Physician Self-Referral Amendments of 1993

Summary: Physician Self-Referral Amendments of 1993 - Amends title XVIII (Medicare) of the Social Security Act to extend the ban on physician self-referrals to all payors and to physical therapy services, radiology and diagnostic imaging services, radiation therapy services, and the furnishing of durable medical equipment. 
Makes changes in the exceptions to ownership and compensation arrangement prohibitions with respect to prepaid plans.

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Physician Self-Referral Amendments 
of 1993''.

SEC. 2. EXTENSION OF PHYSICIAN SELF-REFERRAL LIMITATIONS TO ALL PAYORS.

    Section 1877 of the Social Security Act (42 U.S.C. 1395nn) is 
amended--
            (1) in subsection (a)--
                    (A) in paragraph (1)(A), by striking ``for which 
                payment otherwise may be made under this title'' and 
                inserting ``for which a charge is imposed'', and
                    (B) in paragraph (1)(B), by striking ``under this 
                title'';
            (2) by amending paragraph (1) of subsection (g) to read as 
        follows:
            ``(1) Denial of payment.--No payment may be made under this 
        title, under another Federal health care program, or under a 
        State health care program (as defined in section 1128(h)) for a 
        designated health service for which a claim is presented in 
        violation of subsection (a)(1)(B). No individual, third party 
        payor, or other entity is liable for payment for designated 
        health services for which a claim is presented in violation of 
        such subsection.''; and
            (3) in subsection (g)(3), by striking ``for which payment 
        may not be made under paragraph (1)'' and inserting ``for which 
        such a claim may not be presented under subsection (a)(1)''.

SEC. 3. EXTENSION OF PHYSICIAN SELF-REFERRAL LIMITATIONS TO CERTAIN 
              ADDITIONAL SERVICES.

    (a) In General.--Section 1877 of the Social Security Act is further 
amended--
            (1) by striking ``clinical laboratory services'' and 
        ``clinical laboratory services'' and inserting ``designated 
        health services'' and ``designated health services'', 
        respectively, each place either appears in subsections (a)(1), 
        (b)(2)(A)(ii)(I), (b)(4), (d)(1), (d)(2), and (d)(3), and
            (2) by adding at the end the following new subsection:
    ``(i) Designated Health Services Defined.--In this section, the 
term `designated health services' means--
            ``(1) clinical laboratory services,
            ``(2) physical therapy services,
            ``(3) radiology and diagnostic imaging services,
            ``(4) radiation therapy services, and
            ``(5) the furnishing of durable medical equipment.''.
    (b) Conforming Amendments.--Section 1877 of such Act is further 
amended--
            (1) in subsection (d)(2), by striking ``laboratory'' and 
        inserting ``entity'',
            (2) in subsection (g)(1), by striking ``clinical laboratory 
        service'' and inserting ``designated health service'', and
            (3) in subsection (h)(7)(B), by striking ``clinical 
        laboratory service'' and inserting ``designated health 
        service'', and

SEC. 4. CHANGES IN EXCEPTIONS.

    (a) Health Maintenance Organizations and Managed Care Plans.--
Paragraph (3) of section 1877(b) of the Social Security Act is amended 
to read as follows:
            ``(3) Health maintenance organizations and managed care 
        plans.--
                    ``(A) Health maintenance organizations.--In the 
                case of services furnished by a health maintenance 
                organization to an individual enrolled with the health 
                maintenance organization, including services furnished 
                by--
                            ``(i) an eligible organization (as defined 
                        in section 1876(b));
                            ``(ii) an organization described in section 
                        1833(a)(1)(A);
                            ``(iii) an organization receiving payments 
                        on a prepaid basis under a demonstration 
                        project under section 402(a) of the Social 
                        Security Amendments of 1967 or under section 
                        222(a) of the Social Security Amendments of 
                        1972; and
                            ``(iv) any other entity designated by the 
                        Secretary as a health maintenance organization 
                        for purposes of this subparagraph.
                    ``(B) Certain managed care plans.--In the case of 
                services furnished by a managed care plan (as defined 
                by the Secretary) to an individual enrolled under the 
                plan if--
                            ``(i) the plan selectively contracts with 
                        physicians and with providers of designated 
                        health services; and
                            ``(ii) under the plan physicians bear a 
                        significant financial risk for the cost of 
                        designated health services furnished upon 
                        referral.''.
    (b) Waiver for Valuable Community Services.--Subsection (b)(5) of 
such section is amended by adding at the end the following: ``In making 
such determinations, the Secretary shall specifically consider whether 
the provision of necessary, valuable community services will be 
jeopardized without such an exception.''.
    (c) Exception for Hospitals.--Subparagraph (A) of subsection (d)(3) 
of such section is amended to read as follows:
                    ``(A) at the time the services are furnished, the 
                hospital has a participation agreement in effect under 
                section 1866, and''.

SEC. 5. EFFECTIVE DATES.

    The amendments made by this Act shall apply with respect to a 
referral by a physician for designated health services (as described in 
section 1877(i) of the Social Security Act)--
            (1) made on or after the first day of the first month 
        beginning at least 2 years after the date of the enactment of 
        this Act, in the case of a referral with respect to which a 
        financial relationship (specified in section 1877(a)(2) of the 
        Social Security Act) existed as of the date of the enactment of 
        this Act; or
            (2) made on or after the first day of the first month 
        beginning at least 6 months after the date of the enactment of 
        this Act, with respect to which such a financial relationship 
        did not exist as of the date of the enactment of this Act.