Medicare and Medicaid Amendments of 1980

(Reported to House from the Committee on Interstate and Foreign Commerce with amendment, H. Rept. 96-589 (Part II))

Medicare and Medicaid Amendments of 1980 - Amends part B (Professional Standards Review) of title XI of the Social Security Act to permit an organization qualified for conditional designation as a Professional Standards Review Organization (PSRO) to include health care practitioners, other than physicians and osteopaths, who hold independent hospital admitting privileges, if invited to become members by the organization.

Includes as members of the advisory group for each statewide Professional Standards Review Council at least one registered professional nurse and doctor of dental surgery. Includes one registered professional nurse, one doctor of dental surgery, and one health practitioner other than physicians and osteopaths on the National Professional Standards Review Council.

Revises the duties of a conditionally designated PSRO.

Directs the Secretary to establish a program for the evaluation of the cost-effectiveness of review of particular health care services by PSRO's.

Eliminates the requirement that a PSRO must, if capable, review ambulatory care services provided under the Act within two years of becoming a fully designated PSRO. Authorizes the Secretary of Health, Education, and Welfare to replace one PSRO with another PSRO if the PSRO initially designated is not conducting particular review activities.

Permits a PSRO to withhold any records requested pursuant to a request under the Freedom of Information Act until 180 days after the entry of a final court order ordering disclosure.

Requires a PSRO to consult with representatives of health care practitioners, other than physicians, and representatives of institutional and noninstitutional providers of health care services in relation to the responsibility of a PSRO to review the professional activities of such practitioners and providers.

Authorizes each PSRO to determine, in advance, the medical necessity and appropriateness of any routine diagnostic services furnished in connection with an elective admission to a hospital or other health care facility.

Directs the Secretary, in consultation with the National Professional Standards Review Council, to conduct a nationwide study of the differences in medical criteria and length-of-stay norms utilized by PSRO's in the various regions of the country, and to report to Congress the findings and conclusions.

Declares it to be the policy of the United States that philanthropic support for health care be encouraged and expanded.

States that in determining the reasonable costs of services furnished by nonprofit hospitals under titles V (Maternal and Child Health), XVIII (Medicare) and XIX (Medicaid) of the Social Security Act, gifts, grants and endowments, and other specified items shall not be deducted from any operating costs of such hospitals.

Directs the Secretary to conduct a study of the availability and need for skilled nursing facility services covered under Medicare and Medicaid and to report to Congress concerning such study.

Authorizes the Secretary, under title XVIII and the State under title XIX, in lieu of decertifying a skilled nursing facility which is out of compliance with conditions of participation specified in the Act, to instead deny payment to such a facility for services furnished, if the health and safety of the patients is not immediately jeopardized. Stipulates that the Secretary shall not make such a decision until such facility has had a reasonable opportunity to correct the deficiencies. Authorizes the Secretary, under title XIX, to make an independent and binding determination concerning the extent to which an institution meets the conditions of participation.

Requires, under the Medicare program, a skilled nursing facility to meet such provisions of such edition (as specified by the Secretary ) of the Life Safety Code of the National Fire Protection Association as are applicable to nursing homes.

Provides that criminal penalties for the solicitation of Medicare or Medicaid business shall apply only if such conduct is undertaken knowingly and willfully.

Amends part A (General Provisions) of title XI of the Act to exclude from participation in Medicare or Medicaid any physician or other individual convicted of a criminal offense related to such individual's participation in either program.

Requires any entity receiving payments under the Medicaid program to comply with certain financial reporting requirements.

Authorizes the Secretary to reduce the Federal share of Medicaid payments to a State with respect to expenditures by providers that participate or have participated in the Medicare program and from which the Secretary has been unable to recover Medicare payments or information concerning Medicare overpayments.

Authorizes hospitals under title XVIII which have been granted a certificate of need for the provision of long- term care services to enter agreements under which their inpatient hospital facilities may be used to furnish services which if furnished by a skilled nursing facility would constitute post-hospital extended care services. Provides that, where a hospital has not entered into such an agreement and long-term care services are necessary, payment may be made for such services as if such an agreement were in effect, if the hospital: (1) has an occupancy rate below 80 percent; and (2) could obtain a certificate of need.

Provides Medicaid coverage for skilled nursing facility services and intermediate care facility services furnished by a hospital which has in effect an agreement under title XVIII.

Requires, as a condition for payment to any State under titles V (Maternal and Child Health and Crippled Children's Services) or XIX of the Act for costs incurred in the performance of audits of entities which also provide services under title XVIII, that such audits be coordinated with audits of entities performed for purposes of title XVIII. Directs the Secretary: (1) to establish one or more demonstration projects to demonstrate the feasiblity of creating a single coordinated appeal hearing to adjudicate those administrative cost items which are determined under such a coordinated audit and which such entities dispute and appeal; and (2) to provide for the review of the feasibility of establishing a single coordinated process for the collection of overpayments established in an audit.

Directs the Secretary to establish a voluntary procedure under which health insurance policies offered by private insurers to supplement Medicare may be certified as meeting certain minimum standards with respect to adequacy of coverage, reasonableness of premium charge, and disclosure of information to the insured. Directs the Secretary to submit to Congress, at least once every two years, a report evaluating the effectiveness of such certification program. Provides penalties for any person who knowingly or willfully makes any false representation of a material fact with respect to compliance with such standards or who misrepresents in any way that he or she is acting under the authority of any program of health insurance established by Federal law for the purpose of selling insurance. Directs the Secretary to conduct, in consultation with Federal and State regulatory agencies, the National Association of Insurance Commissioners, private insurers, and organizations representing consumers and the aged, a study of and evaluation of the effectiveness of various State approaches to regulation of private supplementary health insurance and to report to Congress the results of such study and evaluation.

Authorizes the Secretary to enter into agreements with 12 States for the purpose of conducting demonstration projects for the training and employment as homemakers or home health aids of individuals who have been certified by the appropriate State or local government agency as being eligible for financial assistance under a State plan of Aid to Families with Dependent Children approved under title IV of the Act.

Directs the Secretary to submit annual reports to the Congress evaluating the demonstration projects.

Revises provisions of title XVIII of the Act relating to payments to and contractual arrangements with health maintenance organizations (HMO) on behalf of individuals eligible for Medicare. Directs the Secretary to annually determine a per capita rate of payment for each class of individuals entitled to benefits under such title who are enrolled pursuant to this Act with a HMO. Directs the Secretary to define classes of members based on such factors as age, sex, institutional status, disability status and place of residence. Provides a rate for each class equal to 95 percent of the adjusted average per capita cost for that class. Defines the term "adjusted average per capita cost" to mean the average per capita amount that the Secretary estimates would be payable for services furnished under the Medicare program, if the services were to be furnished by other than a HMO.

Redefines HMO to mean a public or private organization which is a qualified HMO as defined in the Public Health Service Act or which: (1) provides at least physicians services, inpatient hospital services, laboratory, X-ray, emergency, and preventive services, and out of area coverage; (2) is compensated on a fixed periodic basis; (3) provides physicians' services primarily either directly through physicians of the organization or through arrangements with physicians; (4) assumes full financial risk for services provided; and (5) has provided adequately against insolvency.

Sets forth provisions governing: (1) the benefit package; (2) limits on deductibles, coinsurance, and copayments; (3) providers; (4) open enrollment; (5) expulsion of members; (6) availability of services; (7) grievance procedures; and (8) quality assurance.

Provides that every individual entitled to benefits under part A (Hospital Insurance) and enrolled under part B (Supplementary Medical Insurance) of title XVIII or part B only shall be eligible to enroll with a HMO with which the Secretary has contracted to provide services.

Sets limits on an HMO's premium rate and the actuarial value of its deductibles, coinsurance, and copayments charged for individuals enrolled under this Act.

Authorizes the Secretary to contract with any HMO that can provide the benefits required by this Act.

Directs the Secretary to conduct studies of: (1) any services offered by an HMO in addition to those provided under the Medicare program; and (2) the reasons why medicare beneficiaries terminate memberships with HMO's. Requires the Secretary to report to Congress concerning such studies.

Extends until December 31, 1980 the program conducted by the Secretary to determine the proficiency of individuals who do not otherwise meet formal qualifications criteria to perform the duties of certain health care personnel.

Directs the Secretary, under Medicare, in assuring the quality of diagnostic tests performed in hospitals and independent laboratories to: (1) only impose requirements necessary to correct deficiencies in the quality of particular types of tests or laboratories; (2) employ quality assurance methods designed to result in the least imposition of costs and the fewest restrictions on personnel who perform or supervise such tests; and (3) employ quality assurance methods which take into account and are appropriate to the different types of laboratories to which they apply.

Sets limits, under the Medicare and Medicaid programs on payments to a physician for laboratory tests reimbursable under those programs. Directs the Secretary to report to Congress concerning such payments.

Allows States to purchase laboratory services for Medicaid through competitive bidding arrangements for a three-year experimental period. Requires such services to be from laboratories: (1) which are found by the Secretary to meet appropriate health and safety standards; (2) no more than 75 percent of whose charges for such services are under Medicare or Medicaid; and (3) which charge Medicaid at rates no higher than the lowest amount charged to others for similar tests. Directs the Secretary to send to Congress an evaluation of such purchase arrangements, with recommendations as to extension or modification. Requires any laboratory services paid for under Medicaid to be provided by a laboratory meeting Medicare's requirements.

Includes, under Medicare, as inpatient hospital services the services of a physician in a teaching hospital only if: (1) the hospital elects to receive any payment due under Medicare for reasonable costs of such services; and (2) all physicians in the hospital agree not to bill charges for professional services rendered in such hospital to individuals covered by Medicare.

Includes within the coverage of Medicaid services rendered by a nurse-midwife, whether or not he or she is supervised by or associated with a physician.

Defines the term "nurse-midwife" to mean a registered nurse who has successfully completed a prescribed course of study or who has been certified by a recognized organization, and who performs services in the area of the management of the care of mothers and babies throughout the maternity cycle.

Provides Medicaid benefits for an individual with a "severe medical disability" if such individual's income does not exceed certain limitations. Defines a "severe medical disability" as one which results in a functional limitation requiring medical assistance for an individual to work.

Provides that cost-of-living benefit increases shall be disregarded in computing income for the purpose of determining eligibility for the Medicaid program for individuals receiving such benefit increases under: (1) title II (Old Age, Survivors, and Disability Insurance) of the Social Security Act; (2) the Railroad Retirement Act of 1974; or (3) certain pension plans relating to veterans.

Authorizes a State, under Medicaid, to declare an individual ineligible for Medicaid for specified periods if within 24 months of applying for such benefits the individual disposed of resources which, if retained, would have caused the individual to be ineligible for such benefits. Sets forth guidelines for determining the length of time such benefits shall be denied, based upon the dollar amount of assets disposed.

Authorizes a State to recover from an individual who was provided Medicaid benefits during a period when such individual should not have received such benefits because of the individual's disposal of assets.

Provides for the participation in Medicaid of American Samoa, the Northern Mariana Islands, and the Trust Territory of the Pacific Islands. Increases the ceilings on Federal Medicaid matching payments to Puerto Rico, Guam, and Virgin Islands. Sets ceilings for payments to American Samoa, the Northern Mariana Islands, and the Trust Territory of the Pacific Islands.

Extends, under the Medicaid, through fiscal year 1983 Federal payments for the costs of long-term care facility inspections.

Extends funding for State Medicaid fraud control units.

Prohibits the Secretary from making Medicaid funds available to States until checks issued by the State for a Medicaid expenditure are cleared for payment.

Authorizes the Secretary to provide for demonstration projects to determine the cost-effectiveness and appropriateness of requiring a second opinion with respect to specified elective surgical procedures before payment may be made under Medicare or Medicaid for the performance of the procedure. Directs the Secretary to analyze the data on the projects and to report to Congress. Provides that an individual shall not be required to participate in such a project unless the individual has provided a written and legally effective informed consent.

Provides that hospitals, under Medicare and Medicaid, reimbursed under the demonstration project reimbursement system shall continue to be reimbursed under that system until either: (1) a third party payor reimburses such a hospital on another basis; or (2) the rate of increase for the previous three year period in costs per inpatient admission is greater than such rate of increase in all other hospitals over the same period.