Emergency Medicare Protection Act of 1996

TABLE OF CONTENTS:

Title I: Medicare Savings

Subtitle A: Provisions Relating to Part A

Subtitle B: Provisions Relating to Part B

Subtitle C: Provisions Relating to Parts A and B

Subtitle D: Medicare Part B Premium

Title II: Expanded Medicare Choice

Title III: National Commission on Medicare Reform

Emergency Medicare Protection Act of 1996 - Title I: Medicare Savings - Subtitle A: Provisions Relating to Part A - Amends title XVIII (Medicare) part A of the Social Security Act (SSA) to revise requirements for the Hospital Insurance program under it in order to achieve Medicare savings through measures involving, among other things: (1) adjustments for estimated case mix increase when recalibrating diagnosis-related group (DRG) prospective payment system (PPS) rates for inpatient hospital services; (2) temporary additional reduction in PPS capital and hospital-specific rates; (3) reduction in adjustment for indirect medical education (IME); (4) revisions in determination of amount of payment for medical education; (5) elimination of disproportionate share (DSH) adjustments and IME payments attributable to outlier payments; (6) changes in the treatment of certain transfer cases; (7) incentive payments for PPS-exempt hospitals; (8) reductions to capital payments for PPS-exempt hospitals; (9) updates to per diem cost limits effective for FY 1996 for skilled nursing facilities based on limits for FY 1993, with payment for such facilities made on an interim prospective basis until FY 1998 when a full prospective payment system is to be implemented; (10) salary equivalency guidelines for various specified therapy services; (11) additional payments to hospitals for graduate medical education programs and managed care enrollees; (12) expanding the choice of base years and eliminating the volume adjustment with regard to sole community hospitals; (13) expanding the essential access community hospital (EACH) program (renamed the rural primary care hospital program) to all States with an end to new EACH designations, a limitation on length of inpatient stays, and certain payment-related changes, among other modifications; (14) permanent grandfathering of rural referral center status; and (15) Medicare-dependent, small, rural hospital payment extension.

(Sec. 11104) Establishes within the Department of Health and Human Services (HHS) the National Commission on Medical Education and Workforce Priorities to develop and recommend to the HHS Secretary specific policies concerning health centers and the health care workforce. Authorizes appropriations.

(Sec. 11118) Amends title XVII (Health Information and Health Promotion) of the Public Health Service Act to direct the HHS Secretary to establish a grant program for promoting the development of rural telemedicine networks under a newly added part B (Telemedicine Development). Authorizes appropriations.

(Sec. 11119) Amends title III (General Powers and Duties of Public Health Service) of the Public Health Service Act to provide for a Rural Health Outreach Grant Program under a newly added part O (Rural Health Outreach Grants). Authorizes appropriations.

Subtitle B: Provisions Relating to Part B - Revises requirements for Medicare's Supplementary Medical Insurance program under SSA title XVIII part B to achieve Medicare savings and provide for coverage of additional benefits through such measures involving, among other things: (1) new updates for physician services; (2) incentives to control high volume for in-hospital physicians' services; (3) reduced payment increases for ambulatory surgical center services for FY 1997 through 2002; (4) reductions in monthly payment amounts for oxygen and oxygen equipment; (5) freezes in the updates for durable medical equipment and orthotics and prosthetics for 1997 through 2002; (6) elimination of formula-driven overpayments for certain outpatient hospital services; (7) reduction in payments for capital-related costs, and for certain other costs, with regard to hospital outpatient services; (8) provision for a prospective payment system for hospital outpatient department services; and (9) program coverage of colorectal screening and of annual screening mammography for women over age 49.

(Sec. 11130) Waives cost-sharing for mammography.

(Sec. 11133) Establishes set payment amounts for certain vaccines and ties annual increases in them to increases in the yearly update for physicians' services for the particular year involved. Eliminates coinsurance and deductible for hepatitis B vaccine.

(Sec. 11134) Provides program coverage of diabetes outpatient self-management training services.

Includes as covered durable medical equipment blood glucose monitors for individuals with diabetes.

(Sec. 11135) Provides limited program coverage of respite services (the temporary care provided to individuals for the purpose of ensuring periodic time-off for co-resident primary informal caregivers).

(Sec. 11136) Revises payments to physician assistants, nurse practitioners, and clinical nurse specialists.

Subtitle C: Provisions Relating to Parts A and B - Directs the HHS Secretary to use a competitive process to contract with centers of excellence for coronary artery bypass surgery or other heart procedures, knee surgery, hip surgery, and other appropriate services, with payment for such services on the basis of specified negotiated or all-inclusive rates. Requires the amount of payment made by the HHS Secretary to the center for covered services to be less than the aggregate amount of payments that would have otherwise been made to it had not such process been in effect.

(Sec. 11142) Restructures payment policy for home health services, among other things: (1) temporarily basing updates to per visit cost limits on pre-July 1, 1994 levels; (2) providing interim reduced cost limits for FY 1997 through 1999; (3) directing the HHS Secretary, for cost reporting periods beginning on or after FY 2000, to provide for payments for home health services in accordance with a PPS which pays home health agencies on a per episode basis; (4) basing payment on the location where the home health service is furnished; and (5) elimination of periodic interim payments for home health agencies.

(Sec. 11147) Provides for permanent extension of certain secondary payer provisions under Medicare, including those for the working disabled.

Subtitle D: Medicare Part B Premium - Modifies Medicare part B premium provisions, directing the HHS Secretary, during each September, to determine and promulgate a monthly premium rate for the succeeding calendar year equal to 50 percent of the monthly actuarial rate for enrollees age 65 and over for that succeeding calendar year.

Title II: Expanded Medicare Choice - Gives Medicare a managed care component under a new part C (Managed Care Organizations) under which every individual entitled to benefits under Medicare part A and enrolled under Medicare part B (or enrolled under part B only) shall be eligible to enroll with any eligible organization contracting with the HHS Secretary to serve the geographic area in which the individual resides. Extends to such individuals a broader choice of managed care coverage through qualified health maintenance organizations, competitive medical plans, preferred provider organizations, or provider sponsored organizations. Delineates the types of benefits offered by each managed care organization or plan, requiring certain minimum services, with supplemental benefits subject to the Secretary's approval and provided at the enrollees' option. Outlines other program particulars regarding internal quality assurance, payment for services, and sanctions for noncompliance with program requirements.

(Sec. 11203) Directs the HHS Secretary to develop and promulgate interim final regulations for: (1) certification standards for eligible organizations; (2) standards for fiscal soundness and requirements against the risk of insolvency for provider sponsored organizations seeking certification as an eligible organization; (3) standards for monitoring eligible organizations under a risk or partial risk contract under this new part; and (4) any other standards or procedures required to implement provisions of part C.

(Sec. 11204) Provides for the applicability of Medicare rates to enrollees who use an out-of-plan service provider.

(Sec. 11205) Directs the HHS Secretary to provide for regulations requiring the collection, analysis, and reporting of data that will permit measurement of outcomes and other indices of the quality of managed care plans under contract with the Secretary.

(Sec. 11206) Allows the HHS Secretary to waive certain HMO- and competitive medical plan (CMP)-related requirements under Medicare with regard to certain described experiments and demonstration projects under provisions for economy while maintaining or improving quality in health services (competitive pricing demonstrations).

(Sec. 11207) Eliminates the health care prepayment plan option for entities eligible to participate under Medicare part C.

(Sec. 11208) Provides various specified changes under the Medicare supplemental policy program, including uniform enrollment periods and community-rated premiums.

(Sec. 11209) Directs the HHS Secretary to develop a standard package of benefits (in addition to those already covered under Medicare) that may be offered by eligible organizations under Medicare part C.

Requires the HHS Secretary to request the National Association of Insurance Commissioners to examine the standard benefit packages for Medicare supplemental health insurance policies and recommend any restructuring needed in order to facilitate to the maximum extent feasible comparison across such policies and benefits offered by eligible organizations. Requires the HHS Secretary, after taking into account any such recommendations, to restructure such packages as needed.

(Sec. 11210) Provides that in any action under the antitrust laws the conduct of an organization that provides health care services in negotiating, making, or performing a contract under Medicare part C, and the conduct of any member of such an organization in carrying out such a contract, shall not be deemed illegal per se if each member of the organization shares, directly or indirectly, substantial financial risk in connection with the organization's operations.

(Sec. 11211) Revises the Public Health Service Act with regard to certain requirements for certificates and laboratory inspections.

(Sec. 11212) Modifies the exceptions under Medicare's limitation on certain physician referrals to both ownership and compensation arrangement prohibitions, among other changes repealing the exception for physicians' services and adding a new exception for shared facility services.

Title III: National Commission on Medicare Reform - Establishes the National Commission on Medicare Reform to: (1) review relevant analyses of the current and long-term financial condition of the Medicare trust funds; (2) identify problems that may threaten the long-term solvency of such funds; (3) analyze potential solutions to such problems that will both assure the financial integrity of the Medicare program and the provision of appropriate benefits under it; (4) provide appropriate recommendations to the HHS Secretary, the President, and the Congress; and (5) develop a legislative proposal to carry them out for submission to the Congress. Outlines the procedures for the Congress to consider such recommendations.

Authorizes appropriations.