Medicare and Medicaid Budget Reconciliation Act of 1993

TABLE OF CONTENTS:

Title I: Short Title

Title II: Table of Contents

Title III: References to Omnibus Budget Reconciliation Act

of 1993

Title IV: Other References in Act

Title V: Reconciliation Provisions Relating to Medicare,

Medicaid, and Other Health Programs

Subtitle A: Medicare Program

Subtitle B: Medicaid Program and Other Care

Provisions

Title I: Short Title - Medicare and Medicaid Budget Reconciliation Act of 1993.

Title II: Table of Contents - (Sec. 201) Sets forth the table of contents of this Act.

Title III: References to Omnibus Budget Reconciliation Act of 1993 - (Sec. 301) Declares that any references to the Omnibus Budget Reconciliation Act of 1993 shall be references to this Act.

Title IV: Other References in Act- (Sec. 401) Declares that, except as otherwise specifically provided, whenever in this Act an amendment is expressed in terms of an amendment to or repeal of a section or other provision, it shall be considered a reference to the Social Security Act (SSA).

States that, in this Act, the terms "OBRA-1986," "OBRA-1987," "OBRA-1989", and "OBRA-1990" refer to the Omnibus Budget Reconciliation Act of 1986 (Public Law 99-509), the Omnibus Budget Reconciliation Act of 1987 (Public Law 100-203), the Omnibus Budget Reconciliation Act of 1989 (Public Law 101-239), and the Omnibus Budget Reconciliation Act of 1990 (Public Law 101-508), respectively.

Title V: Reconciliation Provisions Relating to Medicare, Medicaid, and Other Health Programs - Subtitle A: Medicare Program - Chapter 1: Provisions Relating to Part B - Subchapter A: Physicians' Services - (Sec. 5001) Amends part B (Supplementary Medical Insurance) of SSA Title XVIII (Medicare) to reduce the default update for physicians' services (except primary care services) in 1994.

(Sec. 5002) Revises certain formulae to increase: (1) the Medicare Volume Performance Standards (MVPS) performance standard factor; and (2) the maximum reduction permitted in the annual default update to the Medicare Fee Schedule.

(Sec. 5003) Classifies primary care services as a separate category of services for purposes of setting volume performance standards and annual updates.

(Sec. 5004) Provides for a phased-in reduction in practice cost relative value units for certain services.

(Sec. 5005) Provides for phased-in limitations on payment for anesthesia services where concurrent services are provided under the supervision of an anesthesiologist.

(Sec. 5006) Requires that payments for anesthesia services be based on actual time.

(Sec. 5007) Requires separate payment for the interpretation of electrocardiograms.

(Sec. 5008) Repeals the requirement that payments for new physicians and practitioners be reduced during their first four years of practice.

(Sec. 5009) Requires: (1) consultation with representatives of physicians in the review of geographic adjustment factors for medicare physicians' services; and (2) use of the most recent data in determining such adjustment.

(Sec. 5010) Revises extra-billing limits with respect to Medicare beneficiaries overcharged by nonparticipating physicians or suppliers that do not accept payment on an assignment-related basis.

(Sec. 5011) Directs the Secretary of Health and Human Services (HHS) to develop relative values for use in payment of pediatric services.

(Sec. 5012) Revises the coverage of antigens under the Medicare Fee Schedule.

(Sec. 5013) Prohibits fee charges for certain claims administration functions. Revises requirements for permissible substitute billing arrangements.

Subchapter B: Outpatient Hospital Services and Ambulatory Surgical Services - (Secs. 5021 and 5022) Extends: (1) the ten percent reduction in payments for capital-related costs of outpatient hospital services; and (2) the current 5.8 percent reduction in payments for other costs of outpatient hospital services.

(Sec. 5023) Provides for a one-year freeze in ambulatory surgery rates.

(Sec. 5024) Revises the definition of eye or eye and ear hospitals.

(Sec. 5025) Extends the cap on payments for intraocular lenses.

Subchapter C: Durable Medical Equipment - (Sec. 5031) Revises the payment rules for durable medical equipment (DME), including prosthetic and orthotic items, by substituting the national median for the national weighted average.

(Sec. 5032) Provides for a one-year freeze on payments for parenteral and enteral nutrients, supplies, and equipment.

(Sec. 5033) Revises the categorization of nebulizers and aspirators under the DME fee schedules.

(Sec. 5034) Establishes a certification program for DME suppliers. Prohibits DME suppliers for distributing, for commercial purposes, completed or partially completed certificates of medical necessity to physicians or individuals entitled to benefits.

(Sec. 5035) Requires DME suppliers to use the part B carrier for the area in which the Medicare beneficiary lives. Prohibits carrier shopping.

(Sec. 5036) Prohibits unsolicited telephone contacts from DME suppliers to Medicare beneficiaries.

(Sec. 5037) Prohibits kickback arrangements between DME suppliers and entities that refer patients for covered items.

(Sec. 5038) Revises the treatment of beneficiary liability for noncovered DME services.

(Sec. 5039) Authorizes the Secretary of HHS to adjust DME payments in accordance with a policy of inherent reasonableness.

(Sec. 5040) Sets forth a formula for lump-sum payments for surgical dressings.

(Sec. 5041) Provides for a reduction in payments for TENS devices.

Subchapter D: Part B Premium - (Sec. 5051) Extends the authority for the determination of the part B premium.

Subchapter E: Other Provisions - (Sec. 5061) Reduces to the 76th percentile the national limitation of fee schedules for clinical diagnostic laboratory tests. Limits the annual update to fees to two percent.

(Sec. 5062) Includes inpatient hospital services and diagnostic and therapeutic X-ray services among those covered by rural health clinics and federally qualified health centers.

(Sec. 5063) Applies specified mammography certification requirements to Medicare standards for screening mammography facilities.

(Sec. 5064 and 5066) Extends the Alzheimer's disease demonstration program and certain municipal health service demonstration projects.

(Sec. 5065) Provides Medicare coverage for certain oral cancer drugs.

(Sec. 5067) Provides for treatment of certain Indian health programs and facilities as Federally-qualified health centers.

(Sec. 5068) Revises the ceilings for payment of "clean claims" under Medicare and the circumstances under which interest payments may be made on delayed claims.

(Sec. 5069) Provides for Medicare coverage of certified nurse-midwife services performed outside the maternity cycle.

(Sec. 5069A) Increases the annual cap on the amount of Medicare payments for outpatient physical therapy and occupational therapy services. Requires the Physician Payment Review Commission (PPRC) to study and report to specified congressional committees on the appropriateness of continuing an annual limitation on the amount of such payments.

Chapter 2: Provisions Relating to Parts A and B - (Sec. 5071) Repeals the requirement for a special overhead add-on for the overhead of hospital-based home health agencies.

(Sec. 5072) Directs the Secretary of HHS to study the methodology used to determine payments to hospitals under the Medicare program for the costs of medical residency training, including analysis of the causes of variation among such programs in the per-resident costs of direct graduate medical education, especially the support for them from non-hospital sources.

(Sec. 5073) Revises specified aspects of the Medicare-as-secondary-payer program.

(Sec. 5074) Extends the ban on physician self-referrals to additional designated health services, including home infusion therapy services. Revises specified exceptions to such ban.

(Sec. 5075) Reduces Medicare payments for erythropoietin.

(Sec. 5076) Requires any hospital with organ donors to make an agreement only with the designated organ procurement organization for the geographic area in which the hospital is located.

(Sec. 5077) Amends OBRA-1986 to extend the health maintenance organization (HMO) waiver for the Watts Health Foundation.

(Sec. 5078) Directs the Secretary of HHS to undertake certain outreach activities to increase participation in the Qualified Medicare Beneficiary program.

(Sec. 5079) Amends OBRA-1987 to extend and expand the social health maintenance organization demonstration program.

(Sec. 5080) Amends SSA to repeal the Peer Review Organization (PRO) precertification (second opinion) requirement for certain surgical procedures.

(Sec. 5081) Grants home health agency beneficiaries the right to be informed about Medicare hospice benefits.

(Sec. 5082) Provides, with respect to health maintenance organizations, for: (1) adjustments in Medicare capitation payments to account for regional variations in the application of secondary payor requirements; and (2) revision of the payment methodology for risk contractors.

Chapter 3: Provisions Relating to Medicare Supplemental Insurance Policies - (Sec. 5091) Revises OBRA-1990 with respect to standards for Medicare supplemental insurance policies.

Subtitle B: Medicaid Program and Other Health Care Provisions - Chapter 1: Medicaid Program - Subchapter A: Program Savings Provisions - Part I: Repeal of Mandate - (Sec. 5101) Amends SSA Title XIX (Medicaid) to: (1) repeal the mandate for inclusion of certain personal care services among home health care services in State medical assistance programs; and (2) allow States to provide an optional benefit for personal care services furnished outside the home.

Part II: Outpatient Prescription Drugs - (Sec. 5106) Authorizes States to establish formularies limiting the coverage of prescription drugs under their Medicaid programs.

(Sec. 5107) Repeals the prohibition on the imposition of prior authorization controls on new drugs for the first six months after Food and Drug Administration (FDA) approval.

Part III: Restrictions on Divestiture of Assets and Estate Recovery - (Sec. 5111) Revises the restrictions on the transfer of assets by an individual subsequently applying for Medicaid benefits as an institutionalized individual. Extends the look-back period and repeals the limit on the period of ineligibility because of prohibited transfers, providing for cumulative periods for multiple transfers. Provides for a waiver of eligibility penalties because of undue hardship, and exempts certain trusts for the benefit of disabled individuals from the transfer rules.

(Sec. 5112) Requires States to establish a program for identifying and recovering Medicaid benefits from estates of deceased beneficiaries who have received nursing home or other long-term care services.

(Sec. 5113) Prohibits a State plan from disregarding any assets: (1) to the extent that payments are made under a long-term care insurance policy; or (2) because an individual has received (or is entitled to receive) benefits for a specified period of time under such a policy.

Part IV: Improvement in Identification and Collection of Third Party Payments - (Sec. 5116) Requires States to prohibit insurers, HMOs, and self-funded plans (under the Employee Retirement Income Security Act of 1974 (ERISA) from denying payment for health services to insured individuals who are also Medicaid beneficiaries.

(Sec. 5117) Directs the Secretary of HHS to establish a Health Coverage Clearinghouse to identify insurers, HMOs, ERISA plans, and other third parties which may be liable for payment for services to Medicaid or Medicare beneficiaries. Requires employers to include group health coverage information on employees' W-2 forms.

(Sec. 5118) Requires States to have in effect certain medical child support laws, including a requirement that an insurer (including an HMO or ERISA plan) enroll under family health coverage any child whose parent (otherwise eligible for such coverage) is required by court or administrative order to provide the child with medical support.

Part V: Assuring Proper Payments to Disproportionate Share Hospitals - (Sec. 5121) Prohibits States from designating a hospital as a Medicaid disproportionate share hospital unless at least one percent of its inpatient days were attributable to Medicaid patients. Limits payment adjustments to State or locally-owned or operated hospitals to the costs incurred in providing services to Medicaid-eligible patients and uninsured (indigent without health care coverage) patients, less certain payments received.

Subchapter B: Miscellaneous Provisions- Part I: Anti-fraud and Abuse Provisions - (Sec. 5131) Revises the Medicare rules limiting certain physician referrals for clinical laboratory services.

(Sec. 5132) Provides for intermediate sanctions for kickback violations.

(Sec. 5133) Requires States to expend a certain minimum amount of funds annually for Medicaid fraud control units.

Part II: Managed Care Provisions - (Sec. 5135) Sets forth with respect to Medicaid managed care organizations: (1) prohibitions against affiliations with individuals debarred by Federal agencies; (2) requirements for State conflict-of-interest safeguards in Medicaid risk contracting; (3) financial information disclosure requirements; (4) marketing fraud prohibitions; (5) adequate equity requirements for for-profit entities; (6) requirements for adequate provision against risk of insolvency; and (7) net earnings and additional benefits reporting requirements. Requires the Secretary of HHS to report to the Congress on the earnings of organizations with contracts to receive Medicaid payments on a prepaid capitation or any other risk basis.

(Sec. 5136) Revises the treatment of HMO enrollees in computing the Medicaid inpatient utilization rate in qualifying hospitals as disproportionate share hospitals.

(Secs. 5137 and 5138) Extends: (1) the period of applicability of the enrollment mix requirement to certain HMOs providing services under the Dayton Area Health Plan; and (2) the Medicaid waiver for the Tennessee Primary Care Network.

(Sec. 5139) Waives application of the Medicaid enrollment mix requirement to the District of Columbia Chartered Health Plan, Inc.

(Sec. 5140) Extends the Minnesota Prepaid Medicaid Demonstration Project.

Part III: Emergency Services to Undocumented Aliens - (Sec. 5141 and 5142) Increases the Federal financial participation for emergency medical assistance to undocumented aliens.

(Sec. 5142) Limits Federal Medicaid matching payments to bona fide emergency services for undocumented aliens.

Part IV: Miscellaneous Provisions - (Sec. 5144) Increases the limit on Federal Medicaid matching payments to Puerto Rico and other territories.

(Sec. 5145) Sets forth criteria for Departmental Appeals Board determinations of whether disallowances of Federal Medicaid matching payments to States should be reduced.

(Sec. 5146) Renews the unfunded demonstration project for low-income pregnant women and children.

(Sec. 5147) Provides for optional Medicaid coverage of TB-related services for certain TB-infected individuals.

(Sec. 5148) Specifies the application of mammography certification requirements under the Medicaid program.

(Sec. 5149) Repeals the termination date on the extension of eligibility for working families.

(Sec. 5150) Extends the moratorium on the treatment of certain facilities as institutions for mental diseases.

(Sec. 5150A) Deems as a federally-qualified health center any entity treated as a comprehensive federally funded health center as of January 1, 1990.

(Sec. 5150B) Revises specified nursing facility requirements.

Subchapter C: Miscellaneous and Technical Corrections Relating to OBRA-1990 - (Secs. 5151-5174) Makes technical and conforming amendments to specified sections of OBRA-1990.

Chapter 2: Universal Access to Childhood Immunizations - (Sec. 5181) Amends the Public Health Service Act to establish entitlement and monitoring programs with respect to childhood immunizations.

Directs the Secretary of HHS, acting through the Director of the Centers for Disease Control and Prevention (CDC), to provide for the purchase and delivery on behalf of any applicant State of sufficient quantities of pediatric vaccines to immunize each eligible child in the State who is a Medicaid beneficiary or is uninsured.

Entitles: (1) each State to receive from the Secretary sufficient free vaccine to provide to all eligible children in the State; (2) each health care provider to receive from the State sufficient free vaccine to provide to all eligible children in his or her practice; and (3) each eligible child to receive free vaccine from any willing provider licensed to administer immunizations in the State. Requires participant States to agree to such entitlements. Authorizes eligible children to enforce the rights of the provider if the State fails to carry out its obligation.

Requires States to make health care provider participation voluntary only. Prohibits providers from charging for free vaccine. Allows charges for immunization itself.

Directs the Secretary to publish in the Federal Register criteria for the delivery on behalf of the States of federally-supplied pediatric vaccines to program-registered providers in the State.

Sets forth general State compliance requirements.

Allows States to purchase pediatric vaccine for the immunization of additional categories of otherwise ineligible children.

Requires the Secretary to negotiate with manufacturers of pediatric vaccines for a reasonable purchase price, which would also be available to States that wished to purchase vaccine for otherwise ineligible children.

Requires the Secretary to enter into multi-source contracts with multiple manufacturers of vaccine. Allows such contracts to be for more than one year.

Requires the Secretary to establish: (1) a list of pediatric vaccines recommended for administration to all children for immunization (subject to any established contraindications); and (2) a schedule of nonbinding recommendations for administration of such immunizations.

Establishes the National Childhood Immunization Trust Fund for the immunization program.

Directs the Secretary, acting through the CDC Director, to make formula grants to States annually to establish and maintain a national system, composed of State registries, for monitoring the immunization status of children. Prescribes kinds of data to be collected. Authorizes appropriations.

Authorizes the Secretary, acting through the CDC Director, to make grants to States for carrying out specified activities with respect to achieving certain objectives established by the Secretary for the year 2000 for the immunization status of children in the United States. Authorizes appropriations.

(Sec. 5182) Amends OBRA-1989 and the Public Health Service Act with respect to the National Vaccine Injury Compensation Program.

(Sec. 5183) Amends SSA title XIX (Medicaid) to provide for: (1) immunization outreach through the early and periodic screening, diagnostic, and treatment (EPSDT) services program; (2) coordination with the maternal and child health block grant programs and WIC (Women, Infants, and Children) programs; (3) coverage of public housing health centers as federally-qualified health centers; (4) adequate payment rates for vaccine administration to children; (5) denial of Federal financial participation for administration of single-antigen vaccines if combined-antigen vaccines are medically appropriate; and (6) Medicaid managed care plan compliance with immunization and other EPSDT requirements.

(Sec. 5184) Authorizes a State plan to pay a vaccine manufacturer directly under a volunteer replacement program following certain guidelines.

(Sec. 5185) Amends the Public Health Service Act to authorize the Secretary to make operating grants for up to 21 demonstration projects to provide specified Healthy Start for Infants services in order to meet year 2000 health status objectives for the U.S. population. Prescribes project requirements. Authorizes appropriations.

(Sec. 5186) Increases the authorization of appropriations for the Maternal and Child Health Services Block Grant Program.