Medicare and Medicaid Budget Reconciliation Amendments of 1987

Title I: Short Title - Medicare and Medicaid Budget Reconciliation Amendments of 1987.

Title II: Amendments to Social Security Act - Provides that this Act's amendments shall be considered to be made to the Social Security Act, except as otherwise specified.

Title III: Table of Contents of Title IV - Supplies the table of contents for Title IV of this Act.

Title IV: Medicare and Medicaid Amendments - Subtitle A: Medicare Provisions - Part I: Payment Reforms - Amends part B (Supplementary Medical Insurance) of title XVIII (Medicare) of the Social Security Act to provide for reductions in the prevailing charges, used in determining reasonable charges for Medicare services, for specified surgical procedures. Sets limits on the amount nonparticipating physicians may charge for such procedures.

Reduces the rate of payment for a physician's provision of medical direction to nurse anesthetists when such physician is providing medical direction to two or more nurse anesthetists performing anesthesia services concurrently.

Adjusts the Medicare Economic Index to increase the prevailing charge for a physician's primary care services by six percent in 1988 while increasing such charge for a physician's other services by two percent.

Provides physicians whose primary practice is family practice, general practice, general internal medicine, gynecology, or pediatrics with incentive payments for practicing in underserved rural areas.

Sets forth special Medicare payment rules for durable medical equipment, prosthetic devices, orthotics (leg, arm, back, and neck braces), and prosthetics. Requires the Secretary of Health and Human Services to report to the Congress by 1991 on the impact of such rules on the availability of such services and the appropriateness of increasing payment rates for oxygen and oxygen equipment when a greater volume of oxygen or portable oxygen equipment is used. Places a moratorium, until 1991, on the Secretary's conduct of any demonstration project regarding alternative methods of paying for covered items.

Directs the Secretary to establish, and report to the Congress regarding, fee schedules for radiologic services by August 1, 1988. Requires that such schedules take into account variations in the cost of furnishing services in different areas and result in certain reductions in aggregate Medicare payments for such services. Sets limits on the amount nonparticipating physicians may charge for such services. Authorizes the Secretary to allow physicians and suppliers to become participating physicians or suppliers only with respect to radiologic services.

Directs the Secretary to: (1) establish proposed fee schedules for physician pathology services which may be implemented by 1990; and (2) report to the Congress regarding such fee schedules.

Prohibits the Secretary from implementing or conducting a new study into a prospective payment system for radiologic, physician anesthesia, and physician pathology services under the Medicare program before 1991 unless specifically directed by law to do so.

Makes technical changes regarding a nonparticipating physician's maximum allowable actual charge.

Eliminates the FY 1975 floor on the prevailing charge for a physician service in a locality.

Sets the maximum rate of payment per visit for independent rural health clinic services at $46 in 1988, updated annually thereafter to reflect increases in the Medicare Economic Index. Requires the Secretary to report to the Congress by March 1, 1989, on the adequacy of payments for such services.

Requires that the fee schedule for certified registered nurse anesthetist services be based on data from cost reporting periods beginning in FY 1985 and such other data that the Secretary deems necessary to establish a reasonable fee schedule.

Includes the services of registered nurses as assistants at surgery as "medical and other health services" for which direct Medicare payments may be made. Directs the Secretary to report to the Congress by April 1, 1989, regarding the adequacy of payments for physicians' assistants and registered nurses assisting at surgery.

Establishes a floor on the reasonable charge for each physicians' services equal to 55 percent of the average of the prevailing charge levels for such service in all localities for the year. Increases the prevailing and customary charge for a service when such charges are lower than the reasonable charge floor so that by 1991 prevailing and customary charges are at least equal to the reasonable charge floor for a physicians' service. Prohibits the maximum allowable actual charge of a nonparticipating physician for a covered service furnished in 1989 or 1990 from being less than 96 precent of the minimum allowable pervailing charge for 1989 and 1990. Provides that for physicians' services furnished after 1988 the regular percentage increase in the Medicare Economic Index shall be decreased by two percentage points.

Part 2: Coverage and Eligibility Changes - Amends the Medicare program to provide Medicare coverage for influenza vaccines and their administration.

Limits covered immunosuppressive drugs to prescription drugs used in immunosuppressive therapy.

Provides coverage under part B of the Medicare program of services furnished by a clinical social worker to a member of a health maintenance organization.

Amends part A (Hospital Insurance) of the Medicare program to continue part A eligibility of physically or mentally impaired individuals who were eligible for such benefits by reason of their entitlement to disability benefits under title II (Old Age, Survivors and Disability Insurance) of the Act, but whose title II benefits have been terminated because they engaged in substantial gainful activity. Sets forth enrollment, special enrollment, and coverage periods as well as the contingencies terminating one's enrollment. Conditions such continued part A eligibility upon the payment of a monthly premium.

Requires individuals who are entitled to part B (Supplementary Medical Insurance) Medicare benefits only by reason of their continued part A eligibility provided by this Act to pay a monthly premium set at four times the amount otherwise required under part B. Prohibits such part A and B premiums from exceeding a specified percentage of the individual's adjusted gross income, unless the premium thereby sinks below 25 percent of the premium determined without income restraints.

Amends title II of the Act to provide that when individuals become entitled to OASDI disability benefits by reason of a disability which previously entitled them to such benefits, both periods of entitlement shall count toward the two-year period of OASDI disability benefit entitlement required for Medicare eligibility despite an intervening period of gainful employment.

Provides coverage under part B of the Medicare program for therapeutic shoes furnished to individuals with severe diabetic foot disease.

Part 3: Home Health Care Quality Improvements - Defines as "homebound", a prerequisite of eligibility for Medicare home health services, any person who has a condition which restricts his or her ability to leave the home without support or for whom leaving the home is medically contraindicated.

Requires Medicare fiscal intermediaries which perform home health payment services to provide an explanation of claim denials for home health services and promptly notify the parties requesting a reconsideration of such determinations of the result of such reconsideration. Requires fiscal intermediaries to make partial payments of disputed claims when such notice has not been transmitted within 60 days of receipt of the reconsideration request. Makes an intermediary's performance on appeals of home health care payment determinations part of the Secretary's overall appraisal of the intermediary.

Requires a Medicare home health agency to: (1) protect and promote the rights of each individual under its care; (2) notify the State licensing or certification entity of changes in persons having an ownership or controlling interest in the agency or changes in the organization responsible for managing the agency; (3) furnish items and services through licensed health professionals or persons who have completed or are enrolled in a training program which meets minimum standards established by the Secretary by July 1, 1988; and (4) include the patient's plan of care within its clinical records.

Requires an appropriate State or local agency to conduct an unannounced survey on an average of once a year, but in no case later than 15 months after the previous unannounced survey, and within two months of the receipt of a significant number of complaints against a home health agency, of the quality of patient care provided by such agencies. Authorizes the survey of a home health agency within two months of any change in its ownership, administration, or management. Subjects home health agencies which perform poorly in such surveys to an extended survey. Directs the Secretary to evaluate the assessment process, report to the Congress on the results of such evaluation, and make appropriate modifications to such process by 1991.

Requires that when the Secretary determines that a home health agency's deficiencies immediately jeopardize the health and safety of service recipients the Secretary take immediate action to remove the jeopardy or correct the deficiencies, or terminate the agency's Medicare participation. Authorizes the Secretary to impose intermediate sanctions against an agency whose failure to correct deficiencies does not immediately jeopardize the health and safety of health care beneficiaries, but halts Medicare payments to such agency if six months pass without the correction of deficiencies.

Directs the Secretary to publish and make available to the public without charge a directory of home health agencies certified to participate in the Medicare program, including information regarding all surveys and certifications made with respect to each agency.

Requires appropriate State or local agencies to maintain: (1) toll-free hotlines to receive complaints and answer questions regarding home health agencies in the State or locality; and (2) units with enforcement authority and access to consumer medical records and survey reports to investigate such complaints.

Directs the Secretary to: (1) report to the Congress before 1988 on the appropriateness of reimbursing home health agencies on either a rural or urban basis rather than considering an agencies mix of urban and rural clientele; (2) determine home health agency cost limits on the basis of recent agency cost reports; and (3) establish a demonstration project to develop and test alternative methods of paying home health agencies on a prospective basis for services furnished under the Medicare and Medicaid (title XIX of the Act) programs.

Part 4: Peer Review Organizations - Amends part B (Peer Review) of title XI of the Act to require the physician representative of a peer review organization (PRO) responsible for reviewing the services of a rural hospital to visit such hospital at least quarterly and meet with the hospital staff regarding such review. Requires the Secretary to emphasize a PRO's performance in educating providers and practitioners concerning the review process when evaluating a PRO's performance. Prohibits a PRO's determination that a payment should not be made from becoming final before the physician or provider involved has a reasonable and convenient opportunity to discuss the proposed determination and the physician or provider has had 30-days notice of the proposed determination. Directs the Secretary to report to the Congress within two years of this Act's enactment regarding the educational effectiveness of PROs providing Medicare beneficiaries with payment denial notices when such beneficiaries are not liable for payment. Prohibits the Medicare exclusion of a provider or practitioner pending completion of administrative review procedures unless a hearing before an administrative law judge results in the determination that the provider or practitioner will pose a serious risk to beneficiaries if allowed to continue furnishing Medicare services.

Part 5: Miscellaneous Provisions - Permits Medicare beneficiaries (other than those with end-stage renal disease or already enrolled with organizations providing health services on a prepaid basis) to enroll with eligible organizations with which the Secretary enters a contract for the provision of community nursing and ambulatory care on a prepaid, capitated basis. Lists the services and supplies which comprise community nursing and ambulatory care. Defines an "eligible organization" as a public or private entity which: (1) primarily engages in the provision of community nursing and ambulatory care; (2) provides such care through or under the supervision of a registered nurse; (3) maintains clinical records on all patients; and (4) maintains procedures for referring cases to or consulting with other health care providers.

Requires the Secretary to annually publish a per capita rate of payment for each class of enrollees equal to 95 percent of the adjusted average per capita cost for such class. Directs the Secretary to make monthly prepayments to such organizations in accordance with such rates. Authorizes retroactive payment adjustments to account for differences between the actual number of enrollees and the number of enrollees estimated for the purpose of determining the advance payment. Prohibits: (1) estimated payments for prepaid community nursing and ambulatory care from exceeding the payments which the Secretary estimates would otherwise have been made for such care; and (2) enrollee charges from exceeding charges for which they would be liable in the absence of their enrollment.

Authorizes eligible organizations to provide enrollees with optional additional care. Requires the provision of additional care where the average of the per capita rates of payment to an organization exceeds the adjusted community rate for community nursing and ambulatory care, unless the organization elects to have such payments reduced or withheld.

Makes certain Medicare provisions which are applicable to health maintenance organizations and competitive medical plans applicable to organizations providing care pursuant to this Act, including provisions regarding: (1) enrollment periods; (2) enrollee grievance procedures; (3) health care quality assurance programs; and (4) the organization's status as a secondary payor.

Requires the expedited administrative hearing of an appeal of a determination regarding an individuals entitlement to Medicare benefits or the amount of such benefits when there are no material issues of fact in dispute. Directs the Secretary to establish certain time limits on carriers' hearings regarding their Medicare payment determinations.

Requires the Secretary to promulgate major Medicare rules, requirements, or policy statements through the regulatory process.

Sets forth publication requirements. Prohibits carriers, fiscal intermediaries, or PROs from implementing a policy change affecting a change in Medicare payments without providing 30-days notice of such change to affected parties. Requires the Secretary to include in the publication of a regulation which can reasonably be expected to affect a substantial number of rural health care providers an analysis of the regulation's impact on the access of individuals to rural health care services.

Prohibits the Secretary from requiring carriers to delay payments under part B of the Medicare program.

Treats employees of the Physician Payment Review Commission as employees of the United States Senate for purposes of pay and employment benefits, rights, and privileges.

Limits the podiatrist services which may be considered physicians' services under the Medicare program.

Makes a group health plan the primary payer for items and services covered under Medicare's end-stage renal disease program. Limits minimum utilization rate requirements for end-stage renal disease services to transplantations.

Amends the Omnibus Budget Reconciliation Act of 1986 to delay, from April 1, 1989, to April 1, 1990, the effective date of the prohibition of health maintenance organizations from providing physicians with incentives to reduce or limit services. Delays, from October 1, 1987, to April 1, 1988, the application of certain standards for organ procurement agencies.

Directs the Secretary to: (1) arrange for, and report to the Congress within three years of this Act's enactment on, a study of the Medicare end-stage renal disease program; and (2) study, and report to the Congress by April 1, 1989, on ways to provide adequate payments under part B of the Medicare program for the costs of providing chemotherapy to cancer patients in physicians' offices.

Amends the Omnibus Budget Reconciliation Act of 1985 to delay, from July 1, 1987, to October 1, 1988, the date by which the Secretary must establish a system providing for a unique identifier for each physician furnishing Medicare services.

Authorizes the Secretary to impose sanctions against a person who knowingly and willfully bills a beneficiary for a clinical diagnostic laboratory test for which payment may only be made on an assigned basis in the same manner in which they may be applied against nonparticipating physicians who overcharge for their services.

Requires the Secretary to determine, upon the request of a pediatric heart transplant center, whether such center meets the standards for qualification as a Medicare heart transplant center and issue a certification of such fact if the center meets such standards.

Subtitle B: Provisions Relating to Medicaid Program Part 1 Combatting Infant Mortality - Amends title XIX (Medicaid) of the Act to allow States to extend Medicaid coverage to pregnant women and infants under age one whose family income exceeds current income eligibility standards, but does not exceed 185 percent of the Federal poverty level.

Authorizes States to accelerate the coverage of poor children under age five. (Currently, coverage would not be extended to all poor children under age five until FY 1991). Allows States to extend Medicaid coverage to poor children under age eight.

Directs the Secretary to provide for State demonstration projects to reduce infant mortality and early childhood morbidity by improving the access of Medicaid-eligible pregnant women and children to obstetricians and pediatricians. Increases the Medical assistance percentage for such projects, but sets a FY 1988 limit on the additional Federal Medicaid expenditures which result from such projects. Requires the Secretary to report to the Congress by March 1, 1991, regarding such projects.

Sets forth miscellaneous amendments relating to Medicaid services for pregnant women and children.

Part 2: Addressing Needs of Elderly Poor Subpart A: Improvements for Nursing Home Residents - Amends the Medicaid program to establish a single set of requirements for skilled nursing and intermediate care facilities (other than facilities for the mentally retarded), and to refer to such facilities as "nursing facilities." Sets forth requirements for nursing facilities, including requirements that such facilities: (1) primarily engage in providing residents with nursing care, rehabilitative services, and other health-related services which can only be provided through such facilities, directed toward residents' mental, psychosocial, and physical well-being; (2) provide such care in accordance with a written plan of care initially prepared and periodically reviewed and revised by a licensed health care professional on the basis of assessments of a resident's functional capacity conducted upon the resident's admission and after a significant change in the resident's physical or mental condition, but in no case less often than annually, and reviewed for accuracy at least once every three months; (3) provide, in addition to nursing and rehabilitative services, such physicians' services, medically-related social services, pharmaceutical services, dietician services, and dental services as are required to fulfill each resident's plan of care; (4) not use any individual who is not a licensed health care professional or licensed social worker as a nurse aide after 1989 unless the individual has completed a State-approved training program or is enrolled in such a program, and is competent to provide such services; (5) require a physician's supervision of each patient's care, the maintenance of clinical records on all patients, and, with certain exceptions, the services of a licensed nurse 24 hours a day and a registered nurse eight hours a day, or 16 hours a day if the nursing facility has at least 90 beds; (6) employ a full-time social worker if they have over 120 beds; (7) protect specified patient rights, including the right to appeal an involuntary transfer or discharge from the facility; (8) provide applicants and residents with information regarding the Medicare and Medicaid programs and not require applicants to waive their rights to such benefits or have a third party guarantee payment to the facility as a condition of their admission; (9) safeguard a patient's funds upon the patient's authorization; (10) not admit any new resident, after 1988, who is mentally ill or retarded unless the State mental health authority deems such individual to require nursing facility services and decides whether the individual requires active treatment for mental illness or retardation; (11) notify the agency responsible for licensing the facility of changes in the ownership, control, or administration of the facility; (12) adopt certain measures to preserve facility safety and sanitation; and (13) meet such other conditions which the Secretary deems necessary for patient health and safety.

Requires States to specify, by January 1, 1989, those nurse aide training programs which meet the minimum standards to be established by the Secretary by July 1, 1988, and have the State's approval. Prohibits State approval of a training program offered by a facility that has been out of compliance with this Act's requirements within the previous two years. Requires each State to: (1) establish a registry, by 1989, of all individuals who have satisfactorily completed a nurse aide training program in the State; (2) develop a written notice, by April 1988, of the rights and obligations of nursing facility residents under the Medicaid program; and (3) establish a fair mechanism, by 1989, which meets Federal guidelines to be established by October 1, 1988, for hearing appeals on involuntary transfers of residents from nursing facilities.

Requires that, in addition to the preadmission review of mentally ill or retarded individuals, State mental health authorities conduct an annual review of mentally ill or retarded residents to determine whether such residents require nursing facility services and whether they require active treatment for mental illness or retardation. Directs that such preadmission and annual reviews be conducted in accordance with criteria to be developed by the Secretary by October 1, 1988. Sets forth required nursing facility responses to determinations as to whether such residents need nursing facility services and need, or do not need, active treatment for mental illness or retardation. Gives long-term residents who do not require nursing facility services, but who require active treatment, the choice of remaining in the facility or receiving covered services in an alternative setting. Requires nursing facilities to provide for the active treatment of residents in need of treatment for mental illness or retardation regardless of their continued need for nursing facility services or their discharge from such facility. Requires States to have an appeals process for individuals adversely affected by such preadmission and annual reviews.

Sets the Federal matching percentage for: (1) nurse aide training programs at the Federal assistance percentage plus 25 percent, but not exceeding 90 percent, for FY 1988 and 1989, and at 50 percent thereafter; and (2) preadmission and annual screening of mentally ill or retarded residents at 75 percent.

Directs the Secretary to: (1) provide States with technical assistance in the development and implementation of reimbursement methods for nursing facilities that take into account the case mix of residents in different facilities; and (2) report to the Congress by January 1, 1993, on the progress made in implementing this Act's nursing facility staffing requirements. Requires the Secretary to designate an instrument(s) by April 1, 1990, and States to specify the instrument by July 1, 1990, for use by States in assessing a resident's functional capacity. Requires the Secretary to report to the Congress by January 1, 1992, on the implementation of the resident assessment process. Imposes civil monetary penalties on individuals who falsify resident assessments.

Makes the Secretary responsible for certifying that State nursing facilities comply, and States responsible for certifying that other nursing facilities comply with Medicaid nursing facility requirements. Bases such certification on surveys conducted within two months of any change in the ownership or administration of such a facility, and an annual, unannounced standard survey. Subjects facilities with poor compliance records to extended surveys. Directs the Secretary to: (1) develop and test a protocol for conducting surveys; (2) establish minimum qualifications for surveyors and train them in the use of resident assessment instruments; and (3) conduct sample surveys of nursing facilities, within two months of State surveys, to test the adequacy of State surveys and reduce Federal payments for State Medicaid administrative costs if such State surveys prove inadequate. Authorizes the Secretary to conduct a special survey of a facility when there is reason to question its compliance with this Act.

Requires States to investigate complaints against, and monitor the compliance of Act's requirements if the facility was previously found out of compliance with such requirements or the State has reason to question its compliance.

Requires that certain information regarding nursing facilities and their compliance with this Act's requirements be made available to the public. Provides long-term care ombudsmen, resident's physicians, and the State board which licenses facility administrators with notice of a facility's poor quality of care. Gives State Medicaid fraud and abuse control units access to facility survey and certification information.

Sets the Federal matching percentage for nursing facility certification activities at 90 percent in FY 1990, 85 percent in FY 1991, 80 percent in FY 1992, and 75 percent thereafter.

Eliminates current penalties applied to a State when its control over the utilization of skilled nursing or intermediate care facility services is deemed inadequate. Requires that when the Secretary or a State determines that a nursing facility's deficiencies immediately jeopardize residents' health and safety, immediate action be taken to remove the jeopardy and correct the deficiencies or such facility's participation in Medicaid be terminated. Directs the Secretary and States to apply certain other remedies where the health and safety of facility residents is not immediately jeopardized. Authorizes the imposition of civil money penalties against facilities found to be in compliance with this Act's requirements but to have been out of compliance previously. Provides that if a facility is out of compliance with any of this Act's requirements three months after having been found out of compliance with such requirements or on three consecutive standard surveys, Medicaid payments for newly admitted residents shall be denied and, in the latter case, on-site monitoring of the facility's compliance shall be established. Authorizes each State to establish a program providing rewards to facilities providing the highest quality of care. Sets forth special rules which are to be applied where a State and the Secretary do not agree on a finding of noncompliance or the remedies which should be prescribed.

Requires States to provide each institutionalized Medicaid beneficiary who is not receiving payments under title XVI (Supplemental Security Income) of the Act with a monthly personal needs allowance of at least $35 in 1988, with subsequent annual increases in such allowance reflecting increases in the cost-of-living.

Directs the Secretary to report to the Congress annually on the extent to which nursing facilities are complying with this Act's requirements, and the number and type of enforcement actions taken against such facilities.

Subpart B: Other Provisions - Authorizes California to set a special Medicaid income eligibility level for a family of two individuals both of whom are adults and at least one of whom is aged, blind, or disabled.

Requires a State, under a home or community-based waiver, to cover home or community-based services provided pursuant to a written plan of care to individuals age 65 or older with respect to whom there has been a determination that but for the provision of such services the individuals would require the level of care provided in a skilled nursing or intermediate care facility, the cost of which could be reimbursed under the Medicaid program. Provides that such a waiver shall be for an initial three-year term and, upon a State's request, for additional five years terms. Sets funding limitations.

Provides that for the initial determination of an institutionalized spouse's Medicaid eligibility the institutionalized spouse may transfer his or her resources to the community spouse to the extent the spousal share (computed by dividing the sum of the spouses' resources in half) is less than $12,000 (adjusted annually to reflect changes in the cost-of-living), but attributes any resources not solely in the ownership of the community spouse to the institutionalized spouse if such transfer is not made. Considers resources held in the name of the community spouse to be available to the institutionalized spouse to the extent their value exceeds $48,000 (adjusted annually to reflect changes in the cost-of-living), or, if greater, the amount a court has ordered to be retained by the community spouse for support.

Provides that after the initial eligibility determination: (1) no resources of the community spouse will be considered available to the institutionalized spouse; and (2) the income of the institutionalized spouse will not be considered to include a specified personal needs allowance, community spouse monthly income allowance, family allowance, and incurred expenses for medical or remedial care for the institutionalized spouse that are not covered by a legally liable third party. Sets forth the formulas for determining such allowances. Gives either spouse the right to a hearing to establish that the minimum monthly maintenance needs allowance or community spouse monthly income allowance is not adequate to support the community spouse without financial duress so that an adequate amount of support will be substituted for the allowance. Prohibits the latter allowance from being less than court-ordered support payments.

Delays the Medicaid eligibility of institutionalized individuals who disposed of their resources at less than fair market value within two-years prior to applying for Medicaid benefits. Sets forth situations in which a delay shall not be applied.

Directs the Secretary to report to the Congress by December 31, 1988, on means of recovering amounts from the estates of deceased Medicaid beneficiaries to pay for Medicaid skilled nursing or intermediate care facility services provided to such beneficiaries.

Part 3: Addressing the Needs of Working Welfare Recipients - Amends the Medicaid program to require a State to continue a family's Medicaid eligibility for: (1) six months after the family loses eligibility under part A (Aid to Families with Dependent Children)(AFDC) of title IV of the Act because of increased earnings if the family has received AFDC payments for three of the preceding six months; and (2) for an optional 18 additional months if the family has received the entire six months of extended Medicaid coverage . Terminates extended medicaid coverage if the family ceases to include a dependent child.

Authorizes States to provide the extended Medicaid coverage by paying a family's: (1) expenses for health insurance offered by the caretaker relative's or absent parent's employer; or (2) premium and enrollment costs, during the 18-month extension period, for coverage under a group health plan offered to the caretaker relative, a group health plan offered by the State to its employees, or a health maintenance organization. Requires States offering such alternative coverage to pay, in addition to the premium and enrollment costs for such coverage, any other cost sharing amounts for pregnancy services and ambulatory preventive pediatric care for children born on or after September 30, 1985. Terminates the 18-month extension period if a family's earnings exceed 185 percent of the Federal poverty level or the caretaker relative has no earnings for a month due to his or her voluntary loss of employment without good cause. Authorizes States to impose a premium on families receiving the 18 months of extended coverage, but prohibits its exceeding ten percent of the amount by which a family's earnings exceed minimum monthly wage earnings.

Requires States to extend Medicaid coverage for six months to families who lose family support supplement eligibility as the result of the collection or increased collection of child or spousal support under part D (Child Support and Establishment of Paternity) of title IV of the Act if the family has received supplement payments for three of the preceding six months.

Part 4: Inflation Adjustment for Territories and Miscellaneous Provisions - Amends part A (General Provisions) of title XI of the Act to increase the maximum amount of annual Medicaid payments that may be made to Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa.

Amends the Medicaid program to make it clear that: (1) Medicaid clinic services include services furnished by clinic personnel to the homeless outside the clinic; (2) Medicaid physician services include services furnished by dentists.

Requires each State to specify which hospitals in the State serve a disproportionate number of low-income patients with special needs and increase the rate or amount of Medicaid payments for such services. Sets forth the criteria for determining whether a hospital serves a disproportionate share of low-income patients, including the requirement that such hospitals have at least two obstetricians on staff who have agreed to serve Medicaid beneficiaries.

Treats a department of the New Jersey government as a legal public entity which, after an appropriate arrangement with the Secretary, shall be considered a qualified health maintenance organization for purposes of the minimum enrollment period and restrictions on the termination of enrollment without cause.

States that Medicaid payments for inpatient hospital services or skilled nursing or intermediate care facility services shall not be limited by the Secretary to the amount which would be paid for such services under the Medicare program.

Sets forth technical and miscellaneous amendments.