(without regard to section 408)”. Subtitle C— Utilization and Quality Control Peer Review short title of subtitle Sec. 141. This subtitle may be cited as the “Peer Review Improvement 42 USC 1305 note. Act of 1982”. requirement for secretary to enter into contracts Sec. 142. Section 1862 of the Social Security Act is amended by 42 USC 1395y. adding at the end thereof the following new subsection: “(g) The Secretary shall, in making the determinations under paragraphs (1) and (9) of subsection (a), and for the purposes of promoting the effective, efficient, and economical delivery of health care services, and of promoting the quality of services of the type for which payment may be made under this title, enter into contracts with utilization and quality control peer review organizations pursuant to part B of title XI of this Act.”. 42 USC 1320c. establishment of utilization and quality control peer review program Sec. 143. Part B of title XI of the Social Security Act is amended to read as follows: “PART B— PEER REVIEW OF THE UTILIZATION AND QUALITY OF HEALTH CARE SERVICES “purpose “Sec. 1151. The purpose of this part is to establish the contracting 42 USC 1320c. process which the Secretary must follow pursuant to the requirements of section 1862(g) of this Act, including the definition of the 42 USC 1395y. utilization and quality control peer review organizations with which the Secretary shall contract, the functions such peer review organizations are to perform, the confidentiality of medical records, and related administrative matters to facilitate the carrying out of the purposes of this part. “definition of utilization and quality control peer review organization “Sec. 1152. The term ‘utilization and quality control peer review 42 USC 1320C-1 organization’ means an entity which— “(1) (A) is composed of a substantial number of the licensed doctors of medicine and osteopathy engaged in the practice of medicine or surgery in the area and who are representative of the practicing physicians in the area, designated by the Secretary under section 1153, with respect to which the entity shall perform services under this part, or (B) has available to it, by arrangement or otherwise, the services of a sufficient number of licensed doctors of medicine or osteopathy engaged in the practice of medicine or surgery in such area to assure that adequate peer review of the services provided by the various medical specialties and subspecialties can be assured; and “(2) is able, in the judgment of the Secretary, to perform review functions required under section 1154 in a manner consistent with the efficient and effective administration of this part and to perform reviews of the pattern of quality of care in an area of medical practice where actual performance is measured against objective criteria which define acceptable and adequate practice. “contracts with utilization and quality control peer review organizations “Sec. 1153. (a) (1) The Secretary shall establish throughout the 42 USC 1320C-2. United States geographic areas with respect to which contracts under this part will be made. In establishing such areas, the Secretary shall use the same areas as established under section 1152 of this Act as in effect immediately prior to the date of the enactment of the Peer Review Improvement Act of 1982, but subject to the provisions of paragraph (2). “(2) As soon as practicable after the date of the enactment of the Peer Review Improvement Act of 1982, the Secretary shall consoli-date such geographic areas, taking into account the following criteria: “(A) Each State shall generally be designated as a geographic area for purposes of paragraph (1). “(B) The Secretary shall establish local or regional areas rather than State areas only where the volume of review activity or other relevant factors (as determined by the Secretary) warrant such an establishment, and the Secretary determines that review activity can be carried out with equal or greater efficiency by establishing such local or regional areas. In applying this subparagraph the Secretary shall take into account the number of hospital admissions within each State for which payment may be made under title XVIII or a State plan 42 USC 1395. 42 USC 1396. approved under title XIX, with any State having fewer than 180,000 such admissions annually being established as a single statewide area, and no local or regional area being established which has fewer than 60,000 total hospital admissions (including public and private pay patients) under review annually, unless the Secretary determines that other relevant factors warrant otherwise. “(C) No local or regional area shall be designated which is not a self-contained medical service area, having a full spectrum of services, including medical specialists’ services. “(b) (1) The Secretary shall enter into a contract with a utilization and quality control peer review organization for each area established under subsection (a) if a qualified organization is available in such area and such organization and the Secretary have negotiated a proposed contract which the Secretary determines will be carried out by such organization in a manner consistent with the efficient and effective administration of this part. If more than one such qualified organization meets the requirements of the preceding sentence, priority shall be given to any such organization which is described in section 1152(1)(A). “(2) (A) During the first twelve months in which the Secretary is entering into contracts under this section, the Secretary shall not enter into a contract under this part with any entity which is, or is affiliated with (through management, ownership, or common control), an entity which directly or indirectly makes payments to any practitioner or provider whose health care services are reviewed by such entity or would be reviewed by such entity if it entered into a contract with the Secretary under this part. “(B) If, after the expiration of the twelve-month period referred to in subparagraph (A), the Secretary determines that there is no other entity available for an area with which the Secretary can enter into a contract under this part, the Secretary may then enter into a contract under this part with an entity described in subparagraph (A) for such area if such entity otherwise meets the requirements of this part. “(3) The Secretary shall not enter into a contract under this part with any entity which is, or is affiliated with (through management, ownership, or common control), a health care facility, or association of such facilities, within the area served by such entity or which would be served by such entity if it entered into a contract with the Secretary under this part. “(c) Each contract with an organization under this section shall provide that— “(1) the organization shall perform the functions set forth in section 1154(a), or may subcontract for the performance of all or some of such functions (and for purposes of paragraphs (2) and (3) of subsection (b), a subcontract under this paragraph shall not constitute an affiliation with the subcontractor); “(2) the Secretary shall have the right to evaluate the quality and effectiveness of the organization in carrying out the functions specified in the contract; “(3) the contract shall be for an initial term of two years and shall be renewable on a biennial basis thereafter; “(4) if the Secretary intends not to renew a contract, he shall notify the organization of his decision at least 90 days prior to the expiration of the contract term, and shall provide the organization an opportunity to present data, interpretations of data, and other information pertinent to its performance under the contract, which shall be reviewed in a timely manner by the Secretary; “(5) the organization may terminate the contract upon 90 days notice to the Secretary; “(6) the Secretary may terminate the contract prior to the expiration of the contract term upon 90 days notice to the organization if the Secretary determines that— “(A) the organization does not substantially meet the requirements of section 1152; or “(B) the organization has failed substantially to carry out the contract or is carrying out the contract in a manner inconsistent with the efficient and effective administration of this part, but only after such organization has had an opportunity to submit data and have such data reviewed by the panel established under subsection (d); “(7) the Secretary shall include in the contract negotiated objectives against which the organization’s performance will be judged, and negotiated specifications for use of regional norms, or modifications thereof based on national norms, for performing review functions under the contract; and “(8) reimbursement shall be made to the organization in accordance with the terms of the contract. “(d) (1) Prior to making any termination under subsection (c)(5)(B), the Secretary must provide the organization with an opportunity to provide data, interpretations of data, and other information pertinent to its performance under the contract. Such data and other information shall be reviewed in a timely manner by a panel appointed by the Secretary, and the panel shall submit a report of its findings to the Secretary in a timely manner. The Secretary shall make a copy of the report available to the organization. “(2) The Secretary may accept or not accept the findings of the panel. After the panel has submitted a report with respect to an organization, the Secretary may, with the concurrence of the organization, amend the contract to modify the scope of the functions to be carried out by the organization, or in any other manner. The Secretary may terminate a contract under the authority of subsection (c)(5)(C) upon 90 days notice after the panel has submitted a report, or earlier if the organization so agrees. “(3) A panel appointed by the Secretary under this subsection shall consist of not more than five individuals, each of whom shall be a member of a utilization and quality control peer review organization having a contract with the Secretary under this part. While serving on such panel individuals shall be paid at a per diem rate not to exceed the current per diem equivalent at the time that service on the panel is rendered for grade GS-18 under section 5332 of title 5, United States Code. Appointments shall be made without regard to title 5, United States Code. “(e) Contracting authority of the Secretary under this section may be carried out without regard to any provision of law relating to the making, performance, amendment, or modification of contracts of the United States as the Secretary may determine to be inconsistent with the purposes of this part. The Secretary may use different contracting methods with respect to different geographical areas. “(f) Any determination by the Secretary to terminate or not to renew a contract under this section shall not be subject to judicial review. “functions of peer review organizations “Sec. 1154. (a) Any utilization and quality control peer review 42 USC 1320c-3. organization entering into a contract with the Secretary under this part must perform the following functions: “(1) The organization shall review some or all of the professional activities in the area, subject to the terms of the contract, of physicians and other health care practitioners and institutional and noninstitutional providers of health care services in the provision of health care services and items for which payment may be made (in whole or in part) under title XVIII for 42 USC 1395. the purpose of determining whether— “(A) such services and items are or were reasonable and medically necessary or otherwise allowable under section 1862(a)(1); “(B) the quality of such services meets professionally recognized standards of health care; and “(C) in case such services and items are proposed to be provided in a hospital or other health care facility on an inpatient basis, such services and items could, consistent with the provision of appropriate medical care, be effectively provided more economically on an outpatient basis or in an inpatient health care facility of a different type. “(2) The organization shall determine, on the basis of the review carried out under subparagraphs (A) and (C) of paragraph (1), whether payment shall be made for services under title XVIII. Such determination shall constitute the conclusive determination on those issues for purposes of payment under title XVIII, except that payment may be made if— “(A) such payment is allowed by reason of section 1879; “(B) in the case of inpatient hospital services or posthospital extended care services, the peer review organization determines that additional time is required in order to arrange for postdischarge care, but payment may be continued under this subparagraph for not more than two days, buy only in the case where the provider of such services did not know and could not reasonably have been expected to know (as determined under section 1879) that payment 42 USC 1395pp. would not otherwise be made for such services under title XVIII prior to notification by the organization under paragraph (3); “(C) such determination is changed as the result of any hearing or review of the determination under section 1155; or “(D) such payment is authorized under section 1861(v)(1)(G). 42 USC 1395x. “(3) 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 practitioner or provider, such patient, and the agency or organization responsible for the payment of claims under title XVIII of this Act. In the case of practitioners and providers of services, the organization shall provide an opportunity for discussion and review of the determination. “(4) The organization shall, after consultation with the Secretary, determine the types and kinds of cases (whether by type of health care or diagnosis involved, or whether in terms of other relevant criteria relating to the provision of health care services) with respect to which such organization will, in order to most effectively carry out the purposes of this part, exercise review authority under the contract. The organization shall notify the Secretary periodically with respect to such determinations. “(5) The organization shall consult with nurses and other professional health care practitioners (other than physicians described in section 1861(r)(1)) and with representatives of institutional and noninstitutional providers of health care services, with respect to the organization’s responsibility for the review under paragraph (1) of the professional activities of such practitioners and providers. “(6) The organization shall, consistent with the provisions of its contract under this part, apply professionally developed norms of care, diagnosis, and treatment based upon typical patterns of practice within the geographic area served by the organization as principal points of evaluation and review, taking into consideration national norms where appropriate. Such norms with respect to treatment for particular illnesses or health conditions shall include— “(A) the types and extent of the health care services which, taking into account differing, but acceptable, modes of treatment and methods of organizing and delivering care, are considered within the range of appropriate diagnosis and treatment of such illness or health condition, consistent with professionally recognized and accepted patterns of care; and “(B) the type of health care facility which is considered, consistent with such standards, to be the type in which health care services which are medically appropriate for such illness or condition can most economically be provided. “(7) The organization, to the extent necessary and appropriate to the performance of the contract, shall— “(A) make arrangements to utilize the services of persons who are practitioners of, or specialists in, the various areas of medicine (including dentistry), or other types of health care, which persons shall, to the maximum extent practicable, be individuals engaged in the practice of their profession within the area served by such organization; “(B) undertake such professional inquiries either before or after, or both before and after, the provision of services with respect to which such organization has a responsibility for review which in the judgment of such organization will facilitate its activities; “(C) examine the pertinent records of any practitioner or provider of health care services providing services with respect to which such organization has a responsibility for review under paragraph (1); and “(D) inspect the facilities in which care is rendered or services are provided (which are located in such area) of any practitioner or provider of health care services providing services with respect to which such organization has a responsibility for review under paragraph (1). “(8) The organization shall perform such duties and functions and assume such responsibilities and comply with such other requirements as may be required by this part or under regulations of the Secretary promulgated to carry out the provisions of this part. “(9) The organization shall collect such information relevant to its functions, and keep and maintain such records, in such form as the Secretary may require to carry out the purposes of this part, and shall permit access to and use of any such information and records as the Secretary may require for such purposes, subject to the provisions of section 1160. Post, p. 391. “(10) The organization shall coordinate activities, including information exchanges, which are consistent with economical and efficient operation of programs among appropriate public and private agencies or organizations including— “(A) agencies under contract pursuant to sections 1816 42 USC 1395h, 1395u. and 1842 of this Act; “(B) other peer review organizations having contracts under this part; and “(C) other public or private review organizations as may be appropriate. “(11) The organization shall make available its facilities and resources for contracting with private and public entities paying for health care in its area for review, as feasible and appropriate, of services reimbursed by such entities. “(b) (1) No physician shall be permitted to review— “(A) health care services provided to a patient if he was directly responsible for providing such services; or “(B) health care services provided in or by an institution, organization, or agency, if he or any member of his family has, directly or indirectly, a significant financial interest in such institution, organization, or agency. “(2) For purposes of this subsection, a physician’s family includes only his spouse (other than a spouse who is legally separated from him under a decree of divorce or separate maintenance), children (including legally adopted children), grandchildren, parents, and grandparents. “(c) No utilization and quality control peer review organization shall utilize the services of any individual who is not a duly licensed doctor of medicine, osteopathy, or dentistry to make final determinations of denial decisions in accordance with its duties and functions under this part with respect to the professional conduct of any other duly licensed doctor of medicine, osteopathy, or dentistry, or any act performed by any duly licensed doctor of medicine, osteopathy, or dentistry in the exercise of his profession. “right to hearing and judicial review “Sec. 1155. Any beneficiary who is entitled to benefits under title 42 USC 1320C-4. 42 USC 1395. XVIII, and any practitioner or provider, who is dissatisfied with a determination made by a contracting peer review organization in conducting its review responsibilities under this part, shall be entitled to a reconsideration of such determination by the reviewing organization. Where the reconsideration is adverse to the beneficiary and where the matter in controversy is $200 or more, such beneficiary shall be entitled to a hearing by the Secretary (to the same extent as is provided in section 205(b)), and, where the amount 42 USC 405. in controversy is $2,000 or more, to judicial review of the Secretary’s final decision. “obligations of health care practitioners and providers of health care services; sanctions and penalties; hearings and review “Sec. 1156. (a) It shall be the obligation of any health care 42 USC 1320C-5. practitioner and any other person (including a hospital or other health care facility, organization, or agency) who provides health care services for which payment may be made (in whole or in part) under title XVIII, to assure, to the extent of his authority that services or items ordered or provided by such practitioner or person to beneficiaries and recipients under such title— “(1) will be provided economically and only when, and to the extent, medically necessary; “(2) will be of a quality which meets professionally recognized standards of health care; and “(3) will be supported by evidence of medical necessity and quality in such form and fashion and at such time as may reasonably be required by a reviewing peer review organization in the exercise of its duties and responsibilities. “(b) (1) If after reasonable notice and opportunity for discussion with the practitioner or person concerned, any organization having a contract with the Secretary under this part determines that such practitioner or person has— “(A) failed in a substantial number of cases substantially to comply with any obligation imposed on him under subsection (a), or “(B) grossly and flagrantly violated any such obligation in one or more instances, such organization shall submit a report and recommendations to the Secretary. If the Secretary agrees with such determination, and determines that such practitioner or person, in providing health care services over which such organization has review responsibility and for which payment (in whole or in part) may be made under title XVIII, has demonstrated an unwillingness or a lack of ability substantially to comply with such obligations, the Secretary (in addition to any other sanction provided under law) may exclude (permanently or for such period as the Secretary may prescribe) such practitioner or person from eligibility to provide such services on a reimbursable basis. If the Secretary fails to act upon the recommendations submitted to him by such organization within 120 days after such submission, such practitioner or person shall be excluded from eligibility to provide services on a reimbursable basis until such time as the Secretary determines otherwise. “(2) A determination made by the Secretary under this subsection to exclude a practitioner or person shall be effective at such time and upon such reasonable notice to the public and to the practitioner or person furnishing the services involved as may be specified in regulations. Such determination shall be effective with respect to services furnished to an individual on or after the effective date of such determination (except that in the case of institutional health care services such determination shall be effective in the manner provided in title XVIII with respect to terminations of provider agreements), and shall remain in effect until the Secretary finds and gives reasonable notice to the public that the basis for such determination has been removed and that there is reasonable assurance that it will not recur. “(3) In lieu of the sanction authorized by paragraph (1), the Secretary may require that (as a condition to the continued eligibility of such practitioner or person to provide such health care services on a reimbursable basis) such practitioner or person pays to the United States, in case such acts or conduct involved the provision or ordering by such practitioner or person of health care services which were medically improper or unnecessary, an amount not in excess of the actual or estimated cost of the medically improper or unnecessary services so provided. Such amount may be deducted from any sums owing by the United States (or any instrumentality thereof) to the practitioner or person from whom such amount is claimed. “(4) Any practitioner or person furnishing services described in paragraph (1) who is dissatisfied with a determination made by the Secretary under this subsection shall be entitled to reasonable notice and opportunity for a hearing thereon by the Secretary to the same extent as is provided in section 205(b), and to judicial review of 42 USC 405. the Secretary’s final decision after such hearing as is provided in section 205(g). “(c) It shall be the duty of each utilization and quality control peer review organization to use such authority or influence it may possess as a professional organization, and to enlist the support of any other professional or governmental organization having influence or authority over health care practitioners and any other person (including a hospital or other health care facility, organization, or agency) providing health care services in the area served by such review organization, in assuring that each practitioner or person (referred to in subsection (a)) providing health care services in such area shall comply with all obligations imposed on him under subsection (a). “limitation on liability “Sec. 1157. (a) Notwithstanding any other provision of law, no 42 USC 1320c-6. person providing information to any organization having a contract with the Secretary under this part shall be held, by reason of having provided such information, to have violated any criminal law, or to be civilly liable under any law of the United States or of any State (or political subdivision thereof) unless— “(1) such information is unrelated to the performance of the contract of such organization; or “(2) such information is false and the person providing it knew, or had reason to believe, that such information was false. “(b) No person who is employed by, or who has a fiduciary relationship with, any such organization or who furnishes professional services to such organization, shall be held by reason of the performance by him of any duty, function, or activity required or authorized pursuant to this part or to a valid contract entered into under this part, to have violated any criminal law, or to be civilly liable under any law of the United States or of any State (or political subdivision thereof) provided he has exercised due care. “(c) No doctor of medicine or osteopathy and no provider (including directors, trustees, employees, or officials thereof) of health care services shall be civilly liable to any person under any law of the United States or of any State (or political subdivision thereof) on account of any action taken by him in compliance with or reliance upon professionally developed norms of care and treatment applied by an organization under contract pursuant to section 1153 operating in the area where such doctor of medicine or osteopathy or provider took such action; but only if— “(1) he takes such action in the exercise of his profession as a doctor of medicine or osteopathy or in the exercise of his functions as a provider of health care services; and “(2) he exercised due care in all professional conduct taken or directed by him and reasonably related to, and resulting from, the actions taken in compliance with or reliance upon such professionally accepted norms of care and treatment. “(d) The Secretary shall make payment to an organization under contract with him pursuant to this part, or to any member or employee thereof, or to any person who furnishes legal counsel or services to such organization, in an amount equal to the reasonable amount of the expenses incurred, as determined by the Secretary, in connection with the defense of any suit, action, or proceeding brought against such organization, member, or employee related to the performance of any duty or function under such contract by such organization, member, or employee. “application of this part to certain state programs receiving federal financial assistance “Sec. 1158. (a) A State plan approved under title XIX of this Act 42 USC 1320c-7. 42 USC 1396. may provide that the functions specified in section 1154 may be performed in an area by contract with a utilization and quality control peer review organization that has entered into a contract with the Secretary in accordance with the provisions of section 1862(g). 42 USC 1395y. “(b) In the event a State enters into a contract in accordance with subsection (a), the Federal share of the expenditures made to the contracting organization for its costs in the performance of its functions under the State plan shall be 75 percent (as provided in section 1903(a)(3)(C)). 42 USC 1396b. “authorization for use of certain funds to administer the provisions of this part “Sec. 1159. Expenses incurred in the administration of the contracts 42 USC 1320c-8. 42 USC 1395y. described in section 1862(g) shall be payable from— “(1) funds in the Federal Hospital Insurance Trust Fund; and “(2) funds in the Federal Supplementary Medical Insurance Trust Fund, in such amounts from each of such Trust Funds as the Secretary shall deem to be fair and equitable after taking into consideration the expenses attributable to the administration of this part with respect to each of such programs. The Secretary shall make such transfers of moneys between such Trust Funds as may be appropriate to settle accounts between them in cases where expenses properly payable from one such Trust Fund have been paid from the other such Trust Fund. “prohibition against disclosure of information “Sec. 1160. (a) An organization, in carrying out its functions under 42 USC 1320c-9. a contract entered into under this part, shall not be a Federal agency for purposes of the provisions of section 552 of title 5, United States Code (commonly referred to as the Freedom of Information Act). Any data or information acquired by any such organization in the exercise of its duties and functions shall be held in confidence and shall not be disclosed to any person except— “(1) to the extent that may be necessary to carry out the purposes of this part, “(2) in such cases and under such circumstances as the Secretary shall by regulations provide to assure adequate protection of the rights and interests of patients, health care practitioners, or providers of health care, or “(3) in accordance with subsection (b). “(b) An organization having a contract with the Secretary under this part shall provide in accordance with procedures and safeguards established by the Secretary, data and information— “(1) which may identify specific providers or practitioners as may be necessary— “(A) to assist Federal and State agencies recognized by the Secretary as having responsibility for identifying and investigating cases or patterns of fraud or abuse, which data and information shall be provided by the peer review organization to any such agency at the request of such agency relating to a specific case or pattern; “(B) to assist appropriate Federal and State agencies recognized by the Secretary as having responsibility for identifying cases or patterns involving risks to the public health, which data and information shall be provided by the peer review organization to any such agency— “(i) at the discretion of the peer review organization, at the request of such agency relating to a specific case or pattern with respect to which such agency has made a finding, or has a reasonable belief, that there may be a substantial risk to the public health, or “(ii) upon a finding by, or the reasonable belief of, the peer review organization that there may be a substantial risk to the public health; and “(C) to assist appropriate State agencies recognized by the Secretary as having responsibility for licensing or certification of providers or practitioners, which data and information shall be provided by the peer review organization to any such agency at the request of such agency relating to a specific case, but only to the extent that such data and information is required by the agency in carrying out a function which is within the jurisdiction of such agency under State law; and “(2) to assist the Secretary, and such Federal and State agencies recognized by the Secretary as having health planning or related responsibilities under Federal or State law (including health systems agencies and State health planning and development agencies), in carrying out appropriate health care planning and related activities, which data and information shall be provided in such format and manner as may be prescribed by the Secretary or agreed upon by the responsible Federal and State agencies and such organization, and shall be in the form of aggregate statistical data (without explicitly identifying any individual) on a geographic, institutional, or other basis reflecting the volume and frequency of services furnished, as well as the demographic characteristics of the population subject to review by such organization. The penalty provided in subsection (c) shall not apply to the disclosure of any information received under this subsection, except that such penalty shall apply to the disclosure (by the agency receiving such information) of any such information described in paragraph (1) unless such disclosure is made in a judicial, administrative, or other formal legal proceeding resulting from an investigation conducted by the agency receiving the information. An organization may require payment of a reasonable fee for providing information under this subsection in response to a request for such information. “(c) It shall be unlawful for any person to disclose any such information described in subsection (a) other than for the purposes provided in subsections (a) and (b), and any person violating the provisions of this section shall, upon conviction, be fined not more than $1,000, and imprisoned for not more than 6 months, or both, and shall be required to pay the costs of prosecution. “(d) No patient record in the possession of an organization having a contract with the Secretary under this part shall be subject to subpena or discovery proceedings in a civil action. “annual reports “Sec. 1161. The Secretary shall submit to the Congress not later 42 USC 1320C-10. than April 1 of each year, a full and complete report on the administration, impact, and cost of the program under this part during the preceding fiscal year, including data and information on— “(1) the number, status, and service areas of all utilization and quality control peer review organizations participating in the program; “(2) the number of health care institutions and practitioners whose services are subject to review by such organizations, and the number of beneficiaries and recipients who received services subject to such review during such year; “(3) the various methods of reimbursement utilized in contracts under this part, and the relative efficiency of each such method of reimbursement; “(4) the imposition of penalties and sanctions under this title for violations of law and for failure to comply with the obligations imposed by this part; “(5) the total costs incurred under titles XVIII and XIX of this 42 USC 1395, 1396. Act in the implementation and operation of all procedures required by such titles for the review of services to determine their medical necessity, appropriateness of use, and quality; and “(6) descriptions of the criteria upon which decisions are made, and the selection and relative weights of such criteria. “exemptions of christian science sanatoriums “Sec. 1162. The provisions of this part shall not apply with respect 42 USC 1320c-11. to a Christian Science sanatorium operated, or listed and certified, by the First Church of Christ, Scientist, Boston, Massachusetts. “medical officers in american samoa, the northern mariana islands, and the trust territory of the pacific islands to be included in the utilization and quality control peer review program “Sec. 1163. For purposes of applying this part to American Samoa, 42 USC 1320c-12. the Northern Mariana Islands, and the Trust Territory of the Pacific Islands, individuals licensed to practice medicine in those places shall be considered to be physicians and doctors of medicine.”. facilitation of private review Sec. 144. Section 1866(a)(1) of the Social Security Act is amended— 42 USC 1395cc. (1) by striking out “and” at the end of subparagraphs (A), (B), and (C); (2) by striking out the period at the end of subparagraph (D) and inserting in lieu thereof “, and”; and (3) by inserting after subparagraph (D) the following new subparagraph: “(E) to release data with respect to patients of such provider upon request to an organization having a contract with the Secretary under part B of title XI as may be necessary (i) to 42 USC 1320c. allow such organization to carry out its functions under such contract, or (ii) to allow such organization to carry out similar review functions under any contract the organization may have with a private or public agency paying for health care in the same area with respect to patients who authorize release of such data for such purposes.”. waiver of liability provision Sec. 145. Section 1879(a) of the Social Security Act is amended by 42 USC 1395pp. adding at the end thereof the following new sentence: “Any provider or other person furnishing items or services for which payment may not be made by reason of section 1862(a)(1) or (9) shall be deemed to 42 USC 1395y. have knowledge that payment cannot be made for such items or services if the claim relating to such items or services involves a case, provider or other person furnishing services, procedure, or test, with respect to which such provider or other person has been notified by the Secretary (including notification by a utilization and quality control peer review organization) that a pattern of inappropriate utilization has occurred in the past, and such provider or other person has been allowed a reasonable time to correct such inappropriate utilization.”. medicaid provisions Sec. 146. (a) Section 1902(d) of the Social Security Act is 95 Stat. 795. 42 USC 1396a. amended— (1) by striking out “a Professional Standards Review Organization designated, conditionally or otherwise,” and inserting in lieu thereof “a utilization and quality control peer review organization having a contract with the Secretary”; and (2) by striking out “such Organization (or Organizations)” each place it appears and inserting in lieu thereof in each instance “such organization (or organizations)”. (b) Section 1903(a)(3)(C) of such Act is amended by striking out 95 Stat. 795. 42 USC 1396b. “Professional Standards Review Organization” and inserting in lieu thereof “utilization and quality control peer review organization”. demonstration projects for competitive bidding and other reimbursement methods Sec. 147. Section 402(a)(1) of the Social Security Amendments of 42 USC 1395b-1. 1967 (Public Law 90–248) is amended— (1) by striking out “and” at the end of subparagraph (I); (2) by striking out the period at the end of subparagraph (J) and inserting in lieu thereof “; and”; and (3) by inserting after subparagraph (J) the following new subparagraph: “(K) to determine whether the use of competitive bidding in the awarding of contracts, or the use of other methods of reimbursement, under part B of title XI would be efficient and effective methods of furthering the purposes of that part.”. technical amendments Sec. 148. (a) Section 1862(d)(1)(C) of such Act is amended by 42 USC 1395y. striking out “, on the basis of reports transmitted to him in accordance with section 1157 of this Act (or, in the absence of any such report, on the basis of such data as he acquires in the administration of the program under this title),” and inserting in lieu thereof “on the basis of information acquired by the Secretary in the administration of this title”. (b) Sections 1815(b), 1861(v)(l)(G), and 1861(w)(2) of such Act are 42 USC 1395g, 1395x. each amended by striking out “Professional Standards Review Organization” and inserting in lieu thereof in each instance “quality control and peer review organization”. (c) Section 1832(a)(2)(F)(ii) of such Act is amended by striking out 42 USC 1395k. “Professional Standards Review Organization (designated, conditionally or otherwise,” and inserting in lieu thereof “quality control and peer review organization (having a contract with the Secretary”. (d) Section 1833(i) of such Act is amended by striking out “the 42 USC 1395l. National Professional Standards Review Council and”. (e) Section 1879(e) of such Act is amended by striking out “professional 42 USC 1395pp. standards review organization” and inserting in lieu thereof “quality control and peer review organization”. effective date Sec. 149. The amendments made by this part shall, subject to 42 USC 1320c note. section 150, be effective with respect to contracts entered into or renewed on or after the date of the enactment of this Act. maintenance of current psro agreements Sec. 150. (a) The Secretary of Health and Human Services shall 42 USC 1320c note. not terminate or fail to renew any agreement in effect with a professional standards review organization under part B of title XI 42 USC 1301. of the Social Security Act on the earlier of the date of the enactment of this Act or September 30, 1982 until such time as he enters into a contract with a utilization and quality control peer review organization under such part, as amended by this subtitle, for the area served by such professional standards review organization. In complying with this subsection, the Secretary may renew any such contract with a professional standards review organization for a period of less than 12 months. (b) The provisions of part B of title XI of the Social Security Act as 42 USC 1320c. in effect prior to the amendments made by this subtitle shall remain in effect with respect to contracts with professional standards review organizations in effect on the earlier of the date of the enactment of this Act or September 30, 1982, until such time as such contract is terminated or is not renewed, in accordance with subsection (a). Any matters awaiting a determination by a Statewide Professional Standards Review Council on the date of the enactment of this Act shall be transferred to the Secretary of Health and Human Services for a determination unless such determination is made by such Council within 30 days after the date of the enactment of this Act. No payments shall be made under part B of title XI of 42 USC 1320c. the Social Security Act to Statewide Professional Standards Review Councils for services performed under section 1162 of such Act after 42 USC 1320C-11. the end of such 30-day period. Subtitle D— Aid to Families with Dependent Children rounding of eligibility and benefit amounts Sec. 151. (a) Section 402(a) of the Social Security Act is amended— 95 Stat. 857. 42 USC 602. (1) by striking out “and” at the end of paragraph (32); (2) by striking out the period at the end of paragraph (33) and inserting in lieu thereof “; and”; and (3) by adding at the end thereof the following new paragraph: “(34) provide that both the standard of need applied to a family and the amount of aid determined to be payable, when not a whole dollar amount, shall be rounded to the next lower whole dollar amount.”, (b) The amendment made by this section shall become effective on Effective date. 42 USC 602 note. October 1, 1982. effective date of application; proration of first-month’s afdc benefit Sec. 152. (a) Section 402(a)(10) of the Social Security Act is 42 USC 602. amended— (1) by striking out “provide, effective July 1, 1951, that all individuals” and inserting in lieu thereof “(A) provide that all individuals”; (2) by adding “and” after the semicolon; and (3) by adding at the end thereof the following new subparagraph: “(B) provide that an application for aid under the plan will be effective no earlier than the date such application is filed with the State agency or local agency responsible for the administration of the State plan, and the amount payable for the month in which the application becomes effective, if such application becomes effective after the first day of such month, shall bear the same ratio to the amount which would be payable if the application had been effective on the first day of such month as the number of days in the month including and following the effective date of the application bears to the total number of days in such month;”. (b) The amendments made by this section shall become effective 42 USC 602 note. on October 1, 1982. absence from home solely by reason of uniformed service Sec. 153. (a) Section 406(a)(1) of the Social Security Act is amended 42 USC 606. by inserting “(other than absence occasioned solely by reason of the performance of active duty in the uniformed services of the United States)” after “continued absence from the home”. (b) The amendment made by this section shall become effective on Effective date. 42 USC 606 note. October 1, 1982. job search Sec. 154. (a) Section 402(a) of the Social Security Act (as amended 42 USC 602. by section 151(a) of this Act) is further amended— (1) by striking out “and” at the end of paragraph (33); (2) by striking out the period at the end of paragraph (34) and inserting in lieu thereof “; and”; and (3) by adding at the end thereof the following new paragraph: “(35) at the option of the State, provide— “(A) that as a condition of eligibility for aid under the State plan of any individual claiming such aid who is required to register pursuant to paragraph (19)(A) (or who would be required to register under paragraph (19)(A) but for clause (iii) thereof), including all such individuals or only such groups, types, or classes thereof as the State agency may designate for purposes of this paragraph, such individual will be required to participate in a program of employment search— “(i) beginning at the time he applies for such aid (or an application including his need is filed) and continuing for a period (prescribed by the State) of not more than eight weeks (but this requirement may not be used as a reason for any delay in making a determination of an individual’s eligibility for aid or in issuing a payment to or in behalf of any individual who is otherwise eligible for such aid); and “(ii) at such time or times after the close of the period prescribed under clause (i) as the State agency may determine but not to exceed a total of 8 weeks in any 12 consecutive months; “(B) that any individual participating in a program of employment search under this paragraph will be furnished such transportation and other services, or paid (in advance or by way of reimbursement) such amounts to cover transportation costs and other expenses reasonably incurred in meeting requirements imposed on him under this paragraph, as may be necessary to enable such individual to participate in such program; and “(C) that, in the case of an individual who fails without good cause to comply with requirements imposed upon him under this paragraph, the sanctions imposed by paragraph (19)(F) shall be applied in the same manner as if the individual had made a refusal of the type which would cause the provisions of such paragraph (19)(F) to be applied (except that the State may at its option, for purposes of this paragraph, reduce the period for which such sanctions would otherwise be in effect).”. (b) (1) Section 403(a)(3)(C) of such Act is amended by inserting 42 USC 603. immediately after “expenditures” the following: “(including as expenditures under this subparagraph the value of any services furnished, and the amount of any payments made (to cover expenses incurred by individuals under a program of employment search), under section 402(a)(35)(B))”. (2) Section 403(a)(3) of such Act is further amended by striking out “other than services” in the matter immediately following subparagraph (C) and inserting in lieu thereof the following: “other than services furnished under section 402(a)(35)(B) (as described in the parenthetical phrase in subparagraph (C)), and other than services”. (c) Section 409(b)(3) of such Act is amended— 95 Stat. 846. 42 USC 609. (1) in the first sentence— (A) by inserting “, any program of employment search under section 402(a)(35),” after “pursuant to this section”, (B) by striking out “both such programs” and inserting in lieu thereof “more than one such program”, and (C) by striking out “in the other” and inserting in lieu thereof “in another”; and (2) in the second sentence, by striking out “both such programs” and inserting in lieu thereof “more than one such program”. (d) The amendments made by this section shall become effective Effective date. 42 USC 602 note. on October 1, 1982. proration of standard amount for shelter and utilities Sec. 155. (a) Section 412 of the Social Security Act is amended to 42 USC 612. read as follows: “prorating shelter allowance of afdc family living with another household “Sec. 412. A State plan for aid and services to needy families with children may provide that, in determining the need of any dependent child or relative claiming aid who is living with other individuals (not claiming aid together with such child or relative) as a household (as defined, for purposes of this section, by the Secretary), the amount included in the standard of need, and the payment standard, applied to such child or relative for shelter, utilities, and similar needs may be prorated on a reasonable basis, in such manner and under such circumstances as the State may determine to be appropriate. For purposes of any method of proration used by a State under this section, there shall not be included as a member of a household an individual receiving benefits under title XVI in any 42 USC 1381. month to whom the one-third reduction prescribed by section 1612(a)(2)(A)(i) is applied.". 42 USC 1382a. Effective date. 42 USC 612 note. (b) The amendment made by this section shall become effective on October 1, 1982. limitation on federal financial participation in erroneous assistance expenditures Sec. 156. (a) Section 403(i) of the Social Security Act is amended to 42 USC 603. read as follows: “(i) (1) (A) Notwithstanding subsection (a)(1), if the ratio of a State’s erroneous excess payments (as defined in subparagraph (C) to its total payments under the State plan approved under this part exceeds— “(i) 0.04 for fiscal year 1983, or “(ii) 0.03 for any fiscal year thereafter, then the Secretary shall make no payment for such fiscal year with respect to so much of the erroneous excess payments (as so defined) as exceeds the allowable error rate for such fiscal year. “(B) The Secretary may waive, in certain limited cases, all or part of the reduction required under subparagraph (A) with respect to any State if such State is unable to reach the allowable error rate for a fiscal year despite a good faith effort by such State. “(C) For purposes of this subsection, the term ‘erroneous excess payments’ means the total of (i) payments to ineligible families, and (ii) overpayments to eligible families. “(2) The State agency administering the plan approved under this part shall, at such times and in such form as the Secretary may specify, provide information on the rates of erroneous excess payments made in connection with its administration of such plan, together with any other data he requests that are reasonably necessary for him to carry out the provisions of this subsection. “(3) (A) If a State fails to cooperate with the Secretary in providing information necessary to carry out this subsection, the Secretary, directly or through contractual or such other arrangements as he may find appropriate, shall establish the error rates for that State on the basis of the best data reasonably available to him and in accordance with such techniques for sampling and estimating as he finds appropriate. “(B) In any case in which it is necessary for the Secretary to exercise his authority under subparagraph (A) to determine a State’s error rate for a fiscal year, the amount that would otherwise be payable to such State under this part for quarters in such year shall be reduced by the costs incurred by the Secretary in making (directly or otherwise) such determination. “(4) This subsection shall not apply with respect to Puerto Rico, Guam, or the Virgin Islands.”. (b) Section 403(a) of such Act is amended by striking out “In the 42 USC 603. case of calendar quarters beginning after September 30, 1977, and prior to April 1, 1978, the amount to be paid to each State (as determined under the preceding provisions of this subsection or section 1118, as the case may be) shall be increased in accordance with the provisions of subsection (i) of this section.”. (c) Section 403(j) of such Act is amended by striking out “If the 42 USC 603. dollar error rate of aid furnished by a State” and inserting in lieu thereof “In the case of Puerto Rico, Guam, or the Virgin Islands, if the dollar error rate of aid furnished by such State”. (d) (1) The amendments made by subsections (a) and (b) shall Effective date. 42 USC 603 note. become effective on October 1, 1982. (2) The inapplicability of section 403(j) of the Social Security Act to States other than Puerto Rico, Guam, and the Virgin Islands by reason of the amendment made by subsection (c) shall be effective with respect to six-month periods beginning after April 1983. (e) The regulations currently in effect for fiscal year 1982 with 42 USC 603 note. respect to erroneous payments made by States under a State plan approved under part A of title IV of the Social Security Act (45 CFR 42 USC 601. 205.42) shall remain in effect with respect to erroneous payments made by States until new regulations reflecting the changes made by subsection (a) are promulgated and placed in effect. exclusion from income of certain state payments Sec. 157. (a) The last sentence of section 403(a) of the Social 42 USC 603. Security Act is amended by inserting before the period at the end thereof the following: “, but any such amount, if determined to have been paid by the State in recognition of the difference between the current or anticipated needs of a family for a month based upon actual income or other relevant circumstances for such month, and the needs of such family for such month based upon income and other relevant circumstances as retrospectively determined under section 402(a)(13)(A)(ii), shall not be considered income within the 42 USC 602. meaning of section 402(a)(13) for the purpose of determining the amount of aid in the succeeding months”. (b) The amendment made by this section shall become effective on Effective date. 42 USC 603 note. October 1, 1982. extension of time for states to establish a work incentive demonstration program Sec. 158. (a) Section 445(b)(1) of the Social Security Act is amended 95 Stat. 850. 42 USC 645. by striking out “Not later than sixty days following the date of the enactment of this section” and inserting in lieu thereof “Not later than June 30, 1984”. (b) Section 445(b)(1)(B) of such Act is amended by inserting before the semicolon at the end thereof the following: “, but subject to waiver of such criteria as provided under section 1115”. 42 USC 1315. (c) The amendments made by this section shall become effective Effective date. 42 USC 645 note. on the date of the enactment of this Act. exclusion from income Sec. 159. Notwithstanding any other provision of law, payments 42 USC 602 note. which are made, under a statutorily established State program, to meet certain needs of children receiving aid under the State’s plan approved under part A of title IV of the Social Security Act, if— 42 USC 601. (1) the payments are made to such children by the State agency administering such plan, but are made without Federal financial participation (under section 403(a) of such Act or otherwise), and (2) the State program has been continuously in effect since before January 1, 1979, shall be excluded from the income of such children and their families for purposes of section 402(a)(17) of such Act, and for all the other purposes of such part A and of such plan, effective on the date of the enactment of this Act. technical amendments to social services and foster care provisions in 1981 reconciliation act Sec. 160. (a) Section 1108(a) of the Social Security Act is amended 42 USC 1308. by adding at the end thereof (after and below paragraph (3)(F)) the following new sentence: “Each jurisdiction specified in this subsection may use in its program under title XX any sums available to it under this subsection which are not needed to carry out the programs specified in this subsection.” (b) Section 2003(b) of such Act is amended in the matter following 95 Stat. 868. 42 USC 1397b. clause (2) by inserting “(other than Puerto Rico, Guam, the Virgin Islands, and the Northern Mariana Islands)” after “the population of all the States”. (c) The last sentence of section 1101(a)(1) of such Act is amended 95 Stat. 871. 42 USC 1301. by striking out “American Samoa, the Northern Mariana Islands, and the Trust Territory of the Pacific Islands” and inserting in lieu thereof “Guam, and the Northern Mariana Islands”. (d) Section 2353(r) of the Omnibus Budget Reconciliation Act of 95 Stat. 871. 42 USC 671. 1981 is amended to read as follows: “(r) Section 471(a)(10) of such Act is amended to read as follows: “‘(10) provides for the establishment or designation of a State authority or authorities which shall be responsible for establishing and maintaining standards for foster family homes and child care institutions which are reasonably in accord with recommended standards of national organizations concerned with standards for such institutions or homes, including standards related to admission policies, safety, sanitation, and protection of civil rights, and provides that the standards so established shall be applied by the State to any foster family home or child care institution receiving funds under this part or part B of this title; ’”. (e) The amendments made by this section shall be effective as of Effective date. 42 USC 1301 note. October 1, 1981. delayed effective date in cases requiring conforming state legislation Sec. 161. In the case of a State with respect to which the Secretary 42 USC 602 note. of Health and Human Services has determined that State legislation is required in order to conform the State plan approved under part A of title IV of the Social Security Act to the requirements imposed 42 USC 601. by any amendment made by this subtitle, the State plan shall not be regarded as failing to comply with the requirements of such part solely by reason of its failure to meet the requirements imposed by such amendment prior to the end of the first session of the State legislature which begins after October 1, 1982, or which began prior to October 1, 1982, and remained in session for at least twenty-five calendar days after such date. For purposes of the preceding sentence, the term “session” means a regular, special, budget, or other session of a State legislature. Subtitle E— Child Support Enforcement fee for services to non-afdc families Sec. 171. (a) Section 454(6) of the Social Security Act is amended— 95 Stat. 862. 42 USC 654. (1) in clause (A), by inserting “including, at the option of the State, support collection services for the spouse (or former spouse) with whom the absent parent’s child is living (but only if a support obligation has been established with respect to such spouse),” after “with the State,”; (2) in clause (B), by striking out “services under the State plan (other than collection of support)” and inserting in lieu thereof “such services”; and (3) by amending clause (C) to read as follows: “(C) any costs in excess of the fee so imposed may be collected— “(i) from the parent who owes the child or spousal support obligation involved, or “(ii) at the option of the State, from the individual to whom such services are made available, but only if such State has in effect a procedure whereby all persons in such State having authority to order child or spousal support are informed that such costs are to be collected from the individual to whom such services were made available;”. (b) (1) Section 454 of such Act is further amended— 95 Stat. 863. (A) by adding “and” after the semicolon at the end of paragraph (18); (B) by striking out paragraph (19); and (C) by redesignating paragraph (20) as paragraph (19). (2) Section 2333(c) of the Omnibus Budget Reconciliation Act of 95 Stat. 862. 42 USC 655. 1981 is amended by striking out “Section 453(a) of such Act is amended” and inserting in lieu thereof “Section 455(a) of such Act is amended”. (3) Section 303(e)(2)(A)(iii)(II) of the Social Security Act is amended 42 USC 503. by striking out “454(20)(B)(i)” and inserting in lieu thereof “454(19)(B)(i)”. (c) The amendments made by this section shall be effective on and Effective date. 42 USC 503 note. after August 13, 1981. allotments from pay for child and spousal support owed by members of the uniformed services on active duty Sec. 172. (a) Part D of title IV of the Social Security Act is amended by adding at the end thereof the following new section: “allotments from pay for child and spousal support owed by members of the uniformed services on active duty “Sec. 465. (a) (1) In any case in which child support payments or 42 USC 665. child and spousal support payments are owed by a member of one of the uniformed services (as defined in section 101(3) of title 37, United States Code) on active duty, such member shall be required to make allotments from his pay and allowances (under chapter 13 of title 37, United States Code) as payment of such support, when he has failed to make periodic payments under a support order that meets the criteria specified in section 303(b)(1)(A) of the Consumer Credit Protection Act (15 U.S.C. 1673(b)(1)(A)) and the resulting delinquency in such payments is in a total amount equal to the support payable for two months or longer. Failure to make such payments shall be established by notice from an authorized person (as defined in subsection (b)) to the designated official in the appropriate uniformed service. Such notice (which shall in turn be given to the affected member) shall also specify the person to whom the allotment is to be payable. The amount of the allotment shall be the amount necessary to comply with the order (which, if the order so provides, may include arrearages as well as amounts for current support), except that the amount of the allotment, together with any other amounts withheld for support from the wages of the member, as a percentage of his pay from the uniformed service, shall not exceed the limits prescribed in sections 303 (b) and (c) of the Consumer Credit Protection Act (15 U.S.C. 1673 (b) and (c)). An allotment under this subsection shall be adjusted or discontinued upon notice from the authorized person. “(2) Notwithstanding the preceding provisions of this subsection, no action shall be taken to require an allotment from the pay and allowances of any member of one of the uniformed services under such provisions (A) until such member has had a consultation with a judge advocate of the service involved (as defined in section 801(13) of title 10, United States Code), or with a law specialist (as defined in section 801(11) of such title) in the case of the Coast Guard, or with a legal officer designated by the Secretary concerned (as defined in section 101(5) of title 37, United States Code) in any other case, in person, to discuss the legal and other factors involved with respect to the member’s support obligation and his failure to make payments thereon, or (B) until 30 days have elapsed after the notice described in the second sentence of paragraph (1) is given to the affected member in any case where it has not been possible, despite continuing good faith efforts, to arrange such a consultation. “(b) For purposes of this section the term ‘authorized person’ with “Authorized person.” respect to any member of the uniformed services means— “(1) any agent or attorney of a State having in effect a plan approved under this part who has the duty or authority under such plan to seek to recover any amounts owed by such member as child or child and spousal support (including, when authorized under the State plan, any official of a political subdivision); and “(2) the court which has authority to issue an order against such member for the support and maintenance of a child, or any agent of such court. “(c) The Secretary of Defense, in the case of the Army, Navy, Air Force, and Marine Corps, and the Secretary concerned (as defined in section 101(5) of title 37, United States Code) in the case of each of the other uniformed services, shall each issue regulations applicable to allotments to be made under this section, designating the officials to whom notice of failure to make support payments, or notice to discontinue or adjust an allotment, should be given, prescribing the form and content of the notice and specifying any other rules necessary for such Secretary to implement this section.”. (b) The amendment made by subsection (a) shall become effective Effective date. 42 USC 665 note. on October 1, 1982. reimbursement of state agency in initial month of ineligibility for afdc Sec. 173. (a) Section 454(5) of the Social Security Act is amended 42 USC 654. by inserting “following the first month” after “for any month”. (b) The amendment made by this section shall become effective on Effective date. 42 USC 654 note. October 1, 1982. reduction in certain federal payments to states under child support enforcement program Sec. 174. (a) Section 455(a)(1) of the Social Security Act is amended 42 USC 655. by striking out “75 percent” and inserting in lieu thereof “70 percent”. (b) Section 455(c) of such Act is repealed. (c) Section 458(a) of such Act is amended by striking out “15 per 42 USC 658. centum” and inserting in lieu thereof “12 percent”. (d) The amendment made by subsection (a) shall apply with 42 USC 655 note. respect to quarters beginning on or after October 1, 1982. Subsection (b) shall apply with respect to quarters beginning on or after October 1, 1983; and the amendment made by subsection (c) shall apply with respect to amounts collected on or after October 1, 1983. technical amendments to child support enforcement provisions in reconciliation act Sec. 175. (a) (1) The first sentence of section 452(b) of the Social 42 USC 652 Security Act is amended by striking out “certify” and all that follows and inserting in lieu thereof “certify to the Secretary of the Treasury for collection pursuant to the provisions of section 6305 of the Internal Revenue Code of 1954 the amount of any child support 26 USC 6305. obligation (including any support obligation with respect to the parent who is living with the child and receiving aid under the State plan approved under part A) which is assigned to such State or is undertaken to be collected by such State pursuant to section 454(6).” 42 USC 654. (2) Section 303(e)(2)(A)(i) of such Act is amended by striking out “of 95 Stat. 863. 42 USC 503. this subsection” and inserting in lieu thereof “of paragraph (1)”. (b) The amendments made by this section shall be effective as of Effective date. 42 USC 503 note. October 1, 1981. delayed effective date in cases requiring state legislation SEC. 176. In the case of a State with respect to which the Secretary 42 USC 654 note. of Health and Human Services has determined that State legislation is required in order to conform the State plan approved under part D of title IV of the Social Security Act to the requirements imposed 42 USC 601. by any amendment made by this subtitle, the State plan shall not be regarded as failing to comply with the requirements of such part solely by reason of its failure to meet the requirements imposed by such amendment prior to the end of the first session of the State legislature which begins after October 1, 1982, or which began prior to October 1, 1982, and remained in session for at least twenty-five calendar days after such date. For purposes of the preceding sentence, “Session.” the term “session” means a regular, special, budget, or other session of a State legislature. Subtitle F— Supplemental Security Income effective date of application; proration of initial ssi benefit payment Sec. 181. (a) Section 1611(c) of the Social Security Act is amended 95 Stat. 865. 42 USC 1382. by striking out paragraphs (2) and (3) and inserting in lieu thereof the following new paragraphs: “(2) The amount of such benefit for the month in which an application for benefits becomes effective (or, if the Secretary so determines, for such month and the following month) and for any month immediately following a month of ineligibility for such benefits (or, if the Secretary so determines, for such month and the following month) shall— “(A) be determined on the basis of the income of the individual and the eligible spouse, if any, of such individual and other relevant circumstances in such month; and “(B) in the case of the month in which an application becomes effective or the first month following a period of ineligibility, if such application becomes effective, or eligibility is restored, after the first day of such month, bear the same ratio to the amount of the benefit which would have been payable to such individual if such application had become effective, or eligibility had been restored, on the first day of such month as the number of days in such month including and following the effective date of such application or restoration of eligibility bears to the total number of days in such month. “(3) For purposes of this subsection, an application of an individual for benefits under this title shall be effective on the later of— “(A) the date such application is filed, or “(B) the date such individual first becomes eligible for such benefits with respect to such application.”. (b) The amendment made by this section shall become effective on Effective date. 42 USC 1382 note. October 1, 1982. rounding of ssi eligibility and benefit amounts Sec. 182. (a) Section 1617 of the Social Security Act is amended to 42 USC 1382f. read as follows: “cost-of-living adjustments in benefits “Sec. 1617. (a) Whenever benefit amounts under title II are 42 USC 401. increased by any percentage effective with any month as a result of a determination made under section 215(i)— 42 USC 415. “(1) each of the dollar amounts in effect for such month under subsections (a)(1)(A), (a)(2)(A), (b)(1), and (b)(2) of section 1611, and subsection (a)(1)(A) of section 211 of Public Law 93–66, as 42 USC 1382, 411. specified in such subsections or as previously increased under this section, shall be increased by the amount (if any) by which— “(A) the amount which would have been in effect for such month under such subsection but for the rounding of such amount pursuant to paragraph (2), exceeds “(B) the amount in effect for such month under such subsection; and “(2) the amount obtained under paragraph (1) with respect to each subsection shall be further increased by the same percentage by which benefit amounts under title II are increased for 42 USC 401. such month (and rounded, when not a multiple of $12, to the next lower multiple of $12), effective with respect to benefits for months after such month. “(b) The new dollar amounts to be in effect under section 1611 of Publication in Federal Register. 42 USC 1382, 411. 42 USC 415. this title and under section 211 of Public Law 93–66 by reason of this section shall be published in the Federal Register together with, and at the same time as, the material required by section 215(i)(2)(D) to be published therein by reason of the determination involved.”. (b) The amendment made by this section shall become effective on Effective date. 42 USC 1382f note. October 1, 1982. coordination of ssi and oasdi cost-of-living adjustments Sec. 183. (a) Section 1611(c) of the Social Security Act (as amended 42 USC 1382. by section 181 of this Act) is further amended— (1) in paragraph (1) by striking out “paragraph (2)” and inserting in lieu thereof “paragraphs (2), (3), and (4)”; (2) by redesignating paragraphs (3) and (4) as paragraphs (5) and (6), respectively; and (3) by inserting after paragraph (2) the following new paragraphs: “(3) For purposes of this subsection, an increase in the benefit amount payable under title II (over the amount payable in the preceding month, or, at the election of the Secretary, the second preceding month) to an individual receiving benefits under this title shall be included in the income used to determine the benefit under this title of such individual for any month which is— “(A) the first month in which the benefit amount payable to such individual under this title is increased pursuant to section 1617, or “(B) at the election of the Secretary, the month immediately following such month. “(4) (A) Notwithstanding paragraph (3), if the Secretary determines that reliable information is currently available with respect to the income and other circumstances of an individual for a month (including information with respect to a class of which such individual is a member and information with respect to scheduled cost-of-living adjustments under other benefit programs), the benefit amount of such individual under this title for such month may be determined on the basis of such information. “(B) The Secretary shall prescribe by regulation the circumstances in which information with respect to an event may be taken into account pursuant to subparagraph (A) in determining benefit amounts under this title.”. (b) The amendment made by subsection (a) shall become effective Effective date. 42 USC 1382 note. October 1, 1982. phaseout of hold harmless protection Sec. 184. (a) Section 401 of the Social Security Amendments of 42 USC 1382e note. 1972 (Public Law 92–603) is amended by adding at the end thereof the following new subsection: “(d) In addition to the amount which a State must pay to the Secretary for the fiscal year 1983 or the fiscal year 1984, as determined under subsection (a), the State shall also pay, for the fiscal year 1983, 60 percent of the further amount that would be payable but for the limit specified in subsection (a), and, for the fiscal year 1984, 80 percent of such further amount. For each fiscal year thereafter, the limit prescribed in subsection (a) shall be inapplicable and a State shall pay to the Secretary the full amount of any supplementary payments he makes on behalf of such State.”. (b) The amendment made by subsection (a) shall become effective Effective date. 42 USC 1382e note. on the date of the enactment of this Act. exclusion from resources of burial plots and certain funds set aside for burial expenses Sec. 185. (a) Section 1613(a)(2) of the Social Security Act is 42 USC 1382b. amended by inserting “(A)” after “(2)”, by adding “and” after the semicolon, and by adding at the end thereof the following new subparagraph: “(B) the value of any burial space (subject to such limits as to size or value as the Secretary may by regulation prescribe) held for the purpose of providing a place for the burial of the individual, his spouse, or any other member of his immediate family;”. (b) Section 1613 of such Act is further amended by adding at the end thereof the following new subsection: “Funds Set Aside for Burial Expenses “(d) (1) In determining the resources of an individual, there shall be excluded an amount, not in excess of $1,500 each with respect to such individual and his spouse (if any), that is separately identifiable and has been set aside to meet the burial and related expenses of such individual or spouse if the inclusion of any portion of such amount or amounts would cause the resources of such individual, or of such individual and spouse, to exceed the limits specified in paragraph (1) or (2) (whichever may be applicable) of section 1611(a). 42 USC 1382. “(2) The amount of $1,500, referred to in paragraph (1), with respect to an individual shall be reduced by an amount equal to (A) the total face value of all insurance policies on his life which are owned by him or his spouse and the cash surrender value of which has been excluded in determining the resources of such individual or of such individual and his spouse, and (B) the total of any amounts in an irrevocable trust (or other irrevocable arrangement) available to meet the burial and related expenses of such individual or his spouse. “(3) If the Secretary finds that any part of the amount excluded under paragraph (1) was used for purposes other than those for which it was set aside, he shall reduce any future benefits payable to the eligible individual (or to such individual and his spouse) by an amount equal to such part. “(4) The Secretary may provide by regulations that whenever an amount set aside to meet burial and related expenses is excluded under paragraph (1) in determining the resources of an individual, any interest earned or accrued on such amount (and left to accumulate), and any appreciation in the value of prepaid burial arrangements for which such amount was set aside, shall also be excluded (to such extent and subject to such conditions or limitations as such regulations may prescribe) in determining the resources (and the income) of such individual.”. (c) The amendment made by this section shall take effect on the Effective date. 42 USC 1382b note. first day of the second month after the month in which this Act is enacted. mandatory passthrough under state supplementation provisions Sec. 186. Section 1618 of the Social Security Act is amended by 42 USC 1382g. adding at the end thereof the following new subsection: “(c) Any State which satisfies the requirements of this section solely by reason of subsection (b) for a particular month or months in any 12-month period (described in such subsection) ending on or after June 30, 1982, may elect, with respect to any month in any subsequent 12-month period (so described), to apply subsection (a)(4) as though the reference to December 1976 in such subsection were a reference to the month of December which occurred in the 12-month period immediately preceding such subsequent period.”. treatment of unnegotiated checks under supplemental security income program Sec. 187. (a) Section 1631(i)(2) of the Social Security Act (as added 95 Stat. 866. 42 USC 1383. by section 2343(a) of the Omnibus Budget Reconciliation Act of 1981) is amended by striking out “included in all checks payable to individuals entitled to benefits under this title but” in the first sentence and inserting in lieu thereof “included in all such benefit checks”. (b) The amendment made by subsection (a) shall become effective Effective date. 42 USC 1383 note. October 1, 1982. Subtitle G— Unemployment Compensation rounding of benefit amounts Sec. 191. (a) Section 204(a)(2) of the Federal-State Extended Unemployment 95 Stat. 884. 26 USC 3304 note. Compensation Act of 1970 is amended by striking out “or” at the end of clause (B), and by inserting before the period at the end thereof the following: “, or (D) paid to an individual with respect to a week of unemployment to the extent that such amount exceeds the amount of such compensation which would be paid to such individual if such State had a benefit structure which provided that the amount of compensation otherwise payable to any individual for any week shall be rounded (if not a full dollar amount) to the nearest lower full dollar amount”. (b) (1) Except as provided in paragraph (2), the amendments made Effective date. 42 USC 3304 note. by this section shall apply in the case of compensation paid to individuals during eligibility periods beginning on or after October 1, 1983. (2) In the case of a State with respect to which the Secretary of Labor has determined that State legislation is required in order to provide for rounding down of unemployment compensation amounts, the amendment made by this section shall apply in the case of compensation paid to individuals during eligibility periods which begin on or after October 1, 1983, and after the end of the first session of the State legislature which begins after the date of the enactment of this Act, or which began prior to the date of the enactment of this Act and remained in session for at least twenty-five Calendar days after such date of enactment. For purposes of the “Session.” preceding sentence, the term “session” means a regular, special, budget, or other session of a State legislature. use of certain amounts transferred to state unemployment funds Sec. 192. (a) Paragraph (2) of section 903(c) of the Social Security 42 USC 1103. Act is amended— (1) by striking out “twenty-four” each place it appears and inserting in lieu thereof “thirty-four”; and (2) by striking out “twenty-fourth” in the second sentence and inserting in lieu thereof “thirty-fourth”. (b) Subsection (c) of section 903 of such Act is amended by adding at the end thereof the following new paragraph: “(3) (A) If— “(i) amounts transferred to the account of a State pursuant to subsections (a) and 0?) of this section were used in payment of unemployment benefits to individuals; and “(ii) the Governor of such State submits a request to the Secretary of Labor that such amounts be restored under this paragraph, then the amounts described in clause (i) shall be restored to the status of funds transferred under subsections (a) and (b) of this section which have not been used by eliminating any charge against amounts so transferred for the use of such amounts in the payment of unemployment benefits. “(B) Subparagraph (A) shall apply only to the extent that the amounts described in clause (i) of such subparagraph do not exceed the amount then in the State’s account. “(C) Subparagraph (A) shall not apply if the State has a balance of advances made to its account under title XII of this Act. 42 USC 1321. “(D) If the Secretary of Labor determines that the requirements of this paragraph are met with respect to any request, the Secretary shall notify the Governor of the State that such requirements are met with respect to such request and the amount restored under this paragraph. Such restoration shall be as of the first day of the first month following the month in which the notification is made.”. treatment of certain employees of institutions of higher education Sec. 193. (a) Clause (ii) of section 3304(a)(6)(A) of the Internal 26 USC 3304. Revenue Code of 1954 (relating to requirements for approval of State unemployment compensation laws) is amended to read as follows: “(ii) with respect to services in any other capacity for an educational institution to which section 3309(a)(1) applies— 26 USC 3309. “(I) compensation payable on the basis of such services may be denied to any individual for any week which commences during a period between 2 successive academic years or terms if such individual performs such services in the first of such academic years or terms and there is a reassonable assurance that such individual will perform such services in the second of such academic years or terms, except that “(II) if compensation is denied to any individual for any week under subclause (I) and such individual was not offered an opportunity to perform such services for the educational institution for the second of such academic years or terms, such individual shall be entitled to a retroactive payment of the compensation for each week for which the individual filed a timely claim for compensation and for which compensation was denied solely by reason of subclause (I),”. (b) (1) The amendment made by subsection (a) shall apply to weeks Effective date. 26 USC 3304 note. of unemployment beginning after the date of the enactment of this Act. (2) The amendment made by subsection (a), insofar as it requires retroactive payments of compensation to employees of educational institutions other than institutions of higher education (as defined in section 3304(f) of the Internal Revenue Code of 1954), shall not be a requirement for any State law before January 1, 1984. short-time compensation Sec. 194. (a) It is the purpose of this section to assist States which 26 USC 3304 note. provide partial unemployment benefits to individuals whose work-weeks are reduced pursuant to an employer plan under which such reductions are made in lieu of temporary layoffs. (b) (1) The Secretary of Labor (hereinafter in this section referred to as the “Secretary”) shall develop model legislative language which may be used by States in developing and enacting short-time compensation programs, and shall provide technical assistance to States to assist in developing, enacting, and implementing such short-time compensation program. (2) The Secretary shall conduct a study or studies for purposes of evaluating the operation, costs, effect on the State insured rate of unemployment, and other effects of State short-time compensation programs developed pursuant to this section. (3) This section shall be a three-year experimental provision, and the provisions of this section regarding guidelines shall terminate 3 years following the date of the enactment of this Act. (4) States are encouraged to experiment in carrying out the purpose and intent of this section. However, to assure minimum uniformity. States are encouraged to consider requiring the provisions contained in subsections (c) and (d). (c) For purposes of this section, the term “short-time compensation Definitions. program” means a program under which— (1) individuals whose workweeks have been reduced pursuant to a qualified employer plan by at least 10 per centum will be eligible for unemployment compensation; (2) the amount of unemployment compensation payable to any such individual shall be a pro rata portion of the unemploy-ment compensation which would be payable to the individual if the individual were totally unemployed; (3) eligible employees may be eligible for short-time compensation or regular unemployment compensation, as needed; except that no employee shall be eligible for more than the maximum entitlement during any benefit year to which he or she would have been entitled for total unemployment, and no employee shall be eligible for short-time compensation for more than twenty-six weeks in any twelve-month period; and (4) eligible employees will not be expected to meet the availability for work or work search test requirements while collecting short-time compensation benefits, but shall be available for their normal workweek. (d) For purposes of subsection (c), the term “qualified employer plan” means a plan of an employer or of an employers’ association which association is party to a collective bargaining agreement (hereinafter referred to as “employers’ association”) under which there is a reduction in the number of hours worked by employees rather than temporary layoffs if— (1) the employer’s or employers’ association’s short-time compensation plan is approved by the State agency; (2) the employer or employers’ association certifies to the State agency that the aggregate reduction in work hours pursuant to such plan is in lieu of temporary layoffs which would have affected at least 10 per centum of the employees in the unit or units to which the plan would apply and which would have resulted in an equivalent reduction of work hours; (3) during the previous four months the work force in the affected unit or units has not been reduced by temporary layoffs of more than 10 per centum; (4) the employer continues to provide health benefits, and retirement benefits under defined benefit pension plans (as defined in section 3(35) of the Employee Retirement Income 29 USC 1002. Security Act of 1974, to employees whose workweek is reduced under such plan as though their workweek had not been reduced; and (5) in the case of employees represented by an exclusive bargaining representative, that representative has consented to the plan. The State agency shall review at least annually any qualified employer plan put into effect to assure that it continues to meet the requirements of this subsection and of any applicable State law. (e) Short-time compensation shall be charged in a manner consistent with the State law. (f) For purposes of this section, the term “State” includes the District of Columbia, the Commonwealth of Puerto Rico, and the Virgin Islands. (g) (1) The Secretary shall conduct a study or studies of State short-time compensation programs consulting with employee and employer representatives in developing criteria and guidelines to measure the following factors: (A) the impact of the program upon the unemployment trust fund, and a comparison with the estimated impact on the fund of layoffs which would have occurred but for the existence of the program; (B) the extent to which the program has protected and preserved the jobs of workers, with special emphasis on newly hired employees, minorities, and women; (C) the extent to which layoffs occur in the unit subsequent to initiation of the program and the impact of the program upon the entitlement to unemployment compensation of the employees; (D) where feasible, the effect of varying methods of administration; (E) the effect of short-time compensation on employers’ State unemployment tax rates, including both users and nonusers of short-time compensation, on a State-by-State basis; (F) the effect of various State laws and practices under those laws on the retirement and health benefits of employees who are on short-time compensation programs; (G) a comparison of costs and benefits to employees, employers, and communities from use of short-time compensation and layoffs; (H) the cost of administration of the short-time compensation program; and (I) such other factors as may be appropriate. (2) Not later than October 1, 1985, the Secretary shall submit to Report to President and Congress. the Congress and to the President a final report on the implementation of this section. Such report shall contain an evaluation of short-time compensation programs and shall contain such recommendations as the Secretary deems advisable, including recommendations as to necessary changes in the statistical practices of the Department of Labor.

2. 1982

   Pub. L. 97–248 § 109(a)(2) · 96 Stat. 324

   Added · 42 U.S.C. § 1395xx(b)

   Pub. L. 97–248, § 109(a)(2), added subsec. (b)

   Source evidence

   Code amendment note
   Subsec. (b). Pub. L. 97–248, § 109(a)(2), added subsec. (b).

   Enacted provision · exact public law section
   (2) by adding at the end the following new subsection:

3. 1983

   Pub. L. 98–21 title VI § 602(j) · 97 Stat. 65

   Inserted · 42 U.S.C. § 1395xx(a)(1)(B)

   Pub. L. 98–21 inserted “or on the bases described in section 1395ww of this title”

   Source evidence

   Code amendment note
   Subsec. (a)(1)(B). Pub. L. 98–21 inserted “or on the bases described in section 1395ww of this title”.

   Enacted provision · exact public law section
   (j) Section 1887(a)(1)(B) of such Act is amended by inserting “or on 96 Stat. 337. 42 USC 1395xx. the bases described in section 1886” after “on a reasonable cost basis”.

   Effective date note
   Amendment by Pub. L. 98–21 applicable to items and services furnished by or under arrangement with a hospital beginning with its first cost reporting period that begins on or after Oct. 1, 1983, any change in a hospital’s cost reporting period made after November 1982 to be recognized for such purposes only if the Secretary finds good cause therefor, see section 604(a)(1) of Pub. L. 98–21, set out as a note under section 1395ww of this title.

2 of 3 references resolved to an enrolled provision · 1 partial