Medicare Home Health Access Restoration Act of 1999

Summary: Amends the Balanced Budget Act of 1997 to eliminate the 15 percent contingent reduction in payment amounts under the interim prospective payment system (PPS) for home health services.
Directs: (1) the Secretary to prepare specified informational materials for assisting Medicare beneficiaries with regard to home health services; and (2) the Comptroller General to study and report to Congress on certain aspects of the Medicare home health benefit, including whether it has resulted in overall lower costs to the Federal Government.

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Medicare Home Health Access 
Restoration Act of 1999''.

SEC. 2. ADJUSTMENT TO PER BENEFICIARY LIMITS.

    (a) Increase in Payment Amount to Agencies With Limits Under the 
National Average.--Section 1861(v)(1)(L) of the Social Security Act (42 
U.S.C. 1395x(v)(1)(L)), as amended by section 5101(a) of the Tax and 
Trade Relief Extension Act of 1998 (Public Law 105-277), is amended--
            (1) in clause (v)(I), by inserting ``, clause (ix)'' after 
        ``subject to clause (viii)(I)'';
            (2) in clause (viii)(I), by striking ``during or after 
        fiscal year 1999'' and inserting ``during fiscal year 1999'';
            (3) by redesignating clause (ix) as clause (xii); and
            (4) by inserting after clause (viii) the following new 
        clause:
    ``(ix) In the case of a provider with a 12-month cost reporting 
period ending in fiscal year 1994, if the limit imposed under clause 
(v) (determined without regard to this subclause) for a cost reporting 
period beginning after fiscal year 1999 is less than the median 
described in clause (vi)(I) (but determined as if any reference in 
clause (v) to `98 percent' were a reference to `100 percent'), the 
payment limit for such provider and period shall be equal to--
            ``(I) for cost reporting periods beginning during fiscal 
        year 2000, 90 percent of such median;
            ``(II) for cost reporting periods beginning during fiscal 
        year 2001, 95 percent of such median; and
            ``(III) for cost reporting periods beginning during or 
        after fiscal year 2002, such median.
Each of the amounts specified in subclauses (I) through (III) are such 
amounts as adjusted under clause (iii) to reflect variations in wages 
among different areas.''.
    (b) Establishment of Per Beneficiary Cap; Waiver.--
            (1) In general.--Section 1861(v)(1)(L) of such Act (42 
        U.S.C. 1395x(v)(1)(L)), as amended in subsection (a), is 
        further amended--
                    (A) in clause (v)(I), by inserting ``, and clause 
                (x)'' after ``clause (ix)''; and
                    (B) by inserting after clause (ix), the following 
                new clause:
    ``(x) In the case of a provider with a 12-month cost reporting 
period ending in fiscal year 1994, if the limit imposed under clause 
(v) (determined without regard to this subclause) for a cost reporting 
period beginning after fiscal year 1999 exceeds the median described in 
clause (vi)(I) (but determined as if any reference in clause (v) to `98 
percent' were a reference to `100 percent'), the payment limit for such 
provider and period may not exceed--
            ``(I) for cost reporting periods beginning during fiscal 
        year 2000, an amount equal to 250 percent of such median;
            ``(II) for cost reporting periods beginning during fiscal 
        year 2001, an amount equal to 225 percent of such median; and
            ``(III) for cost reporting periods beginning during or 
        after fiscal year 2002, an amount equal to 200 percent of such 
        median.
Notwithstanding the previous sentence, in the case of such a provider 
that demonstrates to the Secretary (in such form and using such data as 
the Secretary requires) that, for a cost reporting period, the 
provider, or a unit of the provider, specializes in the treatment of 
individuals who, because of age, diagnosis, or other criteria specified 
by the Secretary are substantially more costly-than-average to treat, 
the amount of payment to that provider or unit for such an individual 
for that period is the limitation determined under clause (v).''.
            (2) Consultation.--The Secretary of Health and Human 
        Services shall consult with appropriate organizations, 
        including such organizations representing providers of home 
        health services, physicians, and patients in determining the 
        criteria required for special payment provisions under the 
        second sentence of clause (x) and under clause (xi) of section 
        1861(v)(1)(L) of the Social Security Act (42 U.S.C. 
        1395x(v)(1)(L)), including descriptions of the type of patient, 
        patient condition, unusual variations, and home health service 
        that qualifies for such payment.
    (c) Waiver of Per Beneficiary Limit for Outliers.--
            (1) In general.--Section 1861(v)(1)(L) of such Act (42 
        U.S.C. 1395x(v)(1)(L)), as amended in subsections (a) and (b), 
        is further amended by inserting after clause (x), the following 
        new clause:
    ``(xi)(I) Notwithstanding the applicable limit under clause (v), 
(vi), (viii), (ix), or (x), in the case of a provider that demonstrates 
to the Secretary that with respect to an individual to whom the 
provider furnishes home health services that are 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 limit because of unusual 
variations in the type or amount of medically necessary care (outliers) 
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 Secretary shall establish such criteria as is required 
for payment under this clause, including a description of the type of 
patient, patient condition, unusual variations, and home health service 
that qualifies for such payment.
    ``(III) In making determinations under subclause (I), the Secretary 
shall use data from the cost report, or from other data collected by 
the Secretary, of the provider for such year.
    ``(IV) A provider may make an application for payment under this 
clause for a fiscal year no earlier than the end of the provider's cost 
reporting period beginning in such fiscal year.
    ``(V) In the case of an application for payment under this clause 
that is approved by the Secretary, a provider may elect to receive 
payment on a quarterly basis.''.
            (2) Effective date.--The amendment made by subsection (a) 
        takes effect six months after the date of the enactment of this 
        Act, and applies with respect to applications by home health 
        agencies for payment of reasonable costs for outliers for cost 
        reporting periods ending on or after such date.
    (d) Reports to Congress.--
            (1) Initial report.--Not later than one year after the date 
        of the enactment of this Act, the Secretary of Health and Human 
        Services shall submit to Congress a report describing the 
        effect of the special payment provisions provided for under the 
        second sentence of clause (x) and under clause (xi) of section 
        1861(v)(1)(L) of the Social Security Act (42 U.S.C. 
        1395x(v)(1)(L)). Such report shall include information with 
        respect to the number of home health agencies that requested 
        payment under such provisions and the number of such agencies 
        that received payment under such provisions.
            (2) Final report.--Not later than three years after the 
        date of the enactment of this Act, the Secretary shall submit 
        to Congress a report that updates the report submitted under 
        paragraph (1), including additional information with respect to 
        the illnesses, and the characteristics of such illnesses, of 
        the patients for whom payment under such special provisions was 
        requested, and the characteristics of the home health agencies 
        furnishing home health services to such patients for such 
        illnesses.

SEC. 3. REVISION OF PER VISIT LIMITS.

    Section 1861(v)(1)(L)(i) of the Social Security Act (42 U.S.C. 
1395x(v)(1)(L)(i)), as amended by section 5101(b) of the Tax and Trade 
Relief Extension Act of 1998 (Public Law 105-277), 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 at the end and inserting 
                ``, or''; and
            (3) by adding at the end the following new subclause:
            ``(V) October 1, 1999, 110 percent of such median.''.

SEC. 4. ELIMINATION OF CONTINGENT 15 PERCENT REDUCTION IN PAYMENT 
              LIMITS UNDER THE INTERIM PAYMENT SYSTEM.

    Section 4603 of the Balanced Budget Act of 1997 (Public Law 105-
33), as amended by section 5101(c)(3) of the Tax and Trade Relief 
Extension Act of 1998 (Public Law 105-277) (111 Stat. 471), is amended 
by striking subsection (e).

SEC. 5. INFORMATIONAL MATERIALS FOR MEDICARE BENEFICIARIES WITH RESPECT 
              TO HOME HEALTH SERVICES.

    (a) In General.--The Secretary shall prepare a notice of the rights 
of individuals entitled to benefits under the medicare program (under 
title XVIII of the Social Security Act) to appeal a coverage 
determination with respect to items and services furnished to such 
individual under the program. In the case of such items and services 
consisting of home health services furnished by a home health agency, 
the home health agency shall furnish such notice to such an individual 
upon discharge by the agency of such individual from such services.
    (b) Information for Physicians.--The Secretary shall provide 
guidance for physicians contacted by affected individuals to assist 
such individuals, including specific guidance in the case of such 
individuals for whom home health services are discontinued before the 
recommended treatment is complete, but on behalf of whom payment under 
the limits established under section 1861(v)(1)(L) of the Social 
Security Act (42 U.S.C. 1395x(v)(1)(L)) has been made in full by the 
Secretary to the home health agency. The materials shall include 
telephone numbers and such other information to enable the physician to 
seek further assistance or clarification from individuals within the 
Health Care Financing Administration with appropriate expertise.
    (c) Requests for Additional Resources.--The Secretary may submit to 
Congress an estimate of additional resources required by the Health 
Care Financing Administration to comply with the provisions of the 
section. Any such estimate shall be included in the report required 
under paragraph (1) of section 2(d).
    (d) Effective Date.--By not later than six months after the date of 
the enactment of this Act, the Secretary shall begin distributing to 
home health agencies furnishing home health services under the medicare 
program (under title XVIII of the Social Security Act), and to 
physicians furnishing services under such program, the information 
prepared under this section.

SEC. 6. COMPTROLLER GENERAL STUDY ON MEDICARE HOME HEALTH BENEFIT.

    (a) Study.--
            (1) Cost of services.--The Comptroller General of the 
        United States shall conduct a study on the relationship between 
        the costs to the medicare program (under title XVIII of the 
        Social Security Act) for home health services furnished by home 
        health agencies under the program, and the costs to State and 
        Federal government programs (including the medicare program and 
        the medicaid program (under title XIX of such Act)) for 
        services furnished by rehabilitation agencies, public health 
        agencies, clinics, comprehensive outpatient rehabilitation 
        facilities, skilled nursing facilities under the medicare 
        program, and for long-term care services furnished under the 
        medicaid program (under title XIX of such Act).
            (2) Determination of saving overall to medicare program.--
        The Comptroller General shall also determine whether providing 
        home health services as a benefit under the medicare program 
        has resulted in lower costs overall to the Federal government.
    (b) Report.--Not later than 18 months after the date of the 
enactment of this Act, the Comptroller General shall submit to Congress 
a report describing the results of the study conducted under subsection 
(a).