Medicaid and Medicare Part B Budget Reconciliation Amendments of 1982

(Reported to House from the Committee on Energy and Commerce with amendment, H. Rept. 97-757 (Part I))

Medicaid and Medicare Part B Budget Reconciliation Amendments of 1982 - Title I: Medicaid Savings - Amends title XIX (Medicaid) of the Social Security Act to prohibit with respect to categorically needy beneficiaries: (1) the imposition of any enrollment fee, premium or similar charge; and (2) the imposition of any deduction, cost sharing, or similar charge with respect to emergency services or care and services furnished to an inpatient in a skilled or intermediate nursing facility, a pregnant woman, an individual under 21, or an individual enrolled in a health maintenance organization (HMO). Provides that any deduction, cost sharing or similar charge with respect to: (1) inpatient hospital services may not exceed one dollar per day; (2) outpatient hospital services, physicians' services, or clinic services may not exceed one dollar per visit; and (3) other care and services will be nominal. Permits a charge of up to four dollars per visit for emergency services in certain instances.

Prohibits with respect to medically needy beneficiaries any deduction, cost sharing, or similar charge with respect to care and services which are furnished: (1) to a pregnant woman; (2) to an individual under 21; or (3) for emergency services. Provides that any deduction, cost sharing, or similar charge otherwise imposed will be nominal with respect to other care and services, except that a four dollar charge per visit may be imposed for emergency room services in certain instances.

Prohibits a provider participating under a State's Medicaid plan from denying care or services to a beneficiary because of inability to pay a deduction, cost sharing, or similar charge.

Prohibits the imposition of a lien against the property of any individual prior to his or her death on account of medical assistance paid or to be paid on the individual's behalf under a State's plan except: (1) pursuant to a court judgment; and (2) in the case of the real property of an individual who is an inpatient in a skilled nursing facility or an intermediate care facility and who is reasonably likely to remain an inpatient for the remainder of the individual's life. Provides that if an individual is discharged the lien shall dissolve.

Provides that there shall be no adjustment or recovery of any medical assistance correctly paid on behalf of an individual under the plan, except: (1) in the case of an individual who was 65 or older when he or she received such assistance or with respect to property subject to a lien or a trust established relating to the lien, from the estate or trust on the individual's death; or (2) in the case of property which is subject to a lien and which has been sold, the proceeds of the sale pertaining to the lien shall be put into a trust and, if the lien would have been dissolved (pursuant to discharge from a nursing facility), the trust shall be terminated. Provides that the adjustment or recovery specified above shall be made only after: (1) the death of a surviving spouse; (2) there are no surviving children under 21 or children who are blind or disabled; or (3) in the case of a lien, there is no sibling or child lawfully residing in the home.

Authorizes the denial of assistance to an individual while an inpatient in a nursing facility, if: (1) it is likely that the individual will remain in the facility for the remainder of his or her life; and (2) at any time prior to the month in which the individual applied for assistance the individual disposed of a home for less than fair market value. Provides that an individual shall not be ineligible in certain circumstances (including the circumstance where denial would cause undue hardship).

Directs the Secretary to provide for an adjustment in the amount of payment made to a State so that the State will receive an amount equivalent to the amount it would have been paid under Medicaid if the State had a qualified hospital cost review program, if the annual rate of increase in aggregate hospital inpatient costs per capita or per admission for 1983 or 1984 in a State with an election in effect (as authorized in this Act) is less than the State target rate of increase. Authorizes a State to have the above provisions apply in lieu of an offset for qualified hospital cost review programs for FY 1983 and 1984.

Provides that, for the purposes of title XIX, any individual who meets the following qualifications shall be deemed a recipient of supplemental security income (SSI) under the SSI program (title XVI of the Act): (1) the individual is under 18 and disabled; (2) the individual requires the level of care provided in a hospital, skilled nursing facility, or intermediate care facility, and such care is appropriately provided outside such an institution and is no more expensive than care in such an institution; and (3) if the individual were in an institution, the individual would be eligible for SSI.

Authorizes a State to treat, for purposes of Medicaid eligibility, as an individual receiving Aid to Families with Dependent Children (AFDC) (part A of title IV of the Act) an individual who would be eligible for AFDC but for specified income limitations made under the Omnibus Budget Reconciliation Act of 1981, if the individual meets specified alternative requirements as the State may provide.

Makes technical amendments to the Omnibus Budget Reconcilitation Act of 1981.

Title II: Medicare (Part B) Savings - Amends part B (Supplementary Medical Insurance) of title XVIII (Medicare) of the Social Security Act to reduce the reimbursement for inpatient radiology and pathology services from 100 to 80 percent.

Provides that, in determining the prevailing charge levels for physicians' services rendered during the 12-month period ending September 30, 1983, prevailing charge levels shall not exceed 104 percent of the level in effect for the 12-month period ending June 30, 1982. Provides that, for subsequent periods, the Secretary shall treat the level set during such 12-month period as having fully provided for economic changes which would otherwise have been taken into account. Provides that such limitation shall not apply to any physician with an assignment agreement in effect with the Secretary.

Revises provisions relating to payments to and contractual arrangements with health maintenance organizations (HMOs) on behalf of individuals eligible for Medicare.

Directs the Secretary of Health and Human Services to annually determine a per capita rate of payment for each class of individuals: (1) enrolled with an HMO pursuant to this Act, entitled to benefits under part A (Hospital Insurance) of title XVIII, and enrolled under part B (Supplementary Medical Insurance) of title XVIII; and (2) enrolled with an HMO and enrolled under part B only.

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 an HMO.

Directs the Secretary in establishing classes of individuals to take into consideration age, institutional status, disability status, and place of residence, and other factors determined appropriate by the Secretary.

Redefines an HMO. Requires an HMO to meet certain requirements, including limits on premiums, deductibles, coinsurance, and copayments.

Provides that individuals enrolled in the Medicare program shall be eligible under this Act with any HMO with which the Secretary has contracted.

Prohibits premiums, deductibles, coinsurance, and copayments of an HMO from exceeding the adjusted community rate, for any additional services. Defines the adjusted community rate. Requires an HMO to provide additional benefits which are at least equal in value to the difference between the average per capita payment and the adjusted community rate, if the adjusted community rate is less than the average per capita payment rates of payment. Provides that the additional benefits shall be either reducted charges or additional health benefits.

Requires each contract between the Secretary and an HMO to contain provisions giving the Secretary the right to inspect an HMO's books and to evaluate an HMO's services.

Provides that if the Secretary is not satisfied that an HMO has the capacity to bear the risk of potential losses under a risk-sharing contract under this Act, or if the HMO so elects, the HMO may be reimbursed on the basis of reasonable cost if the Secretary is satisfied that the HMO is able to perform its contractual obligations effectively and efficiently.

Includes in the definition of medical and other health services the services of a physician assistant or a nurse practioner furnished to a member of an HMO.

Provides that the new HMO provisions of this Act shall not apply: (1) to a beneficiary enrolled on the effective date unless the individual requests that they apply or the Secretary determines they should apply because of administrative burdens; (2) to an HMO with a current risk contract or with a demonstration project for five years after the effective date; or (3) to an HMO with an existing demonstration project, if at enactment the HMO was furnishing services pursuant to the contract and the project concludes after enactment.

Directs the Secretary to conduct a study and report to Congress concerning additional benefits selected by HMOs.

Directs the Secretary to conduct a study and report to Congress concerning the extent of, and reasons for, the termination by Medicare and Medicaid beneficiaries of their membership in HMOs.

Permits merchant seamen who are entitled to treatment and hospitalization under the Public Health Service Act and who were eligible for Medicare to enroll in Medicare.