(Sec. 103) Amends SSA title XIX (Medicaid) to increase DSH hospital allotments for Minnesota, New Mexico, and Wyoming.
Amends the Balanced Budget Act of 1997 (BBA '97) to make the Medicaid DSH transition rule permanent.
Title II: Graduate Medical Education - Amends SSA title XVIII with respect to revision of multiyear reduction of indirect graduate medical education (GME) payments.
(Sec. 202) Amends SSA title XVIII parts D (Miscellaneous) and C (Medicare+Choice) with respect to acceleration of payment to hospitals of indirect and direct GME costs for Medicare+Choice enrollees.
(Sec. 203) Amends SSA title XVIII part C with respect to the exclusion of nursing and allied health education costs in calculating the Medicare+Choice payment rate.
Amends SSA title XVIII with respect to: (1) payment to hospitals of nursing and allied health education program costs for Medicare+Choice enrollees; and (2) adjustments to limitations on the number of interns and residents and GME payments for certain interns and residents.
Title III: Hospice Care - Amends SSA title XVIII to increase payments for routine home care and other services included in hospice care for a fiscal year after FY 1999.
Title IV: Skilled Nursing Facilities - Provides that, for purposes of applying any formula under the PPS for covered skilled nursing facility services (SNFs) for services provided between April 1, 2000, and the end of FY 2001, the Secretary shall increase, by a specified applicable payment add-on, the adjusted Federal per diem rate otherwise determined for services provided to any individual during the period in which such individual is in a RUG III case mix category.
(Sec. 402) Amends SSA title XVIII to exclude clinical social worker services and services performed under a contract with a rural health clinic or a Federally-qualified health center from the PPS for SNFs, as well as certain ambulance services, chemotherapy administration services, and other specified items, services, and devices, including swing beds in critical access hospitals.
Title V: Outpatient Rehabilitation Services - Amends title XVIII to repeal for three years a specified financial limitation on outpatient physical therapy services, outpatient occupational therapy services, and outpatient speech-language pathology services covered under Medicare and furnished on or after January 1, 2000. Directs the Secretary to implement by January 1, 2003, a payment system for such services that takes into account the needs of Medicare beneficiaries for differing amounts of therapy based on certain factors.
Title VI: Physicians' Services - Amends SSA title XVIII with respect to payment for physicians' services to revise the formula for determining the update adjustment factor and the formula for determining the sustainable growth rate for all physicians' services.
(Sec. 602) Directs the Secretary to publish in the Federal Register an estimate of the single conversion factor to be used in the next calendar year for reimbursement of physicians' services, and data on which such estimate is based.
Directs the Medicare Payment Advisory Commission (MEDPac) to review annually and report to the Secretary and specified congressional committees on such estimates and data.
Title VII: Home Health - Amends BBA '97 and SSA title XVIII to delay application of the 15 percent reduction in payment rates for home health services until one year after implementation of the PPS for home health services.
(Sec. 702) Amends SSA title XVIII to increase the FY 2000 per visit limit for home health agencies furnishing home health services, but in such a way that has no effect on the PPS for home health services.
(Sec. 703) Requires the Secretary to pay such excess reasonable cost to a home health services provider that furnishes services appropriate to an individual's condition at a reasonable cost which significantly exceeds the applicable per beneficiary limit because of unusual variations in the type or amount of medically necessary care required.
(Sec. 704) Eliminates the 15-minute billing requirement for the payment of claims for home health services furnished on or after October 1, 1998.
(Sec. 705) Provides that, in the case of an overpayment by the Secretary to a home health agency for services furnished during a cost reporting period beginning on or after October 1, 1997, as a result of certain payment limitations, the home health agency may elect to repay the amount of such overpayment ratably over a 36-month period beginning on the overpayment notification date.
(Sec. 706) Amends SSA title XVIII to include medical supplies (but not durable medical equipment) as home health services for purposes of home health consolidated billing.
Title VIII: Medicare+Choice - Amends Medicare part C to delay the submission of proposed premiums, adjusted community rates, and related information each Medicare+Choice organization is required to submit to the Secretary for each Medicare+Choice plan for the service area in which it is intended to be offered in the following year.
(Sec. 802) Reduces from five years to three years the general exclusion period for Medicare+Choice organizations whose contract has been terminated.
(Sec. 803) Authorizes enrollment in alternative Medicare+Choice plans and Medigap coverage in the event of an involuntary termination of Medicare+Choice enrollment.
Guarantees access for certain Medicare beneficiaries to Medigap policies in case of such an involuntary termination.
(Sec. 804) Removes certain age-related restrictions with respect to Medigap protection against medical condition or pre-existing condition discrimination.
Permits an individual who develops end-stage renal disease while enrolled in a Medicare+Choice plan and remains so enrolled to elect to continue enrollment in another Medicare+Choice plan if the original enrollment is discontinued.
(Sec. 805) Extends the Medicare+Choice disenrollment window for certain involuntarily terminated enrollees.
(Sec. 806) Provides under the Medicare+Choice program for continuation of any State law that requires the comprehensive coverage of prescription drugs, or any regulation that carries out such a law if: (1) the State has a waiver in effect with respect to requiring such coverage under Medigap policies; or (2) the Secretary provides for a waiver for the State to impose such a requirement.
(Sec. 807) Exempts certain frail elderly Medicare+Choice beneficiaries from the risk-adjustment system if they are enrolled in a specialized program for the frail elderly.
Sets forth special rules for frail elderly Medicare+Choice beneficiaries enrolled in such specialized programs. Provides for continuous open enrollment for certain such beneficiaries.
Directs the Secretary to develop and implement a program to measure the quality of care provided in specialized programs for the frail elderly in order to reflect their unique health aspects and needs.
(Sec. 808) Extends for an additional three years Medicare community nursing and ambulatory care demonstration projects under the Omnibus Budget Reconciliation Act of 1987.
Title IX: Clinics - Amends SSA title XIX to establish a new PPS for Federally-qualified health centers and rural health clinics under which the State Medicaid plan may provide for payment in any fiscal year to such a center or clinic for certain services in an amount exceeding the amount otherwise required to be paid under the PPS.
[Congressional Bills 106th Congress]
[From the U.S. Government Publishing Office]
[S. 1678 Introduced in Senate (IS)]
106th CONGRESS
1st Session
S. 1678
To amend title XVIII of the Social Security Act to modify the
provisions of the Balanced Budget Act of 1997.
_______________________________________________________________________
IN THE SENATE OF THE UNITED STATES
October 1, 1999
Mr. Daschle (for himself, Mr. Moynihan, Mr. Rockefeller, Mr. Kennedy,
Mr. Kerry, Mr. Baucus, Mr. Bingaman, Ms. Mikulski, Mr. Durbin, Mr.
Reid, Mr. Kerrey, Mr. Torricelli, Mr. Cleland, Mrs. Boxer, Mr. Johnson,
Mr. Reed, Mrs. Murray, Mr. Schumer, Mr. Breaux, Mr. Dodd, Mr. Levin,
Mr. Sarbanes, Mr. Leahy, Mr. Wellstone, Mr. Bryan, Mr. Dorgan, Mr.
Lautenberg, Mr. Byrd, Mr. Harkin, Mrs. Feinstein, Mrs. Lincoln, Mr.
Robb, Mr. Inouye, Mr. Hollings and Mr. Edwards) introduced the
following bill; which was read twice and referred to the Committee on
Finance
_______________________________________________________________________
A BILL
To amend title XVIII of the Social Security Act to modify the
provisions of the Balanced Budget Act of 1997.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE; AMENDMENTS TO SOCIAL SECURITY ACT; TABLE OF
CONTENTS.
(a) Short Title.--This Act may be cited as the ``Medicare
Beneficiary Access to Care Act of 1999''.
(b) Amendments to Social Security Act.--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,
the reference shall be considered to be made to that section or other
provision of the Social Security Act.
(c) Table of Contents.--The table of contents of this Act is as
follows:
Sec. 1. Short title; amendments to Social Security Act; table of
contents.
TITLE I--HOSPITALS
Sec. 101. Multiyear transition to prospective payment system for
hospital outpatient department services.
Sec. 102. Limitation in reduction of payments to disproportionate share
hospitals.
Sec. 103. Changes to DSH allotments and transition rule.
Sec. 104. Revision of criteria for designation as a critical access
hospital.
Sec. 105. Sole community hospitals and Medicare dependent hospitals.
TITLE II--GRADUATE MEDICAL EDUCATION
Sec. 201. Revision of multiyear reduction of indirect graduate medical
education payments.
Sec. 202. Acceleration of GME phase-in.
Sec. 203. Exclusion of nursing and allied health education costs in
calculating Medicare+Choice payment rate.
Sec. 204. Adjustments to limitations on number of interns and
residents.
TITLE III--HOSPICE CARE
Sec. 301. Increase in payments for hospice care.
TITLE IV--SKILLED NURSING FACILITIES
Sec. 401. Modification of case mix categories for certain conditions.
Sec. 402. Exclusion of clinical social worker services and services
performed under a contract with a rural
health clinic or Federally qualified health
center from the PPS for SNFs.
Sec. 403. Exclusion of certain services from the PPS for SNFs.
Sec. 404. Exclusion of swing beds in critical access hospitals from the
PPS for SNFs.
TITLE V--OUTPATIENT REHABILITATION SERVICES
Sec. 501. Modification of financial limitation on rehabilitation
services.
TITLE VI--PHYSICIANS' SERVICES
Sec. 601. Technical amendment to update adjustment factor and physician
sustainable growth rate.
Sec. 602. Publication of estimate of conversion factor and MedPAC
review.
TITLE VII--HOME HEALTH
Sec. 701. Delay in the 15 percent reduction in payments under the PPS
for home health services.
Sec. 702. Increase in per visit limit.
Sec. 703. Treatment of Outliers.
Sec. 704. Elimination of 15-minute billing requirement.
Sec. 705. Recoupment of overpayments.
Sec. 706. Refinement of home health agency consolidated billing.
TITLE VIII--MEDICARE+CHOICE
Sec. 801. Delay in ACR deadline under the Medicare+Choice program.
Sec. 802. Change in time period for exclusion of Medicare+Choice
organizations that have had a contract
terminated.
Sec. 803. Enrollment of medicare beneficiaries in alternative
Medicare+Choice plans and medigap coverage
in case of involuntary termination of
Medicare+Choice enrollment.
Sec. 804. Applying medigap and Medicare+Choice protections to disabled
and ESRD medicare beneficiaries.
Sec. 805. Extended Medicare+Choice disenrollment window for certain
involuntarily terminated enrollees.
Sec. 806. Nonpreemption of State prescription drug coverage mandates in
case of approved State medigap waivers.
Sec. 807. Modification of payment rules for certain frail elderly
Medicare beneficiaries.
Sec. 808. Extension of Medicare community nursing organization
demonstration projects.
TITLE IX--CLINICS
Sec. 901. New prospective payment system for Federally-qualified health
centers and rural health clinics under the
Medicaid Program.
TITLE I--HOSPITALS
SEC. 101. MULTIYEAR TRANSITION TO PROSPECTIVE PAYMENT SYSTEM FOR
HOSPITAL OUTPATIENT DEPARTMENT SERVICES.
(a) In General.--Section 1833(t) (42 U.S.C. 1395(t)) is amended by
adding at the end the following:
``(10) Multiyear transition.--
``(A) In general.--In the case of covered OPD
services furnished by a hospital during a transition
year, the Secretary shall increase the payments for
such services under the prospective payment system
established under this subsection by the amount (if
any) that the Secretary determines is necessary to
ensure that the payment to cost ratio of the hospital
for the transition year equals the applicable
percentage of the payment to cost ratio of the hospital
for 1996.
``(B) Payment to cost ratio.--
``(i) In general.--The payment to cost
ratio of a hospital for any year is the ratio
which--
``(I) the hospital's reimbursement
under this part for covered OPD
services furnished during the year,
including through cost-sharing
described in subparagraph (D)(ii),
bears to
``(II) the cost of such services.
``(ii) Calculation of 1996 payment to cost
ratio.--The Secretary shall determine each
hospital's payment to cost ratio for 1996 as if
the amendments to this title by the provisions
of section 4521 of the Balanced Budget Act of
1997 were in effect in 1996.
``(iii) Transition years.--The Secretary
shall estimate each payment to cost ratio of a
hospital for any transition year before the beginning of such year.
``(C) Interim payments.--
``(i) In general.--The Secretary shall make
interim payments to a hospital during any
transition year for which the Secretary
estimates a payment is required under
subparagraph (A).
``(ii) Adjustments.--If the Secretary makes
payments under clause (i) for any transition
year, the Secretary shall make retrospective
adjustments to each hospital based on its
settled cost report so that the amount of any
additional payment to a hospital for such year
equals the amount described in subparagraph
(A).
``(D) Definitions.--In this paragraph:
``(i) Applicable percentage.--The term
`applicable percentage' means, with respect to
covered OPD services furnished during--
``(I) the first full year (and any
portion of the immediately preceding
year) for which the prospective payment
system under this subsection is in
effect, 95 percent;
``(II) the second full calendar
year for which such system is in
effect, 90 percent; and
``(III) the third full calendar
year for which such system is in
effect, 85 percent.
``(ii) Cost-sharing.--The term `cost-
sharing' includes--
``(I) copayment amounts described
in paragraph (5);
``(II) coinsurance described in
section 1866(a)(2)(A)(ii); and
``(III) the deductible described
under section 1833(b).
``(iii) Transition year.--The term
`transition year' means any year (or portion
thereof) described in clause (i).
``(E) Effect on copayments.--Nothing in this
paragraph shall be construed as affecting the
unadjusted copayment amount described in paragraph
(3)(B).
``(F) Application without regard to budget
neutrality.--The transitional payments made under this
paragraph--
``(i) shall not be considered an adjustment
under paragraph (2)(E); and
``(ii) shall not be implemented in a budget
neutral manner.''.
(b) Special Rule for Rural and Cancer Hospitals.--Section 1833(t)
(42 U.S.C. 1395(t)), as amended by subsection (a), is amended by adding
at the end the following:
``(11) Special rule for rural and cancer hospitals.--
``(A) In general.--For each year (or portion
thereof), beginning in 2000, in the case of covered OPD
services furnished by a medicare-dependent, small rural
hospital (as defined in section 1886(d)(5)(G)(iv)), a
sole community hospital (as defined in section
1886(d)(5)(D)(iii)), or in a hospital described in
section 1886(d)(1)(B)(v), the Secretary shall increase
the payments for such services under the prospective
payment system established under this subsection by the
amount (if any) that the Secretary determines is
necessary to ensure that the payment to cost ratio of
the hospital (as determined pursuant to paragraph
(10)(B)) for the year equals the payment to cost ratio
of the hospital for 1996 (as calculated under clause
(ii) of such paragraph).
``(B) Interim payments.--
``(i) In general.--The Secretary shall make
interim payments to a hospital during any year
for which the Secretary estimates a payment is
required under subparagraph (A).
``(ii) Adjustments.--If the Secretary makes
payments under clause (i) for any year, the
Secretary shall make retrospective adjustments
to each hospital based on its settled cost
report so that the amount of any additional
payment to a hospital for such year equals the
amount described in subparagraph (A).
``(C) Effect on copayments.--Nothing in this
paragraph shall be construed as affecting the
unadjusted copayment amount described in paragraph
(3)(B).
``(D) Application without regard to budget
neutrality.--The payments made under this paragraph--
``(i) shall not be considered an adjustment
under paragraph (2)(E); and
``(ii) shall not be implemented in a budget
neutral manner.''.
(c) Effective Date.--The amendments made by this section shall take
effect as if included in the amendments made by section 4523 of the
Balanced Budget Act of 1997 (Public Law 105-33; 111 Stat. 445).
SEC. 102. LIMITATION IN REDUCTION OF PAYMENTS TO DISPROPORTIONATE SHARE
HOSPITALS.
(a) In General.--Section 1886(d)(5)(F)(ix) (42 U.S.C.
1395ww(d)(5)(F)(ix)) is amended--
(1) in subclause (II)--
(A) by striking ``fiscal year 1999,'' and inserting
``each of fiscal years 1999, 2000, 2001, and 2002,'';
and
(B) by inserting ``and'' after the semicolon;
(2) by striking subclauses (III), (IV), and (V); and
(3) by redesignating subclause (VI) as subclause (III).
(b) Effective Date.--The amendments made by subsection (a) shall
take effect as if included in the amendments made by section 4403 of
the Balanced Budget Act of 1997 (Public Law 105-33; 111 Stat. 398).
SEC. 103. CHANGES TO DSH ALLOTMENTS AND TRANSITION RULE.
(a) Change in Disproportionate Share Hospital Allotments.--Section
1923(f)(2) (42 U.S.C. 1396r-4(f)(2)) is amended, in the table contained
in such section and in the DSH Allotments for fiscal years 2000, 2001,
and 2002--
(1) for Minnesota, by striking ``16'' and inserting ``33'';
(2) for New Mexico, by striking ``5'' and inserting ``9'';
and
(3) for Wyoming, by striking ``0'' and inserting ``0.1''.
(b) Making Medicaid DSH Transition Rule Permanent.--Section 4721(e)
of the Balanced Budget Act of 1997 is amended--
(1) in the matter before paragraph (1), by striking
``1923(g)(2)(A)'' and ``1396r-4(g)(2)(A)'' and inserting
``1923(g)(2)'' and ``1396r-4(g)(2)'', respectively;
(2) in paragraphs (1) and (2)--
(A) by striking ``, and before July 1, 1999''; and
(B) by striking ``in such section'' and inserting
``in subparagraph (A) of such section''; and
(3) by striking ``and'' at the end of paragraph (1), by
striking the period at the end of paragraph (2) and inserting
``; and'', and by adding at the end the following:
``(3) effective for State fiscal years that begin on or
after July 1, 1999, `or (b)(1)(B)' were inserted in
1923(g)(2)(B)(ii)(I) after `(b)(1)(A)'.''.
(c) Effective Date.--The amendments made by this section shall take
effect as if included in the enactment of the Balanced Budget Act of
1997 (Public Law 105-33; 111 Stat. 251).
SEC. 104. REVISION OF CRITERIA FOR DESIGNATION AS A CRITICAL ACCESS
HOSPITAL.
(a) Criteria for Designation.--Section 1820(c)(2)(B)(iii) (42
U.S.C. 1395i-4(c)(2)(B)(iii)) is amended by striking ``to exceed 96
hours'' and all that follows before the semicolon and inserting ``to
exceed, on average, 96 hours per patient''.
(b) Effective Date.--The amendment made by subsection (a) shall
take effect 60 days after the date of enactment of this Act.
SEC. 105. SOLE COMMUNITY HOSPITALS AND MEDICARE DEPENDENT HOSPITALS.
(a) In General.--Section 1886(b)(3)(B)(iv) (42 U.S.C.
1395ww(b)(3)(B)(iv)) is amended--
(1) in subclause (III), by striking ``and'' at the end;
(2) in subclause (IV)--
(A) by striking ``fiscal year 1996 and each
subsequent fiscal year'' and inserting ``fiscal years
1996 through 1999''; and
(B) by striking the period at the end and inserting
``, and''; and
(3) by adding at the end the following:
``(V) for fiscal year 2000 and each subsequent fiscal year,
the market basket percentage increase.''.
(b) Effective Date.--The amendments made by subsection (a) shall
take effect on the date of enactment of this Act.
TITLE II--GRADUATE MEDICAL EDUCATION
SEC. 201. REVISION OF MULTIYEAR REDUCTION OF INDIRECT GRADUATE MEDICAL
EDUCATION PAYMENTS.
(a) In General.--Section 1886(d)(5)(B)(ii) (42 U.S.C.
1395ww(d)(5)(B)(ii)) is amended by striking subclauses (III), (IV), and
(V) and inserting the following:
``(III) during each of fiscal years
1999 through 2007, `c' is equal to 1.6;
and
``(IV) on or after October 1, 2007,
`c' is equal to 1.35.''.
(b) Effective Date.--The amendments made by subsection (a) shall
take effect as if included in section 4621 of the Balanced Budget Act
of 1997 (Public Law 105-33; 111 Stat. 475).
SEC. 202. ACCELERATION OF GME PHASE-IN.
(a) Acceleration of Payment to Hospitals of Indirect and Direct
Medical Education Costs for Medicare+Choice Enrollees.--
(1) In general.--Section 1886(h)(3)(D)(ii) (42 U.S.C.
1395ww(h)(3)(D)(ii)) is amended by striking subclauses (IV) and
(V) and inserting the following:
``(IV) 100 percent in 2001 and
subsequent years.''.
(2) Acceleration of carve-out.--Section 1853(c)(3)(B)(ii)
(42 U.S.C. 1395w-23(c)(3)(B)(ii)) is amended--
(A) in subclause (III), by inserting ``and'' at the
end;
(B) by striking subclause (IV); and
(C) by redesignating subclause (V) as subclause
(IV).
(b) Effective Date.--The amendments made by subsection (a) shall
take effect as if included in the enactment of the Balanced Budget Act
of 1997 (Public Law 105-33; 111 Stat. 251).
SEC. 203. EXCLUSION OF NURSING AND ALLIED HEALTH EDUCATION COSTS IN
CALCULATING MEDICARE+CHOICE PAYMENT RATE.
(a) Excluding Costs in Calculating Payment Rate.--
(1) In general.--Section 1853(c)(3)(C)(i) (42 U.S.C. 1395w-
23(c)(3)(C)(i)) is amended--
(A) in subclause (I), by striking ``and'' at the
end;
(B) in subclause (II), by striking the period at
the end and inserting ``, and''; and
(C) by adding at the end the following:
``(III) for costs attributable to
approved nursing and allied health
education programs under section
1861(v).''.
(2) Effective date.--The amendments made by paragraph (1)
shall apply in determining the annual per capita rate of
payment for years beginning with 2001.
(b) Payment to Hospitals of Nursing and Allied Health Education
Program Costs for Medicare+Choice Enrollees.--Section 1861(v)(1) (42
U.S.C. 1395x(v)(1)) is amended by adding at the end the following:
``(V)(i) In determining the amount of payment to a hospital for
portions of cost reporting periods occurring on or after January 1,
2001, with respect to the reasonable costs for approved nursing and
allied health education programs, individuals who are enrolled with a
Medicare+Choice organization under part C shall be treated as if they
were not so enrolled.
``(ii) The Secretary shall establish rules for applying clause (i)
to a hospital reimbursed under a reimbursement system authorized under
section 1814(b)(3) in the same manner as it would apply to the hospital
if it were not reimbursed under such section.''.
SEC. 204. ADJUSTMENTS TO LIMITATIONS ON NUMBER OF INTERNS AND
RESIDENTS.
(a) Indirect Graduate Medical Education Adjustment.--Section
1886(d)(5)(B)(v) (42 U.S.C. 1395ww(d)(5)(B)(v)) is amended--
(1) by striking ``(v) In determining'' and inserting
``(v)(I) Subject to subclause (II), in determining'';
(2) by striking ``in the hospital with respect to the
hospital's most recent cost reporting period ending on or
before December 31, 1996'' and inserting ``who were appointed
by the hospital's approved medical residency training programs
for the hospital's most recent cost reporting period ending on
or before December 31, 1996''; and
(3) by adding at the end the following:
``(II) Beginning on or after January 1, 1997, in the case of a
hospital that sponsors only 1 allopathic or osteopathic residency
program, the limit determined for such hospital under subclause (I)
may, at the hospital's discretion, be increased by 1 for each calendar
year but shall not exceed a total of 3 more than the limit determined
for the hospital under subclause (I).''.
(b) Direct Graduate Medical Education Adjustment.--
(1) Limitation on number of residents.--Section
1886(h)(4)(F) (42 U.S.C. 1395ww(h)(4)(F)) is amended by
inserting ``who were appointed by the hospital's approved
medical residency training programs'' after ``may not exceed
the number of such full-time equivalent residents''.
(2) Funding for programs.--Section 1886(h)(4)(H)(i) (42
U.S.C. 1395ww(h)(4)(H)(i)) is amended in the second sentence,
by inserting ``, including facilities that are not located in
an underserved rural area but have established separately
accredited rural training tracks'' before the period.
(c) GME Payments for Certain Interns and Residents.--
(1) Indirect and direct medical education.--Each limitation
regarding the number of residents or interns for which payment
may be made under section 1886 of the Social Security Act (42
U.S.C. 1395ww) is increased by the number of applicable
residents (as defined in paragraph (2)).
(2) Applicable resident defined.--In this subsection, the
term ``applicable resident'' means a resident or intern that--
(A) participated in graduate medical education at a
facility of the Department of Veterans Affairs;
(B) was subsequently transferred on or after
January 1, 1997, and before July 31, 1998, to a
hospital and the hospital was not a Department of
Veterans Affairs facility; and
(C) was transferred because the approved medical
residency program in which the resident or intern
participated would lose accreditation by the
Accreditation Council on Graduate Medical Education if
such program continued to train residents at the
Department of Veterans Affairs facility.
(d) Effective Date.--This section shall take effect as if included
in the enactment of the Balanced Budget Act of 1997 (Public Law 105-33;
111 Stat. 251).
TITLE III--HOSPICE CARE
SEC. 301. INCREASE IN PAYMENTS FOR HOSPICE CARE.
(a) In General.--Section 1814(i)(1)(C)(ii)(VI) (42 U.S.C.
1395f(i)(1)(C)(ii)(VI)) is amended by striking ``through 2002'' and
inserting ``and 1999''.
(b) Effective Date.--The amendments made by this section shall take
effect as if included in the amendments made by section 4441 of the
Balanced Budget Act of 1997 (Public Law 105-33; 111 Stat. 422).
TITLE IV--SKILLED NURSING FACILITIES
SEC. 401. MODIFICATION OF CASE MIX CATEGORIES FOR CERTAIN CONDITIONS.
(a) In General.--For purposes of applying any formula under
paragraph (1) of section 1888(e) of the Social Security Act (42 U.S.C.
1395yy(e)), for services provided on or after April 1, 2000, and before
the earlier of October 1, 2001, or the date described in subsection
(d), the Secretary of Health and Human Services shall increase the
adjusted Federal per diem rate otherwise determined under paragraph (4)
of such section for services provided to any individual during the
period in which such individual is in a RUG III category by the
applicable payment add-on as determined in accordance with the
following table:
RUG III category Applicable paymentadd-on
RUB........................................... $23.06
RVC........................................... $76.25
RVB........................................... $30.36
RHC........................................... $54.07
RHB........................................... $27.28
RMC........................................... $69.98
RMB........................................... $30.09
SE3........................................... $98.41
SE2........................................... $89.05
SSC........................................... $46.80
SSB........................................... $55.56
SSA........................................... $59.94.
(b) Update.--The Secretary shall update the applicable payment add-
on under subsection (a) for fiscal year 2001 by the skilled nursing
facility market basket percentage change (as defined under section
1888(e)(5)(B) of the Social Security Act (42 U.S.C. 1395yy(e)(5)(B)))
applicable to such fiscal year.
(c) Rule of Construction.--Nothing in this section shall be
construed as permitting the Secretary of Health and Human Services to
include any applicable payment add-on determined under subsection (a)
in updating the Federal per diem rate under section 1888(e)(4) of the
Social Security Act (42 U.S.C. 1395yy(e)(4)).
(d) Date Described.--The date described in this subsection is the
date that the Secretary of Health and Human Services--
(1) refines the case mix classification system under
section 1888(e)(4)(G)(i) of the Social Security Act (42 U.S.C.
1395yy(e)(4)(G)(i)) to better account for medically complex
patients; and
(2) implements such refined system.
SEC. 402. EXCLUSION OF CLINICAL SOCIAL WORKER SERVICES AND SERVICES
PERFORMED UNDER A CONTRACT WITH A RURAL HEALTH CLINIC OR
FEDERALLY QUALIFIED HEALTH CENTER FROM THE PPS FOR SNFS.
(a) In General.--Section 1888(e)(2)(A)(ii) (42 U.S.C.
1395yy(e)(2)(A)(ii)) is amended--
(1) in the first sentence, by inserting ``clinical social
worker services,'' after ``qualified psychologist services,'';
and
(2) by inserting after the first sentence the following:
``Services described in this clause also include services that
are provided by a physician, a physician assistant, a nurse
practitioner, a qualified psychologist, or a clinical social
worker who is employed, or otherwise under contract, with a
rural health clinic or a Federally qualified health center.''.
(b) Conforming Amendment.--Section 1861(hh)(2) (42 U.S.C.
1395x(hh)(2)) is amended by striking ``and other than services
furnished to an inpatient of a skilled nursing facility which the
facility is required to provide as a requirement for participation''.
(c) Effective Date.--The amendments made by this section shall
apply to services provided on or after the date which is 60 days after
the date of enactment of this Act.
SEC. 403. EXCLUSION OF CERTAIN SERVICES FROM THE PPS FOR SNFS.
(a) In General.--Section 1888(e)(2)(A)(ii) (42 U.S.C.
1395yy(e)(2)(A)(ii)), as amended by section 402, is amended--
(1) in the first sentence, by inserting ``ambulance
services, services identified by HCPCS code in Program
Memorandum Transmittal No. A-98-37 issued in November 1998 (but
without regard to the setting in which such services are
furnished),'' after ``subparagraphs (F) and (O) of section
1861(s)(2),''; and
(2) by inserting after the second sentence the following:
``In addition to the services described in the previous
sentences, services described in this clause include
chemotherapy items (identified as of July 1, 1999, by HCPCS
codes J9000-J9020, J9040-J9151, J9170-J9185, J9200-J9201,
J9206-J9208, J9211, J9230-J9245, and J9265-J9600), chemotherapy
administration services (identified as of July 1, 1999, by
HCPCS codes 36260-36262, 36489, 36530-36535, 36640, 36823, and
96405-96542), radioisotope services (identified as of July 1,
1999, by HCPCS codes 79030-79440), and customized prosthetic
devices (identified as of July 1, 1999, by HCPCS codes L5050-
L5340, L5500-L5610, L5613-L5986, L5988, L6050-L6370, L6400-
L6880, L6920-L7274, and L7362-L7366).''.
(b) Effective Date.--The amendments made by this section shall
apply to services furnished on or after the date which is 60 days after
the date of enactment of this Act.
SEC. 404. EXCLUSION OF SWING BEDS IN CRITICAL ACCESS HOSPITALS FROM THE
PPS FOR SNFS.
(a) In General.--Section 1888(e)(7) of the Social Security Act (42
U.S.C. 1395yy(e)(7)) is amended--
(1) in the heading, by striking ``Transition'' and
inserting ``Special Rules'';
(2) in subparagraph (A), by striking ``In general.--The''
and inserting ``Transition.--Except as provided in subparagraph
(C), the''; and
(3) by adding at the end the following:
``(C) Exemption of swing beds in critical
access hospitals from PPS.--The prospective
payment system under this subsection shall not
apply (and section 1834(g) shall apply) to
services provided by a critical access hospital
under an agreement described in subparagraph
(B).''.
(b) Effective Date.--The amendments made by this section shall
apply to services provided on or after October 1, 1999.
TITLE V--OUTPATIENT REHABILITATION SERVICES
SEC. 501. MODIFICATION OF FINANCIAL LIMITATION ON REHABILITATION
SERVICES.
(a) 3-Year Repeal.--Section 1833(g) (42 U.S.C. 1395l(g)) is amended
by adding at the end the following:
``(4) Subject to paragraph (6), the provisions of paragraphs (1)
through (3) shall not apply to outpatient physical therapy services,
outpatient occupational therapy services, and outpatient speech-
language pathology services covered under this title and furnished on
or after January 1, 2000.
``(5)(A) Notwithstanding the preceding provisions of this
subsection and subject to subparagraph (B), with respect to services
described in paragraph (4) that are furnished on or after January 1,
2003, the Secretary shall implement, by not later than January 1, 2003,
a payment system for such services that takes into account the needs of
beneficiaries under this title for differing amounts of therapy based
on factors such as diagnosis, functional status, and prior use of
services.
``(B) The payment system established under subparagraph (A) shall
be designed so that the system shall not result in any increase or
decrease in the expenditures under this title on a fiscal year basis,
determined as if paragraph (4) had not been enacted.
``(6) If the Secretary for any reason does not implement the
payment system described in paragraph (5) on or before January 1, 2003,
paragraph (4) shall not apply with respect to services described in
such paragraph that are furnished on or after such date and before the
date on which the Secretary implements such payment system.''.
(b) Effective Date.--The amendment made by this section shall take
effect as if included in the enactment of the Balanced Budget Act of
1997 (Public Law 105-33; 111 Stat. 251).
TITLE VI--PHYSICIANS' SERVICES
SEC. 601. TECHNICAL AMENDMENT TO UPDATE ADJUSTMENT FACTOR AND PHYSICIAN
SUSTAINABLE GROWTH RATE.
(a) Update Adjustment Factor.--
(1) Change to calendar year basis.--Section 1848(d) (42
U.S.C. 1395w-4(d)) is amended--
(A) in paragraph (1), by striking subparagraph (E)
and inserting the following:
``(E) Publication.--The Secretary shall publish in
the Federal Register--
``(i) not later than November 1 of each
year (beginning with 1999), the conversion
factor that will apply to physicians' services
for the succeeding year and the update
determined under paragraph (3) for such year;
and
``(ii) not later than November 1 of 1999--
``(I) the special update for the
year 2000 under paragraph (3)(E)(i);
and
``(II) the estimated special
adjustments for years 2001 through 2006
under paragraph (3)(E)(ii).''; and
(B) in paragraph (3)(C)--
(i) in the matter preceding clause (i), by
striking ``the 12-month period ending with
March 31 of'';
(ii) in clause (i)--
(I) by striking ``1997'' and
inserting ``1996,''; and
(II) by striking ``such 12-month
period'' and inserting ``1996''; and
(iii) in clause (ii)--
(I) by inserting a comma after
``subsequent year''; and
(II) by striking ``fiscal year
which begins during such 12-month
period'' and inserting ``year
involved''.
(2) Formula for determining the update adjustment factor.--
Section 1848(d)(3) (42 U.S.C. 1395w-4(d)(3)) is amended--
(A) in subparagraph (A)--
(i) in clause (ii), by striking ``(divided
by 100),'' and inserting a period; and
(ii) by striking the matter following
clause (ii);
(B) in subparagraph (B)--
(i) in the matter preceding clause (i), by
inserting ``the sum of'' after ``Secretary)
to''; and
(ii) by striking clauses (i) and (ii) and
inserting the following:
``(i) the figure arrived at by--
``(I) determining the difference
between the allowed expenditures for
physicians' services for the prior year
(as determined under subparagraph (C))
and the actual expenditures for such
services for that year;
``(II) dividing that difference by
the actual expenditures for such
services in that year; and
``(III) multiplying that quotient
by 0.75; and
``(ii) the figure arrived at by--
``(I) determining the difference
between the allowed expenditures for
physicians' services (as determined
under subparagraph (C)) from 1996
through the prior year and the actual
expenditures for such services during
that period, corrected with the best
available data;
``(II) dividing that difference by
actual expenditures for such services
for the prior year as increased by the
sustainable growth rate under
subsection (f) for the year whose
update adjustment factor is to be
determined; and
``(III) multiplying that quotient
by 0.33.''; and
(C) by amending subparagraph (D) to read as
follows:
``(D) Restriction on update adjustment factor.--The
update adjustment factor determined under subparagraph
(B) for a year may not be less than negative 0.07 or
greater than 0.03.''.
(3) Special provisions.--Section 1848(d)(3) (42 U.S.C.
1395w-4(d)(3)) is amended--
(A) in subparagraph (A), in the matter preceding
clause (i), by striking ``subparagraph (D)'' and
inserting ``subparagraphs (D) and (E)''; and
(B) by adding at the end the following:
``(E) Special update and adjustments.--
``(i) Year 2000.--For the year 2000, the
update under this paragraph shall be the
percentage that the Secretary estimates will,
without regard to any otherwise applicable
restriction, result in expenditures equal to
the expenditures that would have occurred in
that year in the absence of the amendments made
by section 601 of the Medicare Beneficiary
Access to Care Act of 1999.
``(ii) Years 2001-2006.--For each of the
years 2001 through 2006, the Secretary shall
make that adjustment to the update for that
year which the Secretary estimates will,
without regard to any otherwise applicable
restriction, result in expenditures equal to
the expenditures that would have occurred for
that year in the absence of the amendments made
by section 601 of the Medicare Beneficiary
Access to Care Act of 1999.''.
(b) Sustainable Growth Rate.--Section 1848(f) (42 U.S.C. 1395w-
4(f)) is amended--
(1) by striking paragraph (1) and inserting the following:
``(1) Publication.--Not later than November 1 of each year
(beginning with 1999), the Secretary shall publish in the
Federal Register the sustainable growth rate as determined
under this subsection for the succeeding year, the current
year, and each of the preceding 2 years.''; and
(2) in paragraph (2)--
(A) by striking ``fiscal'' each place it appears;
and
(B) in the matter preceding subparagraph (A), by
striking ``year 1998'' and inserting ``1997''.
(c) Data To Be Used in Determining the Sustainable Growth Rate.--
Section 1848(f) (42 U.S.C. 1395w-4(f)) is amended--
(1) by redesignating paragraph (3) as paragraph (4); and
(2) by inserting after paragraph (2) the following:
``(3) Methodology.--For purposes of determining the update
adjustment factor under subsection (d)(3)(B) and the allowed
expenditures under subsection (d)(3)(C) for a year, the
sustainable growth rate for each year taken into consideration
in the determination under paragraph (2) shall be determined as
follows:
``(A) For purposes of such calculations for the
year 2000, the sustainable growth rate shall be
determined on the basis of the best data available to
the Secretary as of September 1, 1999.
``(B) For purposes of such calculations for each
year after the year 2000--
``(i) the sustainable growth rate for such
year and each of the 2 preceding years shall be
determined on the basis of the best data
available to the Secretary as of September 1 of
such year; and
``(ii) the sustainable growth rate for each
year preceding the years specified in clause
(i) shall be the rate used for such year in
such calculation for the immediately preceding
year.''.
(d) Effective Date.--
(1) In general.--Subject to paragraph (2), the amendments
made by this section shall take effect as if included in the
enactment of the Balanced Budget Act of 1997 (Public Law 105-
33; 111 Stat. 251).
(2) No effect on updates for 1998 and 1999.--The amendments
made by this section shall have no effect on the updates
established by the Secretary for 1998 and 1999, and such
established updates may not be changed.
SEC. 602. PUBLICATION OF ESTIMATE OF CONVERSION FACTOR AND MEDPAC
REVIEW.
(a) Publication.--Not later than April 15 of each year (beginning
in 2000), the Secretary of Health and Human Services (in this section
referred to as the ``Secretary'') shall publish in the Federal
Register--
(1) an estimate of the single conversion factor to be used
in the next calendar year for reimbursement of physicians
services under section 1848 of the Social Security Act (42
U.S.C. 1395w-4); and
(2) the data on which such estimate is based.
(b) MedPAC Review and Report.--
(1) Review.--The Medicare Payment Advisory Commission (in
this section referred to as ``MedPAC'') shall annually review
the estimates and data published by the Secretary pursuant to
subsection (a).
(2) Report.--Not later than June 30 of each year (beginning
in 2000), MedPAC shall submit a report to the Secretary and to
the committees of jurisdiction in Congress on the review
conducted pursuant to paragraph (1), together with any
recommendations as determined appropriate by MedPAC.
TITLE VII--HOME HEALTH
SEC. 701. DELAY IN THE 15 PERCENT REDUCTION IN PAYMENTS UNDER THE PPS
FOR HOME HEALTH SERVICES.
(a) Contingency Reduction.--Section 4603(e) of the Balanced Budget
Act of 1997 (42 U.S.C. 1395fff note), as amended by section 5101(c)(3)
of the Tax and Trade Relief Extension Act of 1998 (contained in
division J of Public Law 105-277), is amended by striking ``September
30, 2000'' and inserting ``September 30, 2002''.
(b) Prospective Payment System.--Section 1895(b)(3)(A) (42 U.S.C.
1395fff(b)(3)(A)), as amended by section 5101 of the Tax and Trade
Relief Extension Act of 1998 (contained in division J of Public Law
105-277), is amended by striking clause (i) and inserting the
following:
``(i) In general.--Under such system the
Secretary shall provide for computation of a
standard prospective payment amount (or
amounts) as follows:
``(I) Such amount (or amounts)
shall initially be based on the most
current audited cost report data
available to the Secretary and shall be
computed in a manner so that the total
amounts payable under the system for
fiscal year 2001, shall be equal to the
total amount that would have been made
if the system had not been in effect;
``(II) For fiscal year 2003 such
amount (or amounts), shall be equal to
the amount (or amounts) that would have
been determined under subclause (I), if
the reduction in limits described in
clause (ii) had been in effect for
fiscal year 2001, and updated under
subparagraph (B) for fiscal years 2002
and 2003.
Each such amount shall be standardized in a
manner that eliminates the effect of variations
in relative case mix and wage levels among
different home health agencies in a budget
neutral manner consistent with the case mix and
wage level adjustments provided under paragraph
(4)(A). Under the system, the Secretary may
recognize regional differences or differences
based upon whether or not the services or
agency are in an urbanized area.''.
SEC. 702. INCREASE IN PER VISIT LIMIT.
(a) Interim Payment System.--Section 1861(v)(1)(L)(i) (42 U.S.C.
1395x(v)(1)(L)(i)), as amended by section 701(b), is amended--
(1) in subclause (IV), by striking ``or'';
(2) in subclause (V)--
(A) by inserting ``and before October 1, 1999,''
after ``October 1, 1998,''; and
(B) by striking the period and inserting ``, or'';
and
(3) by adding at the end the following:
``(VI) October 1, 1999, 112 percent of such median.''.
(b) Ensuring the Increase in Per Visit Limit Has No Effect on the
Prospective Payment System.--The second sentence of section
1895(b)(3)(A)(i) (42 U.S.C. 1395fff(b)(3)(A)(i)), as amended by section
5101(c)(1)(B) of the Tax and Trade Relief Extension Act of 1998
(contained in division J of Public Law 105-277) and section 701(b), is
amended--
(1) in subclause (I), by inserting ``but if the reference
in section 1861(v)(1)(L)(i)(VI) to 112 percent were a reference
to 106 percent'' after ``if the system had not been in
effect''; and
(2) in subclause (II), by inserting ``and if the reference
in section 1861(v)(1)(L)(i)(VI) to 112 percent were a reference
to 106 percent'' after ``clause (ii) had been in effect for
fiscal year 2001''.
SEC. 703. TREATMENT OF OUTLIERS.
(a) Waiver of Per Beneficiary Limits for Outliers.--Section
1861(v)(1)(L) (42 U.S.C. 1395x(v)(1)(L)), as amended by section 5101 of
the Tax and Trade Relief Extension Act of 1998 (contained in division J
of Public Law 105-277), is amended--
(1) by redesignating clause (ix) as clause (x); and
(2) by inserting after clause (viii) the following:
``(ix)(I) Notwithstanding the applicable per beneficiary limit
under clause (v), (vi), or (viii), but subject to the applicable per
visit limit under clause (i), in the case of a provider that
demonstrates to the Secretary that with respect to an individual to
whom the provider furnished home health services appropriate to the
individual's condition (as determined by the Secretary) at a reasonable
cost (as determined by the Secretary), and that such reasonable cost
significantly exceeded such applicable per beneficiary limit because of
unusual variations in the type or amount of medically necessary care
required to treat the individual, the Secretary, upon application by
the provider, shall pay to such provider for such individual such
reasonable cost.
``(II) The total amount of the additional payments made to home
health agencies pursuant to subclause (I) in any fiscal year shall not
exceed an amount equal to 2 percent of the amounts that would have been
paid under this subparagraph in such year if this clause had not been
enacted.''.
(b) Effective Date.--The amendments made by subsection (a) shall
take effect on the date of enactment of this Act, and shall apply to
each application for payment of reasonable costs for outliers submitted
by any home health agency for cost reporting periods ending on or after
October 1, 1999.
SEC. 704. ELIMINATION OF 15-MINUTE BILLING REQUIREMENT.
(a) In General.--Section 1895(c) (42 U.S.C. 1395fff(c)) is amended
to read as follows:
``(c) Requirements for Payment Information.--With respect to home
health services furnished on or after October 1, 1998, no claim for
such a service may be paid under this title unless the claim has the
unique identifier (provided under section 1842(r)) for the physician
who prescribed the services or made the certification described in
section 1814(a)(2) or 1835(a)(2)(A).''
(b) Effective Date.--The amendment made by subsection (a) shall
apply to claims submitted on or after the date which is 60 days after
the date of enactment of this section.
SEC. 705. RECOUPMENT OF OVERPAYMENTS.
(a) 36-Month Repayment Period.--In the case of an overpayment by
the Secretary of Health and Human Services to a home health agency for
home health services furnished during a cost reporting period beginning
on or after October 1, 1997, as a result of payment limitations
provided for under clause (v), (vi), or (viii) of section 1861(v)(1)(L)
of the Social Security Act (42 U.S.C. 1395x(v)(1)(L)), the home health
agency may elect to repay the amount of such overpayment ratably over a
36-month period beginning on the date of notification of such
overpayment.
(b) No Interest on Overpayment Amounts.--In the case of an agency
that makes an election under subsection (a), no interest shall accrue
on the outstanding balance of the amount of overpayment during such 36-
month period.
(c) Termination.--No election under subsection (a) may be made for
cost reporting periods, or portions of cost reporting periods,
beginning on or after the date of the implementation of the prospective
payment system for home health services under section 1895 of the
Social Security Act (42 U.S.C. 1395fff).
(d) Effective Date.--The provisions of subsection (a) shall apply
to debts that are outstanding as of the date of enactment of this Act.
SEC. 706. REFINEMENT OF HOME HEALTH AGENCY CONSOLIDATED BILLING.
(a) In General.--Section 1842(b)(6)(F) (42 U.S.C. 1395u(b)(6)(F))
is amended by inserting ``(including medical supplies described in
section 1861(m)(5), but excluding durable medical equipment described
in such section)'' after ``home health services''.
(b) Conforming Amendment.--Section 1862(a)(21) (42 U.S.C.
1395y(a)(21)) is amended by inserting ``(including medical supplies
described in section 1861(m)(5), but excluding durable medical
equipment described in such section)'' after ``home health services''.
(c) Effective Date.--The amendments made by this section shall take
effect as if included in the amendments made by section 4603 of the
Balanced Budget Act of 1997 (Public Law 105-33; 111 Stat. 467).
TITLE VIII--MEDICARE+CHOICE
SEC. 801. DELAY IN ACR DEADLINE UNDER THE MEDICARE+CHOICE PROGRAM.
(a) Delay in Deadline for Submission of Adjusted Community Rates
and Related Information.--Section 1854(a)(1) (42 U.S.C. 1395w-24(a)(1))
is amended by striking ``May 1'' and inserting ``July 1''.
(b) Adjustment in Information Disclosure Provisions.--Section
1851(d)(2)(A)(ii) (42 U.S.C. 1395w-21(d)(2)(A)(ii)) is amended in the
first sentence by inserting ``, to the extent such information is
available at the time of preparation of the material for mailing''
before the period.
(c) Effective Date.--The amendments made by this section shall take
effect on the date of enactment of this Act.
SEC. 802. CHANGE IN TIME PERIOD FOR EXCLUSION OF MEDICARE+CHOICE
ORGANIZATIONS THAT HAVE HAD A CONTRACT TERMINATED.
(a) In General.--Section 1857(c)(4) (42 U.S.C. 1395w-27(c)(4)) is
amended by striking ``5-year period'' and inserting ``3-year period''.
(b) Effective Date.--The amendment made by subsection (a) shall
apply to contract years beginning on or after January 1, 1999.
SEC. 803. ENROLLMENT OF MEDICARE BENEFICIARIES IN ALTERNATIVE
MEDICARE+CHOICE PLANS AND MEDIGAP COVERAGE IN CASE OF
INVOLUNTARY TERMINATION OF MEDICARE+CHOICE ENROLLMENT.
(a) Permitting Enrollment in Alternative Plans Upon Receipt of
Notice of Medicare+Choice Plan Termination.--
(1) Medicare+choice plans.--Section 1851(e)(4) (42 U.S.C.
1395w-21(e)(4)) is amended by striking subparagraph (A) and
inserting the following:
``(A)(i) the certification of the organization or
plan under this part has been terminated, or the
organization or plan has notified the individual of an
impending termination of such certification; or
``(ii) the organization has terminated or otherwise
discontinued providing the plan in the area in which
the individual resides, or has notified the individual
of an impending termination or discontinuation of such
plan;''.
(2) Medigap plans.--
(A) In general.--Section 1882(s)(3)(A) (42 U.S.C.
1395ss(s)(3)(A)) is amended in the matter following
clause (iii)--
(i) by inserting ``(92 days in the case of
a termination or discontinuation of coverage
under the types of circumstances described in
section 1851(e)(4)(A))'' after ``63 days'';
(ii) by inserting ``(or, if elected by the
individual, the date of notification of the
individual by the plan or organization of the
impending termination or discontinuance of the
plan in the area in which the individual
resides)'' after ``the date of the termination
of enrollment described in such subparagraph'';
and
(iii) by inserting ``(or date of such
notification)'' after ``the date of termination
or disenrollment''.
(B) Effective date.--The amendments made by this
paragraph shall apply to notices of intended
termination made by group health plans and
Medicare+Choice organizations after the date of
enactment of this Act.
(b) Guaranteed Access for Certain Medicare Beneficiaries to Medigap
Policies in Case of Involuntary Termination of Coverage Under a
Medicare+Choice Plan.--
(1) In general.--Section 1882(s)(3)(C)(iii) (42 U.S.C.
1395ss(s)(3)(C)(iii)) is amended by inserting ``or an
individual described in clause (ii) or (iii) of subparagraph
(B) in the case of circumstances described in section
1851(e)(4)(A)'' after ``subparagraph (B)(vi)''.
(2) Effective date.--
(A) In general.--Subject to subparagraph (B), the
amendment made by paragraph (1) shall apply to
terminations of coverage effected on or after the date
of enactment of this Act.
(B) Transitional medigap open enrollment period for
certain individuals affected by plan withdrawals.--In
the case of an individual described in clause (ii) or
(iii) of subparagraph (B) of section 1882(s)(3) of the
Social Security Act in the case of circumstances
described in section 1851(e)(4)(A) of such Act
(relating to discontinuation of a plan or organization
entirely or in an area), if the termination or
discontinuation of coverage occurred after December 31,
1998, and before the date of enactment of this Act, the
provisions of subparagraph (A) of section 1882(s)(3)
such Act (in the matter up to and including clause
(iii) thereof) shall apply to such an individual who
seeks enrollment under a medicare supplemental policy
during the 92-day period beginning with the first month
that begins more than 30 days after the date of
enactment of this Act in the same manner as such
provisions apply to an individual described in the
matter following such clause (iii).
SEC. 804. APPLYING MEDIGAP AND MEDICARE+CHOICE PROTECTIONS TO DISABLED
AND ESRD MEDICARE BENEFICIARIES.
(a) Assuring Availability of Medigap Coverage.--
(1) In general.--Section 1882(s) (42 U.S.C. 1395ss(s)) is
amended--
(A) in paragraph (2)(A), by striking ``is 65 years
of age or older and is'' and inserting ``is first'';
(B) in paragraph (2)(D), by striking ``who is 65
years of age or older as of the date of issuance and'';
and
(C) in paragraph (3)(B)(vi), by striking ``at age
65''.
(2) Effective date.--The amendments made by paragraph (1)
shall apply to terminations of coverage effected on or after
the date of enactment of this Act, regardless of when the
individuals become eligible for benefits under part A or B of
title XVIII of the Social Security Act.
(b) Permitting ESRD Beneficiaries To Elect Another Medicare+Choice
Plan in Case of Plan Discontinuance.--
(1) In general.--Section 1851(a)(3)(B) (42 U.S.C. 1395w-
21(a)(3)(B)) is amended by striking ``except that'' and all
that follows and inserting the following: ``except that--
``(i) an individual who develops end-stage
renal disease while enrolled in a
Medicare+Choice plan may continue to be
enrolled in that plan; and
``(ii) in the case of such an individual
who is enrolled in a Medicare+Choice plan under
clause (i) (or subsequently under this clause),
if the enrollment is discontinued under section
1851(e)(4)(A) the individual will be treated as
a `Medicare+Choice eligible individual' for
purposes of electing to continue enrollment in
another Medicare+Choice plan.''.
(2) Effective date.--
(A) The amendment made by paragraph (1) shall apply
to terminations and discontinuations occurring on or
after the date of enactment of this Act.
(B) Clause (ii) of section 1851(a)(3)(B) of the
Social Security Act (as inserted by such amendment)
also shall apply to individuals whose enrollment in a
Medicare+Choice plan was terminated or discontinued
after December 31, 1998, and before the date of
enactment of this Act. In applying this subparagraph,
such an individual shall be treated, for purposes of
part C of title XVIII of the Social Security Act, as
having discontinued enrollment in such a plan as of the
date of enactment of this Act.
SEC. 805. EXTENDED MEDICARE+CHOICE DISENROLLMENT WINDOW FOR CERTAIN
INVOLUNTARILY TERMINATED ENROLLEES.
(a) Previous Medigap Enrollees.--Section 1882(s)(3)(B)(v)(III) (42
U.S.C. 1395ss(s)(3)(B)(v)(III)) is amended--
(1) by inserting ``(aa)'' after ``(III)'';
(2) by striking the period and inserting ``, or''; and
(3) by adding at the end the following:
``(bb) during the 12-month period described in item
(aa), is disenrolled under the circumstances described
in section 1851(e)(4)(A) from the organization
described in subclause (II); enrolls, without an
intervening enrollment, with another such organization;
and subsequently disenrolls during such period (during
which the enrollee is permitted to disenroll under
section 1851(e)).''.
(b) Initial Medigap Enrollees.--Section 1882(s)(3)(B)(vi) (42
U.S.C. 1395ss(s)(3)(B)(vi)), as amended by section 804(a)(1)(C), is
amended--
(1) by striking ``benefits under part A, enrolls'' and
inserting ``benefits under part A--
``(I) enrolls'';
(2) by striking the period and inserting ``, or''; and
(3) by adding at the end the following:
``(II)(aa) enrolls in a Medicare+Choice plan under part C,
which enrollment is terminated or discontinued under the
circumstances described in section 1851(e)(4)(A), and
``(bb) subsequently enrolls, without an intervening
enrollment, in another Medicare+Choice plan, and disenrolls
from such plan by not later than 12 months after the effective
date of the enrollment in the Medicare+Choice plan described in
item (aa).''.
(c) Effective Date.--The amendments made by this section shall
apply to terminations and discontinuations occurring on or after the
date of enactment of this Act.
SEC. 806. NONPREEMPTION OF STATE PRESCRIPTION DRUG COVERAGE MANDATES IN
CASE OF APPROVED STATE MEDIGAP WAIVERS.
(a) In General.--Section 1856(b)(3) (42 U.S.C. 1395w-26(b)(3)) is
amended--
(1) in subparagraph (A), by striking ``The standards'' and
inserting ``Subject to subparagraph (C), the standards''; and
(2) by adding at the end the following:
``(C) Continuation of state prescription drug
laws.--Subparagraph (A) shall not supersede any State
law that requires the comprehensive coverage of
prescription drugs or any regulation that carries out
such a law, if--
``(i) the State has a waiver in effect
under section 1882(p)(6)(A) with respect to
requiring such coverage under Medicare
supplemental policies; or
``(ii) the Secretary provides for a waiver
for the State to impose such a requirement
under section 1882(p)(6)(B).''.
(b) Medigap Waiver.--Section 1882(p)(6) (42 U.S.C. 1395ss(p)(6)) is
amended--
(1) by inserting ``(A)'' after ``(6)''; and
(2) by adding at the end the following:
``(B) The Secretary also may waive the application of the standards
described in paragraph (1)(A)(i) so that a State may include
comprehensive prescription drug coverage among the benefits required
for all Medicare supplemental policies.''.
(c) Effective Date.--The amendments made by this section shall take
effect on the date of enactment of this Act.
SEC. 807. MODIFICATION OF PAYMENT RULES FOR CERTAIN FRAIL ELDERLY
MEDICARE BENEFICIARIES.
(a) Modification of Payment Rules.--Section 1853 (42 U.S.C. 1395w-
23) is amended--
(1) in subsection (a)--
(A) in paragraph (1)(A), by striking ``subsections
(e) and (f)'' and inserting ``subsections (e) through
(i)'';
(B) in paragraph (3)(D), by inserting ``and
paragraph (4)'' after ``section 1859(e)(4)''; and
(C) by adding at the end the following:
``(4) Exemption from risk-adjustment system for frail
elderly beneficiaries enrolled in specialized programs for the
frail elderly.--
``(A) In general.--During the period described in
subparagraph (B), the risk-adjustment described in
paragraph (3) shall not apply to a frail elderly
Medicare+Choice beneficiary (as defined in subsection
(i)(3)) who is enrolled in a Medicare+Choice plan under
a specialized program for the frail elderly (as defined
in subsection (i)(2)).
``(B) Period of application.--The period described
in this subparagraph begins with January 2000, and ends
with the first month for which the Secretary certifies
to Congress that a comprehensive risk adjustment
methodology under paragraph (3)(C) (that takes into
account the types of factors described in subsection
(i)(1)) is being fully implemented.''; and
(2) by adding at the end the following:
``(i) Special Rules for Frail Elderly Enrolled in Specialized
Programs for the Frail Elderly.--
``(1) Development and implementation of new payment
system.--The Secretary shall develop and implement (as soon as
possible after the date of enactment of this subsection),
during the period described in subsection (a)(4)(B), a payment
methodology for frail elderly Medicare+Choice beneficiaries
enrolled in a Medicare+Choice plan under a specialized program
for the frail elderly (as defined in paragraph (2)(A)). Such
methodology shall account for the prevalence, mix, and severity
of chronic conditions among such beneficiaries and shall
include medical diagnostic factors from all provider settings
(including hospital and nursing facility settings). It shall
include functional indicators of health status and such other
factors as may be necessary to achieve appropriate payments for
plans serving such beneficiaries.
``(2) Specialized program for the frail elderly
described.--
``(A) In general.--For purposes of this part, the
term `specialized program for the frail elderly' means
a program which the Secretary determines--
``(i) is offered under this part as a
distinct part of a Medicare+Choice plan;
``(ii) primarily enrolls frail elderly
Medicare+Choice beneficiaries; and
``(iii) has a clinical delivery system that
is specifically designed to serve the special
needs of such beneficiaries and to coordinate
short-term and long-term care for such
beneficiaries through the use of a team
described in subparagraph (B) and through the
provision of primary care services to such
beneficiaries by means of such a team at the
nursing facility involved.
``(B) Specialized team.--A team described in this
subparagraph--
``(i) includes--
``(I) a physician; and
``(II) a nurse practitioner or
geriatric care manager, or both; and
``(ii) has as members individuals who have
special training and specialize in the care and
management of the frail elderly beneficiaries.
``(3) Frail elderly medicare+choice beneficiary
described.--For purposes of this part, the term `frail elderly
Medicare+Choice beneficiary' means a Medicare+Choice eligible
individual who--
``(A) is residing in a skilled nursing facility or
a nursing facility (as defined for purposes of title
XIX) for an indefinite period and without any intention
of residing outside the facility; and
``(B) has a severity of condition that makes the
individual frail (as determined under guidelines
approved by the Secretary).''.
(b) Continuous Open Enrollment for Certain Frail Elderly Medicare
Beneficiaries.--
(1) In general.--Section 1851(e) (42 U.S.C. 1395w-21(e)) is
amended by adding at the end the following:
``(7) Special rules for frail elderly medicare+choice
beneficiaries enrolling in specialized programs for the frail
elderly.--There shall be a continuous open enrollment period
for any frail elderly Medicare+Choice beneficiary (as defined
in section 1853(i)(3)) who is seeking to enroll in a
Medicare+Choice plan under a specialized program for the frail
elderly (as defined in section 1853(i)(2)).''.
(2) Conforming Amendments.--
(A) Open enrollment periods.--Section 1851(e)(6)
(42 U.S.C. 1395w-21(e)(6)) is amended--
(i) in subparagraph (A), by striking
``and'' at the end;
(ii) by redesignating subparagraph (B) as
subparagraph (C); and
(iii) by inserting after subparagraph (A)
the following:
``(B) that is offering a specialized program for
the frail elderly (as defined in section 1853(i)(2)),
shall accept elections at any time for purposes of
enrolling frail elderly Medicare+Choice beneficiaries
(as defined in section 1853(i)(3)) in such program;
and''.
(B) Effectiveness of elections.--Section 1851(f)(4)
(42 U.S.C. 1395w-21(f)(4)) is amended by striking
``subsection (e)(4)'' and inserting ``paragraph (4) or
(7) of subsection (e)''.
(c) Development of Quality Measurement Program for Specialized
Programs for the Frail Elderly.--Section 1852(e) (42 U.S.C. 1395w-
22(e)) is amended by adding at the end the following:
``(5) Quality measurement program for specialized programs
for the frail elderly as part of medicare+choice plans.--The
Secretary shall develop and implement a program to measure the
quality of care provided in specialized programs for the frail
elderly (as defined in section 1853(i)(2)) in order to reflect
the unique health aspects and needs of frail elderly
Medicare+Choice beneficiaries (as defined in section
1853(i)(3)). Such quality measurements may include indicators
of the prevalence of pressure sores, reduction of iatrogenic
disease, use of urinary catheters, use of antianxiety
medications, use of advance directives, incidence of pneumonia,
and incidence of congestive heart failure.''.
(d) Effective Dates.--
(1) In general.--Except as provided in paragraph (2), the
amendments made by this section shall take effect on the date
of enactment of this Act.
(2) Development of quality measurement program for
specialized programs for the frail elderly.--The Secretary of
Health and Human Services shall first provide for the
implementation of the quality measurement program for
specialized programs for the frail elderly under the amendment
made by subsection (c) by not later than July 1, 2000.
SEC. 808. EXTENSION OF MEDICARE COMMUNITY NURSING ORGANIZATION
DEMONSTRATION PROJECTS.
Notwithstanding any other provision of law and in addition to the
extension provided under section 4019 of the Balanced Budget Act of
1997 (Public Law 105-33; 111 Stat. 347), demonstration projects
conducted under section 4079 of the Omnibus Budget Reconciliation Act
of 1987 (Public Law 100-203; 101 Stat. 1330-121) shall be conducted for
an additional period of 3 years, and the deadline for any report
required relating to the results of such projects shall be not later
than 6 months before the end of such additional period.
TITLE IX--CLINICS
SEC. 901. NEW PROSPECTIVE PAYMENT SYSTEM FOR FEDERALLY-QUALIFIED HEALTH
CENTERS AND RURAL HEALTH CLINICS UNDER THE MEDICAID
PROGRAM.
(a) In General.--Section 1902(a)(13) (42 U.S.C. 1396a(a)(13)) is
amended--
(1) in subparagraph (A), by adding ``and'' at the end;
(2) in subparagraph (B), by striking ``and'' at the end;
and
(3) by striking subparagraph (C).
(b) New Prospective Payment System.--Section 1902 (42 U.S.C. 1396a)
is amended by adding at the end the following:
``(aa) Payment for Services Provided by Federally-Qualified Health
Centers and Rural Health Clinics.--
``(1) In general.--Beginning with fiscal year 2000 and each
succeeding fiscal year, the State plan shall provide for
payment for services described in section 1905(a)(2)(C)
furnished by a Federally-qualified health center and services
described in section 1905(a)(2)(B) furnished by a rural health
clinic in accordance with the provisions of this subsection.
``(2) Fiscal year 2000.--For fiscal year 2000, the State
plan shall provide for payment for such services in an amount
(calculated on a per visit basis) that is equal to 100 percent
of the costs of the center or clinic of furnishing such
services during fiscal year 1999 which are reasonable and
related to the cost of furnishing such services, or based on
such other tests of reasonableness as the Secretary prescribes
in regulations under section 1833(a)(3), or in the case of
services to which such regulations do not apply, the same
methodology used under section 1833(a)(3), adjusted to take
into account any increase in the scope of such services
furnished by the center or clinic during fiscal year 2000.
``(3) Fiscal year 2001 and succeeding years.--For fiscal
year 2001 and each succeeding fiscal year, the State plan shall
provide for payment for such services in an amount (calculated
on a per visit basis) that is equal to the amount calculated
for such services under this subsection for the preceding
fiscal year--
``(A) increased by the percentage increase in the
MEI (medicare economic index) (as defined in section
1842(i)(3)) applicable to primary care services (as
defined in section 1842(i)(4)) for that fiscal year;
and
``(B) adjusted to take into account any increase in
the scope of such services furnished by the center or
clinic during that fiscal year.
``(4) Establishment of initial year payment amount for new
centers or clinics.--In any case in which an entity first
qualifies as a Federally-qualified health center or rural
health clinic after October 1, 2000, the State plan shall
provide for payment for services described in section
1905(a)(2)(C) furnished by the center or services described in
section 1905(a)(2)(B) furnished by the clinic in the first
fiscal year in which the center or clinic qualifies in an
amount (calculated on a per visit basis) that is equal to 100
percent of the costs of furnishing such services during such
fiscal year in accordance with the regulations and methodology
referred to in paragraph (2). For each fiscal year following
the fiscal year in which the entity first qualifies as a
Federally-qualified health center or rural health clinic, the
State plan shall provide for the payment amount to be
calculated in accordance with paragraph (3) of this subsection.
``(5) Administration in the case of managed care.--In the
case of services furnished by a Federally-qualified health
center or rural health clinic pursuant to a contract between
the center or clinic and a managed care entity (as defined in
section 1932(a)(1)(B)), the State plan shall provide for
payment to the center or clinic (at least quarterly) by the
State of a supplemental payment equal to the amount (if any) by
which the amount determined under paragraphs (2), (3), and (4)
of this subsection exceeds the amount of the payments provided
under the contract.
``(6) Alternative payment system.--Notwithstanding any
other provision of this section, the State plan may provide for
payment in any fiscal year to a Federally-qualified health
center for services described in section 1905(a)(2)(C) or to a
rural health clinic for services described in section
1905(a)(2)(B) in an amount that is in excess of the amount
otherwise required to be paid to the center or clinic under
this subsection.''.
(c) Conforming Amendments.--
(1) Section 4712 of the Balanced Budget Act of 1997 (Public
Law 105-33; 111 Stat. 508) is amended by striking subsection
(c).
(2) Section 1915(b) (42 U.S.C. 1396n(b)) is amended by
striking ``1902(a)(13)(E)'' and inserting ``1902(aa)''.
(d) Effective Date.--The amendments made by this section shall take
effect on October 1, 1999.
<all>
Introduced in Senate
Sponsor introductory remarks on measure. (CR S11761-11762, S11769)
Read twice and referred to the Committee on Finance.
Star Print ordered on S.1678.
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