Medicare and Medicaid Budget Reconciliation Amendments of 1983

(Reported to House from the Committee on Energy and Commerce with amendment, H. Rept. 98-442(Part I))

Medicare and Medicaid Budget Reconciliation Amendments of 1983 Title I: Medicare Reconciliation Amendments - Part A: Payment and Coverage - Related Changes - Directs the Secretary of Health and Human Services to establish a national fee schedule for diagnostic laboratory tests for which payment is made under part B (Supplementary Medical Insurance) of title XVIII of the Social Security Act. Directs the Secretary to set the fee schedule at 60 percent of the prevailing charges paid under part B for similar diagnostic laboratory tests during the fee screen year beginning July 1, 1983. Directs the Secretary, in addition to the amounts provided under the fee schedule, to provide for and establish a nominal fee payable to cover the costs of collecting the sample in a diagnostic laboratory test. Provides for Medicare payment of the lesser of 80 percent (or 100 percent in the case of tests for which payment is made on basis of an assignment or in the situation of the death of a beneficiary) of the amount determined by the Secretary or the amount of billed charges. Eliminates the part B deductible for laboratory tests paid on the basis of an assignment and in the case of payment on behalf of a deceased beneficiary. Amends title XIX (Medicaid) to provide for Medicaid coverage of laboratory tests to the extent such coverage is provided under Medicare.

Provides for Medicare coverage of hepatitis B vaccine and its administration in a hospital or renal dialysis facility.

Revises provisions under part B of title XVIII relating to payment for the services of a teaching physician to limit, for the purposes of determining the customary charge, the consideration of charges made by a physician outside of teaching to charges made by nonteaching physicians. Provides that if all the teaching physicians in the hospital agree to have payment made for all physicians' services under part B furnished patients in the hospital on the basis of an assignment, the carrier shall take into account the amounts otherwise payable under part B with respect to similar services in the same locality.

Directs the Secretary to compile annually a list of physicians serving individuals enrolled under part B indicating the share of claims which each physician has accepted on an assignment basis in the preceding year. Directs the Secretary to: (1) publish annually a list of all physicians who have agreed to accept payment on the basis of an assignment; and (2) annually provide enrollees with a list of physicians in their area who accept assignments.

Directs the Secretary to study and report to Congress on methods by which payment amounts and other program policies under part B may be modified to: (1) eliminate inequities in the relative amounts paid to physicians by type of service, locality, and specialty; (2) increase incentives for physicians and other suppliers to accept assignments; and (3) provide incentives for physicians and other providers not to provide increased or otherwise excessive amounts of hospital, physician, and other health care services. Directs the Secretary, in order to carry out the study and facilitate congressional review, to compile a centralized Medicare part B charge data base utilizing information gathered by Medicare carriers and used by the carriers in making the 1984 reasonable charge updates.

Directs the Secretary to issue revisions to the current guidelines for payment under part B for physicians' services for the transtelephonic monitoring of cardiac pacemakers. Requires such guidelines to include provisions regarding the specifications for and frequency of transtelephonic monitoring procedures which will be found reasonable and necessary. Directs the Secretary to: (1) review, and report to the appropriate congressional committees, regarding the appropriateness of the current rate of part B reimbursement for physicians' services associated with the implantation or replacement of pacemaker devices and pacemaker leads; and (2) consider reducing the recognized rates for such services by 20 percent.

Directs the Secretary, through the Administrator of the Food and Drug Administration, to provide for a registry of all cardiac pacemaker devices and pacemaker leads for which payment was made under title XVIII. Directs the Secretary, in any case where the Secretary has reason to believe that replacement of a cardiac pacemaker device or lead for which Medicare payment is or may be requested is related to the malfunction of a device or lead, to require the testing of the device.

Directs the Secretary to provide that payment will not be made under part B for a physician's debridement of mycotic toenails to the extent such debridement is performed more than once every 60 days, unless the medical necessity for more frequent treatment is documented by the physician.

Repeals specified requirements relating to the coverage of tuberculosis treatments under Medicare and Medicaid (title XIX of the Social Security Act).

Repeals the requirement that psychiatric hospitals must be accredited by the Joint Commission on Accreditation of Hospitals in order to participate in Medicare and Medicaid.

Permits part B payments to be made to an entity: (1) which provides coverage of the services under a health benefits plan; (2) which has paid the person who provided the service the amount which that person has accepted as payment in full for the service; and (3) to which the individual has agreed in writing that payment may be made.

Authorizes the United States to bring an action directly against third party insurance programs for Medicare costs.

Authorizes the Secretary to terminate an agreement with a provider if any individual who directly or indirectly owns or controls five percent or more of the provider's business has been convicted of certain Medicare- or Medicaid-related offenses.

Provides for a 30-day period of coverage for services furnished by a home health agency following the termination of the agency's agreement.

Directs the Secretary to establish a single 30-day period each year during which all eligible health maintenance organizations and competitive medical plans must provide for open enrollment in each area served by more than one such eligible organization.

Authorizes the Secretary, if patient health and safety is not jeopardized, to apply less severe sanctions than are presently available for dealing with an end-stage renal disease facility which is not in compliance with applicable regulations.

Authorizes the Secretary, under title XVIII, to establish a national end-stage renal disease medical information system. (Currently, the Secretary is required to establish renal disease networks.) Provides that: (1) a network cannot be eliminated until the Secretary has in operation an alternative means of performing the essential data collection activities presently performed by renal disease networks; and (2) such elimination cannot occur before January 1, 1984.

Title II: Medicaid Reconciliation Amendments - Part A: Maternal and Child Health Amendments - Provides that the Federal medical assistance percentage, under title XIX of the Social Security Act, shall be 100 percent with respect to amounts expended as medical assistance for services furnished to a "qualified pregnant woman or child." Defines a qualified pregnant woman or child as an individual who was not eligible for categorically needy coverage under Medicaid as of June 30, 1983, and who is: (1) under five years of age and who meets Aid to Families with Dependent Children (part A of title IV of the Act) requirements but does not receive cash payments and is a categorically needy individual; or (2) a pregnant woman who, at the State's option, may be deemed an AFDC recipient for Medicaid purposes or who is a member of a family which would be eligible for AFDC if the State's AFDC plan required payment of aid with respect to dependent children deprived of parental support by reason of the unemployment of a parent who is the principal earner.

Authorizes a State's Medicaid plan to not take into account the financial responsibility of any individual for an applicant or recipient who is a pregnant woman under 21 who does not have legal custody over other children, unless the applicant or recipient is the individual's spouse, except that a State may limit the applicability of this provision to applicants and recipients living in such an individual's household or in a custodial institution for pregnant women.

Provides that a child born to a woman eligible for and receiving Medicaid as of the child's birth shall be deemed to have applied for medical assistance and been found eligible for assistance on the child's birth date and shall remain eligible for assistance for one year so long as the child is a member of the women's household and the woman remains eligible for assistance.

Part B: Miscellaneous Medicaid Changes - Revises Medicaid provisions relating to medically needy income levels. Provides that in the case of a family consisting of only two individuals both of whom are adults and at least one of whom is aged, blind, or disabled, the term "highest amount which would ordinarily be paid to a family of the same size" under the State's plan approved under part A of title IV of the Social Security Act shall, at the State's option, be the amount determined by the State to be the amount of aid which would ordinarily be payable under such plan to a family which consists of one adult and two children and which is without any income or resources.

Revises Medicaid provisions relating to the recertification of need for stays in skilled nursing and intermediate care facilities. Requires recertifications for intermediate care facility patients to occur on or before 60 days of admission, six, 12, 18, and 24 months afterwards, and annually thereafter. Requires recertifications for skilled nursing facility patients to occur on or before 30, 60, and 90 days of admission, and every 60 days thereafter. Revises the penalty formula for noncompliance with the recertification requirements.

Authorizes the Secretary to modify or waive the requirement which limits the total combined Medicare and Medicaid membership to 75 percent for a health maintenance organization if the organization: (1) is a nonprofit organization with at least 25,000 members; (2) is and has been a qualified health maintenance organization for at least four years; (3) provides basic health services through members of the staff of the organization; (4) is located in a medically underserved area; and (5) previously received a membership requirement waiver.

Prohibits Medicaid copayments for prescribed drugs.

Increases the maximum amount of Medicaid payments available to Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa.

Provides that Medicaid provisions requiring a reduction of the amount of payment otherwise to be made to a public psychiatric hospital due to the level of care received in such hospital shall not apply to payments to hospitals before July 1, 1985. Provides that such a reduction made for payments during the twelve- month period ending June 30, 1986, and during the twelve-month period ending June 30, 1987, shall be one-third and two-thirds, respectively, of the amount of the reduction which would otherwise be required.

Title III: Recovery of Hill-Burton Funds - Amends the Public Health Service Act to revise provisions relating to the recovery of Federal expenditures from a hospital or other medical facility under certain conditions. Provides that the United States shall be entitled to recover, whether from the transfer or or transferee, an amount (determined as specified below) which is any such facility which received Federal funds for construction or modernization under the Public Health Service Act, at any time within 20 years after the completion of construction or modernization: (1) is sold or transferred to any entity which is not qualified to file an application under such Act for a construction or modernization project or which is not approved as a transferee by a State; or (2) ceases to be a public health center or a public or other nonprofit hospital, outpatient facility, facility for long-term care, or rehabilitation facility. Provides that the amount the United States is entitled to recover, subject to certain exceptions, shall be an amount bearing the same ratio to the then value of so much of the facility as constituted an approved project as the amount of the Federal financial participation bore to the cost of the construction or modernization of such project.

Title IV: Technical Amendments Relating to Title V or Title XIX of the Social Security Act - Makes technical amendments to titles V (Maternal and Child Health Services) and XIX of the Social Security Act.