II

103D CONGRESS

1ST SESSION S. 176

To amend title XVIII of the Social Security Act with respect to essential

access community hospitals, the rural transition grant program, regional

referral centers, medicare-dependent small rural hospitals, interpretation

of electrocardiograms, payments for new physicians and practitioners,

prohibitions on carrier forum shopping, treatment of nebulizers and aspirators, and rural hospital demonstrations.

IN THE SENATE OF THE UNITED STATES

JANUARY 21 (legislative day, JANUARY 5), 1993

Mr. DOLE (for himself, Mr. MCCAIN, Mr. DANFORTH, Mr. GRASSLEY, Mr.

DURENBERGER, Mrs. KASSEBAUM, Mr. CRAIG, Mr. NICKLES, Mr. JEFFORDS, Mr. BOND, Mr. PACKWOOD, Mr. BURNS, Mr. MCCONNELL, Mr.

WALLOP, Mr. SHELBY, Mr. BOREN, and Mr. BAUCUS) introduced the following bill; which was read twice and referred to the Committee on Finance

A BILL

To amend title XVIII of the Social Security Act with respect

to essential access community hospitals, the rural transition grant program, regional referral centers, medicaredependent small rural hospitals, interpretation of electrocardiograms, payments for new physicians and practitioners, prohibitions on carrier forum shopping, treatment of nebulizers and aspirators, and rural hospital

demonstrations.

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled,
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1 SECTION 1. SHORT TITLE; REFERENCES IN ACT.

2 (a) SHORT TITLE.—This Act may be cited as the

3 ‘‘Medicare Amendments of 1993’’.

4 (b) REFERENCES IN ACT.—Except as otherwise spe5 cifically provided, whenever in this Act, an amendment is

6 expressed in terms of an amendment to or repeal of a sec7 tion or other provision, the reference shall be considered

8 to be made to that section or other provision of the Social

9 Security Act.

10 SEC. 2. ESSENTIAL ACCESS COMMUNITY HOSPITAL (EACH)

11 AMENDMENTS.

12 (a) INCREASING NUMBER OF PARTICIPATING

13 STATES.—Section 1820(a)(1) (42 U.S.C. 1395i–4(a)(1))

14 is amended by striking ‘‘7’’ and inserting ‘‘9’’.

15 (b) TREATMENT OF INPATIENT HOSPITAL SERVICES

16 PROVIDED IN RURAL PRIMARY CARE HOSPITALS.—

17 (1) IN GENERAL.—Section 1820(f)(1)(F) (42

18 U.S.C. 1395i–4(f)(1)(F)) is amended to read as fol19 lows:

20 ‘‘(F) subject to paragraph (4), provides not

21 more than 6 inpatient beds (meeting such con22 ditions as the Secretary may establish) for pro23 viding inpatient care to patients requiring sta24 bilization before discharge or transfer to a hos25 pital, except that the facility may not provide

26 any inpatient hospital services—
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1 ‘‘(i) to any patient whose attending

2 physician does not certify that the patient

3 may reasonably be expected to be dis4 charged or transferred to a hospital within

5 72 hours of admission to the facility; or

6 ‘‘(ii) consisting of surgery or any

7 other service requiring the use of general

8 anesthesia (other than surgical procedures

9 specified by the Secretary under section

10 1833(i)(1)(A)), unless the attending physi11 cian certifies that the risk associated with

12 transferring the patient to a hospital for

13 such services outweighs the benefits of

14 transferring the patient to a hospital for

15 such services.’’.

16 (2) LIMITATION ON AVERAGE LENGTH OF

17 STAY.—Section 1820(f) (42 U.S.C. 1395i–4(f)) is

18 amended by adding at the end the following new

19 paragraph:

20 ‘‘(4) LIMITATION ON AVERAGE LENGTH OF IN21 PATIENT STAYS.—The Secretary may terminate a

22 designation of a rural primary care hospital under

23 paragraph (1) if the Secretary finds that the average

24 length of stay for inpatients at the facility during

25 the previous year in which the designation was in ef-
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1 fect exceeded 72 hours. In determining the compli2 ance of a facility with the requirement of the pre3 vious sentence, there shall not be taken into account

4 periods of stay of inpatients in excess of 72 hours

5 to the extent such periods exceed 72 hours because

6 transfer to a hospital is precluded because of inclem7 ent weather or other emergency conditions.’’.

8 (3) CONFORMING AMENDMENT.—Section

9 1814(a)(8) (42 U.S.C. 1395f(a)(8)) is amended by

10 striking ‘‘such services’’ and all that follows and in11 serting ‘‘the individual may reasonably be expected

12 to be discharged or transferred to a hospital within

13 72 hours after admission to the rural primary care

14 hospital.’’.

15 (4) GAO REPORTS.—Not later than 2 years

16 after the date of the enactment of this Act, the

17 Comptroller General shall submit reports to the Con18 gress on—

19 (A) the application of the requirements

20 under section 1820(f) of the Social Security Act

21 (as amended by this subsection) that rural pri22 mary care hospitals provide inpatient care only

23 to those individuals whose attending physicians

24 certify may reasonably be expected to be dis25 charged within 72 hours after admission and
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1 maintain an average length of inpatient stay

2 during a year that does not exceed 72 hours;

3 and

4 (B) the extent to which such requirements

5 have resulted in such hospitals providing inpa6 tient care beyond their capabilities or have lim7 ited the ability of such hospitals to provide

8 needed services.

9 (c) DESIGNATION OF HOSPITALS.—

10 (1) PERMITTING DESIGNATION OF HOSPITALS

11 LOCATED IN URBAN AREAS.—

12 (A) IN GENERAL.—Section 1820 (42

13 U.S.C. 1395i–4) is amended—

14 (i) by striking paragraph (1) of sub15 section (e) and redesignating paragraphs

16 (2) through (6) as paragraphs (1) through

17 (5);

18 (ii) in subsection (e)(1)(A) (as redes19 ignated by subparagraph (A))—

20 (I) by striking ‘‘is located’’ and

21 inserting ‘‘except in the case of a hos22 pital located in an urban area, is lo23 cated’’

24 (II) by striking ‘‘, (ii)’’ and in25 serting ‘‘or (ii)’’, and
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1 (III) by striking ‘‘or (iii)’’ and all

2 that follows through ‘‘section,’’; and

3 (iii) in subsection (i)(1)(B), by strik4 ing ‘‘paragraph (3)’’ and inserting ‘‘para5 graph (2)’’.

6 (B) NO CHANGE IN MEDICARE PROSPEC7 TIVE PAYMENT.—Section 1886(d)(5)(D) (42

8 U.S.C. 1395ww(d)(5)(D)) is amended—

9 (i) in clause (iii)(III), by inserting ‘‘lo10 cated in a rural area and’’ after ‘‘that is’’,

11 and

12 (ii) in clause (v), by inserting ‘‘located

13 in a rural area and’’ after ‘‘in the case of

14 a hospital’’.

15 (2) PERMITTING HOSPITALS LOCATED IN AD16 JOINING STATES TO PARTICIPATE IN STATE PRO17 GRAM.—

18 (A) IN GENERAL.—Section 1820 (42

19 U.S.C. 1395i–4) is amended—

20 (i) by redesignating subsection (k) as

21 subsection (l); and

22 (ii) by inserting after subsection (j)

23 the following new subsection:
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1 ‘‘(k) ELIGIBILITY OF HOSPITALS NOT LOCATED IN

2 PARTICIPATING STATES.—Notwithstanding any other

3 provision of this section—

4 ‘‘(1) for purposes of including a hospital or fa5 cility as a member institution of a rural health net6 work, a State may designate a hospital or facility

7 that is not located in the State as an essential access

8 community hospital or a rural primary care hospital

9 if the hospital or facility is located in an adjoining

10 State and is otherwise eligible for designation as

11 such a hospital;

12 ‘‘(2) the Secretary may designate a hospital or

13 facility that is not located in a State receiving a

14 grant under subsection (a)(1) as an essential access

15 community hospital or a rural primary care hospital

16 if the hospital or facility is a member institution of

17 a rural health network of a State receiving a grant

18 under such subsection; and

19 ‘‘(3) a hospital or facility designated pursuant

20 to this subsection shall be eligible to receive a grant

21 under subsection (a)(2).’’.

22 (B) CONFORMING AMENDMENTS.—(i) Sec23 tion 1820(c)(1) (42 U.S.C. 1395i–4(c)(1)) is

24 amended by striking ‘‘paragraph (3)’’ and in25 serting ‘‘paragraph (3) or subsection (k)’’.
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1 (ii) Paragraphs (1)(A) and (2)(A) of sec2 tion 1820(i) (42 U.S.C. 1395i–4(i)) are each

3 amended—

4 (I) in clause (i), by striking ‘‘(a)(1)’’

5 and inserting ‘‘(a)(1) (except as provided

6 in subsection (k))’’, and

7 (II) in clause (ii), by striking ‘‘sub8 paragraph (B)’’ and inserting ‘‘subpara9 graph (B) or subsection (k)’’.

10 (d) SKILLED NURSING SERVICES IN RURAL PRIMARY

11 CARE HOSPITALS.—Section 1820(f)(3) (42 U.S.C. 1395i–

12 4(f)(3)) is amended by striking ‘‘because the facility’’ and

13 all that follows and inserting the following: ‘‘because, at

14 the time the facility applies to the State for designation

15 as a rural primary care hospital, there is in effect an

16 agreement between the facility and the Secretary under

17 section 1883 under which the facility’s inpatient hospital

18 facilities are used for the furnishing of extended care serv19 ices, except that the number of beds used for the furnish20 ing of such services may not exceed the total number of

21 licensed inpatient beds at the time the facility applies to

22 the State for such designation (minus the number of inpa23 tient beds used for providing inpatient care pursuant to

24 paragraph (1)(F)). For purposes of the previous sentence,

25 the number of beds of the facility used for the furnishing
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1 of extended care services shall not include any beds of a

2 unit of the facility that is licensed as a distinct-part skilled

3 nursing facility at the time the facility applies to the State

4 for designation as a rural primary care hospital.’’.

5 (e) PAYMENT FOR OUTPATIENT RURAL PRIMARY

6 CARE HOSPITAL SERVICES.—Section 1834(g)(1) (42

7 U.S.C. 1395m(g)(1)) is amended by adding at the end the

8 following:

9 ‘‘The amount of payment shall be determined under

10 either method without regard to the amount of the

11 customary or other charge.’’.

12 (f) CLARIFICATION OF PHYSICIAN STAFFING RE13 QUIREMENT FOR RURAL PRIMARY CARE HOSPITALS.—

14 Section 1820(f)(1)(H) (42 U.S.C. 1395i–4(f)(1)(H)) is

15 amended by striking the period and inserting the follow16 ing: ‘‘, except that in determining whether a facility meets

17 the requirements of this subparagraph, subparagraphs (E)

18 and (F) of that paragraph shall be applied as if any ref19 erence to a ‘physician’ is a reference to a physician as de20 fined in section 1861(r)(1).’’.

21 (g) TECHNICAL AMENDMENTS RELATING TO PART

22 A DEDUCTIBLE, COINSURANCE, AND SPELL OF ILL23 NESS.—(1) Section 1812(a)(1) (42 U.S.C. 1395d(a)(1))

24 is amended—
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1 (A) by striking ‘‘inpatient hospital services’’ the

2 first place it appears and inserting ‘‘inpatient hos3 pital services or inpatient rural primary care hos4 pital services’’;

5 (B) by striking ‘‘inpatient hospital services’’ the

6 second place it appears and inserting ‘‘such serv7 ices’’; and

8 (C) by striking ‘‘and inpatient rural primary

9 care hospital services’’.

10 (2) Sections 1813(a) and 1813(b)(3)(A) (42 U.S.C.

11 1395e(a), 1395e(b)(3)(A)) are each amended by striking

12 ‘‘inpatient hospital services’’ each place it appears and in13 serting ‘‘inpatient hospital services or inpatient rural pri14 mary care hospital services’’.

15 (3) Section 1813(b)(3)(B) (42 U.S.C.

16 1395e(b)(3)(B)) is amended by striking ‘‘inpatient hos17 pital services’’ and inserting ‘‘inpatient hospital services,

18 inpatient rural primary care hospital services’’.

19 (4) Section 1861(a) (42 U.S.C. 1395x(a)) is amend20 ed—

21 (A) in paragraph (1), by striking ‘‘inpatient

22 hospital services’’ and inserting ‘‘inpatient hospital

23 services, inpatient rural primary care hospital serv24 ices’’; and
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1 (B) in paragraph (2), by striking ‘‘hospital’’

2 and inserting ‘‘hospital or rural primary care hos3 pital’’.

4 (h) AUTHORIZATION OF APPROPRIATIONS.—Section

5 1820(l) (42 U.S.C. 1395i–4(l)), as redesignated by sub6 section (c)(2), is amended by striking ‘‘1990, 1991, and

7 1992’’ and inserting ‘‘1990 through 1995’’.

8 (i) EFFECTIVE DATE.—The amendments made by

9 this section shall take effect on the date of the enactment

10 of this Act.

11 SEC. 3. REAUTHORIZATION OF RURAL TRANSITION GRANT

12 PROGRAM.

13 Section 4005(e)(9) of the Omnibus Budget Reconcili14 ation Act of 1987 (Public Law 100–203) is amended by

15 striking ‘‘1992’’ and inserting ‘‘1992 and $30,000,000 for

16 each of fiscal years 1993 through 1997’’.

17 SEC. 4. REGIONAL REFERRAL CENTERS.

18 (a) EXTENSION THROUGH FISCAL YEAR 1994.—

19 (1) IN GENERAL.—Section 6003(d) of the Om20 nibus Budget Reconciliation Act of 1989 (42 U.S.C.

21 1395ww note) is amended by striking ‘‘October 1,

22 1992’’ and inserting ‘‘October 1, 1994’’.

23 (2) PAYMENT ADJUSTMENT.—

24 (A) IN GENERAL.—In the case of a hos25 pital which would have retained its status as a
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1 regional referral center during the period de2 scribed in subparagraph (B) if the amendments

3 made by paragraph (1) had been included in

4 the enactment of section 6003(d) of the Omni5 bus Budget Reconciliation Act of 1989 (42

6 U.S.C. 1395ww note), the Secretary of Health

7 and Human Services shall make a lump sum

8 payment to such hospital based on the dif9 ference between the aggregate payments (ex10 cluding outlier payments) such hospital would

11 have received during such period if such hos12 pital was classified as a regional referral center

13 during such period and the aggregate payments

14 (excluding outlier payments) such hospital actu15 ally received during such period.

16 (B) DEFINITION.—The period described in

17 this subparagraph is the period beginning the

18 day after the last day a hospital was classified

19 as a regional referral center under section

20 6003(d) of the Omnibus Budget Reconciliation

21 Act of 1989 (42 U.S.C. 1395ww note) and end22 ing on the date of the enactment of the amend23 ments made by paragraph (1)

24 (b) PERMITTING HOSPITALS TO DECLINE RECLASSI25 FICATION.—
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1 (1) IN GENERAL.—If any hospital fails to qual2 ify as a rural referral center under section

3 1886(d)(5)(C) of the Social Security Act as a result

4 of a decision by the Medicare Geographic Classifica5 tion Review Board under section 1886(d)(10) of

6 such Act to reclassify the hospital as being located

7 in an urban area for fiscal year 1993, the Secretary

8 of Health and Human Services shall—

9 (A) notify such hospital of such failure to

10 qualify,

11 (B) provide an opportunity for such hos12 pital to decline such reclassification, and

13 (C) if the hospital declines such reclassi14 fication, administer the Social Security Act

15 (other than section 1886(d)(8)(D) of such Act)

16 for fiscal year 1993 as if the decision by the

17 Review Board had not occurred.

18 (2) PAYMENT ADJUSTMENT.—In the case of a

19 hospital which declines a reclassification under para20 graph (1)(C), the Secretary of Health and Human

21 Services shall make a lump sum payment to such

22 hospital for any period in which such hospital was

23 reclassified under section 1886(d)(10) of the Social

24 Security Act based on the difference between the ag25 gregate payments (excluding outlier payments) such
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1 hospital would have received during such period if

2 such hospital was classified as a regional referral

3 center during such period and the aggregate pay4 ments (excluding outlier payments) such hospital ac5 tually received during such period.

6 SEC. 5. MEDICARE-DEPENDENT, SMALL RURAL HOSPITALS.

7 (a) IN GENERAL.—Section 1886(d)(5)(G) of the So8 cial Security Act (42 U.S.C. 1395ww(d)(5)(G)) is amend9 ed—

10 (1) by amending clause (i) to read as follows:

11 ‘‘(i) In the case of a subsection (d) hospital which

12 is a medicare-dependent, small rural hospital, payment

13 under paragraph (1)(A) for discharges occurring before

14 October 1, 1994, shall be—

15 ‘‘(I) for any cost reporting period beginning on

16 or after April 1, 1990, and ending before March 31,

17 1994, the amount determined under clause (ii); and

18 ‘‘(II) for any cost reporting period beginning on

19 or after April 1, 1993, the amount determined under

20 clause (ii) by substituting ‘50 percent’ for ‘100 per21 cent’.’’,

22 (2) by redesignating clauses (ii) and (iii), as

23 clauses (iii) and (iv), respectively, and

24 (3) by inserting after clause (i) the following

25 new clause:
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1 ‘‘(ii) The amount determined under this clause is the

2 sum of—

3 ‘‘(I) the amount determined under paragraph

4 (1)(A)(iii), and

5 ‘‘(II) 100 percent of the excess (if any) of—

6 ‘‘(aa) the hospital’s target amount for the

7 cost reporting period, as defined in subsection

8 (b)(3)(D), over

9 ‘‘(bb) the amount determined under para10 graph (1)(A)(iii).’’.

11 (b) PERMITTING HOSPITALS TO DECLINE RECLASSI12 FICATION.—

13 (1) IN GENERAL.—If any hospital fails to qual14 ify as a medicare-dependent, small rural hospital

15 under section 1886(d)(5)(G)(i) of the Social Security

16 Act as a result of a decision by the Medicare Geo17 graphic Classification Review Board under section

18 1886(d)(10) of such Act to reclassify the hospital as

19 being located in an urban area for fiscal year 1993,

20 the Secretary of Health and Human Services shall—

21 (A) notify such hospital of such failure to

22 qualify,

23 (B) provide an opportunity for such hos24 pital to decline such reclassification, and
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1 (C) if the hospital declines such reclassi2 fication, administer the Social Security Act

3 (other than section 1886(d)(8)(D) of such Act)

4 for fiscal year 1993 as if the decision by the

5 Review Board had not occurred.

6 (2) PAYMENT ADJUSTMENT.—In the case of a

7 hospital which declines a reclassification under para8 graph (1)(C), the Secretary of Health and Human

9 Services shall make a lump sum payment to such

10 hospital for any period in which such hospital was

11 reclassified under section 1886(d)(10) of the Social

12 Security Act based on the difference between the ag13 gregate payments (excluding outlier payments) such

14 hospital would have received during such period if

15 such hospital was classified as a medicare-depend16 ent, small rural hospital during such period and the

17 aggregate payments (excluding outlier payments)

18 such hospital actually received during such period.

19 SEC. 6. SEPARATE PAYMENT FOR INTERPRETATION OF

20 ELECTROCARDIOGRAMS.

21 (a) IN GENERAL.—Paragraph (3) of section 1848(b)

22 (42 U.S.C. 1395w–4(b)) is amended to read as follows:

23 ‘‘(3) TREATMENT OF INTERPRETATION OF

24 ELECTROCARDIOGRAMS.—The Secretary—
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1 ‘‘(A) shall make separate payment under

2 this section for the interpretation of electro3 cardiograms performed or ordered to be per4 formed as part of or in conjunction with a visit

5 to or a consultation with a physician, and

6 ‘‘(B) shall adjust the relative values estab7 lished for visits and consultations under sub8 section (c) so as not to include relative value

9 units for interpretations of electrocardiograms

10 in the relative value for visits and

11 consultations.’’.

12 (b) ASSURING BUDGET NEUTRALITY.—Section

13 1848(c)(2) (42 U.S.C. 1395w–4(c)(2)) is amended by add14 ing at the end the following new subparagraph:

15 ‘‘(E) BUDGET NEUTRALITY ADJUST16 MENTS.—The Secretary—

17 ‘‘(i) shall reduce the relative values

18 for all services (other than anesthesia serv19 ices) established under this paragraph

20 (and, in the case of anesthesia services, the

21 conversion factor established by the Sec22 retary for such services) by such percent23 age as the Secretary determines to be nec24 essary so that, beginning in 1996, the

25 amendment made by section 6(a) of the
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1 Medicare Amendments of 1993 would not

2 result in expenditures under this section

3 that exceed the amount of such expendi4 tures that would have been made if such

5 amendment had not been made, and

6 ‘‘(ii) shall reduce the amounts deter7 mined under subsection (a)(2)(B)(i)(I) by

8 such percentage as the Secretary deter9 mines to be required to assure that, taking

10 into account the reductions made under

11 clause (i), the amendment made by section

12 6(a) of the Medicare Amendments of 1993

13 would not result in expenditures under this

14 section in 1993 that exceed the amount of

15 such expenditures that would have been

16 made if such amendment had not been

17 made.’’.

18 (c) CONFORMING AMENDMENTS.—Section 1848 (42

19 U.S.C. 1395w–4) is amended—

20 (1) in subsection (a)(2)(B)(i)(I), by inserting

21 ‘‘and as adjusted under subsection (c)(2)(E)(ii)’’

22 after ‘‘for 1993’’;

23 (2) in subsection (c)(2)(A)(i), by adding at the

24 end the following: ‘‘Such relative values are subject

25 to adjustment under subparagraph (E)(i).’’; and
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1 (3) in subsection (i)(1)(B), by adding at the

2 end ‘‘including adjustments under subsection

3 (c)(2)(E),’’.

4 (d) EFFECTIVE DATE.—The amendments made by

5 this section shall apply to services furnished on or after

6 January 1, 1993.

7 SEC. 7. PAYMENTS FOR NEW PHYSICIANS AND PRACTITION8 ERS.

9 (a) EQUAL TREATMENT OF NEW PHYSICIANS AND

10 PRACTITIONERS.—(1) Section 1848(a) (42 U.S.C.

11 1395w–4(a)) is amended by striking paragraph (4).

12 (2) Section 1842(b)(4) (42 U.S.C. 1395u(b)(4)) is

13 amended by striking subparagraph (F).

14 (b) BUDGET NEUTRALITY ADJUSTMENT.—Notwith15 standing any other provision of law, the Secretary of

16 Health and Human Services shall reduce the following val17 ues and amounts for 1993 (to be applied for that year

18 and subsequent years) by such uniform percentage as the

19 Secretary determines to be required to assure that the

20 amendments made by subsection (a) will not result in ex21 penditures under part B of title XVIII of the Social Secu22 rity Act in 1993 that exceed the amount of such expendi23 tures that would have been made if such amendments had

24 not been made:
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1 (1) The relative values established under section

2 1848(c) of such Act for services (other than anesthe3 sia services) and, in the case of anesthesia services,

4 the conversion factor established under section 1848

5 of such Act for such services.

6 (2) The amounts determined under section

7 1848(a)(2)(B)(i)(I) of such Act.

8 (3) The prevailing charges or fee schedule

9 amounts to be applied under such part for services

10 of a health care practitioner (as defined in section

11 1842(b)(4)(F)(ii)(I) of such Act, as in effect before

12 the date of the enactment of this Act).

13 (c) CONFORMING AMENDMENTS.—Section 1848 (42

14 U.S.C. 1395w–4), as amended by section 6(c) of this sub15 title, is amended—

16 (1) in subsection (a)(2)(B)(i)(I), by inserting

17 ‘‘and section 7(b) of the Medicare Amendments of

18 1993’’ after ‘‘(c)(2)(E)(ii)’’;

19 (2) in subsection (c)(2)(A)(i), by inserting ‘‘and

20 section 7(b) of the Medicare Amendments of 1993’’

21 after ‘‘under subparagraph (E)(i)’’; and

22 (3) in subsection (i)(1)(B), by inserting ‘‘and

23 section 7(b) of the Medicare Amendments of 1993’’

24 after ‘‘under subsection (c)(2)(E)’’.
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1 (d) EFFECTIVE DATE.—The amendments made by

2 subsection (a) shall apply to services furnished on or after

3 January 1, 1993.

4 SEC. 8. PROHIBITION AGAINST CARRIER FORUM SHOP5 PING.

6 (a) IN GENERAL.—Section 1834(a)(12) (42 U.S.C.

7 1395m(a)(12)) is amended to read as follows:

8 ‘‘(12) USE OF CARRIERS TO PROCESS

9 CLAIMS.—

10 ‘‘(A) DESIGNATION OF REGIONAL CAR11 RIERS.—The Secretary may designate, by regu12 lation under section 1842, one carrier for one

13 or more entire regions to process all claims

14 within the region for covered items under this

15 section.

16 ‘‘(B) PROHIBITION AGAINST CARRIER

17 SHOPPING.—(i) No supplier of a covered item

18 may present or cause to be presented a claim

19 for payment under this part unless such claim

20 is presented to the appropriate carrier.

21 ‘‘(ii) For purposes of clause (i), the term

22 ‘appropriate carrier’ means the carrier having

23 jurisdiction over the geographic area that in24 cludes the permanent residence of the patient to

25 whom the item is furnished.’’.
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1 (b) EFFECTIVE DATE.—The amendment made by

2 subsection (a) shall apply to items furnished on or after

3 July 1, 1993.

4 (c) CLARIFICATION OF AUTHORITY TO DESIGNATE

5 CARRIERS FOR OTHER ITEMS AND SERVICES.—Nothing

6 in this subsection or the amendment made by this sub7 section may be construed to restrict the authority of the

8 Secretary of Health and Human Services to designate re9 gional carriers or modify claims jurisdiction rules with re10 spect to items or services under part B of the medicare

11 program that are not covered items under section 1834(a)

12 of the Social Security Act or prosthetic devices or orthotics

13 and prosthetics under section 1834(h) of such Act.

14 SEC. 9. TREATMENT OF NEBULIZERS AND ASPIRATORS.

15 (a) IN GENERAL.—Section 1834(a)(3)(A) (42 U.S.C.

16 1395m(a)(3)(A)) is amended by striking ‘‘ventilators, as17 pirators, IPPB machines, and nebulizers’’ and inserting

18 ‘‘ventilators and IPPB machines’’.

19 (b) PAYMENT FOR ACCESSORIES RELATING TO

20 NEBULIZERS AND ASPIRATORS.—Section 1834(a) (42

21 U.S.C. 1395m(a)) is amended by inserting after para22 graph (14) the following new paragraph:

23 ‘‘(15) PAYMENT FOR ACCESSORIES RELATING

24 TO NEBULIZERS AND ASPIRATORS.—In the case of

25 accessories to be used in conjunction with a
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1 nebulizer or aspirator for which payment is made

2 under this subsection, payment shall be made in ac3 cordance with paragraph (2) of this subsection.’’.

4 (c) EFFECTIVE DATE.—The amendments made by

5 this section shall apply to items furnished on or after Jan6 uary 1, 1993.

7 SEC. 10. EXTENSION OF RURAL HOSPITAL DEMONSTRA8 TION.

9 Section 4008(i)(1) of the Omnibus Budget Reconcili10 ation Act of 1990 is amended by adding at the end the

11 following new sentence: ‘‘The Secretary shall continue any

12 such demonstration project until at least December 31,

13 1995.’’.

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