Calendar No. 295

103D CONGRESS

1ST SESSION S. 1668

A BILL

To amend the Social Security Act and related Acts

N

ments, and for other purposes.to make miscellaneous and technical amendOVEMBER 17 (legislative day, NOVEMBER 2), 1993

Placed on the calendar
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Calendar No. 295

103D CONGRESS

1ST SESSION S. 1668

To amend the Social Security Act and related Acts to make miscellaneous

and technical amendments, and for other purposes.

IN THE SENATE OF THE UNITED STATES

NOVEMBER 17 (legislative day, NOVEMBER 2), 1993

Mr. MOYNIHAN, from the Committee on Finance, reported the following

original bill; which was read twice and placed on the calendar

A BILL

To amend the Social Security Act and related Acts to make

miscellaneous and technical amendments, and for other

purposes.

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled,

3 SECTION 1. SHORT TITLE.

4 This Act may be cited as the ‘‘Social Security Act

5 Amendments of 1993’’.

6 SEC. 2. REFERENCES IN ACT; TABLE OF CONTENTS.

7 (a) AMENDMENTS TO SOCIAL SECURITY ACT.—Ex8 cept as otherwise specifically provided, whenever in this
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1 Act an amendment is expressed in terms of an amendment

2 to or repeal of a section or other provision, the reference

3 shall be considered to be made to that section or other

4 provision of the Social Security Act.

5 (b) REFERENCES TO OBRA.—In this Act, the terms

6 ‘‘OBRA–1986’’, ‘‘OBRA–1987’’, ‘‘OBRA–1989’’,

7 ‘‘OBRA–1990’’, and ‘‘OBRA–1993’’ refer to the Omnibus

8 Budget Reconciliation Act of 1986 (Public Law 99–509),

9 the Omnibus Budget Reconciliation Act of 1987 (Public

10 Law 100–203), the Omnibus Budget Reconciliation Act

11 of 1989 (Public Law 101–239), the Omnibus Budget Rec12 onciliation Act of 1990 (Public Law 101–508), and the

13 Omnibus Budget Reconciliation Act of 1993 (Public Law

14 103–66), respectively.

15 (c) TABLE OF CONTENTS.—The table of contents is

16 as follows:

Sec. 1. Short title.

Sec. 2. References in Act; table of contents.

TITLE I—MEDICARE PROVISIONS

Subtitle A—Provisions Relating to Part A

Sec. 101. Provisions relating to adjustments to standardized amounts for wages

and wage-related costs.

Sec. 102. Essential access community hospital (EACH) amendments.

Sec. 103. Provisions relating to rural health transition grant program.

Sec. 104. Psychology services in hospitals.

Sec. 105. Medicare-dependent, small rural hospitals and sole community hospitals.

Sec. 106. Skilled nursing facilities.

Sec. 107. Notification of availability of hospice benefit.

Sec. 108. Clarifying expertise of individuals to serve on the Prospective Payment Assessment Commission.

Sec. 109. Authority for budget neutral adjustments for changes in payment

amounts for transfer cases.
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Sec. 110. Clarification of DRG payment window expansion; miscellaneous and

technical corrections.

Subtitle B—Provisions Relating to Part B

PART I—PHYSICIANS’ SERVICES

Sec. 121. Development and implementation of resource-based methodology for

practice expenses.

Sec. 122. Geographic cost of practice index refinements.

Sec. 123. Extra-billing limits.

Sec. 124. Relative values for pediatric services.

Sec. 125. Administration of claims relating to physicians’ services.

Sec. 126. Miscellaneous and technical corrections.

PART II—DURABLE MEDICAL EQUIPMENT

Sec. 131. Certification of suppliers.

Sec. 132. Prohibition against carrier forum shopping.

Sec. 133. Restrictions on certain marketing and sales activities.

Sec. 134. Kickback clarification.

Sec. 135. Beneficiary liability for noncovered services.

Sec. 136. Adjustments for inherent reasonableness.

Sec. 137. Miscellaneous and technical corrections.

PART III—OTHER ITEMS AND SERVICES

Sec. 141. Ambulatory surgical center services.

Sec. 142. Study of medicare coverage of patient care costs associated with clinical trials of new cancer therapies.

Sec. 143. Study of annual cap on amount of medicare payment for outpatient

physical therapy and occupational therapy services.

Sec. 144. Payment of part B premium late enrollment penalties by States.

Sec. 145. Treatment of inpatients and provision of diagnostic x-ray services by

rural health clinics and federally qualified health centers.

Sec. 146. Application of mammography certification requirements.

Sec. 147. Coverage of services of speech-language pathologists and audiologists.

Sec. 148. Miscellaneous and technical corrections.

Subtitle C—Provisions Relating to Parts A and B

Sec. 151. Medicare secondary payer reforms.

Sec. 152. Physician ownership and referral.

Sec. 153. Definition of FMGEMS examination for payment of direct graduate

medical education.

Sec. 154. Qualified medicare beneficiary outreach.

Sec. 155. Hospital agreements with organ procurement organizations.

Sec. 156. Peer review organizations.

Sec. 157. Health maintenance organizations.

Sec. 158. Home health agencies.

Sec. 159. Permanent extension of authority to contract with fiscal

intermediaries and carriers on other than a cost basis.

Sec. 160. Miscellaneous and technical corrections.

Subtitle D—Provisions Relating to Medicare Supplemental Insurance Policies

Sec. 171. Standards for medicare supplemental insurance policies.
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TITLE II—MEDICAID PROVISIONS

Subtitle A—Substantive Provisions

PART I—MANAGED CARE PROVISIONS

Sec. 201. Medicaid managed care antifraud provisions.

Sec. 202. Extension of medicaid waiver for Tennessee Primary Care Network.

Sec. 203. Waiver of application of medicaid enrollment mix requirement to District of Columbia Chartered Health Plan, Inc.

Sec. 204. Waiver of application of medicaid enrollment mix requirement to

Managed Health Services Insurance Corporation of Milwaukee,

Wisconsin.

Sec. 205. Extension of Minnesota prepaid medicaid demonstration project.

PART II—HOME AND COMMUNITY-BASED SERVICES WAIVER PROVISIONS

Sec. 211. Elimination of requirement of prior institutionalization with respect

to habilitation services furnished under a waiver for home or

community-based services.

Sec. 212. Relief from third party liability requirements when cost-effective.

Sec. 213. State expenditures for medical assistance with respect to home and

community-based services provided under a waiver.

PART III—OTHER PROVISIONS

Sec. 221. Presumptive eligibility for pregnant women.

Sec. 222. Criteria for determining the amount of disallowances.

Sec. 223. Intermediate sanctions for kickback violations.

Sec. 224. Technical amendment related to taxes on certain health care items

and services.

Sec. 225. Application of mammography certification requirements under the

medicaid program.

Sec. 226. Nursing home reform.

Sec. 227. Increase in authorization of appropriations for the maternal and child

health services block grant program.

Subtitle B—Miscellaneous and Technical Corrections Relating to OBRA–1990

Sec. 241. Effective date.

Sec. 242. Corrections relating to section 4401 (drug rebate program).

Sec. 243. Corrections relating to section 4402 (enrollment under group health

plans).

Sec. 244. Corrections relating to section 4501 (low-income medicare beneficiaries).

Sec. 245. Corrections relating to section 4601 (child health).

Sec. 246. Corrections relating to section 4602 (outreach locations).

Sec. 247. Corrections relating to section 4604 (payment for hospital services for

children under 6 years of age).

Sec. 248. Corrections relating to section 4703 (payment adjustments for disproportionate share hospitals).

Sec. 249. Corrections relating to section 4704 (Federally-qualified health centers).

Sec. 250. Corrections relating to section 4708 (substitute physicians).

Sec. 251. Corrections relating to section 4711 (home and community care for

frail elderly).
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Sec. 252. Corrections relating to section 4712 (community supported living arrangements).

Sec. 253. Correction relating to section 4713 (COBRA continuation coverage).

Sec. 254. Correction relating to section 4716 (medicaid transition for family assistance).

Sec. 255. Corrections relating to section 4718 (medically needy income levels

for certain 1-member families).

Sec. 256. Corrections relating to section 4723 (medicaid spend-down option).

Sec. 257. Corrections relating to section 4724 (optional State disability determinations).

Sec. 258. Correction relating to section 4732 (special rules for health maintenance organizations).

Sec. 259. Corrections relating to section 4747 (coverage of HIV-positive individuals).

Sec. 260. Correction relating to section 4751 (advanced directives).

Sec. 261. Corrections relating to section 4752 (physicians’ services).

Sec. 262. Corrections relating to section 4801 (nursing home reform).

Sec. 263. Other technical corrections.

Subtitle C—Miscellaneous and Technical Corrections Relating to OBRA–1993

Sec. 271. Effective date.

Sec. 272. Corrections relating to section 13601 (personal care services).

Sec. 273. Corrections relating to section 13604 (emergency services for aliens).

Sec. 274. Corrections relating to section 13611 (transfers of assets; treatment

of certain trusts).

Sec. 275. Corrections relating to section 13612 (medicaid estate recoveries).

Sec. 276. Corrections relating to section 13622 (liability of third parties to pay

for care and services).

Sec. 277. Corrections relating to section 13623 (medical child support).

Sec. 278. Corrections relating to section 13624 (physician referrals).

Sec. 279. Corrections relating to section 13631 (medicaid pediatric immunization provisions).

Sec. 280. Corrections relating to section 13643 (demonstration projects).

TITLE III—INCOME SECURITY, HUMAN RESOURCES, AND

RELATED PROGRAMS

Subtitle A—Child Welfare, Foster Care, Adoption

Sec. 301. Required protections for foster children.

Sec. 302. Conformity reviews.

Sec. 303. States required to report on measures taken to comply with the Indian Child Welfare Act.

Sec. 304. Child welfare traineeships.

Sec. 305. Dispositional hearing.

Sec. 306. Elimination of foster care ceilings and of authority to transfer unused

foster care funds to child welfare services programs.

Sec. 307. Demonstration projects.

Sec. 308. Placement accountability.

Sec. 309. Payments of State claims for foster care and adoption assistance.

Sec. 310. Effect of failure to carry out State plan.

Subtitle B—Child Support Enforcement

Sec. 311. Reports to credit bureaus on persons delinquent in child support payments.
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Sec. 312. Technical amendments to provision on State paternity establishment

programs.

Sec. 313. Agreement to assist in locating missing children under the parent locator service.

Subtitle C—Supplemental Security Income

Sec. 321. Definition of disability for children under age 18 applied to all individuals under age 18.

Sec. 322. Commission on Childhood Disability.

Sec. 323. Exemption from pass-along requirements.

Subtitle D—Aid to Families With Dependent Children

Sec. 331. Simplification of income and eligibility verification system.

Sec. 332. Measurement and reporting of welfare receipt.

Sec. 333. New Hope demonstration project.

Sec. 334. Delay in requirement that outlying areas operate an AFDC–up program.

Sec. 335. New York State child support demonstration program.

Sec. 336. State option to use retrospective budgeting without monthly reporting.

Subtitle E—JOBS Program

Sec. 341. Expansion of coverage for Indian tribes.

Sec. 342. Report to the Congress with respect to performance standards in the

JOBS program.

Subtitle F—Unemployment Insurance

Sec. 351. Extension of reporting date for advisory council.

Sec. 352. Technical amendment to unemployment trust fund.

Subtitle G—Other Provisions

Sec. 361. Extension of demonstration to expand job opportunities.

Sec. 362. Early childhood development projects.

Sec. 363. Reallocation of funds under title XX for empowerment and enterprise

grants.

Sec. 364. Corrections related to the income security and human resources provisions of OBRA–1990.

Sec. 365. Technical corrections related to the human resource and income security provisions of OBRA–1989.

Sec. 366. Technical correction related to the human resource and income security provisions of OBRA–1993.

Sec. 367. Elimination of obsolete provisions relating to treatment of the earned

income tax credit.

Sec. 368. Redesignation of certain provisions.
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1 TITLE I—MEDICARE PROVISIONS

2 Subtitle A—Provisions Relating to

3 Part A

4 SEC. 101. PROVISIONS RELATING TO ADJUSTMENTS TO

5 STANDARDIZED AMOUNTS FOR WAGES AND

6 WAGE-RELATED COSTS.

7 (a) USE OF OCCUPATIONAL MIX IN GUIDELINES FOR

8 DETERMINATION OF AREA WAGE INDEX.—

9 (1) IN GENERAL.—Section 1886(d)(10)(D)(i)(I)

10 (42 U.S.C. 1395ww(d)(10)(D)(i)(I)) is amended by

11 inserting ‘‘(to the extent the Secretary determines

12 appropriate)’’ after ‘‘taking into account’’.

13 (2) EFFECTIVE DATE.—The amendment made

14 by paragraph (1) shall take effect as if included in

15 the enactment of OBRA–1989.

16 (b) CONFORMING AMENDMENTS RELATING TO GEO17 GRAPHIC AREA USED TO DETERMINE WAGE INDEX AP18 PLICABLE TO HOSPITAL.—(1) Section 1886(d)(8)(C) (42

19 U.S.C. 1395ww(d)(8)(C)), as amended by section

20 13501(b)(1) of OBRA–1993, is amended—

21 (A) in clause (iv), by striking ‘‘paragraph (1)’’

22 and inserting ‘‘paragraph (10)’’; and

23 (B) by adding at the end the following new

24 clause:
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1 ‘‘(v) This subparagraph shall apply with respect to

2 discharges occurring in a fiscal year only if the Secretary

3 uses a method for making adjustments to the DRG pro4 spective payment rate for area differences in hospital wage

5 levels under paragraph (3)(E) for the fiscal year that is

6 based on the use of Metropolitan Statistical Area classi7 fications.’’.

8 (2) Section 1886(d)(10) (42 U.S.C. 1395ww(d)(10))

9 is amended—

10 (A) in subparagraph (C)(i)(II), by striking ‘‘the

11 area wage index applicable’’ and inserting ‘‘the fac12 tor used to adjust the DRG prospective payment

13 rate for area differences in hospital wage levels that

14 applies’’; and

15 (B) in subparagraph (D)—

16 (i) by redesignating clause (ii) as clause

17 (iii), and

18 (ii) by inserting after clause (i) the follow19 ing new clause:

20 ‘‘(ii) Notwithstanding clause (i), if the Secretary uses

21 a method for making adjustments to the DRG prospective

22 payment rate for area differences in hospital wage levels

23 under paragraph (3)(E) that is not based on the use of

24 Metropolitan Statistical Area classifications, the Secretary

25 may revise the guidelines published under clause (i) to the
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1 extent such guidelines are used to determine the appro2 priateness of the geographic area in which the hospital is

3 determined to be located for purposes of making such ad4 justments.’’.

5 (c) ADJUSTMENT OF LABOR AND NON-LABOR POR6 TIONS OF STANDARDIZED AMOUNTS.—Section

7 1886(d)(3)(A)(iii) (42 U.S.C. 1395ww(d)(3)(A)(iii)) is

8 amended by adding at the end the following: ‘‘For dis9 charges occurring on or after October 1, 1994, the Sec10 retary shall adjust the ratio of the labor portion to non11 labor portion of each average standardized amount to

12 equal such ratio for the national average of all standard13 ized amounts.’’.

14 SEC. 102. ESSENTIAL ACCESS COMMUNITY HOSPITAL

15 (EACH) AMENDMENTS.

16 (a) INCREASING NUMBER OF PARTICIPATING

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

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

19 (b) TREATMENT OF INPATIENT HOSPITAL SERVICES

20 PROVIDED IN RURAL PRIMARY CARE HOSPITALS.—

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

22 U.S.C. 1395i–4(f)(1)(F)) is amended to read as fol23 lows:

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

25 more than 6 inpatient beds (meeting such con-
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1 ditions as the Secretary may establish) for pro2 viding inpatient care to patients requiring sta3 bilization before discharge or transfer to a hos4 pital, except that the facility may not provide

5 any inpatient hospital services—

6 ‘‘(i) to any patient whose attending

7 physician does not certify that the patient

8 may reasonably be expected to be dis9 charged or transferred to a hospital within

10 72 hours of admission to the facility; or

11 ‘‘(ii) consisting of surgery or any

12 other service requiring the use of general

13 anesthesia (other than surgical procedures

14 specified by the Secretary under section

15 1833(i)(1)(A)), unless the attending physi16 cian certifies that the risk associated with

17 transferring the patient to a hospital for

18 such services outweighs the benefits of

19 transferring the patient to a hospital for

20 such services.’’.

21 (2) LIMITATION ON AVERAGE LENGTH OF

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

23 amended by adding at the end the following new

24 paragraph:
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1 ‘‘(4) LIMITATION ON AVERAGE LENGTH OF IN2 PATIENT STAYS.—The Secretary may terminate a

3 designation of a rural primary care hospital under

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

5 length of stay for inpatients at the facility during

6 the previous year in which the designation was in ef7 fect exceeded 72 hours. In determining the compli8 ance of a facility with the requirement of the pre9 vious sentence, there shall not be taken into account

10 periods of stay of inpatients in excess of 72 hours

11 to the extent such periods exceed 72 hours because

12 transfer to a hospital is precluded because of inclem13 ent weather or other emergency conditions.’’.

14 (3) CONFORMING AMENDMENT.—Section

15 1814(a)(8) (42 U.S.C. 1395f(a)(8)) is amended by

16 striking ‘‘such services’’ and all that follows and in17 serting ‘‘the individual may reasonably be expected

18 to be discharged or transferred to a hospital within

19 72 hours after admission to the rural primary care

20 hospital.’’.

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

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

23 Comptroller General shall submit reports to Con24 gress on—
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1 (A) the application of the requirements

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

3 (as amended by this subsection) that rural pri4 mary care hospitals provide inpatient care only

5 to those individuals whose attending physicians

6 certify may reasonably be expected to be dis7 charged within 72 hours after admission and

8 maintain an average length of inpatient stay

9 during a year that does not exceed 72 hours;

10 and

11 (B) the extent to which such requirements

12 have resulted in such hospitals providing inpa13 tient care beyond their capabilities or have lim14 ited the ability of such hospitals to provide

15 needed services.

16 (c) DESIGNATION OF HOSPITALS.—

17 (1) PERMITTING DESIGNATION OF HOSPITALS

18 LOCATED IN URBAN AREAS.—

19 (A) IN GENERAL.—Section 1820 (42

20 U.S.C. 1395i–4) is amended—

21 (i) by striking paragraph (1) of sub22 section (e) and redesignating paragraphs

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

24 (5);
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1 (ii) in subsection (e)(1)(A) (as redes2 ignated by subparagraph (A))—

3 (I) by striking ‘‘is located’’ and

4 inserting ‘‘except in the case of a hos5 pital located in an urban area, is lo6 cated’’,

7 (II) by striking ‘‘, (ii)’’ and in8 serting ‘‘or (ii)’’, and

9 (III) by striking ‘‘or (iii)’’ and all

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

11 (iii) in subsection (i)(1)(B), by strik12 ing ‘‘paragraph (3)’’ and inserting ‘‘para13 graph (2)’’.

14 (B) NO CHANGE IN MEDICARE PROSPEC15 TIVE PAYMENT.—Section 1886(d)(5)(D) (42

16 U.S.C. 1395ww(d)(5)(D)) is amended—

17 (i) in clause (iii)(III), by inserting ‘‘lo18 cated in a rural area and’’ after ‘‘that is’’,

19 and

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

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

22 a hospital’’.

23 (2) PERMITTING HOSPITALS LOCATED IN AD24 JOINING STATES TO PARTICIPATE IN STATE PRO25 GRAM.—
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1 (A) IN GENERAL.—Section 1820 (42

2 U.S.C. 1395i–4) is amended—

3 (i) by redesignating subsection (k) as

4 subsection (l); and

5 (ii) by inserting after subsection (j)

6 the following new subsection:

7 ‘‘(k) ELIGIBILITY OF HOSPITALS NOT LOCATED IN

8 PARTICIPATING STATES.—Notwithstanding any other

9 provision of this section—

10 ‘‘(1) for purposes of including a hospital or fa11 cility as a member institution of a rural health net12 work, a State may designate a hospital or facility

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

14 community hospital or a rural primary care hospital

15 if the hospital or facility is located in an adjoining

16 State and is otherwise eligible for designation as

17 such a hospital;

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

19 facility that is not located in a State receiving a

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

21 community hospital or a rural primary care hospital

22 if the hospital or facility is a member institution of

23 a rural health network of a State receiving a grant

24 under such subsection; and
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1 ‘‘(3) a hospital or facility designated pursuant

2 to this subsection shall be eligible to receive a grant

3 under subsection (a)(2).’’.

4 (B) CONFORMING AMENDMENTS.—(i) Sec5 tion 1820(c)(1) (42 U.S.C. 1395i–4(c)(1)) is

6 amended by striking ‘‘paragraph (3)’’ and in7 serting ‘‘paragraph (3) or subsection (k)’’.

8 (ii) Paragraphs (1)(A) and (2)(A) of sec9 tion 1820(i) (42 U.S.C. 1395i–4(i)) are each

10 amended—

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

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

13 in subsection (k))’’, and

14 (II) in clause (ii), by striking ‘‘sub15 paragraph (B)’’ and inserting ‘‘subpara16 graph (B) or subsection (k)’’.

17 (d) SKILLED NURSING SERVICES IN RURAL PRIMARY

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

19 4(f)(3)) is amended by striking ‘‘because the facility’’ and

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

21 the time the facility applies to the State for designation

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

23 agreement between the facility and the Secretary under

24 section 1883 under which the facility’s inpatient hospital

25 facilities are used for the furnishing of extended care serv-
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1 ices, except that the number of beds used for the furnish2 ing of such services may not exceed the total number of

3 licensed inpatient beds at the time the facility applies to

4 the State for such designation (minus the number of inpa5 tient beds used for providing inpatient care pursuant to

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

7 the number of beds of the facility used for the furnishing

8 of extended care services shall not include any beds of a

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

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

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

12 (e) DEADLINE FOR DEVELOPMENT OF PROSPECTIVE

13 PAYMENT SYSTEM FOR INPATIENT RURAL PRIMARY

14 CARE HOSPITAL SERVICES.—Section 1814(l)(2) (42

15 U.S.C. 1395f(l)(2)) is amended by striking ‘‘January 1,

16 1993’’ and inserting ‘‘January 1, 1996’’.

17 (f) PAYMENT FOR OUTPATIENT RURAL PRIMARY

18 CARE HOSPITAL SERVICES.—

19 (1) IMPLEMENTATION OF PROSPECTIVE PAY20 MENT SYSTEM.—Section 1834(g) (42 U.S.C.

21 1395m(g)) is amended—

22 (A) in paragraph (1), by striking ‘‘during

23 a year before 1993’’ and inserting ‘‘during a

24 year before the prospective payment system de25 scribed in paragraph (2) is in effect’’; and
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1 (B) in paragraph (2), by striking ‘‘January

2 1, 1993,’’ and inserting ‘‘January 1, 1996,’’.

3 (2) NO USE OF CUSTOMARY CHARGE IN DETER4 MINING PAYMENT.—Section 1834(g)(1) (42 U.S.C.

5 1395m(g)(1)) is amended by adding at the end the

6 following new flush sentence:

7 ‘‘The amount of payment shall be determined under

8 either method without regard to the amount of the

9 customary or other charge.’’.

10 (g) CLARIFICATION OF PHYSICIAN STAFFING RE11 QUIREMENT FOR RURAL PRIMARY CARE HOSPITALS.—

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

13 amended by striking the period and inserting the follow14 ing: ‘‘, except that in determining whether a facility meets

15 the requirements of this subparagraph, subparagraphs (E)

16 and (F) of that paragraph shall be applied as if any ref17 erence to a ‘physician’ is a reference to a physician as de18 fined in section 1861(r)(1).’’.

19 (h) TECHNICAL AMENDMENTS RELATING TO PART

20 A DEDUCTIBLE, COINSURANCE, AND SPELL OF ILL21 NESS.—(1) Section 1812(a)(1) (42 U.S.C. 1395d(a)(1))

22 is amended—

23 (A) by striking ‘‘inpatient hospital services’’ the

24 first place it appears and inserting ‘‘inpatient hos-
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1 pital services or inpatient rural primary care hos2 pital services’’;

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

4 second place it appears and inserting ‘‘such serv5 ices’’; and

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

7 care hospital services’’.

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

9 1395e(a), 1395e(b)(3)(A)) are each amended by striking

10 ‘‘inpatient hospital services’’ each place it appears and in11 serting ‘‘inpatient hospital services or inpatient rural pri12 mary care hospital services’’.

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

14 1395e(b)(3)(B)) is amended by striking ‘‘inpatient hos15 pital services’’ and inserting ‘‘inpatient hospital services,

16 inpatient rural primary care hospital services’’.

17 (4) Section 1861(a) (42 U.S.C. 1395x(a)) is amend18 ed—

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

20 hospital services’’ and inserting ‘‘inpatient hospital

21 services, inpatient rural primary care hospital serv22 ices’’; and

23 (B) in paragraph (2), by striking ‘‘hospital’’

24 and inserting ‘‘hospital or rural primary care hos25 pital’’.
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1 (i) AUTHORIZATION OF APPROPRIATIONS.—Section

2 1820(l) (42 U.S.C. 1395i–4(l)), as redesignated by sub3 section (c)(2)(A), is amended by striking ‘‘1990, 1991,

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

5 (j) EFFECTIVE DATE.—The amendments made by

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

7 of this Act.

8 SEC. 103. PROVISIONS RELATING TO RURAL HEALTH TRAN9 SITION GRANT PROGRAM.

10 (a) ELIGIBILITY OF RURAL PRIMARY CARE HOS11 PITALS FOR GRANTS.—

12 (1) IN GENERAL.—Section 4005(e)(2) of

13 OBRA–1987 is amended in the matter preceding

14 subparagraph (A) by inserting ‘‘any rural primary

15 care hospital designated by the Secretary under sec16 tion 1820(i)(2) of the Social Security Act, or’’ after

17 ‘‘means’’.

18 (2) EFFECTIVE DATE.—The amendment made

19 by paragraph (1) shall apply to grants made on or

20 after October 1, 1993.

21 (b) EXTENSION OF AUTHORIZATION OF APPROPRIA22 TIONS.—Section 4005(e)(9) of OBRA–1987 is amended—

23 (1) by striking ‘‘1989 and’’ and inserting

24 ‘‘1989,’’; and
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1 (2) by striking ‘‘1992’’ and inserting ‘‘1992

2 and $30,000,000 for each of fiscal years 1993

3 through 1997’’.

4 (c) FREQUENCY OF REQUIRED REPORTS.—Section

5 4008(e)(8)(B) of OBRA–1987 is amended by striking

6 ‘‘every 6 months’’ and inserting ‘‘every 12 months’’.

7 SEC. 104. PSYCHOLOGY SERVICES IN HOSPITALS.

8 Section 1861(e)(4) (42 U.S.C. 1395x(e)(4)) is

9 amended by striking ‘‘physician;’’ and inserting ‘‘physi10 cian, except that a patient receiving qualified psychologist

11 services (as defined in subsection (ii)) may be under the

12 care of a clinical psychologist with respect to such services

13 to the extent permitted under State law;’’.

14 SEC. 105. MEDICARE-DEPENDENT, SMALL RURAL HOS15 PITALS AND SOLE COMMUNITY HOSPITALS.

16 (a) MEDICARE DEPENDENT, SMALL RURAL HOS17 PITALS.—

18 (1) CLARIFICATION OF ADDITIONAL PAY19 MENT.—Section 1886(d)(5)(G)(ii)(I) (42 U.S.C.

20 1395ww(d)(5)(G)(ii)(I)), as amended by section

21 13501(e)(1) of OBRA–1993, is amended by striking

22 ‘‘the first 3 12-month cost reporting periods that

23 begin’’ and inserting ‘‘the 36-month period begin24 ning with the first day of the cost reporting period

25 that begins’’.
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1 (2) CONFORMING TARGET AMOUNTS TO EXTEN2 SION OF ADDITIONAL PAYMENTS.—Section

3 1886(b)(3)(D) (42 U.S.C. 1395ww(b)(3)(D)) is

4 amended in the matter preceding clause (i) by strik5 ing ‘‘March 31, 1993’’ and inserting ‘‘September 30,

6 1994’’.

7 (b) CLARIFICATION OF UPDATES.—Section

8 1886(b)(3)(B)(iv)(II) (42 U.S.C.

9 1395ww(b)(3)(B)(iv)(II)), as added by section

10 13501(a)(2) of OBRA–1993, is amended by striking

11 ‘‘(taking into account’’ and all that follows through

12 ‘‘1994)’’ and inserting ‘‘(adjusted to exclude any portion

13 of a cost reporting period beginning during fiscal year

14 1993 for which the applicable percentage increase is deter15 mined under subparagraph (I))’’.

16 SEC. 106. SKILLED NURSING FACILITIES.

17 (a) CONSTRUCTION OF WAGE INDEX.—Not later

18 than 1 year after the date of the enactment of this Act,

19 the Secretary of Health and Human Services shall begin

20 to collect data on employee compensation and paid hours

21 of employment in skilled nursing facilities for the purpose

22 of constructing a skilled nursing facility wage index ad23 justment to the routine service cost limits required under

24 section 1888(a)(4) of the Social Security Act.
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1 (b) CLARIFICATION OF REPEAL OF UTILIZATION RE2 VIEW REQUIREMENTS.—

3 (1) IN GENERAL.—(A) Section 1814(a)(5) (42

4 U.S.C. 1395f(a)(5)) is amended—

5 (i) by striking ‘‘and with respect’’ and all

6 that follows through ‘‘regulations’’;

7 (ii) by striking ‘‘or skilled nursing facility,

8 as the case may be’’; and

9 (iii) by striking ‘‘or facility’’.

10 (B) Section 1866(d) (42 U.S.C. 1395cc(d)) is

11 amended—

12 (i) by striking ‘‘or skilled nursing facility’’;

13 (ii) by striking ‘‘or facility’’ each place it

14 appears;

15 (iii) by striking ‘‘or for post-hospital’’ and

16 all that follows through ‘‘the case may be’’; and

17 (iv) by striking ‘‘, or (in the case of’’ and

18 all that follows through ‘‘transfer agreement,’’.

19 (2) EFFECTIVE DATE.—The amendments made

20 by paragraph (1) shall take effect as if included in

21 the enactment of OBRA–1987.

22 (c) CONFORMING AMENDMENTS TO NURSING HOME

23 REFORM.—
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1 (1) SUSPENSION OF DECERTIFICATION OF

2 NURSES AIDE TRAINING AND COMPETENCY EVALUA3 TION PROGRAMS BASED ON EXTENDED SURVEYS.—

4 (A) IN GENERAL.—Section

5 1819(f)(2)(B)(iii)(I)(b) (42 U.S.C. 1395i–

6 3(f)(2)(B)(iii)(I)(b)) is amended by striking the

7 semicolon and inserting the following: ‘‘, unless

8 the survey shows that the facility is in compli9 ance with the requirements of subsections (b),

10 (c), and (d) of this section;’’.

11 (B) EFFECTIVE DATE.—The amendment

12 made by subparagraph (A) shall take effect as

13 if included in the enactment of OBRA–1990.

14 (2) REQUIREMENTS FOR CONSULTANTS CON15 DUCTING REVIEWS ON USE OF DRUGS.—

16 (A) IN GENERAL.—Section 1819(c)(1)(D)

17 (42 U.S.C. 1395i–3(c)(1)(D)) is amended by

18 adding at the end the following sentence: ‘‘In

19 determining whether such a consultant is quali20 fied to conduct reviews under the preceding sen21 tence, the Secretary shall take into account the

22 needs of nursing facilities under this title to

23 have access to the services of such a consultant

24 on a timely basis.’’.
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1 (B) EFFECTIVE DATE.—The amendment

2 made by subparagraph (A) shall take effect as

3 if included in the enactment of OBRA–1987.

4 (3) INCREASE IN MINIMUM AMOUNT REQUIRED

5 FOR SEPARATE DEPOSIT OF PERSONAL FUNDS.—

6 (A) IN GENERAL.—Section

7 1819(c)(6)(B)(i) (42 U.S.C. 1395i–

8 3(c)(6)(B)(i)) is amended by striking ‘‘$50’’

9 and inserting ‘‘$100’’.

10 (B) EFFECTIVE DATE.—The amendment

11 made by subparagraph (A) shall take effect

12 January 1, 1994.

13 (4) DUE PROCESS PROTECTIONS FOR NURSE

14 AIDES.—

15 (A) PROHIBITING STATE FROM INCLUDING

16 UNDOCUMENTED ALLEGATIONS IN NURSES

17 AIDE REGISTRY.—Section 1819(e)(2)(B) (42

18 U.S.C. 1395i–3(e)(2)(B)) is amended by strik19 ing the period at the end of the first sentence

20 and inserting the following: ‘‘, but shall not in21 clude any allegations of resident abuse or ne22 glect or misappropriation of resident property

23 that are not specifically documented by the

24 State under such subsection.’’.
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1 (B) DUE PROCESS REQUIREMENTS FOR

2 REBUTTING ALLEGATIONS.—Section

3 1819(g)(1)(C) (42 U.S.C. 1395i–3(g)(1)(C)) is

4 amended by striking the second sentence and

5 inserting the following: ‘‘The State shall, after

6 providing the individual involved with a written

7 notice of the allegations (including a statement

8 of the availability of a hearing for the individual

9 to rebut the allegations) and the opportunity

10 for a hearing on the record, make a written

11 finding as to the accuracy of the allegations.’’.

12 (C) EFFECTIVE DATE.—The amendments

13 made by this paragraph shall take effect Janu14 ary 1, 1994.

15 (d) CORRECTIONS RELATING TO SECTION 4008.—

16 (1) Section 1819(b)(5)(D) (42 U.S.C. 1395i–

17 3(b)(5)(D)), as amended by section 4008(h)(1)(D)

18 of OBRA–1990, is amended by striking the comma

19 before ‘‘or a new competency evaluation program.’’.

20 (2) Section 1819(b)(5)(G) (42 U.S.C. 1395i–

21 3(b)(5)(G)) is amended by striking ‘‘or licensed or

22 certified social worker’’ and inserting ‘‘licensed or

23 certified social worker, registered respiratory thera24 pist, or certified respiratory therapy technician’’.
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1 (3) Section 1819(f)(2)(B)(i) (42 U.S.C. 1395i–

2 3(f)(2)(B)(i)) is amended by striking ‘‘facilities,’’

3 and inserting ‘‘facilities (subject to clause (iii)),’’.

4 (4) Section 1819(f)(2)(B)(iii)(I)(c) (42 U.S.C.

5 1395i–3(f)(2)(B)(iii)(I)(c)) is amended by striking

6 ‘‘clauses’’ each place it appears and inserting

7 ‘‘clause’’.

8 (5) Section 1819(g)(5)(B) (42 U.S.C. 1395i–

9 3(g)(5)(B)) is amended by striking ‘‘paragraphs’’

10 and inserting ‘‘paragraph’’.

11 (6) Section 4008(h)(1)(F)(ii) of OBRA–1990 is

12 amended—

13 (A) by striking ‘‘The amendments’’ and in14 serting ‘‘(I) The amendments’’;

15 (B) by striking ‘‘nursing facility’’ each

16 place it appears and inserting ‘‘skilled nursing

17 facility’’;

18 (C) by redesignating subclauses (I)

19 through (V) as items (aa) through (ee); and

20 (D) by adding at the end the following new

21 subclause:

22 ‘‘(II) Notwithstanding subclause (I)

23 and subject to section 1819(f)(2)(B)(iii)(I)

24 of the Social Security Act (as amended by

25 clause (i)), a State may approve a training
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1 and competency evaluation program or a

2 competency evaluation program offered by

3 or in a skilled nursing facility described in

4 subclause (I) if, during the previous 2

5 years, item (aa), (bb), (cc), (dd), or (ee) of

6 subclause (I) did not apply to the facil7 ity.’’.

8 (7) EFFECTIVE DATE.—The amendments made

9 by this subsection shall take effect as if included in

10 the enactment of OBRA–1990.

11 SEC. 107. NOTIFICATION OF AVAILABILITY OF HOSPICE

12 BENEFIT.

13 (a) IN GENERAL.—Section 1861(ee)(2)(D) (42

14 U.S.C. 1395x(ee)(2)(D)) is amended by inserting ‘‘, in15 cluding hospice services,’’ after ‘‘post-hospital services’’.

16 (b) EFFECTIVE DATE.—The amendment made by

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

18 the first day of the first month beginning more than one

19 year after the date of the enactment of this Act.

20 SEC. 108. CLARIFYING EXPERTISE OF INDIVIDUALS TO

21 SERVE ON THE PROSPECTIVE PAYMENT AS22 SESSMENT COMMISSION.

23 Section 1886(e)(6)(B) (42 U.S.C. 1395ww(e)(6)(B))

24 is amended by striking ‘‘hospital reimbursement, hospital

25 financial management’’ and inserting ‘‘health facility man-
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1 agement, reimbursement of health facilities or other pro2 viders of services which reflect the scope of the Commis3 sion’s responsibilities’’.

4 SEC. 109. AUTHORITY FOR BUDGET NEUTRAL ADJUST5 MENTS FOR CHANGES IN PAYMENT AMOUNTS

6 FOR TRANSFER CASES.

7 Section 1886(d)(5)(I) (42 U.S.C. 1395ww(d)(5)) is

8 amended—

9 (1) by inserting ‘‘(i)’’ after ‘‘(I)’’; and

10 (2) by adding at the end the following new

11 clause:

12 ‘‘(ii) In making adjustments under clause (i) for

13 transfer cases (as defined by the Secretary) in a fiscal

14 year, the Secretary may make adjustments to each of the

15 average standardized amounts determined under para16 graph (3) to assure that the aggregate payments made

17 under this subsection for such fiscal year are not greater

18 or lesser than those that would have otherwise been made

19 in such fiscal year.’’.

20 SEC. 110. CLARIFICATION OF DRG PAYMENT WINDOW EX21 PANSION; MISCELLANEOUS AND TECHNICAL

22 CORRECTIONS.

23 (a) CLARIFICATION OF DRG PAYMENT WINDOW EX24 PANSION.—The first sentence of section 1886(a)(4) (42

25 U.S.C. 1395ww(a)(4)) is amended by inserting ‘‘(or, in the
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1 case of a hospital that is not a subsection (d) hospital,

2 during the 1 day)’’ after ‘‘3 days’’.

3 (b) TECHNICAL CORRECTION RELATING TO RESI4 DENT ASSESSMENT IN NURSING HOMES.—Section

5 1819(b)(3)(C)(i)(I) (42 U.S.C. 1395i–3(b)(3)(C)(i)(I)) is

6 amended by striking ‘‘not later than’’ before ‘‘14 days’’.

7 (c) TECHNICAL CORRECTION RELATING TO APPLICA8 BLE ADJUSTMENT FACTOR FOR INDIRECT MEDICAL

9 EDUCATION ADJUSTMENT.—Section 1886(d)(5)(B)(ii)

10 (42 U.S.C. 1395ww(d)(5)(B)(ii)) is amended by striking

11 ‘‘May 1, 1986,’’ and inserting ‘‘October 1, 1988,’’.

12 (d) CLERICAL CORRECTIONS.—(1) Section

13 1814(i)(1)(C)(i) (42 U.S.C. 1395f(i)(1)(C)(i)) is amended

14 by striking ‘‘1990’’ and inserting ‘‘1990,’’.

15 (2) Section 1816(f)(2)(A)(ii) (42 U.S.C.

16 1396h(f)(2)(A)(ii)) is amended by striking ‘‘such agency’’

17 and inserting ‘‘such agency’s’’.

18 Subtitle B—Provisions Relating to

19 Part B

20 PART I—PHYSICIANS’ SERVICES

21 SEC. 121. DEVELOPMENT AND IMPLEMENTATION OF RE22 SOURCE-BASED METHODOLOGY FOR PRAC23 TICE EXPENSES.

24 (a) DEVELOPMENT.—
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1 (1) IN GENERAL.—The Secretary of Health and

2 Human Services shall develop a methodology for im3 plementing in 1997 a resource-based system for de4 termining practice expense relative value units for

5 each physicians’ service. The methodology utilized

6 shall recognize the staff, equipment, and supplies

7 used in the provision of various medical and surgical

8 services in various settings.

9 (2) REPORT.—The Secretary shall transmit a

10 report by June 30, 1995, on the methodology devel11 oped under paragraph (1) to the Committees on

12 Ways and Means and Energy and Commerce of the

13 House of Representatives and the Committee on Fi14 nance of the Senate. The report shall include a pres15 entation of data utilized in developing the methodol16 ogy and an explanation of the methodology.

17 (b) IMPLEMENTATION.—

18 (1) IN GENERAL.—Section 1848(c)(2)(C)(ii)

19 (42 U.S.C. 1395w–4(c)(2)(C)(ii)) is amended—

20 (A) by inserting ‘‘for the service for years

21 before 1997’’ before ‘‘equal to’’,

22 (B) by striking the period at the end of

23 subclause (II) and inserting a comma, and

24 (C) by adding after and below subclause

25 (II) the following:
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1 ‘‘and for years beginning with 1997 based

2 on the relative practice expense resources

3 involved in furnishing the service.’’.

4 (2) CONFORMING AMENDMENT.—Section

5 1848(c)(3)(C)(ii) (42 U.S.C. 1395w–4(c)(3)(C)(ii))

6 is amended by striking ‘‘The practice’’ and inserting

7 ‘‘For years before 1997, the practice’’.

8 (3) APPLICATION OF CERTAIN PROVISIONS.—In

9 implementing the amendment made by paragraph

10 (1)(C), the provisions of clauses (ii)(II) and (iii) of

11 section 1848(c)(2)(B) of the Social Security Act

12 shall apply in the same manner as they apply to ad13 justments under clause (ii)(I) of such section.

14 SEC. 122. GEOGRAPHIC COST OF PRACTICE INDEX REFINE15 MENTS.

16 (a) REQUIRING CONSULTATION WITH REPRESENTA17 TIVES OF PHYSICIANS IN REVIEWING GEOGRAPHIC AD18 JUSTMENT FACTORS.—Section 1848(e)(1)(C) (42 U.S.C.

19 1395w–4(e)(1)(C)) is amended by striking ‘‘shall review’’

20 and inserting ‘‘shall, in consultation with appropriate rep21 resentatives of physicians, review’’.

22 (b) USE OF MOST RECENT DATA IN GEOGRAPHIC

23 ADJUSTMENT.—Section 1848(e)(1) (42 U.S.C. 1395w–

24 4(e)(1)) is amended by adding at the end the following

25 new subparagraph:
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1 ‘‘(D) USE OF RECENT DATA.—In estab2 lishing indices and index values under this

3 paragraph, the Secretary shall use the most re4 cent data available relating to practice ex5 penses, malpractice expenses, and physician

6 work effort in different fee schedule areas.’’.

7 (c) DEADLINE FOR INITIAL REVIEW AND REVI8 SION.—The Secretary of Health and Human Services

9 shall first review and revise geographic adjustment factors

10 under section 1848(e)(1)(C) of the Social Security Act by

11 not later than January 1, 1995. Not later than April 1,

12 1994, the Secretary shall study and report to the Commit13 tee on Finance of the Senate and the Committee on Ways

14 and Means and the Committee on Energy and Commerce

15 of the House of Representatives on the construction of the

16 geographic cost of practice index under section

17 1848(e)(1)(A)(i) of such Act.

18 (d) REPORT ON REVIEW PROCESS.—Not later than

19 1 year after the date of the enactment of this Act, the

20 Secretary of Health and Human Services shall study and

21 report to the Committee on Finance of the Senate and

22 the Committee on Ways and Means and the Committee

23 on Energy and Commerce of the House of Representatives

24 on—
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1 (1) the data necessary to review and revise the

2 indices established under section 1848(e)(1)(A) of

3 the Social Security Act, including—

4 (A) the shares allocated to physicians’

5 work effort, practice expenses (other than mal6 practice expenses), and malpractice expenses;

7 (B) the weights assigned to the input com8 ponents of such shares; and

9 (C) the index values assigned to such com10 ponents;

11 (2) any limitations on the availability of data

12 necessary to review and revise such indices at least

13 every three years;

14 (3) ways of addressing such limitations, with

15 particular attention to the development of alternative

16 data sources for input components for which current

17 index values are based on data collected less fre18 quently than every three years; and

19 (4) the costs of developing more accurate and

20 timely data.

21 SEC. 123. EXTRA-BILLING LIMITS.

22 (a) ENFORCEMENT OF LIMITS.—Section 1848(g) (42

23 U.S.C. 1395w–4(g)), as amended by section 13517(a) of

24 OBRA–1993, is amended—
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1 (1) by amending paragraph (1) to read as fol2 lows:

3 ‘‘(1) LIMITATION ON ACTUAL CHARGES.—

4 ‘‘(A) IN GENERAL.—In the case of a

5 nonparticipating physician or nonparticipating

6 supplier or other person (as defined in section

7 1842(i)(2)) who does not accept payment on an

8 assignment-related basis for a physician’s serv9 ice furnished with respect to an individual en10 rolled under this part, the following rules apply:

11 ‘‘(i) APPLICATION OF LIMITING

12 CHARGE.—No person may bill or collect an

13 actual charge for the service in excess of

14 the limiting charge described in paragraph

15 (2) for such service.

16 ‘‘(ii) NO LIABILITY FOR EXCESS

17 CHARGES.—No person is liable for pay18 ment of any amounts billed for the service

19 in excess of such limiting charge.

20 ‘‘(iii) CORRECTION OF EXCESS

21 CHARGES.—If such a physician, supplier,

22 or other person bills, but does not collect,

23 an actual charge for a service in violation

24 of clause (i), the physician, supplier, or

25 other person shall reduce on a timely basis
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1 the actual charge billed for the service to

2 an amount not to exceed the limiting

3 charge for the service.

4 ‘‘(iv) REFUND OF EXCESS COLLEC5 TIONS.—If such a physician, supplier, or

6 other person collects an actual charge for

7 a service in violation of clause (i), the phy8 sician, supplier, or other person shall pro9 vide on a timely basis a refund to the indi10 vidual charged in the amount by which the

11 amount collected exceeded the limiting

12 charge for the service. The amount of such

13 a refund shall be reduced to the extent the

14 individual has an outstanding balance owed

15 by the individual to the physician.

16 ‘‘(B) SANCTIONS.—If a physician, supplier,

17 or other person—

18 ‘‘(i) knowingly and willfully bills or

19 collects for services in violation of subpara20 graph (A)(i) on a repeated basis, or

21 ‘‘(ii) fails to comply with clause (iii)

22 or (iv) of subparagraph (A) on a timely

23 basis,

24 the Secretary may apply sanctions against the

25 physician, supplier, or other person in accord-
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1 ance with paragraph (2) of section 1842(j). In

2 applying this subparagraph, paragraph (4) of

3 such section applies in the same manner as

4 such paragraph applies to such section and any

5 reference in such section to a physician is

6 deemed also to include a reference to a supplier

7 or other person under this subparagraph.

8 ‘‘(C) TIMELY BASIS.—For purposes of this

9 paragraph, a correction of a bill for an excess

10 charge or refund of an amount with respect to

11 a violation of subparagraph (A)(i) in the case of

12 a service is considered to be provided ‘on a

13 timely basis’, if the reduction or refund is made

14 not later than 30 days after the date the physi15 cian, supplier, or other person is notified by the

16 carrier under this part of such violation and of

17 the requirements of subparagraph (A).’’; and

18 (2) in paragraph (3)(B)—

19 (A) by inserting after the first sentence the

20 following: ‘‘No person is liable for payment of

21 any amounts billed for such a service in viola22 tion of the previous sentence.’’, and

23 (B) in the last sentence, by striking ‘‘pre24 vious sentence’’ and inserting ‘‘first sentence’’.
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1 (b) CLARIFICATION OF MANDATORY ASSIGNMENT

2 RULES FOR CERTAIN PRACTITIONERS.—

3 (1) IN GENERAL.—Section 1842(b) (42 U.S.C.

4 1395u(b)), as amended by section 126(e), is amend5 ed by adding at the end the following new para6 graph:

7 ‘‘(18)(A) Payment for any service furnished by a

8 practitioner described in subparagraph (C) and for which

9 payment may be made under this part on a reasonable

10 charge or fee schedule basis may only be made under this

11 part on an assignment-related basis.

12 ‘‘(B) A practitioner described in subparagraph (C) or

13 other person may not bill (or collect any amount from)

14 the individual or another person for any service described

15 in subparagraph (A), except for deductible and coinsur16 ance amounts applicable under this part. No person is lia17 ble for payment of any amounts billed for such a service

18 in violation of the previous sentence. If a practitioner or

19 other person knowingly and willfully bills (or collects an

20 amount) for such a service in violation of such sentence,

21 the Secretary may apply sanctions against the practitioner

22 or other person in the same manner as the Secretary may

23 apply sanctions against a physician in accordance with

24 subsection (j)(2) in the same manner as such section ap25 plies with respect to a physician. Paragraph (4) of sub-
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1 section (j) shall apply in this subparagraph in the same

2 manner as such paragraph applies to such section.

3 ‘‘(C) A practitioner described in this subparagraph

4 is any of the following:

5 ‘‘(i) A physician assistant, nurse practitioner, or

6 clinical nurse specialist (as defined in section

7 1861(aa)(5)).

8 ‘‘(ii) A certified registered nurse anesthetist (as

9 defined in section 1861(bb)(2)).

10 ‘‘(iii) A certified nurse-midwife (as defined in

11 section 1861(gg)(2)).

12 ‘‘(iv) A clinical social worker (as defined in sec13 tion 1861(hh)(1)).

14 ‘‘(v) A clinical psychologist (as defined by the

15 Secretary for purposes of section 1861(ii)).

16 ‘‘(D) For purposes of this paragraph, a service fur17 nished by a practitioner described in subparagraph (C) in18 cludes any services and supplies furnished as incident to

19 the service as would otherwise be covered under this part

20 if furnished by a physician or as incident to a physician’s

21 service.’’.

22 (2) CONFORMING AMENDMENTS.—

23 (A) Section 1833 (42 U.S.C. 1395l) is

24 amended—
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1 (i) in subsection (l)(5), by striking

2 subparagraph (B) and redesignating sub3 paragraph (C) as subparagraph (B);

4 (ii) by striking subsection (p); and

5 (iii) in subsection (r), by striking

6 paragraph (3) and redesignating para7 graph (4) as paragraph (3).

8 (B) Section 1842(b)(12) (42 U.S.C.

9 1395u(b)(12)) is amended by striking subpara10 graph (C).

11 (c) INFORMATION ON EXTRA-BILLING LIMITS.—

12 (1) PART OF EXPLANATION OF MEDICARE BEN13 EFITS.—Section 1842(h)(7) (42 U.S.C.

14 1395u(h)(7)) is amended—

15 (A) by striking ‘‘and’’ at the end of sub16 paragraph (B),

17 (B) in subparagraph (C), by striking ‘‘shall

18 include’’,

19 (C) in subparagraph (C), by striking the

20 period at the end and inserting ‘‘, and’’, and

21 (D) by adding at the end the following new

22 subparagraph:

23 ‘‘(D) in the case of services for which the billed

24 amount exceeds the limiting charge imposed under

25 section 1848(g), information regarding such applica-
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1 ble limiting charge (including information concern2 ing the right to a refund under section

3 1848(g)(1)(A)(iv)).’’.

4 (2) DETERMINATIONS BY CARRIERS.—Subpara5 graph (G) of section 1842(b)(3) (42 U.S.C.

6 1395u(b)(3)) is amended to read as follows:

7 ‘‘(G) will, for a service that is furnished with

8 respect to an individual enrolled under this part,

9 that is not paid on an assignment-related basis, and

10 that is subject to a limiting charge under section

11 1848(g)—

12 ‘‘(i) determine, prior to making payment,

13 whether the amount billed for such service ex14 ceeds the limiting charge applicable under sec15 tion 1848(g)(2);

16 ‘‘(ii) notify the physician, supplier, or other

17 person periodically (but not less often than once

18 every 30 days) of determinations that amounts

19 billed exceeded such applicable limiting charges;

20 and

21 ‘‘(iii) provide for prompt response to in22 quiries of physicians, suppliers, and other per23 sons concerning the accuracy of such limiting

24 charges for their services;’’.
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1 (d) REPORT ON CHARGES IN EXCESS OF LIMITING

2 CHARGE.—Section 1848(g)(6)(B) (42 U.S.C. 1395w–

3 4(g)(6)(B)) is amended by inserting ‘‘information on the

4 extent to which actual charges exceed limiting charges, the

5 number and types of services involved, and the average

6 amount of excess charges and information’’ after ‘‘report

7 to the Congress’’.

8 (e) MISCELLANEOUS AND TECHNICAL AMEND9 MENTS.—Section 1833(h)(5)(D) (42 U.S.C.

10 1395l(h)(5)(D)) is amended—

11 (1) by striking ‘‘paragraphs (2) and (3)’’ and

12 by inserting ‘‘paragraph (2)’’; and

13 (2) by adding at the end the following: ‘‘Para14 graph (4) of such section shall apply in this sub15 paragraph in the same manner as such paragraph

16 applies to such section.’’.

17 (f) EFFECTIVE DATES.—

18 (1) ENFORCEMENT; MISCELLANEOUS AND

19 TECHNICAL AMENDMENTS.—The amendments made

20 by subsections (a) and (e) shall apply to services fur21 nished on or after the date of the enactment of this

22 Act; except that the amendments made by sub23 section (a) shall not apply to services of a

24 nonparticipating supplier or other person furnished

25 before January 1, 1994.
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1 (2) PRACTITIONERS.—The amendments made

2 by subsection (b) shall apply to services furnished on

3 or after January 1, 1994.

4 (3) EOMBS.—The amendments made by sub5 section (c)(1) shall apply to explanations of benefits

6 provided on or after July 1, 1994.

7 (4) CARRIER DETERMINATIONS.—The amend8 ments made by subsection (c)(2) shall apply to con9 tracts as of January 1, 1994.

10 (5) REPORT.—The amendment made by sub11 section (d) shall apply to reports for years beginning

12 with 1994.

13 SEC. 124. RELATIVE VALUES FOR PEDIATRIC SERVICES.

14 (a) IN GENERAL.—The Secretary of Health and

15 Human Services shall fully develop, by not later than Oc16 tober 1, 1994, relative values for the full range of pediatric

17 physicians’ services which are consistent with the relative

18 values developed for other physicians’ services under sec19 tion 1848(c) of the Social Security Act. In developing such

20 values, the Secretary shall conduct such refinements as

21 may be necessary to produce appropriate estimates for

22 such relative values.

23 (b) STUDY.—

24 (1) IN GENERAL.—The Secretary shall conduct

25 a study of the relative values for pediatric and other
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1 services to determine whether there are significant

2 variations in the resources used in providing similar

3 services to different populations. In conducting such

4 study, the Secretary shall consult with appropriate

5 organizations representing pediatricians and other

6 physicians and physical and occupational therapists.

7 (2) REPORT.—Not later than July 1, 1995, the

8 Secretary shall submit to Congress a report on the

9 study conducted under paragraph (1). Such report

10 shall include any appropriate recommendations re11 garding needed changes in coding or other payment

12 policies to ensure that payments for pediatric serv13 ices appropriately reflect the resources required to

14 provide these services.

15 SEC. 125. ADMINISTRATION OF CLAIMS RELATING TO PHY16 SICIANS’ SERVICES.

17 (a) LIMITATION ON CARRIER USER FEES.—Section

18 1842(c) (42 U.S.C. 1395u(c)) is amended by adding at

19 the end the following new paragraph:

20 ‘‘(4) Neither a carrier nor the Secretary may impose

21 a fee under this title—

22 ‘‘(A) for the filing of claims related to physi23 cians’ services,
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1 ‘‘(B) for an error in filing a claim relating to

2 physicians’ services or for such a claim which is de3 nied,

4 ‘‘(C) for any appeal under this title with respect

5 to physicians’ services,

6 ‘‘(D) for applying for (or obtaining) a unique

7 identifier under subsection (r), or

8 ‘‘(E) for responding to inquiries respecting phy9 sicians’ services or for providing information with re10 spect to medical review of such services.’’.

11 (b) CLARIFICATION OF PERMISSIBLE SUBSTITUTE

12 BILLING ARRANGEMENTS.—

13 (1) IN GENERAL.—Clause (D) of section

14 1842(b)(6) (42 U.S.C. 1395u(b)(6)) is amended to

15 read as follows: ‘‘(D) payment may be made to a

16 physician for physicians’ services (and services fur17 nished incident to such services) furnished by a sec18 ond physician to patients of the first physician if (i)

19 the first physician is unavailable to provide the serv20 ices; (ii) the services are furnished pursuant to an

21 arrangement between the two physicians that (I) is

22 informal and reciprocal, or (II) involves per diem or

23 other fee-for-time compensation for such services;

24 (iii) the services are not provided by the second phy25 sician over a continuous period of more than 60
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1 days; and (iv) the claim form submitted to the car2 rier for such services includes the second physician’s

3 unique identifier (provided under the system estab4 lished under subsection (r)) and indicates that the

5 claim meets the requirements of this subparagraph

6 for payment to the first physician’’.

7 (2) EFFECTIVE DATE.—The amendment made

8 by paragraph (1) shall apply to services furnished on

9 or after the first day of the first month beginning

10 more than 60 days after the date of the enactment

11 of this Act.

12 SEC. 126. MISCELLANEOUS AND TECHNICAL CORRECTIONS.

13 (a) OVERVALUED PROCEDURES.—(1) Section

14 1842(b)(16)(B)(iii) (42 U.S.C. 1395u(b)(16)(B)(iii)) is

15 amended—

16 (A) by striking ‘‘, simple and subcutaneous’’,

17 (B) by striking ‘‘; small’’ and inserting ‘‘and

18 small’’,

19 (C) by striking ‘‘treatments;’’ the first place it

20 appears and inserting ‘‘and’’,

21 (D) by striking ‘‘lobectomy;’’,

22 (E) by striking ‘‘enterectomy; colectomy; chole23 cystectomy;’’,

24 (F) by striking ‘‘; transurerethral resection’’

25 and inserting ‘‘and resection’’, and
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1 (G) by striking ‘‘sacral laminectomy;’’.

2 (2) Section 4101(b)(2) of OBRA–1990 is amended—

3 (A) in the matter before subparagraph (A), by

4 striking ‘‘1842(b)(16)’’ and inserting

5 ‘‘1842(b)(16)(B)’’, and

6 (B) in subparagraph (B)—

7 (i) by striking ‘‘, simple and subcutane8 ous’’,

9 (ii) by striking ‘‘(HCPCS codes 19160 and

10 19162)’’ and inserting ‘‘(HCPCS code 19160)’’,

11 and

12 (iii) by striking all that follows ‘‘(HCPCS

13 codes 92250’’ and inserting ‘‘and 92260).’’.

14 (b) RADIOLOGY SERVICES.—(1) Section 1834(b)(4)

15 (42 U.S.C. 1395m(b)(4)) is amended by redesignating the

16 subparagraphs (E) and (F) redesignated by section

17 4102(a)(1) of OBRA–1990 as subparagraphs (F) and

18 (G), respectively.

19 (2) Section 1834(b)(4)(D) (42 U.S.C.

20 1395m(b)(4)(D)) is amended—

21 (A) in the matter before clause (i), by striking

22 ‘‘shall be determined as follows:’’ and inserting

23 ‘‘shall, subject to clause (vii), be reduced to the ad24 justed conversion factor for the locality determined

25 as follows:’’,
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1 (B) in clause (iv), by striking ‘‘LOCAL ADJUST2 MENT.—Subject to clause (vii), the conversion factor

3 to be applied to’’ and inserting ‘‘ADJUSTED CONVER4 SION FACTOR.—The adjusted conversion factor for’’,

5 (C) in clause (vii), by striking ‘‘under this sub6 paragraph’’, and

7 (D) in clause (vii), by inserting ‘‘reduced under

8 this subparagraph by’’ after ‘‘shall not be’’.

9 (3) Section 4102(c)(2) of OBRA–1990 is amended

10 by striking ‘‘radiology services’’ and all that follows and

11 inserting ‘‘nuclear medicine services.’’.

12 (4) Section 4102(d) of OBRA–1990 is amended by

13 striking ‘‘new paragraph’’ and inserting ‘‘new subpara14 graph’’.

15 (5) Section 1834(b)(4)(E) (42 U.S.C.

16 1395m(b)(4)(E)) is amended by inserting ‘‘RULE FOR

17 CERTAIN SCANNING SERVICES.—’’ after ‘‘(E)’’.

18 (6) Section 1848(a)(2)(D)(iii) (42 U.S.C. 1395w–

19 4(a)(2)(D)(iii)) is amended by striking ‘‘that are subject

20 to section 6105(b) of the Omnibus Budget Reconciliation

21 Act of 1989’’ and by striking ‘‘provided under such sec22 tion’’ and inserting ‘‘provided under section 6105(b) of the

23 Omnibus Budget Reconciliation Act of 1989’’.

24 (c) ANESTHESIA SERVICES.—(1) Section 4103(a) of

25 OBRA–1990 is amended by striking ‘‘REDUCTION IN FEE
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1 SCHEDULE’’ and inserting ‘‘REDUCTION IN PREVAILING

2 CHARGES’’.

3 (2) Section 1842(q)(1)(B) (42 U.S.C.

4 1395u(q)(1)(B)) is amended—

5 (A) in the matter before clause (i), by striking

6 ‘‘shall be determined as follows:’’ and inserting

7 ‘‘shall, subject to clause (iv), be reduced to the ad8 justed prevailing charge conversion factor for the lo9 cality determined as follows:’’, and

10 (B) in clause (iii), by striking ‘‘Subject to

11 clause (iv), the prevailing charge conversion factor to

12 be applied in’’ and inserting ‘‘The adjusted prevail13 ing charge conversion factor for’’.

14 (d) ASSISTANTS AT SURGERY.—(1) Section 4107(c)

15 of OBRA–1990 is amended by inserting ‘‘(a)(1)’’ after

16 ‘‘subsection’’.

17 (2) Section 4107(a)(2) of OBRA–1990 is amended

18 by adding at the end the following: ‘‘In applying section

19 1848(g)(2)(D) of the Social Security Act for services of

20 an assistant-at-surgery furnished during 1991, the recog21 nized payment amount shall not exceed the maximum

22 amount specified under section 1848(i)(2)(A) of such Act

23 (as applied under this paragraph in such year).’’.

24 (e) TECHNICAL COMPONENTS OF DIAGNOSTIC SERV25 ICES.—Section 1842(b) (42 U.S.C. 1395u(b)) is amended
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1 by redesignating paragraph (18), as added by section

2 4108(a) of OBRA–1990, as paragraph (17) and, in such

3 paragraph, by inserting ‘‘, tests specified in paragraph

4 (14)(C)(i),’’ after ‘‘diagnostic laboratory tests’’.

5 (f) STATEWIDE FEE SCHEDULES.—Section 4117 of

6 OBRA–1990 is amended—

7 (1) in subsection (a)—

8 (A) by striking ‘‘(a) IN GENERAL.—’’, and

9 (B) by striking ‘‘, if the’’ and all that fol10 lows through ‘‘1991,’’; and

11 (2) by striking subsections (b), (c), and (d).

12 (g) STUDY OF AGGREGATION RULE FOR CLAIMS OF

13 SIMILAR PHYSICIAN SERVICES.—Section 4113 of OBRA–

14 1990 is amended—

15 (1) by inserting ‘‘of the Social Security Act’’

16 after ‘‘1869(b)(2)’’; and

17 (2) by striking ‘‘December 31, 1992’’ and in18 serting ‘‘December 31, 1993’’.

19 (h) OTHER MISCELLANEOUS AND TECHNICAL

20 AMENDMENTS.—(1) The heading of section 1834(f) (42

21 U.S.C. 1395m(f)) is amended by striking ‘‘FISCAL YEAR’’.

22 (2)(A) Section 4105(b) of OBRA–1990 is amended—

23 (i) in paragraph (2), by striking ‘‘amendments’’

24 and inserting ‘‘amendment’’, and
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1 (ii) in paragraph (3), by striking ‘‘amendments

2 made by paragraphs (1) and (2)’’ and inserting

3 ‘‘amendment made by paragraph (1)’’.

4 (B) Section 1848(f)(2)(C) (42 U.S.C. 1395w–

5 4(f)(2)(C)) is amended by inserting ‘‘PERFORMANCE

6 STANDARD RATES OF INCREASE FOR FISCAL YEAR

7 1991.—’’ after ‘‘(C)’’.

8 (C) Section 4105(d) of OBRA–1990 is amended by

9 inserting ‘‘PUBLICATION OF PERFORMANCE STANDARD

10 RATES.—’’ after ‘‘(d)’’.

11 (3) Section 4106(c) of OBRA–1990 is amended by

12 inserting ‘‘of the Social Security Act’’ after

13 ‘‘1848(d)(1)(B)’’.

14 (4) Section 4114 of OBRA–1990 is amended by

15 striking ‘‘patients’’ the second place it appears.

16 (5) Section 1848(e)(1)(C) (42 U.S.C. 1395w–

17 4(e)(1)(C)) is amended by inserting ‘‘date of the’’ after

18 ‘‘since the’’.

19 (6) Section 4118(f)(1)(D) of OBRA–1990 is amend20 ed by striking ‘‘is amended’’.

21 (7) Section 4118(f)(1)(N)(ii) of OBRA–1990 is

22 amended by striking ‘‘subsection (f)(5)(A)’’ and inserting

23 ‘‘subsection (f)(5)(A))’’.

24 (8) Section 1845(e) (42 U.S.C. 1395w–1(e)) is

25 amended—
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1 (A) by striking paragraph (2); and

2 (B) by redesignating paragraphs (3), (4), and

3 (5) as paragraphs (2), (3), and (4).

4 (9) Section 4118(j)(2) of OBRA–1990 is amended by

5 striking ‘‘In section’’ and inserting ‘‘Section’’.

6 (10)(A) Section 1848(i)(3) (42 U.S.C. 1395w–

7 4(i)(3)) is amended by striking the space before the period

8 at the end.

9 (B) Section 1834(a)(10)(B) (42 U.S.C.

10 1395m(a)(10)(B)) is amended—

11 (i) by striking ‘‘apply to’’ and inserting ‘‘would

12 otherwise apply to’’, and

13 (ii) by inserting before the period at the end

14 ‘‘but for the application of section 1848(i)(3)’’.

15 (i) OTHER CORRECTIONS.—(1) Effective on the date

16 of the enactment of this Act, section 6102(d)(4) of

17 OBRA–1989 is amended by striking all that follows the

18 first sentence.

19 (2) Effective for payments for fiscal years beginning

20 with fiscal year 1994, section 1842(c)(1) (42 U.S.C.

21 1395u(c)(1)) is amended—

22 (A) in subparagraph (A), by striking ‘‘(A) Any

23 contract’’ and inserting ‘‘Any contract’’; and

24 (B) by striking subparagraph (B).
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1 (j) EFFECTIVE DATE.—Except as provided in sub2 section (i), the amendments made by this section and the

3 provisions of this section shall take effect as if included

4 in the enactment of OBRA–1990.

5 PART II—DURABLE MEDICAL EQUIPMENT

6 SEC. 131. CERTIFICATION OF SUPPLIERS.

7 (a) REQUIREMENTS.—

8 (1) IN GENERAL.—Section 1834 (42 U.S.C.

9 1395m), as amended by section 13544(b)(1) of

10 OBRA–1993, is amended by adding at the end the

11 following new subsection:

12 ‘‘(j) REQUIREMENTS FOR SUPPLIERS OF MEDICAL

13 EQUIPMENT AND SUPPLIES.—

14 ‘‘(1) ISSUANCE AND RENEWAL OF SUPPLIER

15 NUMBER.—

16 ‘‘(A) PAYMENT.—Except as provided in

17 subparagraph (C), no payment may be made

18 under this part after May 1, 1994, for items

19 furnished by a supplier of medical equipment

20 and supplies unless such supplier obtains (and

21 renews at such intervals as the Secretary may

22 require) a supplier number.

23 ‘‘(B) STANDARDS FOR POSSESSING A SUP24 PLIER NUMBER.—A supplier may not obtain a

25 supplier number unless—
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1 ‘‘(i) for medical equipment and sup2 plies furnished on or after May 1, 1994,

3 and before January 1, 1996, the supplier

4 meets standards prescribed by the Sec5 retary in regulations issued on June 18,

6 1992; and

7 ‘‘(ii) for medical equipment and sup8 plies furnished on or after January 1,

9 1996, the supplier meets revised standards

10 prescribed by the Secretary (in consulta11 tion with representatives of suppliers of

12 medical equipment and supplies, carriers,

13 and consumers) that shall include require14 ments that the supplier—

15 ‘‘(I) comply with all applicable

16 State and Federal licensure and regu17 latory requirements;

18 ‘‘(II) maintain a physical facility

19 on an appropriate site;

20 ‘‘(III) have proof of appropriate

21 liability insurance; and

22 ‘‘(IV) meet such other require23 ments as the Secretary may specify.

24 ‘‘(C) EXCEPTION FOR ITEMS FURNISHED

25 AS INCIDENT TO A PHYSICIAN’S SERVICE.—
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1 Subparagraph (A) shall not apply with respect

2 to medical equipment and supplies furnished in3 cident to a physician’s service.

4 ‘‘(D) PROHIBITION AGAINST MULTIPLE

5 SUPPLIER NUMBERS.—The Secretary may not

6 issue more than one supplier number to any

7 supplier of medical equipment and supplies un8 less the issuance of more than one number is

9 appropriate to identify subsidiary or regional

10 entities under the supplier’s ownership or con11 trol.

12 ‘‘(E) PROHIBITION AGAINST DELEGATION

13 OF SUPPLIER DETERMINATIONS.—The Sec14 retary may not delegate (other than by contract

15 under section 1842) the responsibility to deter16 mine whether suppliers meet the standards nec17 essary to obtain a supplier number.

18 ‘‘(2) CERTIFICATES OF MEDICAL NECESSITY.—

19 ‘‘(A) STANDARDIZED CERTIFICATES.—Not

20 later than October 1, 1994, the Secretary shall,

21 in consultation with carriers under this part,

22 develop one or more standardized certificates of

23 medical necessity (as defined in subparagraph

24 (C)) for medical equipment and supplies for
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1 which the Secretary determines that such a cer2 tificate is necessary.

3 ‘‘(B) LIMITATION ON INFORMATION PRO4 VIDED BY SUPPLIERS ON CERTIFICATES OF

5 MEDICAL NECESSITY.—

6 ‘‘(i) IN GENERAL.—Effective May 1,

7 1994, a supplier of medical equipment and

8 supplies may distribute to physicians, or to

9 individuals entitled to benefits under this

10 part, a certificate of medical necessity for

11 commercial purposes which contains no

12 more than the following information com13 pleted by the supplier:

14 ‘‘(I) An identification of the sup15 plier and the beneficiary to whom

16 such medical equipment and supplies

17 are furnished.

18 ‘‘(II) A description of such medi19 cal equipment and supplies.

20 ‘‘(III) Any product code identify21 ing such medical equipment and sup22 plies.

23 ‘‘(IV) Any other administrative

24 information (other than information
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1 relating to the beneficiary’s medical

2 condition) identified by the Secretary.

3 ‘‘(ii) INFORMATION ON PAYMENT

4 AMOUNT AND CHARGES.—If a supplier dis5 tributes a certificate of medical necessity

6 containing any of the information per7 mitted to be supplied under clause (i), the

8 supplier shall also list on the certificate of

9 medical necessity the fee schedule amount

10 and the supplier’s charge for the medical

11 equipment or supplies being furnished

12 prior to distribution of such certificate to

13 the physician.

14 ‘‘(iii) PENALTY.—Any supplier of

15 medical equipment and supplies who know16 ingly and willfully distributes a certificate

17 of medical necessity in violation of clause

18 (i) or fails to provide the information re19 quired under clause (ii) is subject to a civil

20 money penalty in an amount not to exceed

21 $1,000 for each such certificate of medical

22 necessity so distributed. The provisions of

23 section 1128A (other than subsections (a)

24 and (b)) shall apply to civil money pen25 alties under this subparagraph in the same
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1 manner as they apply to a penalty or pro2 ceeding under section 1128A(a).

3 ‘‘(C) DEFINITION.—For purposes of this

4 paragraph, the term ‘certificate of medical ne5 cessity’ means a form or other document con6 taining information required by the carrier to

7 be submitted to show that an item is reasonable

8 and necessary for the diagnosis or treatment of

9 illness or injury or to improve the functioning

10 of a malformed body member.

11 ‘‘(3) COVERAGE AND REVIEW CRITERIA.—

12 ‘‘(A) DEVELOPMENT AND ESTABLISH13 MENT.—Not later than January 1, 1996, the

14 Secretary, in consultation with representatives

15 of suppliers of medical equipment and supplies,

16 individuals enrolled under this part, and appro17 priate medical specialty societies, shall develop

18 and establish coverage and utilization review

19 criteria for 100 items of medical equipment and

20 supplies selected in accordance with the stand21 ards described in subparagraph (B). The Sec22 retary shall publish the criteria as part of the

23 instructions available to suppliers under this

24 part and no further publication, including publi-
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1 cation in the Federal Register, shall be re2 quired.

3 ‘‘(B) STANDARDS FOR SELECTING ITEMS

4 SUBJECT TO CRITERIA.—The Secretary may se5 lect an item for coverage under the criteria de6 veloped and established under subparagraph

7 (A) if the Secretary finds that—

8 ‘‘(i) the item is frequently purchased

9 or rented by beneficiaries;

10 ‘‘(ii) the item is frequently subject to

11 a determination that such item is not

12 medically necessary; or

13 ‘‘(iii) a wide variation in the coverage

14 or utilization criteria applied to the item

15 exists among carriers (as of the date of the

16 enactment of this subsection).

17 ‘‘(C) ANNUAL REVIEW AND EXPANSION OF

18 ITEMS SUBJECT TO CRITERIA.—The Secretary

19 shall annually review the coverage and utiliza20 tion of items of medical equipment and supplies

21 to determine whether items not included among

22 the items selected under subparagraph (A)

23 should be made subject to coverage and utiliza24 tion review criteria, and, if appropriate, shall
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1 develop and apply such criteria to such addi2 tional items.

3 ‘‘(4) DEFINITION.—The term ‘medical equip4 ment and supplies’ means—

5 ‘‘(A) durable medical equipment (as de6 fined in section 1861(n));

7 ‘‘(B) prosthetic devices (as described in

8 section 1861(s)(8));

9 ‘‘(C) orthotics and prosthetics (as de10 scribed in section 1861(s)(9));

11 ‘‘(D) surgical dressings (as described in

12 section 1861(s)(5));

13 ‘‘(E) such other items as the Secretary

14 may determine; and

15 ‘‘(F) for purposes of paragraphs (1) and

16 (3)—

17 ‘‘(i) home dialysis supplies and equip18 ment (as described in section

19 1861(s)(2)(F)),

20 ‘‘(ii) immunosuppressive drugs (as de21 scribed in section 1861(s)(2)(J)),

22 ‘‘(iii) therapeutic shoes for diabetics

23 (as described in section 1861(s)(12)),
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1 ‘‘(iv) oral drugs prescribed for use as

2 an anticancer therapeutic agent (as de3 scribed in section 1861(s)(2)(Q)), and

4 ‘‘(v) self-administered erythropoetin

5 (as described in section 1861(s)(2)(P)).’’.

6 (2) CONFORMING AMENDMENT.—Effective Oc7 tober 1, 1994, paragraph (16) of section 1834(a)

8 (42 U.S.C. 1395m(a)) is repealed.

9 (b) USE OF COVERED ITEMS BY DISABLED BENE10 FICIARIES.—

11 (1) IN GENERAL.—The Secretary of Health and

12 Human Services, in consultation with representa13 tives of suppliers of durable medical equipment

14 under part B of the medicare program and individ15 uals entitled to benefits under such program on the

16 basis of disability, shall conduct a study of the ef17 fects of the methodology for determining payments

18 for items of such equipment under such part on the

19 ability of such individuals to obtain items of such

20 equipment, including customized items.

21 (2) REPORT.—Not later than one year after the

22 date of the enactment of this Act, the Secretary

23 shall submit a report to Congress on the study con24 ducted under paragraph (1), and shall include in the

25 report such recommendations as the Secretary con-
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1 siders appropriate to assure that disabled medicare

2 beneficiaries have access to items of durable medical

3 equipment.

4 (c) CRITERIA FOR TREATMENT OF ITEMS AS PROS5 THETIC DEVICES OR ORTHOTICS AND PROSTHETICS.—

6 Not later than one year after the date of the enactment

7 of this Act, the Secretary of Health and Human Services

8 shall submit a report to the Committees on Ways and

9 Means and Energy and Commerce of the House of Rep10 resentatives and the Committee on Finance of the Senate

11 describing prosthetic devices or orthotics and prosthetics

12 covered under part B of the medicare program that do

13 not require individualized or custom fitting and adjust14 ment to be used by a patient. Such report shall include

15 recommendations for an appropriate methodology for de16 termining the amount of payment for such items under

17 such program.

18 SEC. 132. PROHIBITION AGAINST CARRIER FORUM SHOP19 PING.

20 (a) IN GENERAL.—

21 (1) PROHIBITION DESCRIBED.—Section

22 1834(a)(12) (42 U.S.C. 1395m(a)(12)) is amended

23 to read as follows:

24 ‘‘(12) USE OF CARRIERS TO PROCESS

25 CLAIMS.—
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1 ‘‘(A) DESIGNATION OF REGIONAL CAR2 RIERS.—The Secretary may designate, one car3 rier for one or more entire regions to process all

4 claims within the region for covered items

5 under this section.

6 ‘‘(B) PROHIBITION AGAINST CARRIER

7 SHOPPING.—(i) Unless permitted by the Sec8 retary, no supplier of a covered item may

9 present or cause to be presented a claim for

10 payment under this part unless such claim is

11 presented to the appropriate regional carrier (as

12 designated by the Secretary).

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

14 ‘appropriate regional carrier’ means the carrier

15 having jurisdiction over the geographic area

16 that includes the permanent residence of the

17 patient to whom the item is furnished.’’.

18 (2) CLARIFICATION OF AUTHORITY TO DES19 IGNATE CARRIERS FOR OTHER ITEMS AND SERV20 ICES.—Nothing in the amendment made by para21 graph (1) may be construed to restrict the authority

22 of the Secretary of Health and Human Services to

23 designate regional carriers or modify claims jurisdic24 tion rules with respect to items or services under

25 part B of the medicare program that are not covered
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1 items under section 1834(a) of the Social Security

2 Act or prosthetic devices or orthotics and prosthetics

3 under section 1834(h) of such Act.

4 (b) EFFECTIVE DATE.—The amendment made by

5 subsection (a) shall apply to claims processed on or after

6 May 1, 1994.

7 SEC. 133. RESTRICTIONS ON CERTAIN MARKETING AND

8 SALES ACTIVITIES.

9 (a) PROHIBITING UNSOLICITED TELEPHONE CON10 TACTS FROM SUPPLIERS OF DURABLE MEDICAL EQUIP11 MENT TO MEDICARE BENEFICIARIES.—

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

13 1395m(a)) is amended by adding at the end the fol14 lowing new paragraph:

15 ‘‘(17) PROHIBITION AGAINST UNSOLICITED

16 TELEPHONE CONTACTS BY SUPPLIERS.—

17 ‘‘(A) IN GENERAL.—A supplier of a cov18 ered item under this subsection may not contact

19 an individual enrolled under this part by tele20 phone regarding the furnishing of a covered

21 item to the individual unless 1 of the following

22 applies:

23 ‘‘(i) The individual has given written

24 permission to the supplier to make contact
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1 by telephone regarding the furnishing of a

2 covered item.

3 ‘‘(ii) The supplier has furnished a cov4 ered item to the individual and the supplier

5 is contacting the individual only regarding

6 the furnishing of such covered item.

7 ‘‘(iii) If the contact is regarding the

8 furnishing of a covered item other than a

9 covered item already furnished to the indi10 vidual, the supplier has furnished at least

11 1 covered item to the individual during the

12 15-month period preceding the date on

13 which the supplier makes such contact.

14 ‘‘(B) PROHIBITING PAYMENT FOR ITEMS

15 FURNISHED SUBSEQUENT TO UNSOLICITED

16 CONTACTS.—If a supplier knowingly contacts

17 an individual in violation of subparagraph (A),

18 no payment may be made under this part for

19 any item subsequently furnished to the individ20 ual by the supplier.

21 ‘‘(C) EXCLUSION FROM PROGRAM FOR

22 SUPPLIERS ENGAGING IN PATTERN OF UNSO23 LICITED CONTACTS.—If a supplier knowingly

24 contacts individuals in violation of subpara25 graph (A) to such an extent that the supplier’s
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1 conduct establishes a pattern of contacts in vio2 lation of such subparagraph, the Secretary shall

3 exclude the supplier from participation in the

4 programs under this Act, in accordance with

5 the procedures set forth in subsections (c), (f),

6 and (g) of section 1128.’’.

7 (2) REQUIRING REFUND OF AMOUNTS COL8 LECTED FOR DISALLOWED ITEMS.—Section 1834(a)

9 (42 U.S.C. 1395m(a)), as amended by paragraph

10 (1), is amended by adding at the end the following

11 new paragraph:

12 ‘‘(18) REFUND OF AMOUNTS COLLECTED FOR

13 CERTAIN DISALLOWED ITEMS.—

14 ‘‘(A) IN GENERAL.—If a nonparticipating

15 supplier furnishes to an individual enrolled

16 under this part a covered item for which no

17 payment may be made under this part by rea18 son of paragraph (17)(B), the supplier shall re19 fund on a timely basis to the patient (and shall

20 be liable to the patient for) any amounts col21 lected from the patient for the item, unless—

22 ‘‘(i) the supplier establishes that the

23 supplier did not know and could not rea24 sonably have been expected to know that
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1 payment may not be made for the item by

2 reason of paragraph (17)(B), or

3 ‘‘(ii) before the item was furnished,

4 the patient was informed that payment

5 under this part may not be made for that

6 item and the patient has agreed to pay for

7 that item.

8 ‘‘(B) SANCTIONS.—If a supplier knowingly

9 and willfully fails to make refunds in violation

10 of subparagraph (A), the Secretary may apply

11 sanctions against the supplier in accordance

12 with section 1842(j)(2).

13 ‘‘(C) NOTICE.—Each carrier with a con14 tract in effect under this part with respect to

15 suppliers of covered items shall send any notice

16 of denial of payment for covered items by rea17 son of paragraph (17)(B) and for which pay18 ment is not requested on an assignment-related

19 basis to the supplier and the patient involved.

20 ‘‘(D) TIMELY BASIS DEFINED.—A refund

21 under subparagraph (A) is considered to be on

22 a timely basis only if—

23 ‘‘(i) in the case of a supplier who does

24 not request reconsideration or seek appeal

25 on a timely basis, the refund is made with-
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1 in 30 days after the date the supplier re2 ceives a denial notice under subparagraph

3 (C), or

4 ‘‘(ii) in the case in which such a re5 consideration or appeal is taken, the re6 fund is made within 15 days after the date

7 the supplier receives notice of an adverse

8 determination on reconsideration or ap9 peal.’’.

10 (b) CONFORMING AMENDMENT.—Section 1834(h)(3)

11 (42 U.S.C. 1395m(h)(3)) is amended by striking ‘‘Para12 graph (12)’’ and inserting ‘‘Paragraphs (12) and (17)’’.

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

14 subsections (a) and (b) shall apply to items furnished after

15 the expiration of the 60-day period that begins on the date

16 of the enactment of this Act.

17 SEC. 134. KICKBACK CLARIFICATION.

18 (a) IN GENERAL.—Section 1128B(b)(3)(B) (42

19 U.S.C. 1320a–7b(b)(3)(B)) is amended by inserting be20 fore the semicolon the following: ‘‘(except that in the case

21 of a contract supply arrangement between any entity and

22 a supplier of medical supplies and equipment (as defined

23 in section 1834(j)(4), but not including items described

24 in subparagraph (F) of such section), such employment

25 shall not be considered bona fide to the extent that it in-
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1 cludes tasks of a clerical and cataloging nature in trans2 mitting to suppliers assignment rights of individuals eligi3 ble for benefits under part B of title XVIII, or perform4 ance of warehousing or stock inventory functions)’’.

5 (b) EFFECTIVE DATE.—The amendment made by

6 subsection (a) shall apply with respect to services fur7 nished on or after the first day of the first month that

8 begins after the expiration of the 60-day period beginning

9 on the date of the enactment of this Act.

10 SEC. 135. BENEFICIARY LIABILITY FOR NONCOVERED

11 SERVICES.

12 (a) UNASSIGNED CLAIMS.—

13 (1) IN GENERAL.—Section 1834(j) (42 U.S.C.

14 1395m(i)), as added by section 131(a)(1), is amend15 ed—

16 (A) by redesignating paragraph (4) as

17 paragraph (5), and

18 (B) by inserting after paragraph (3) the

19 following new paragraph:

20 ‘‘(4) LIMITATION ON PATIENT LIABILITY.—If a

21 supplier of medical equipment and supplies (as de22 fined in paragraph (5))—

23 ‘‘(A) furnishes an item or service to a ben24 eficiary for which no payment may be made by

25 reason of paragraph (1);
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1 ‘‘(B) furnishes an item or service to a ben2 eficiary for which payment is denied in advance

3 under subsection (a)(15); or

4 ‘‘(C) furnishes an item or service to a ben5 eficiary for which payment is denied under sec6 tion 1862(a)(1);

7 any expenses incurred for items and services fur8 nished to an individual by such a supplier not on an

9 assigned basis shall be the responsibility of such

10 supplier. The individual shall have no financial re11 sponsibility for such expenses and the supplier shall

12 refund on a timely basis to the individual (and shall

13 be liable to the individual for) any amounts collected

14 from the individual for such items or services. The

15 provisions of subsection (a)(18) shall apply to re16 funds required under the previous sentence in the

17 same manner as such provisions apply to refunds

18 under such subsection.’’.

19 (2) CONFORMING AMENDMENT.—Section

20 1128B(b)(3)(B) (42 U.S.C. 1320a–7b(b)(3)(B)), as

21 amended by section 134(a), is amended by striking

22 ‘‘1834(j)(4)’’ and inserting ‘‘1834(j)(5)’’.

23 (b) ASSIGNED CLAIMS.—Section 1879 (42 U.S.C.

24 1395pp) is amended by adding at the end the following

25 new subsection:
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1 ‘‘(h) If a supplier of medical equipment and supplies

2 (as defined in section 1834(j)(5))—

3 ‘‘(1) furnishes an item or service to a bene4 ficiary for which no payment may be made by reason

5 of section 1834(j)(1);

6 ‘‘(2) furnishes an item or service to a bene7 ficiary for which payment is denied in advance under

8 section 1834(a)(15); or

9 ‘‘(3) furnishes an item or service to a bene10 ficiary for which no payment may be made by reason

11 of section 1834(a)(17)(B),

12 any expenses incurred for items and services furnished to

13 an individual by such a supplier on an assignment-related

14 basis shall be the responsibility of such supplier. The indi15 vidual shall have no financial responsibility for such ex16 penses and the supplier shall refund on a timely basis to

17 the individual (and shall be liable to the individual for)

18 any amounts collected from the individual for such items

19 or services. The provisions of section 1834(a)(18) shall

20 apply to refunds required under the previous sentence in

21 the same manner as such provisions apply to refunds

22 under such section.’’.

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

24 this section shall apply to items or services furnished on

25 or after October 1, 1994.
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1 SEC. 136. ADJUSTMENTS FOR INHERENT REASONABLE2 NESS.

3 (a) ADJUSTMENTS MADE TO FINAL PAYMENT

4 AMOUNTS.—

5 (1) IN GENERAL.—Section 1834(a)(10)(B) (42

6 U.S.C. 1395m(a)(10)(B)) is amended by adding at

7 the end the following: ‘‘In applying such provisions

8 to payments for an item under this subsection, the

9 Secretary shall make adjustments to the payment

10 basis for the item described in paragraph (1)(B) if

11 the Secretary determines (in accordance with such

12 provisions and on the basis of prices and costs appli13 cable at the time the item is furnished) that such

14 payment basis is not inherently reasonable.’’.

15 (2) EFFECTIVE DATE.—The amendment made

16 by paragraph (1) shall take effect on the date of the

17 enactment of this Act.

18 (b) ADJUSTMENT REQUIRED FOR CERTAIN ITEMS.—

19 (1) IN GENERAL.—In accordance with section

20 1834(a)(10)(B) of the Social Security Act (as

21 amended by subsection (a)), the Secretary of Health

22 and Human Services shall determine whether the

23 payment amounts for the items described in para24 graph (2) are not inherently reasonable, and shall

25 adjust such amounts in accordance with such section

26 if the amounts are not inherently reasonable.
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1 (2) ITEMS DESCRIBED.—The items referred to

2 in paragraph (1) are decubitus care equipment,

3 transcutaneous electrical nerve stimulators, and any

4 other items considered appropriate by the Secretary.

5 SEC. 137. MISCELLANEOUS AND TECHNICAL CORRECTIONS.

6 (a) UPDATES TO PAYMENT AMOUNTS.—(1) Subpara7 graph (A) of section 1834(a)(14) (42 U.S.C.

8 1395m(a)(14)) is amended to read as follows:

9 ‘‘(A) for 1991 and 1992, the percentage

10 increase in the consumer price index for all

11 urban consumers (U.S. city average) for the 12-

12 month period ending with June of the previous

13 year reduced by 1 percentage point; and’’.

14 (2) The amendment made by paragraph (1) shall be

15 effective on the date of the enactment of this Act.

16 (b) ADVANCE DETERMINATIONS OF COVERAGE.—(1)

17 Effective on the date of the enactment of this Act, section

18 1834(a)(15) (42 U.S.C. 1395m(a)(15)) is amended to

19 read as follows:

20 ‘‘(15) ADVANCE DETERMINATIONS OF COV21 ERAGE FOR CERTAIN ITEMS.—

22 ‘‘(A) DEVELOPMENT OF LISTS OF ITEMS

23 BY SECRETARY.—The Secretary may develop

24 and periodically update a list of items for which

25 payment may be made under this subsection
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1 that the Secretary determines, on the basis of

2 prior payment experience, are frequently subject

3 to unnecessary utilization throughout a carrier’s

4 entire service area or a portion of such area.

5 ‘‘(B) DEVELOPMENT OF LISTS OF SUPPLI6 ERS BY SECRETARY.—The Secretary may de7 velop and periodically update a list of suppliers

8 of items for which payment may be made under

9 this subsection with respect to whom—

10 ‘‘(i) the Secretary has found that a

11 substantial number of claims for payment

12 under this part for items furnished by the

13 supplier have been denied on the basis of

14 the application of section 1862(a)(1); or

15 ‘‘(ii) the Secretary has identified a

16 pattern of overutilization resulting from

17 the business practice of the supplier.

18 ‘‘(C) DETERMINATIONS OF COVERAGE IN

19 ADVANCE.—A carrier shall determine in ad20 vance of delivery of an item whether payment

21 for the item may not be made because the item

22 is not covered or because of the application of

23 section 1862(a)(1) if—
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1 ‘‘(i) the item is included on the list

2 developed by the Secretary under subpara3 graph (A);

4 ‘‘(ii) the item is furnished by a sup5 plier included on the list developed by the

6 Secretary under subparagraph (B); or

7 ‘‘(iii) the item is a customized item

8 (other than inexpensive items specified by

9 the Secretary) and the patient to whom the

10 item is to be furnished or the supplier re11 quests that such advance determination be

12 made.’’.

13 (2) Effective for standards applied for contract years

14 beginning after the date of the enactment of this Act, sec15 tion 1842(c) (42 U.S.C. 1395u(c)), as amended by section

16 125(a), is amended by adding at the end the following new

17 paragraph:

18 ‘‘(5) Each contract under this section which provides

19 for the disbursement of funds, as described in subsection

20 (a)(1)(B), shall require the carrier to meet criteria devel21 oped by the Secretary to measure the timeliness of carrier

22 responses to requests for payment of items described in

23 section 1834(a)(15)(C).’’.

24 (3) Effective on the date of the enactment of this Act,

25 section 1834(h)(3) (42 U.S.C. 1395m(h)(3)), as amended
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1 by section 133(b), is amended by striking ‘‘(12) and (17)’’

2 and inserting ‘‘(12), (15), and (17)’’.

3 (c) STUDY OF VARIATIONS IN DURABLE MEDICAL

4 EQUIPMENT SUPPLIER COSTS.—

5 (1) COLLECTION AND ANALYSIS OF SUPPLIER

6 COST DATA.—The Administrator of the Health Care

7 Financing Administration shall, in consultation with

8 appropriate organizations, collect data on supplier

9 costs of durable medical equipment for which pay10 ment may be made under part B of the medicare

11 program, and shall analyze such data to determine

12 the proportions of such costs attributable to the

13 service and product components of furnishing such

14 equipment and the extent to which such proportions

15 vary by type of equipment and by the geographic re16 gion in which the supplier is located.

17 (2) DEVELOPMENT OF GEOGRAPHIC ADJUST18 MENT INDEX; REPORTS.—Not later than January 1,

19 1995—

20 (A) the Administrator shall submit a re21 port to the Committees on Energy and Com22 merce and Ways and Means of the House of

23 Representatives and the Committee on Finance

24 of the Senate on the data collected and the

25 analysis conducted under paragraph (1), and
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1 shall include in such report the Administrator’s

2 recommendations for a geographic cost adjust3 ment index for suppliers of durable medical

4 equipment under the medicare program and an

5 analysis of the impact of such proposed index

6 on payments under the medicare program; and

7 (B) the Comptroller General shall submit a

8 report to the Committees on Energy and Com9 merce and Ways and Means of the House of

10 Representatives and the Committee on Finance

11 of the Senate analyzing on a geographic basis

12 the supplier costs of durable medical equipment

13 under the medicare program.

14 (d) OXYGEN RETESTING.—(1) Section

15 1834(a)(5)(E) (42 U.S.C. 1395m(a)(5)(E)) is amended by

16 striking ‘‘55’’ and inserting ‘‘56’’.

17 (2) The amendment made by paragraph (1) shall be

18 effective on the date of the enactment of this Act.

19 (e) OTHER MISCELLANEOUS AND TECHNICAL

20 AMENDMENTS.—(1) Section 4152(a)(3) of OBRA–1990

21 is amended by striking ‘‘amendment made by subsection

22 (a)’’ and inserting ‘‘amendments made by this sub23 section’’.
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1 (2) Section 4152(c)(2) of OBRA–1990 is amended

2 by striking ‘‘1395m(a)(7)(A)’’ and inserting

3 ‘‘1395m(a)(7)’’.

4 (3) Section 1834(a)(7)(A)(iii)(II) (42 U.S.C.

5 1395m(a)(7)(A)(iii)(II)) is amended by striking ‘‘clause

6 (v)’’ and inserting ‘‘clause (vi)’’.

7 (4) Section 1834(a)(7)(C)(i) (42 U.S.C.

8 1395m(a)(7)(C)(i)) is amended by striking ‘‘or paragraph

9 (3)’’.

10 (5) Section 1834(a)(3) (42 U.S.C. 1395m(a)(3)) is

11 amended by striking subparagraph (D).

12 (6) Section 4153(c)(1) of OBRA–1990 is amended

13 by striking ‘‘1834(a)’’ and inserting ‘‘1834(h)’’.

14 (7) Section 4153(d)(2) of OBRA–1990 is amended

15 by striking ‘‘Reconiliation’’ and inserting ‘‘Reconcili16 ation’’.

17 (8)(A) Section 1834(a) (42 U.S.C. 1395m(a)) is

18 amended by striking paragraph (6).

19 (B) Section 1834(a) (42 U.S.C. 1395m(a)) is amend20 ed—

21 (i) in subparagraphs (A) and (B) of paragraph

22 (1), by striking ‘‘(2) through (7)’’ each place it ap23 pears and inserting ‘‘(2) through (5) and (7)’’;

24 (ii) in paragraph (7), by striking ‘‘(2) through

25 (6)’’ and inserting ‘‘(2) through (5)’’;
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1 (iii) in paragraph (8), by striking ‘‘paragraphs

2 (6) and (7)’’ each place it appears in the matter pre3 ceding subparagraph (A) and in subparagraph (C)

4 and inserting ‘‘paragraph (7)’’; and

5 (iv) in paragraph (8)(A)(i), by striking ‘‘de6 scribed—’’ and all that follows and inserting ‘‘de7 scribed in paragraph (7) equal to the average of the

8 purchase prices on the claims submitted on an as9 signment-related basis for the unused item supplied

10 during the 6-month period ending with December

11 1986.’’.

12 (9) The amendments made by this subsection shall

13 take effect as if included in the enactment of OBRA–1990.

14 PART III—OTHER ITEMS AND SERVICES

15 SEC. 141. AMBULATORY SURGICAL CENTER SERVICES.

16 (a) PAYMENT AMOUNTS FOR SERVICES FURNISHED

17 IN AMBULATORY SURGICAL CENTERS.—

18 (1) USE OF SURVEY TO DETERMINE INCURRED

19 COSTS.—Section 1833(i)(2)(A)(i) (42 U.S.C.

20 1395l(i)(2)(A)(i)) is amended by striking the comma

21 at the end and inserting the following: ‘‘, as deter22 mined in accordance with a survey (based upon a

23 representative sample of procedures and facilities)

24 taken not later than January 1, 1995, and every 5
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1 years thereafter, of the actual audited costs incurred

2 by such centers in providing such services,’’.

3 (2) AUTOMATIC APPLICATION OF INFLATION

4 ADJUSTMENT.—Section 1833(i)(2) (42 U.S.C.

5 1395l(i)(2)) is amended—

6 (A) in the second sentence of subpara7 graph (A) and the second sentence of subpara8 graph (B), by striking ‘‘and may be adjusted by

9 the Secretary, when appropriate,’’; and

10 (B) by adding at the end the following new

11 subparagraph:

12 ‘‘(C) Notwithstanding the second sentence of sub13 paragraph (A) or the second sentence of subparagraph

14 (B), if the Secretary has not updated amounts established

15 under such subparagraphs with respect to facility services

16 furnished during a fiscal year (beginning with fiscal year

17 1996), such amounts shall be increased by the percentage

18 increase in the consumer price index for all urban consum19 ers (U.S. city average) as estimated by the Secretary for

20 the 12-month period ending with the midpoint of the year

21 involved.’’.

22 (3) CONSULTATION REQUIREMENT.—The sec23 ond sentence of section 1833(i)(1) (42 U.S.C.

24 1395l(i)(1)) is amended by striking the period and
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1 inserting the following: ‘‘, in consultation with ap2 propriate trade and professional organizations.’’.

3 (b) ADJUSTMENTS TO PAYMENT AMOUNTS FOR NEW

4 TECHNOLOGY INTRAOCULAR LENSES.—

5 (1) ESTABLISHMENT OF PROCESS FOR REVIEW

6 OF AMOUNTS.—Not later than 1 year after the date

7 of the enactment of this Act, the Secretary of

8 Health and Human Services (in this subsection re9 ferred to as the ‘‘Secretary’’) shall develop and im10 plement a process under which interested parties

11 may request review by the Secretary of the appro12 priateness of the reimbursement amount provided

13 under section 1833(i)(2)(A)(iii) of the Social Secu14 rity Act with respect to a class of new technology

15 intraocular lenses. For purposes of the preceding

16 sentence, an intraocular lens may not be treated as

17 a new technology lens unless it has been approved

18 by the Food and Drug Administration.

19 (2) FACTORS CONSIDERED.—In determining

20 whether to provide an adjustment of payment with

21 respect to a particular lens under paragraph (1), the

22 Secretary shall take into account whether use of the

23 lens is likely to result in reduced risk of

24 intraoperative or postoperative complication or trau25 ma, accelerated postoperative recovery, reduced in-
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1 duced astigmatism, improved postoperative visual

2 acuity, more stable postoperative vision, or other

3 comparable clinical advantages.

4 (3) NOTICE AND COMMENT.—The Secretary

5 shall publish notice in the Federal Register from

6 time to time (but no less often than once each year)

7 of a list of the requests that the Secretary has re8 ceived for review under this subsection, and shall

9 provide for a 30-day comment period on the lenses

10 that are the subjects of the requests contained in

11 such notice. The Secretary shall publish a notice of

12 the Secretary’s determinations with respect to intra13 ocular lenses listed in the notice within 90 days after

14 the close of the comment period.

15 (4) EFFECTIVE DATE OF ADJUSTMENT.—Any

16 adjustment of a payment amount (or payment limit)

17 made under this subsection shall become effective

18 not later than 30 days after the date on which the

19 notice with respect to the adjustment is published

20 under paragraph (3).

21 (c) TECHNICAL CORRECTION RELATING TO BLEND

22 AMOUNTS FOR AMBULATORY SURGICAL CENTER PAY23 MENTS.—
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1 (1) IN GENERAL.—Subclauses (I) and (II) of

2 section 1833(i)(3)(B)(ii) (42 U.S.C.

3 1395l(i)(3)(B)(ii)) are each amended—

4 (A) by striking ‘‘for reporting’’ and insert5 ing ‘‘for portions of cost reporting’’; and

6 (B) by striking ‘‘and on or before’’ and in7 serting ‘‘and ending on or before’’.

8 (2) EFFECTIVE DATE.—The amendments made

9 by paragraph (1) shall take effect as if included in

10 the enactment of OBRA–1990.

11 (d) TECHNICAL CORRECTION RELATED TO CATA12 RACT SURGERY.—Effective as if included in the enact13 ment of OBRA–1990, section 4151(c)(3) of such Act is

14 amended by striking ‘‘for the insertion of an intraocular

15 lens’’ and inserting ‘‘for an intraocular lens inserted’’.

16 SEC. 142. STUDY OF MEDICARE COVERAGE OF PATIENT

17 CARE COSTS ASSOCIATED WITH CLINICAL

18 TRIALS OF NEW CANCER THERAPIES.

19 (a) STUDY.—The Secretary of Health and Human

20 Services shall conduct a study of the effects of expressly

21 covering under the medicare program the patient care

22 costs for beneficiaries enrolled in clinical trials of new can23 cer therapies, where the protocol for the trial has been

24 approved by the National Cancer Institute or meets simi-
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1 lar scientific and ethical standards, including approval by

2 an institutional review board. The study shall include—

3 (1) an estimate of the cost of such coverage,

4 taking into account the extent to which medicare

5 currently pays for such patient care costs in prac6 tice;

7 (2) an assessment of the extent to which such

8 clinical trials represent the best available treatment

9 for the patients involved and of the effects of partici10 pation in the trials on the health of such patients;

11 (3) an assessment of whether progress in devel12 oping new anticancer therapies would be assisted by

13 medicare coverage of such patient care costs; and

14 (4) an evaluation of whether there should be

15 special criteria for the admission of medicare bene16 ficiaries (on account of their age or physical condi17 tion) to clinical trials for which medicare would pay

18 the patient care costs.

19 (b) REPORT.—Not later than 2 years after the date

20 of the enactment of this Act, the Secretary of Health and

21 Human Services shall submit a report on the study con22 ducted under subsection (a) to the Committee on Ways

23 and Means and the Committee on Energy and Commerce

24 of the House of Representatives and the Committee on

25 Finance of the Senate. Such report shall include rec-
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1 ommendations as to the coverage under the medicare pro2 gram of patient care costs of beneficiaries enrolled in clini3 cal trials of new cancer therapies.

4 SEC. 143. STUDY OF ANNUAL CAP ON AMOUNT OF MEDI5 CARE PAYMENT FOR OUTPATIENT PHYSICAL

6 THERAPY AND OCCUPATIONAL THERAPY

7 SERVICES.

8 (a) STUDY.—The Secretary of Health and Human

9 Services shall conduct a study of the appropriateness of

10 continuing an annual limitation on the amount of payment

11 for outpatient services of independently practicing physical

12 and occupational therapists under the medicare program.

13 (b) REPORT.—By not later than January 1, 1995,

14 the Secretary shall submit to the Committees on Energy

15 and Commerce and Ways and Means of the House of Rep16 resentatives and the Committee on Finance of the Senate

17 a report on the study conducted under subsection (a).

18 Such report shall include such recommendations for

19 changes in such annual limitation as the Secretary finds

20 appropriate.

21 SEC. 144. PAYMENT OF PART B PREMIUM LATE ENROLL22 MENT PENALTIES BY STATES.

23 Section 1839 (42 U.S.C. 1395r) is amended by add24 ing at the end the following new subsection:
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1 ‘‘(g)(1) Upon the request of a State, the Secretary

2 may enter into an agreement with the State under which

3 the State agrees to pay on a quarterly or other periodic

4 basis to the Secretary (to be deposited in the Treasury

5 to the credit of the Federal Supplementary Medical Insur6 ance Trust Fund) an amount equal to the amount of the

7 part B late enrollment premium increases with respect to

8 the premiums for eligible individuals (as defined in para9 graph (3)(A)).

10 ‘‘(2) No part B late enrollment premium increase

11 shall apply to an eligible individual for premiums for

12 months for which the amount of such an increase is pay13 able under an agreement under paragraph (1).

14 ‘‘(3) In this subsection:

15 ‘‘(A) The term ‘eligible individual’ means an in16 dividual who is enrolled under this part B and who

17 is within a class of individuals specified in the agree18 ment under paragraph (1).

19 ‘‘(B) The term ‘part B late enrollment premium

20 increase’ means any increase in a premium as a re21 sult of the application of subsection (b).’’.
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1 SEC. 145. TREATMENT OF INPATIENTS AND PROVISION OF

2 DIAGNOSTIC X-RAY SERVICES BY RURAL

3 HEALTH CLINICS AND FEDERALLY QUALI4 FIED HEALTH CENTERS.

5 (a) TREATMENT OF INPATIENTS.—Section 1861(aa)

6 (42 U.S.C. 1395x(aa)) is amended—

7 (1) in paragraph (1), in the matter following

8 subparagraph (C), by striking ‘‘as an outpatient’’

9 and inserting ‘‘as a patient’’;

10 (2) in paragraph (2)(A), by striking ‘‘furnishing

11 to outpatients’’ and inserting ‘‘furnishing to pa12 tients’’; and

13 (3) in paragraph (3), in the matter following

14 subparagraph (B), by striking ‘‘as an outpatient’’

15 and inserting ‘‘as a patient’’.

16 (b) TREATMENT OF DIAGNOSTIC X-RAY SERV17 ICES.—Section 1861(aa) (42 U.S.C. 1395x(aa)) is further

18 amended—

19 (1) in paragraph (1)(A), by inserting ‘‘(i)’’ after

20 ‘‘(A)’’ and by adding at the end the following: ‘‘and

21 (ii) diagnostic x-ray services,’’, and

22 (2) in paragraph (2)(A), by striking ‘‘(A)’’ and

23 inserting ‘‘(A)(i)’’.

24 (c) CONFORMING AMENDMENT.—Section

25 1862(a)(14) (42 U.S.C. 1395y(a)(14)) is amended by

26 striking ‘‘and services of a certified registered nurse anes-
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1 thetist’’ and inserting ‘‘services of a certified registered

2 nurse anesthetist, rural health clinic services, and Feder3 ally-qualified health center services’’.

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

5 this section shall take effect on January 1, 1994, and shall

6 apply to services furnished on or after such date.

7 SEC. 146. APPLICATION OF MAMMOGRAPHY CERTIFI8 CATION REQUIREMENTS.

9 (a) SCREENING MAMMOGRAPHY.—Section 1834(c)

10 (42 U.S.C. 1395m(c)) is amended—

11 (1) in paragraph (1)(B), by striking ‘‘meets the

12 quality standards established under paragraph (3)’’

13 and inserting ‘‘is conducted by a facility that has a

14 certificate (or provisional certificate) issued under

15 section 354 of the Public Health Service Act’’;

16 (2) in paragraph (1)(C)(iii), by striking ‘‘para17 graph (4)’’ and inserting ‘‘paragraph (3)’’;

18 (3) by striking paragraph (3); and

19 (4) by redesignating paragraphs (4) and (5) as

20 paragraphs (3) and (4).

21 (b) DIAGNOSTIC MAMMOGRAPHY.—Section

22 1861(s)(3) (42 U.S.C. 1395x(s)(3)) is amended by insert23 ing ‘‘and including diagnostic mammography if conducted

24 by a facility that has a certificate (or provisional certifi-
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1 cate) issued under section 354 of the Public Health Serv2 ice Act’’ after ‘‘necessary’’.

3 (c) CONFORMING AMENDMENTS.—(1) Section

4 1862(a)(1)(F) (42 U.S.C. 1395y(a)(1)(F)) is amended by

5 striking ‘‘or which does not meet the standards established

6 under section 1834(c)(3)’’ and inserting ‘‘or which is not

7 conducted by a facility described in section

8 1834(c)(1)(B)’’.

9 (2) Section 1863 (42 U.S.C. 1395z) is amended by

10 striking ‘‘or whether screening mammography meets the

11 standards established under section 1834(c)(3),’’.

12 (3) The first sentence of section 1864(a) (42 U.S.C.

13 1395aa(a)) is amended by striking ‘‘, or whether screening

14 mammography meets the standards established under sec15 tion 1834(c)(3)’’.

16 (4) The third sentence of section 1865(a) (42 U.S.C.

17 1395bb(a)) is amended by striking ‘‘1834(c)(3),’’.

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

19 this section shall apply to mammography furnished by a

20 facility on and after the first date that the certificate re21 quirements of section 354(b) of the Public Health Service

22 Act apply to such mammography conducted by such facil23 ity.
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1 SEC. 147. COVERAGE OF SERVICES OF SPEECH-LANGUAGE

2 PATHOLOGISTS AND AUDIOLOGISTS.

3 (a) SERVICES DEFINED.—Section 1861 (42 U.S.C.

4 1395x), as amended by section 148(f)(6)(E), is amended

5 by inserting after subsection (kk) the following new sub6 section:

7 ‘‘Speech-Language Pathology Services; Audiology

8 Services

9 ‘‘(ll)(1) The term ‘speech-language pathology serv10 ices’ means such speech, language, and related function

11 assessment and rehabilitation services furnished by a

12 qualified speech-language pathologist as the speech-lan13 guage pathologist is legally authorized to perform under

14 State law (or the State regulatory mechanism provided by

15 State law) as would otherwise be covered if furnished by

16 a physician.

17 ‘‘(2) The term ‘audiology services’ means such hear18 ing and balance assessment services furnished by a quali19 fied audiologist as the audiologist is legally authorized to

20 perform under State law (or the State regulatory mecha21 nism provided by State law), as would otherwise be cov22 ered if furnished by a physician.

23 ‘‘(3) In this subsection:

24 ‘‘(A) The term ‘qualified speech-language pa25 thologist’ means an individual with a master’s or

26 doctoral degree in speech-language pathology who—
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1 ‘‘(i) is licensed as a speech-language pa2 thologist by the State in which the individual

3 furnishes such services, or

4 ‘‘(ii) in the case of an individual who fur5 nishes services in a State which does not license

6 speech-language pathologists, has successfully

7 completed 350 clock hours of supervised clinical

8 practicum (or is in the process of accumulating

9 such supervised clinical experience), performed

10 not less than 1 month of supervised full-time

11 speech-language pathology services after obtain12 ing a master’s or doctoral degree in speech-lan13 guage pathology or a related field, and success14 fully completed a national examination in

15 speech-language pathology approved by the Sec16 retary.

17 ‘‘(B) The term ‘qualified audiologist’ means an

18 individual with a master’s or doctoral degree in

19 audiology who—

20 ‘‘(i) is licensed as a speech-language pa21 thologist by the State in which the individual

22 furnishes such services, or

23 ‘‘(ii) in the case of an individual who fur24 nishes services in a State which does not license

25 speech-language pathologists, has successfully
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1 completed 350 clock hours of supervised clinical

2 practicum (or is in the process of accumulating

3 such supervised clinical experience), performed

4 not less than 1 month of supervised full-time

5 speech-language pathology services after obtain6 ing a master’s or doctoral degree in speech-lan7 guage pathology or a related field, and success8 fully completed a national examination in

9 speech-language pathology approved by the Sec10 retary.’’.

11 (b) CONFORMING AMENDMENTS RELATING TO MED12 ICARE TREATMENT OF SPEECH AND LANGUAGE SERV13 ICES.—

14 (1) EXTENDED CARE SERVICES.—Section

15 1861(h)(3) (42 U.S.C. 1395x(h)(3)) is amended by

16 striking ‘‘, occupational, or speech therapy’’ and in17 serting ‘‘or occupational therapy or speech-language

18 pathology services’’.

19 (2) HOME HEALTH SERVICES.—Section

20 1861(m)(2) (42 U.S.C. 1395x(m)(2)) is amended by

21 striking ‘‘, occupational, or speech therapy’’ and in22 serting ‘‘or occupational therapy or speech-language

23 pathology services’’.

24 (3) OUTPATIENT PHYSICAL THERAPY SERV25 ICES.—The fourth sentence of section 1861(p) (42
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1 U.S.C. 1395x(p)) is amended by striking ‘‘speech

2 pathology services’’ and inserting ‘‘speech-language

3 pathology services’’.

4 (4) COMPREHENSIVE OUTPATIENT REHABILITA5 TION FACILITY SERVICES.—Section 1861(cc)(1)(B)

6 (42 U.S.C. 1395x(cc)(1)(B)) is amended by striking

7 ‘‘speech pathology services’’ and inserting ‘‘speech8 language pathology services’’.

9 (5) HOSPICE CARE.—Section 1861(dd)(1)(B)

10 (42 U.S.C. 1395x(dd)(1)(B)) is amended by striking

11 ‘‘therapy or speech-language pathology’’ and insert12 ing ‘‘therapy, or speech-language pathology serv13 ices’’.

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

15 this section shall take effect on January 1, 1994.

16 SEC. 148. MISCELLANEOUS AND TECHNICAL CORRECTIONS.

17 (a) REVISION OF INFORMATION ON PART B CLAIMS

18 FORMS.—Section 1833(q)(1) (42 U.S.C. 1395l(q)(1)) is

19 amended—

20 (1) by striking ‘‘provider number’’ and inserting

21 ‘‘unique physician identification number’’; and

22 (2) by striking ‘‘and indicate whether or not the

23 referring physician is an interested investor (within

24 the meaning of section 1877(h)(5))’’.
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1 (b) CONSULTATION FOR SOCIAL WORKERS.—Effec2 tive with respect to services furnished on or after January

3 1, 1991, section 6113(c) of OBRA–1989 is amended—

4 (1) by inserting ‘‘and clinical social worker

5 services’’ after ‘‘psychologist services’’; and

6 (2) by striking ‘‘psychologist’’ the second and

7 third place it appears and inserting ‘‘psychologist or

8 clinical social worker’’.

9 (c) REPORTS ON HOSPITAL OUTPATIENT PAY10 MENT.—(1) OBRA–1989 is amended by striking section

11 6137.

12 (2) Section 1135(d) (42 U.S.C. 1320b–5(d)) is

13 amended—

14 (A) by striking paragraph (6); and

15 (B) in paragraph (7)—

16 (i) by striking ‘‘systems’’ each place it ap17 pears and inserting ‘‘system’’; and

18 (ii) by striking ‘‘paragraphs (1) and (6)’’

19 and inserting ‘‘paragraph (1)’’.

20 (d) RADIOLOGY AND DIAGNOSTIC SERVICES PRO21 VIDED IN HOSPITAL OUTPATIENT DEPARTMENTS.—(1)

22 Effective as if included in the enactment of OBRA–1989,

23 section 1833(n)(1)(B)(i)(II) (42 U.S.C.

24 1395l(n)(1)(B)(i)(II)) is amended—
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1 (A) by inserting ‘‘and for services described in

2 subsection (a)(2)(E)(ii) furnished on or after Janu3 ary 1, 1992’’ after ‘‘1989’’; and

4 (B) by striking ‘‘1842(b)’’ and inserting

5 ‘‘1842(b) (or, in the case of services furnished on or

6 after January 1, 1992, under section 1848)’’.

7 (2) Effective as if included in the enactment of

8 OBRA–1989, section 1833(n)(1)(B)(i)(II) (42 U.S.C.

9 1395l(n)(1)(B)(i)(II)) is amended by striking ‘‘January 1,

10 1989’’ and inserting ‘‘April 1, 1989’’.

11 (e) PAYMENTS TO NURSE PRACTITIONERS IN RURAL

12 AREAS (SECTION 4155 OF OBRA–1990).—(1) Section

13 1861(s)(2)(K)(iii) (42 U.S.C. 1395x(s)(2)(K)(iii)) is

14 amended—

15 (A) by striking ‘‘subsection (aa)(3)’’ and insert16 ing ‘‘subsection (aa)(5)’’; and

17 (B) by striking ‘‘subsection (aa)(4)’’ and insert18 ing ‘‘subsection (aa)(6)’’.

19 (2) Section 1833(r)(1) (42 U.S.C. 1395l(r)(1)) is

20 amended—

21 (A) by striking ‘‘ambulatory’’ each place it ap22 pears and inserting ‘‘or ambulatory’’; and

23 (B) by striking ‘‘center,’’ and inserting ‘‘cen24 ter’’.
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1 (3) Section 1833(r)(2)(A) (42 U.S.C. 1395l(r)(2)(A))

2 is amended by striking ‘‘subsection (a)(1)(M)’’ and insert3 ing ‘‘subsection (a)(1)(O)’’.

4 (4) Section 1861(b)(4) (42 U.S.C. 1395x(b)(4)) is

5 amended by striking ‘‘subsection (s)(2)(K)(i)’’ and insert6 ing ‘‘clauses (i) or (iii) of subsection (s)(2)(K)’’.

7 (5) Section 1861(aa)(5) (42 U.S.C. 1395x(aa)(5)) is

8 amended by striking ‘‘this Act’’ and inserting ‘‘this title’’.

9 (6) Section 1862(a)(14) (42 U.S.C. 1395y(a)(14)) is

10 amended by striking ‘‘1861(s)(2)(K)(i)’’ and inserting

11 ‘‘1861(s)(2)(K)(i) or 1861(s)(2)(K)(iii)’’.

12 (7) Section 1866(a)(1)(H) (42 U.S.C.

13 1395cc(a)(1)(H)) is amended by striking

14 ‘‘1861(s)(2)(K)(i)’’ and inserting ‘‘1861(s)(2)(K)(i) or

15 1861(s)(2)(K)(iii)’’.

16 (f) OTHER MISCELLANEOUS AND TECHNICAL

17 AMENDMENTS.—

18 (1) IMMEDIATE ENROLLMENT IN PART B BY IN19 DIVIDUALS COVERED BY AN EMPLOYMENT-BASED

20 PLAN.—(A) Subparagraphs (A) and (B) of section

21 1837(i)(3) (42 U.S.C. 1395p(i)(3)) are each amend22 ed—

23 (i) by striking ‘‘beginning with the first

24 day of the first month in which the individual

25 is no longer enrolled’’ and inserting ‘‘including
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1 each month during any part of which the indi2 vidual is enrolled’’; and

3 (ii) by striking ‘‘and ending seven months

4 later’’ and inserting ‘‘ending with the last day

5 of the eighth consecutive month in which the in6 dividual is at no time so enrolled’’.

7 (B) Paragraphs (1) and (2) of section 1838(e)

8 (42 U.S.C. 1395q(e)) are amended to read as fol9 lows:

10 ‘‘(1) in any month of the special enrollment pe11 riod in which the individual is at any time enrolled

12 in a plan (specified in subparagraph (A) or (B), as

13 applicable, of section 1837(i)(3)) or in the first

14 month following such a month, the coverage period

15 shall begin on the first day of the month in which

16 the individual so enrolls (or, at the option of the in17 dividual, on the first day of any of the following

18 three months), or

19 ‘‘(2) in any other month of the special enroll20 ment period, the coverage period shall begin on the

21 first day of the month following the month in which

22 the individual so enrolls.’’.

23 (C) The amendments made by subparagraphs

24 (A) and (B) shall take effect on the first day of the

25 first month that begins after the expiration of the
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1 120-day period that begins on the date of the enact2 ment of this Act.

3 (2) CLINICAL DIAGNOSTIC LABORATORY

4 TESTS.—Section 4154(e)(5) of OBRA–1990 is

5 amended by striking ‘‘(1)(A)’’ and inserting

6 ‘‘(1)(A),’’.

7 (3) SEPARATE PAYMENT UNDER PART B FOR

8 CERTAIN SERVICES.—Section 4157(a) of OBRA–

9 1990 is amended by striking ‘‘(a) SERVICES OF’’

10 and all that follows through ‘‘Section’’ and inserting

11 ‘‘(a) TREATMENT OF SERVICES OF CERTAIN

12 HEALTH PRACTITIONERS.—Section’’.

13 (4) COMMUNITY HEALTH CENTERS AND RURAL

14 HEALTH CLINICS.—(A) The fourth sentence of sec15 tion 1861(aa)(2) (42 U.S.C. 1395x(aa)(2)) is

16 amended—

17 (i) by striking ‘‘certification’’ the first

18 place it appears and inserting ‘‘approval’’; and

19 (ii) by striking ‘‘the Secretary’s approval

20 or disapproval of the certification’’ and insert21 ing ‘‘Secretary’s approval or disapproval’’.

22 (B) Section 4161(a)(7)(B) of OBRA–1990 is

23 amended by inserting ‘‘and to the Committee on Fi24 nance of the Senate’’ after ‘‘Representatives’’.
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1 (5) SCREENING MAMMOGRAPHY.—Section 4163

2 of OBRA–1990 is amended—

3 (A) by adding at the end of subsection (d)

4 the following new paragraph:

5 ‘‘(3) The amendment made by paragraph

6 (2)(A)(iv) shall apply to screening pap smears per7 formed on or after July 1, 1990.’’; and

8 (B) in subsection (e), by striking ‘‘The

9 amendments’’ and inserting ‘‘Except as pro10 vided in subsection (d)(3), the amendments’’.

11 (6) INJECTABLE DRUGS FOR TREATMENT OF

12 OSTEOPOROSIS.—

13 (A) CLARIFICATION OF DRUGS COV14 ERED.—The section 1861(jj) (42 U.S.C.

15 1395x(jj)) inserted by section 4156(a)(2) of

16 OBRA–1990 is amended—

17 (i) in the matter preceding paragraph

18 (1), by striking ‘‘a bone fracture related

19 to’’; and

20 (ii) in paragraph (1), by striking ‘‘pa21 tient’’ and inserting ‘‘individual has suf22 fered a bone fracture related to post-meno23 pausal osteoporosis and that the individ24 ual’’.
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1 (B) LIMITING COVERAGE TO DRUGS PRO2 VIDED BY HOME HEALTH AGENCIES.—(i) The

3 section 1861(jj) (42 U.S.C. 1395x(jj)) inserted

4 by section 4156(a)(2) of OBRA–1990 is

5 amended by striking ‘‘if’’ and inserting ‘‘by a

6 home health agency if’’.

7 (ii) Section 1861(m)(5) (42 U.S.C.

8 1395x(m)(5)) is amended by striking ‘‘but ex9 cluding’’ and inserting ‘‘and a covered

10 osteoporosis drug (as defined in subsection

11 (kk), but excluding other’’.

12 (iii) Section 1861(s)(2) (42 U.S.C.

13 1395x(s)(2)) is amended—

14 (I) by adding ‘‘and’’ at the end of

15 subparagraph (N), and

16 (II) by striking subparagraph (O) and

17 redesignating subparagraph (P) as sub18 paragraph (O).

19 (C) PAYMENT BASED ON REASONABLE

20 COST.—Section 1833(a)(2) (42 U.S.C.

21 1395l(a)(2)) is amended—

22 (i) in subparagraph (A), by striking

23 ‘‘health services’’ and inserting ‘‘health

24 services (other than a covered osteoporosis

25 drug (as defined in section 1861(kk)))’’;
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1 (ii) by striking ‘‘and’’ at the end of

2 subparagraph (D);

3 (iii) by striking the semicolon at the

4 end of subparagraph (E) and inserting ‘‘;

5 and’’; and

6 (iv) by adding at the end the following

7 new subparagraph:

8 ‘‘(F) with respect to a covered osteoporosis

9 drug (as defined in section 1861(kk)) furnished

10 by a home health agency, 80 percent of the rea11 sonable cost of such service, as determined

12 under section 1861(v);’’.

13 (D) APPLICATION OF PART B DEDUCT14 IBLE.—Section 1833(b)(2) (42 U.S.C.

15 1395l(b)(2)) is amended by striking ‘‘services’’

16 and inserting ‘‘services (other than a covered

17 osteoporosis drug (as defined in section

18 1861(kk)))’’.

19 (E) COVERED OSTEOPOROSIS DRUG (SEC20 TION 4156 OF OBRA–1990).—Section 1861 (42

21 U.S.C. 1395x) is amended, in the subsection

22 (jj) inserted by section 4156(a)(2) of OBRA–

23 1990, by striking ‘‘(jj) The term’’ and inserting

24 ‘‘(kk) The term’’.
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1 (7) OTHER MISCELLANEOUS AND TECHNICAL

2 CORRECTIONS.—

3 (A) OWNERSHIP DISCLOSURE REQUIRE4 MENTS.—(i) Section 1124A(a)(2)(A) (42

5 U.S.C. 1320a–3a(a)(2)(A)) is amended by

6 striking ‘‘of the Social Security Act’’.

7 (ii) Section 4164(b)(4) of OBRA–1990 is

8 amended by striking ‘‘paragraph’’ and inserting

9 ‘‘paragraphs’’.

10 (B) DIRECTORY OF UNIQUE PHYSICIAN

11 IDENTIFIER NUMBERS.—Section 4164(c) of

12 OBRA–1990 is amended by striking ‘‘publish’’

13 and inserting ‘‘publish, and shall periodically

14 update,’’.

15 (g) EFFECTIVE DATE.—Except as otherwise provided

16 in this section, the amendments made by this section shall

17 take effect as if included in the enactment of OBRA–1990.

18 Subtitle C—Provisions Relating to

19 Parts A and B

20 SEC. 151. MEDICARE SECONDARY PAYER REFORMS.

21 (a) IMPROVING IDENTIFICATION OF MEDICARE SEC22 ONDARY PAYER SITUATIONS.—

23 (1) SURVEY OF BENEFICIARIES.—
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1 (A) IN GENERAL.—Section 1862(b)(5) (42

2 U.S.C. 1395y(b)(5)) is amended by adding at

3 the end the following new subparagraph:

4 ‘‘(D) OBTAINING INFORMATION FROM

5 BENEFICIARIES.—Before an individual applies

6 for benefits under part A or enrolls under part

7 B, the Administrator shall mail the individual a

8 questionnaire to obtain information on whether

9 the individual is covered under a primary plan

10 and the nature of the coverage provided under

11 the plan, including the name, address, and iden12 tifying number of the plan.’’.

13 (B) DISTRIBUTION OF QUESTIONNAIRE BY

14 CONTRACTOR.—The Secretary of Health and

15 Human Services shall enter into an agreement

16 with an entity not later than July 1, 1994, to

17 distribute the questionnaire described in section

18 1862(b)(5)(D) of the Social Security Act (as

19 added by subparagraph (A)).

20 (C) NO MEDICARE SECONDARY PAYER DE21 NIAL BASED ON FAILURE TO COMPLETE QUES22 TIONNAIRE.—Section 1862(b)(2) (42 U.S.C.

23 1395y(b)(2)) is amended by adding at the end

24 the following new subparagraph:
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1 ‘‘(C) TREATMENT OF QUESTIONNAIRES.—

2 The Secretary may not fail to make payment

3 under subparagraph (A) solely on the ground

4 that an individual failed to complete a question5 naire concerning the existence of a primary

6 plan.’’.

7 (2) MANDATORY SCREENING BY PROVIDERS

8 AND SUPPLIERS UNDER PART B.—

9 (A) IN GENERAL.—Section 1862(b) (42

10 U.S.C. 1395y(b)) is amended by adding at the

11 end the following new paragraph:

12 ‘‘(6) SCREENING REQUIREMENTS FOR PROVID13 ERS AND SUPPLIERS.—

14 ‘‘(A) IN GENERAL.—Notwithstanding any

15 other provision of this title, no payment may be

16 made for any item or service furnished under

17 part B unless the entity furnishing such item or

18 service completes (to the best of its knowledge

19 and on the basis of information obtained from

20 the individual to whom the item or service is

21 furnished) the portion of the claim form relat22 ing to the availability of other health benefit

23 plans.

24 ‘‘(B) PENALTIES.—An entity that know25 ingly, willfully, and repeatedly fails to complete
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1 a claim form in accordance with subparagraph

2 (A) or provides inaccurate information relating

3 to the availability of other health benefit plans

4 on a claim form under such subparagraph shall

5 be subject to a civil money penalty of not to ex6 ceed $2,000 for each such incident. The provi7 sions of section 1128A (other than subsections

8 (a) and (b)) shall apply to a civil money penalty

9 under the previous sentence in the same man10 ner as such provisions apply to a penalty or

11 proceeding under section 1128A(a).’’.

12 (B) EFFECTIVE DATE.—The amendment

13 made by subparagraph (A) shall apply with re14 spect to items and services furnished on or

15 after January 1, 1994.

16 (b) IMPROVEMENTS IN RECOVERY OF PAYMENTS

17 FROM PRIMARY PAYERS.—

18 (1) SUBMISSION OF REPORTS ON EFFORTS TO

19 RECOVER ERRONEOUS PAYMENTS.—

20 (A) FISCAL INTERMEDIARIES UNDER PART

21 A.—Section 1816 (42 U.S.C. 1396h) is amend22 ed by adding at the end the following new sub23 section:

24 ‘‘(k) An agreement with an agency or organization

25 under this section shall require that such agency or orga-
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1 nization submit an annual report to the Secretary describ2 ing the steps taken to recover payments made for items

3 or services for which payment has been or could be made

4 under a primary plan (as defined in section

5 1862(b)(2)(A)).’’.

6 (B) CARRIERS UNDER PART B.—Section

7 1842(b)(3) (42 U.S.C. 1395u(b)(3)) is amend8 ed—

9 (i) by striking ‘‘and’’ at the end of

10 subparagraph (G);

11 (ii) by striking ‘‘and’’ at the end of

12 subparagraph (H); and

13 (iii) by inserting after subparagraph

14 (H) the following new subparagraph:

15 ‘‘(I) will submit annual reports to the Secretary

16 describing the steps taken to recover payments made

17 under this part for items or services for which pay18 ment has been or could be made under a primary

19 plan (as defined in section 1862(b)(2)(A)); and’’.

20 (2) REQUIREMENTS UNDER CARRIER PERFORM21 ANCE EVALUATION PROGRAM.—

22 (A) FISCAL INTERMEDIARIES UNDER PART

23 A.—Section 1816(f)(1)(A) (42 U.S.C.

24 1396h(f)(1)(A)) is amended by striking ‘‘proc25 essing’’ and inserting ‘‘processing (including the
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1 agency’s or organization’s success in recovering

2 payments made under this title for services for

3 which payment has been or could be made

4 under a primary plan (as defined in section

5 1862(b)(2)(A)))’’.

6 (B) CARRIERS UNDER PART B.—Section

7 1842(b)(2) (42 U.S.C. 1395u(b)(2)) is amended

8 by adding at the end the following new sub9 paragraph:

10 ‘‘(D) In addition to any other standards and criteria

11 established by the Secretary for evaluating carrier per12 formance under this paragraph relating to avoiding erro13 neous payments, the carrier shall be subject to standards

14 and criteria relating to the carrier’s success in recovering

15 payments made under this part for items or services for

16 which payment has been or could be made under a pri17 mary plan (as defined in section 1862(b)(2)(A)).’’.

18 (3) DEADLINE FOR REIMBURSEMENT BY PRI19 MARY PLANS.—

20 (A) IN GENERAL.—Section

21 1862(b)(2)(B)(i) (42 U.S.C. 1395y(b)(2)(B)(i))

22 is amended by adding at the end the following

23 sentence: ‘‘If reimbursement is not made to the

24 appropriate Trust Fund before the expiration of

25 the 60-day period that begins on the date such
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1 notice or other information is received, the Sec2 retary may charge interest (beginning with the

3 date on which the notice or other information

4 is received) on the amount of the reimburse5 ment until reimbursement is made (at a rate

6 determined by the Secretary in accordance with

7 regulations of the Secretary of the Treasury

8 applicable to charges for late payments).’’.

9 (B) CONFORMING AMENDMENT.—The

10 heading of clause (i) of section 1862(b)(2)(B) is

11 amended to read as follows: ‘‘REPAYMENT RE12 QUIRED.—’’.

13 (C) EFFECTIVE DATE.—The amendments

14 made by this paragraph shall apply to payments

15 for items and services furnished on or after the

16 date of the enactment of this Act.

17 (4) EFFECTIVE DATE.—The amendments made

18 by paragraphs (1) and (2) shall apply to contracts

19 with fiscal intermediaries and carriers under title

20 XVIII of the Social Security Act for years beginning

21 with 1994.

22 (c) MISCELLANEOUS AND TECHNICAL CORREC23 TIONS.—

24 (1) Effective as if included in the enactment of

25 OBRA–1993, section 1862(b)(1)(A) (42 U.S.C.
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1 1395y(b)(1)(A)), as amended by section 13561(e)(1)

2 of OBRA–1993, is amended—

3 (A) in clause (i)(II), by striking ‘‘over (and

4 the individual’s spouse age 65 or older) who is

5 covered under the plan by virtue of the individ6 ual’s current employment status with an em7 ployer’’ and inserting ‘‘older (and the spouse

8 age 65 or older of any individual) who has cur9 rent employment status with an employer’’; and

10 (B) in clause (ii), by striking ‘‘or employee

11 organization that has 20 or more individuals in

12 current employment status’’ and inserting ‘‘that

13 has 20 or more employees’’.

14 (2) Effective as if included in the enactment of

15 OBRA–1993, section 1837(i) (42 U.S.C. 1395p(i))

16 is amended—

17 (A) by striking ‘‘as an active individual (as

18 those terms are defined in section

19 1862(b)(1)(B)(iv))’’ each place it appears in the

20 second sentence of paragraph (1), and the sec21 ond sentence of paragraph (2) and inserting

22 ‘‘(as that term is defined in section

23 1862(b)(1)(B)(iv)) by reason of the individual’s

24 current employment status (or the current em-
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1 ployment status of a family member of the indi2 vidual)’’;

3 (B) in paragraph (3)(B), by striking ‘‘as

4 an active individual in a large group health plan

5 (as such terms are defined in section

6 1862(b)(1)(B)(iv))’’ and inserting ‘‘in a large

7 group health plan (as that term is defined in

8 section 1862(b)(1)(B)(iv)) by reason of the in9 dividual’s current employment status (or the

10 current employment status of a family member

11 of the individual)’’;

12 (C) in the second sentence of paragraph

13 (2) (as amended by subparagraph (A)), by

14 striking ‘‘as an active individual’’ and inserting

15 ‘‘by reason of the individual’s current employ16 ment status (or the current employment status

17 of a family member of the individual)’’; and

18 (D) by inserting ‘‘status’’ after ‘‘current

19 employment’’ each place it appears in para20 graphs (1)(A), (2)(B), (2)(C), and (3)(A).

21 (3) Effective as if included in the enactment of

22 OBRA–1993, the second sentence of section 1839(b)

23 (42 U.S.C. 1395r(b)) is amended—

24 (A) by inserting ‘‘status’’ after ‘‘current

25 employment’’, and
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1 (B) by striking ‘‘as an active individual (as

2 those terms are defined in section

3 1862(b)(1)(B)(iv))’’ and inserting ‘‘(as that

4 term is defined in section 1862(b)(1)(B)(iv)) by

5 reason of the individual’s current employment

6 status (or the current employment status of a

7 family member of the individual)’’.

8 (4) Effective as if included in the enactment of

9 OBRA–1990, the sentence in section 1862(b)(1)(C)

10 added by section 4203(c)(1)(B) of OBRA–1990 is

11 amended by striking ‘‘clauses (i) and (ii)’’ and in12 serting ‘‘this subparagraph’’.

13 (5) Effective as if included in the enactment of

14 OBRA–1989, section 1862(b)(1)(C) is amended in

15 the matter after clause (ii), by striking ‘‘taking into

16 account that’’ and inserting ‘‘paying benefits second17 ary to this title when’’.

18 (6) Effective as if included in the enactment of

19 OBRA–1989, section 1862(b)(5)(C)(i) (42 U.S.C.

20 1395y(b)(5)(C)(i)) is amended by striking

21 ‘‘6103(l)(12)(D)(iii)’’ and inserting

22 ‘‘6103(l)(12)(E)(iii)’’.

23 (7) Effective as if included in the enactment of

24 OBRA–1990, section 4203(c)(2) of such Act is

25 amended—
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1 (A) by striking ‘‘the application of clause

2 (iii)’’ and inserting ‘‘the second sentence’’;

3 (B) by striking ‘‘on individuals’’ and all

4 that follows through ‘‘section 226A of such

5 Act’’;

6 (C) in clause (ii), by striking ‘‘clause’’ and

7 inserting ‘‘sentence’’;

8 (D) in clause (v), by adding ‘‘and’’ at the

9 end; and

10 (E) in clause (vi)—

11 (i) by inserting ‘‘of such Act’’ after

12 ‘‘1862(b)(1)(C)’’, and

13 (ii) by striking the period at the end

14 and inserting the following: ‘‘, without re15 gard to the number of employees covered

16 by such plans.’’.

17 (8) Effective as if included in the enactment of

18 OBRA–1990, section 4203(d) of OBRA–1990 is

19 amended by striking ‘‘this subsection’’ and inserting

20 ‘‘this section’’.

21 (9) Effective as if included in the enactment of

22 OBRA–1993, section 13561(e)(1)(D) of OBRA–

23 1993 is amended—
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1 (A) by inserting ‘‘effective as if included in

2 the enactment of OBRA–1989,’’ after ‘‘(D)’’,

3 and

4 (B) by striking ‘‘of each subparagraph’’.

5 (10) The amendment made by section

6 13561(e)(1)(G) of OBRA–1993, to the extent it re7 lates to the definition of large group health plan,

8 shall be effective as if included in the enactment of

9 OBRA–1989.

10 SEC. 152. PHYSICIAN OWNERSHIP AND REFERRAL.

11 (a) IN GENERAL.—Section 1877(f) (42 U.S.C.

12 1395nn) is amended—

13 (1) in the matter before paragraph (1), by in14 serting ‘‘, investment, and compensation’’ after

15 ‘‘ownership’’;

16 (2) in paragraph (2), by inserting ‘‘, or with a

17 compensation arrangement (as described in sub18 section (a)(2)(B)),’’ after ‘‘investment interest (as

19 described in subsection (a)(2)(A))’’;

20 (3) in paragraph (2), by inserting ‘‘interest or

21 who have such a compensation relationship with the

22 entity’’ before the period at the end;

23 (4) in the fourth sentence, by striking ‘‘covered

24 items and’’ and inserting ‘‘designated health’’; and

25 (5) by striking the third and fifth sentences.
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1 (b) RADIOLOGY SERVICES.—Section 1877(h)(6) (42

2 U.S.C. 1395nn(h)(6)), as amended by section 13562(a)(2)

3 of OBRA–1993, is amended—

4 (1) in subparagraph (D), by striking ‘‘or other

5 diagnostic services’’ and inserting ‘‘services, includ6 ing magnetic resonance imaging, computerized axial

7 tomography scans, and ultrasound services’’; and

8 (2) in subparagraphs (E), (F), and (H), by in9 serting ‘‘and supplies’’ before the period at the end.

10 (c) REVISION OF EFFECTIVE DATE EXCEPTION PRO11 VISION.—Section 13562(b)(2) of OBRA–1993 is amended

12 by striking subparagraphs (A) and (B) and inserting the

13 following:

14 ‘‘(A) the second sentence of subsection

15 (a)(2), and subsections (b)(2)(B) and (d)(2), of

16 section 1877 of the Social Security Act (as in

17 effect on the day before the date of the enact18 ment of this Act) shall apply instead of the cor19 responding provisions in section 1877 (as

20 amended by this Act);

21 ‘‘(B) section 1877(b)(4) of the Social Se22 curity Act (as in effect on the day before the

23 date of the enactment of this Act) shall apply;

24 ‘‘(C) the requirements of section

25 1877(c)(2) of the Social Security Act (as
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1 amended by this Act) shall not apply to any se2 curities of a corporation that meets the require3 ments of section 1877(c)(2) of the Social Secu4 rity Act (as in effect on the day before the date

5 of the enactment of this Act);

6 ‘‘(D) section 1877(e)(3) of the Social Secu7 rity Act (as amended by this Act) shall apply,

8 except that it shall not apply to any arrange9 ment that meets the requirements of subsection

10 (e)(2) or subsection (e)(3) of section 1877 of

11 the Social Security Act (as in effect on the day

12 before the date of the enactment of this Act);

13 ‘‘(E) the requirements of clauses (iv) and

14 (v) of section 1877(h)(4)(A), and of clause (i)

15 of section 1877(h)(4)(B), of the Social Security

16 Act (as amended by this Act) shall not apply;

17 and

18 ‘‘(F) section 1877(h)(4)(B) of the Social

19 Security Act (as in effect on the day before the

20 date of the enactment of this Act) shall apply

21 instead of section 1877(h)(4)(A)(ii) of such Act

22 (as amended by this Act).’’.

23 (d) EFFECTIVE DATES.—
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1 (1) The amendments made by subsections (a)

2 and (b) shall apply to referrals made on or after

3 January 1, 1995.

4 (2) The amendment made by subsection (c)

5 shall apply as if included in the enactment of

6 OBRA–1993.

7 SEC. 153. DEFINITION OF FMGEMS EXAMINATION FOR PAY8 MENT OF DIRECT GRADUATE MEDICAL EDU9 CATION.

10 (a) IN GENERAL.—Section 1886(h)(5)(E) (42 U.S.C.

11 1395ww(h)(5)(E)) is amended by inserting ‘‘or any suc12 cessor examination’’ after ‘‘Medical Sciences’’.

13 (b) EFFECTIVE DATE.—The amendment made by

14 subsection (a) shall apply as if included in the enactment

15 of the Consolidated Omnibus Budget Reconciliation Act

16 of 1985 (Public Law 99–272).

17 SEC. 154. QUALIFIED MEDICARE BENEFICIARY OUTREACH.

18 Not later than 1 year after the date of the enactment

19 of this Act, the Secretary of Health and Human Services

20 shall establish and implement a method for obtaining in21 formation from newly eligible medicare beneficiaries that

22 may be used to determine whether such beneficiaries may

23 be eligible for medical assistance for medicare cost-sharing

24 under State medicaid plans as qualified medicare bene-
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1 ficiaries, and for transmitting such information to the

2 State in which such a beneficiary resides.

3 SEC. 155. HOSPITAL AGREEMENTS WITH ORGAN PROCURE4 MENT ORGANIZATIONS.

5 (a) HOSPITAL AGREEMENTS.—

6 (1) IN GENERAL.—

7 (A) IDENTIFICATION OF ORGAN DO8 NORS.—Section 1138(a)(1)(A)(iii) (42 U.S.C.

9 1320b–8(a)(1)(A)(iii)) is amended to read as

10 follows:

11 ‘‘(iii) require that such hospital’s des12 ignated organ procurement agency (as defined

13 in paragraph (3)(B)) is notified of potential

14 organ donors;’’.

15 (B) AGREEMENTS WITH DESIGNATED

16 ORGAN PROCUREMENT AGENCIES.—Section

17 1138(a)(1) (42 U.S.C. 1320b–8(a)(1)) is

18 amended—

19 (i) by striking the period at the end of

20 subparagraph (B) and inserting ‘‘; and’’;

21 and

22 (ii) by adding at the end the following

23 new subparagraph:

24 ‘‘(C) the hospital or rural primary care hospital

25 has an agreement (as defined in paragraph (3)(A))
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1 only with such hospital’s designated organ procure2 ment agency.’’.

3 (C) WAIVER OF REQUIREMENTS RELATED

4 TO AGREEMENTS.—Section 1138(a) (42 U.S.C.

5 1320b–8(a)) is amended—

6 (i) by redesignating paragraph (2) as

7 paragraph (3); and

8 (ii) by inserting after paragraph (1)

9 the following new paragraph:

10 ‘‘(2)(A) The Secretary shall grant a waiver of the re11 quirements under subparagraphs (A)(iii) and (C) of para12 graph (1) to a hospital or rural primary care hospital de13 siring to enter into an agreement with an organ procure14 ment agency other than such hospital’s designated organ

15 procurement agency if the Secretary determines that—

16 ‘‘(i) the waiver is expected to increase organ do17 nation; and

18 ‘‘(ii) the waiver will assure equitable treatment

19 of patients referred for transplants within the serv20 ice area served by such hospital’s designated organ

21 procurement agency and within the service area

22 served by the organ procurement agency with which

23 the hospital seeks to enter into an agreement under

24 the waiver.
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1 ‘‘(B) In making a determination under subparagraph

2 (A), the Secretary may consider factors that would in3 clude, but not be limited to—

4 ‘‘(i) cost effectiveness;

5 ‘‘(ii) improvements in quality;

6 ‘‘(iii) whether there has been any change in a

7 hospital’s designated organ procurement agency due

8 to a change made on or after December 28, 1992,

9 in the definitions for metropolitan statistical areas

10 (as established by the Office of Management and

11 Budget); and

12 ‘‘(iv) the length and continuity of a hospital’s

13 relationship with an organ procurement agency other

14 than the hospital’s designated organ procurement

15 agency;

16 except that nothing in this subparagraph shall be con17 strued to permit the Secretary to grant a waiver that does

18 not meet the requirements of subparagraph (A).

19 ‘‘(C) Any hospital or rural primary care hospital

20 seeking a waiver under subparagraph (A) shall submit an

21 application to the Secretary containing such information

22 as the Secretary determines appropriate.

23 ‘‘(D) The Secretary shall—

24 ‘‘(i) publish a public notice of any waiver appli25 cation received from a hospital or rural primary care
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1 hospital under this paragraph within 30 days of re2 ceiving such application; and

3 ‘‘(ii) prior to making a final determination on

4 such application under subparagraph (A), offer in5 terested parties the opportunity to submit written

6 comments to the Secretary during the 60-day period

7 beginning on the date such notice is published.’’.

8 (D) DEFINITIONS.—Section 1138(a)(3)

9 (42 U.S.C. 1320b–8(a)(3)), as redesignated by

10 subparagraph (C), is amended to read as fol11 lows:

12 ‘‘(3) For purposes of this subsection—

13 ‘‘(A) the term ‘agreement’ means an agreement

14 described in section 371(b)(3)(A) of the Public

15 Health Service Act;

16 ‘‘(B) the term ‘designated organ procurement

17 agency’ means, with respect to a hospital or rural

18 primary care hospital, the organ procurement agency

19 designated pursuant to subsection (b) for the service

20 area in which such hospital is located; and

21 ‘‘(C) the term ‘organ’ means a human kidney,

22 liver, heart, lung, pancreas, and any other human

23 organ or tissue specified by the Secretary for pur24 poses of this subsection.’’.
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1 (2) EXISTING AGREEMENTS.—Any hospital or

2 rural primary care hospital which has an agreement

3 (as defined in section 1138(a)(3)(A) of the Social

4 Security Act) with an organ procurement agency

5 other than such hospital’s designated organ procure6 ment agency (as defined in section 1138(a)(3)(B) of

7 such Act) on the date of the enactment of this sec8 tion shall, if such hospital desires to continue such

9 agreement on and after the effective date of the

10 amendments made by paragraph (1), submit an ap11 plication to the Secretary for a waiver under section

12 1138(a)(2) of such Act not later than January 1,

13 1995, and such agreement may continue in effect

14 pending the Secretary’s determination with respect

15 to such application.

16 (3) EFFECTIVE DATE.—The amendments made

17 by paragraph (1) shall apply to hospitals and rural

18 primary care hospitals participating in the programs

19 under titles XVIII and XIX of the Social Security

20 Act beginning January 1, 1995.

21 (b) STUDY ON HOSPITAL AGREEMENTS WITH ORGAN

22 PROCUREMENT AGENCIES.—

23 (1) IN GENERAL.—The Office of Technology

24 Assessment (referred to in this section as the

25 ‘‘OTA’’) shall, pursuant to the approval of the Tech-
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1 nology Assessment Board of the OTA, conduct a

2 study to determine the efficacy and fairness of re3 quiring a hospital to enter into an agreement under

4 section 371(b)(3)(A) of the Public Health Service

5 Act with the organ procurement agency designated

6 pursuant to section 1138(b) of the Social Security

7 Act for the service area in which such hospital is lo8 cated and the impact of such requirement on the ef9 ficacy and fairness of organ procurement and dis10 tribution.

11 (2) REPORT.—Not later than 2 years after the

12 date of the enactment of this Act, the OTA shall

13 complete the study required under paragraph (1)

14 and prepare and submit to the Committee on Fi15 nance and the Committee on Labor and Human Re16 sources of the Senate and the Committee on Ways

17 and Means and the Committee on Energy and Com18 merce of the House of Representatives a report con19 taining the findings of such study and the implica20 tions of such findings with respect to policies affect21 ing organ procurement and distribution.

22 SEC. 156. PEER REVIEW ORGANIZATIONS.

23 (a) REPEAL OF PRO PRECERTIFICATION REQUIRE24 MENT FOR CERTAIN SURGICAL PROCEDURES.—
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1 (1) IN GENERAL.—Section 1164 (42 U.S.C.

2 1320c–13) is repealed.

3 (2) CONFORMING AMENDMENTS.—

4 (A) Section 1154 (42 U.S.C. 1320c–3) is

5 amended—

6 (i) in subsection (a), by striking para7 graph (12), and

8 (ii) in subsection (d), by striking

9 ‘‘(and except as provided in section

10 1164)’’.

11 (B) Section 1833 (42 U.S.C. 1395l) is

12 amended—

13 (i) in subsection (a)(1)(D)(i), by strik14 ing ‘‘, or for tests furnished in connection

15 with obtaining a second opinion required

16 under section 1164(c)(2) (or a third opin17 ion, if the second opinion was in disagree18 ment with the first opinion)’’;

19 (ii) in subsection (a)(1), by striking

20 subparagraph (G);

21 (iii) in subsection (a)(2)(A), by strik22 ing ‘‘, to items and services (other than

23 clinical diagnostic laboratory tests) fur24 nished in connection with obtaining a sec25 ond opinion required under section
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1 1164(c)(2) (or a third opinion, if the sec2 ond opinion was in disagreement with the

3 first opinion),’’;

4 (iv) in subsection (a)(2)(D)(i)—

5 (I) by striking ‘‘basis,’’ and in6 serting ‘‘basis or’’, and

7 (II) by striking ‘‘, or for tests

8 furnished in connection with obtaining

9 a second opinion required under sec10 tion 1164(c)(2) (or a third opinion, if

11 the second opinion was in disagree12 ment with the first opinion)’’;

13 (v) in subsection (a)(3), by striking

14 ‘‘and for items and services furnished in

15 connection with obtaining a second opinion

16 required under section 1164(c)(2), or a

17 third opinion, if the second opinion was in

18 disagreement with the first opinion’’; and

19 (vi) in the first sentence of subsection

20 (b), by striking ‘‘(4)’’ and all that follows

21 through ‘‘and (5)’’ and inserting ‘‘and

22 (4)’’.

23 (C) Section 1834(g)(1)(B) (42 U.S.C.

24 1395m(g)(1)(B)) is amended by striking ‘‘and

25 for items and services furnished in connection
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1 with obtaining a second opinion required under

2 section 1164(c)(2), or a third opinion, if the

3 second opinion was in disagreement with the

4 first opinion’’.

5 (D) Section 1862(a) (42 U.S.C. 1395y(a))

6 is amended—

7 (i) by adding ‘‘or’’ at the end of para8 graph (14),

9 (ii) by striking ‘‘; or’’ at the end of

10 paragraph (15) and inserting a period, and

11 (iii) by striking paragraph (16).

12 (E) The third sentence of section

13 1866(a)(2)(A) (42 U.S.C. 1395w(a)(2)(A)) is

14 amended by striking ‘‘, with respect to items

15 and services furnished in connection with ob16 taining a second opinion required under section

17 1164(c)(2) (or a third opinion, if the second

18 opinion was in disagreement with the first opin19 ion),’’.

20 (3) EFFECTIVE DATE.—The amendments made

21 by this subsection shall apply to services provided on

22 or after the date of the enactment of this Act.

23 (b) MISCELLANEOUS AND TECHNICAL CORREC24 TIONS.—(1) The third sentence of section 1156(b)(1) (42
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1 U.S.C. 1320c–5(b)(1)) is amended by striking ‘‘whehter’’

2 and inserting ‘‘whether’’.

3 (2)(A) Section 1154(a)(9)(B) (42 U.S.C. 1320c–

4 3(a)(9)(B)) is amended to read as follows:

5 ‘‘(B) If the organization finds, after reasonable

6 notice to and opportunity for discussion with the

7 physician or practitioner concerned, that the physi8 cian or practitioner has furnished services in viola9 tion of section 1156(a) and the organization deter10 mines that the physician or practitioner should enter

11 into a corrective action plan under section

12 1156(b)(1), the organization shall notify the State

13 board or boards responsible for the licensing or dis14 ciplining of the physician or practitioner of its find15 ing and of any action taken as a result of the find16 ing.’’.

17 (B) Subparagraph (D) of section 1160(b)(1) (42

18 U.S.C. 1320c–9(b)(1)) is amended to read as follows:

19 ‘‘(D) to provide notice in accordance with

20 section 1154(a)(9)(B);’’.

21 (3) Section 4205(d)(2)(B) of OBRA–1990 is amend22 ed by striking ‘‘amendments’’ and inserting ‘‘amend23 ment’’.

24 (4) Section 1160(d) (42 U.S.C. 1320c–9(d)) is

25 amended by striking ‘‘subpena’’ and inserting ‘‘subpoena’’.
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1 (5) Section 4205(e)(2) of OBRA–1990 is amended

2 by striking ‘‘amendments’’ and inserting ‘‘amendment’’

3 and by striking ‘‘all’’.

4 (6)(A) Except as provided in subparagraph (B), the

5 amendments made by this subsection shall take effect as

6 if included in the enactment of OBRA–1990.

7 (B) The amendments made by paragraph (2) (relat8 ing to the requirement on reporting of information to

9 State boards) shall take effect on the date of the enact10 ment of this Act.

11 SEC. 157. HEALTH MAINTENANCE ORGANIZATIONS.

12 (a) ADJUSTMENT IN MEDICARE CAPITATION PAY13 MENTS TO TAKE INTO ACCOUNT SECONDARY PAYER STA14 TUS.—

15 (1) IN GENERAL.—In defining the classes to be

16 used in determining the annual per capita rate of

17 payment under section 1876(a)(1)(B) of the Social

18 Security Act to an eligible organization with a risk19 sharing contract under such section (for months be20 ginning after June 1994), the Secretary of Health

21 and Human Services shall treat as a separate class

22 individuals entitled to benefits under title XVIII of

23 such Act with respect to whom there is a group

24 health plan that is a primary plan (within the mean25 ing of section 1862(b)(2)(A) of such Act).
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1 (2) DEADLINE FOR ANNOUNCEMENT OF

2 RATES.—Not later than May 15, 1994, the Sec3 retary shall announce annual per capita rates of

4 payment for eligible organizations described in para5 graph (1) that take into account the separate treat6 ment of individuals with respect to whom there is a

7 group health plan that is a primary plan.

8 (b) REVISIONS IN THE PAYMENT METHODOLOGY

9 FOR RISK CONTRACTORS.—Section 4204(b) of OBRA–

10 1990 is amended to read as follows:

11 ‘‘(b) REVISIONS IN THE PAYMENT METHODOLOGY

12 FOR RISK CONTRACTORS.—(1)(A) Not later than October

13 1, 1994, the Secretary of Health and Human Services (in

14 this subsection referred to as the ‘Secretary’) shall submit

15 a proposal to the Congress that provides for revisions to

16 the payment method to be applied in years beginning with

17 1996 for organizations with a risk-sharing contract under

18 section 1876(g) of the Social Security Act.

19 ‘‘(B) In proposing the revisions required under sub20 paragraph (A), the Secretary shall consider—

21 ‘‘(i) the difference in costs associated with med22 icare beneficiaries with differing health status and

23 demographic characteristics; and
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1 ‘‘(ii) the effects of using alternative geographic

2 classifications on the determinations of costs associ3 ated with beneficiaries residing in different areas.

4 ‘‘(2) Not later than 3 months after the date of sub5 mittal of the proposal under paragraph (1), the Comptrol6 ler General shall review the proposal and shall report to

7 Congress on the appropriateness of the proposed modifica8 tions.’’.

9 (c) MISCELLANEOUS AND TECHNICAL CORREC10 TIONS.—(1) Section 1876(a)(3) (42 U.S.C.

11 1395mm(a)(3)) is amended by striking ‘‘subsection

12 (c)(7)’’ and inserting ‘‘subsections (c)(2)(B)(ii) and

13 (c)(7)’’.

14 (2) Section 4204(c)(3) of OBRA–1990 is amended

15 by striking ‘‘for 1991’’ and inserting ‘‘for years beginning

16 with 1991’’.

17 (3) Section 4204(d)(2) of OBRA–1990 is amended

18 by striking ‘‘amendment’’ and inserting ‘‘amendments’’.

19 (4) Section 1876(a)(1)(E)(ii)(I) (42 U.S.C.

20 1395mm(a)(1)(E)(ii)(I)) is amended by striking the

21 comma after ‘‘contributed to’’.

22 (5) Section 4204(e)(2) of OBRA–1990 is amended

23 by striking ‘‘(which has a risk-sharing contract under sec24 tion 1876 of the Social Security Act)’’.
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1 (6) Section 4204(f)(4) of OBRA–1990 is amended by

2 striking ‘‘final’’.

3 (7) Section 1862(b)(3)(C) (42 U.S.C.

4 1395y(b)(3)(C)) is amended—

5 (A) in the heading, by striking ‘‘PLAN’’ and in6 serting ‘‘PLAN OR A LARGE GROUP HEALTH PLAN’’;

7 (B) by striking ‘‘group health plan’’ and insert8 ing ‘‘group health plan or a large group health

9 plan’’;

10 (C) by striking ‘‘, unless such incentive is also

11 offered to all individuals who are eligible for cov12 erage under the plan’’; and

13 (D) by striking ‘‘the first sentence of subsection

14 (a) and other than subsection (b)’’ and inserting

15 ‘‘subsections (a) and (b)’’.

16 (8) The amendments made by this subsection shall

17 take effect as if included in the enactment of OBRA–1990.

18 SEC. 158. HOME HEALTH AGENCIES.

19 (a) USE OF MOST CURRENT DATA IN DETERMINING

20 WAGE INDEX.—

21 (1) IN GENERAL.—Section 1861(v)(1)(L)(iii)

22 (42 U.S.C. 1395x(v)(1)(L)(iii)) is amended by strik23 ing ‘‘as of such date to’’ and inserting ‘‘and deter24 mined using the survey of the most recent available

25 wages and wage-related costs of’’.
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1 (2) EFFECTIVE DATE.—The amendment made

2 by paragraph (1) shall apply with respect to cost re3 porting periods beginning on or after July 1, 1996.

4 (b) CLARIFICATION OF EXTENSION OF WAIVER OF

5 LIABILITY.—

6 (1) IN GENERAL.—The second sentence of sec7 tion 9205 of the Consolidated Omnibus Budget Rec8 onciliation Act of 1985 is amended by striking ‘‘No9 vember 1, 1990’’ and inserting ‘‘December 31,

10 1995’’.

11 (2) EFFECTIVE DATE.—The amendment made

12 by paragraph (1) shall take effect as if included in

13 the enactment of OBRA–1990.

14 SEC. 159. PERMANENT EXTENSION OF AUTHORITY TO CON15 TRACT WITH FISCAL INTERMEDIARIES AND

16 CARRIERS ON OTHER THAN A COST BASIS.

17 (a) IN GENERAL.—Section 2326(a) of the Deficit Re18 duction Act of 1984, as amended by section 6215 of

19 OBRA–1989, is amended in the third sentence by striking

20 ‘‘during such period’’ and inserting ‘‘beginning with fiscal

21 year 1990 and any subsequent fiscal year’’.

22 (b) EFFECTIVE DATE.—The amendment made by

23 subsection (a) shall apply beginning with fiscal year 1994.
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1 SEC. 160. MISCELLANEOUS AND TECHNICAL CORRECTIONS.

2 (a) SURVEY AND CERTIFICATION REQUIREMENTS.—

3 (1) Section 1864 (42 U.S.C. 1395aa) is amended—

4 (A) in subsection (e), by striking ‘‘title’’ and in5 serting ‘‘title (other than any fee relating to section

6 353 of the Public Health Service Act)’’; and

7 (B) in the first sentence of subsection (a), by

8 striking ‘‘1861(s) or’’ and all that follows through

9 ‘‘Service Act,’’ and inserting ‘‘1861(s),’’.

10 (2) An agreement made by the Secretary of Health

11 and Human Services with a State under section 1864(a)

12 of the Social Security Act may include an agreement that

13 the services of the State health agency or other appro14 priate State agency (or the appropriate local agencies) will

15 be utilized by the Secretary for the purpose of determining

16 whether a laboratory meets the requirements of section

17 353 of the Public Health Service Act.

18 (b) HOME DIALYSIS DEMONSTRATION TECHNICAL

19 CORRECTIONS.—Section 4202 of OBRA–1990 is amend20 ed—

21 (1) in subsection (b)(1)(A), by striking ‘‘home

22 hemodialysis staff assistant’’ and inserting ‘‘quali23 fied home hemodialysis staff assistant (as described

24 in subsection (d))’’;
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1 (2) in subsection (b)(2)(B)(ii)(I), by striking

2 ‘‘(as adjusted to reflect differences in area wage

3 levels)’’;

4 (3) in subsection (c)(1)(A), by striking

5 ‘‘skilled’’; and

6 (4) in subsection (c)(1)(E), by striking ‘‘(b)(4)’’

7 and inserting ‘‘(b)(2)’’.

8 (c) TECHNICAL CORRECTION TO REVISIONS OF COV9 ERAGE FOR IMMUNOSUPPRESSIVE DRUG THERAPY.—Sec10 tion 1861(s)(2)(J) (42 U.S.C. 1395x(s)(2)(J)), as amend11 ed by section 13565 of OBRA–1993, is amended—

12 (1) by redesignating clauses (ii) through (v) as

13 clauses (iii) through (vi); and

14 (2) by striking clause (i) and inserting the fol15 lowing:

16 ‘‘(i) before 1994, within 12 months after

17 the date of the transplant procedure,

18 ‘‘(ii) to an individual who receives a trans19 plant during 1994, within 487 days after the

20 date of the transplant procedure,’’.

21 (d) OTHER MISCELLANEOUS AND TECHNICAL PRO22 VISIONS.—(1) Section 1833 (42 U.S.C. 1395l) is amended

23 by redesignating the subsection (r) added by section

24 4206(b)(2) of OBRA–1990 as subsection (s).
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1 (2) Section 1866(f)(1) (42 U.S.C. 1395cc(f)(1)) is

2 amended by striking ‘‘1833(r)’’ and inserting ‘‘1833(s)’’.

3 (3) Section 4201(d)(2) of OBRA–1990 is amended

4 by striking ‘‘(B) by striking’’, ‘‘(C) by striking’’, and ‘‘(3)

5 by adding’’ and inserting ‘‘(i) by striking’’, ‘‘(ii) by strik6 ing’’, and ‘‘(B) by adding’’, respectively.

7 (4) The section following section 4206 of OBRA–

8 1990 is amended by striking ‘‘SEC. 4027.’’ and inserting

9 ‘‘SEC. 4207.’’, and in this subtitle is referred to as section

10 4207 of OBRA–1990.

11 (5)(A) Section 4207(a)(1) of OBRA–1990 is amend12 ed by adding closing quotation marks and a period after

13 ‘‘such review.’’.

14 (B) Section 4207(a)(4) of OBRA–1990 is amended

15 by striking ‘‘this subsection’’ and inserting ‘‘paragraphs

16 (2) and (3)’’.

17 (C) Section 4207(b)(1) of OBRA–1990 is amended

18 by striking ‘‘section 3(7)’’ and inserting ‘‘section

19 601(a)(1)’’.

20 (6) Section 2355(b)(1)(B) of the Deficit Reduction

21 Act of 1984, as amended by section 4207(b)(4)(B)(ii) of

22 OBRA–1990, is amended—

23 (A) by striking ‘‘12907(c)(4)(A)’’ and inserting

24 ‘‘4207(b)(4)(B)(i)’’, and
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1 (B) by striking ‘‘feasibilitly’’ and inserting ‘‘fea2 sibility’’.

3 (7) Section 4207(b)(4)(B)(iii)(III) of OBRA–1990 is

4 amended by striking the period at the end and inserting

5 a semicolon.

6 (8) Subsections (c)(3) and (e) of section 2355 of the

7 Deficit Reduction Act of 1984, as amended by section

8 4207(b)(4)(B) of OBRA–1990, are each amended by

9 striking ‘‘12907(c)(4)(A)’’ each place it appears and in10 serting ‘‘4207(b)(4)(B)’’.

11 (9) Section 4207(c)(2) of OBRA–1990 is amended

12 by striking ‘‘the Committee on Ways and Means’’ each

13 place it appears and inserting ‘‘the Committees on Ways

14 and Means and Energy and Commerce’’.

15 (10) Section 4207(d) of OBRA–1990 is amended by

16 redesignating the second paragraph (3) (relating to effec17 tive date) as paragraph (4).

18 (11) Section 4207(i)(2) of OBRA–1990 is amend19 ed—

20 (A) by striking the period at the end of clause

21 (iii) and inserting a semicolon, and

22 (B) in clause (v), by striking ‘‘residents’’ and

23 inserting ‘‘patients’’.
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1 (12) Section 4207(j) of OBRA–1990 is amended by

2 striking ‘‘title’’ each place it appears and inserting ‘‘sub3 title’’.

4 Subtitle D—Provisions Relating to

5 Medicare Supplemental Insur6 ance Policies

7 SEC. 171. STANDARDS FOR MEDICARE SUPPLEMENTAL IN8 SURANCE POLICIES.

9 (a) SIMPLIFICATION OF MEDICARE SUPPLEMENTAL

10 POLICIES.—

11 (1) Section 4351 of OBRA–1990 is amended by

12 striking ‘‘(a) IN GENERAL.—’’.

13 (2) Section 1882(p) (42 U.S.C. 1395ss(p)) is

14 amended—

15 (A) in paragraph (1)(A)—

16 (i) by striking ‘‘promulgates’’ and in17 serting ‘‘changes the revised NAIC Model

18 Regulation (described in subsection (m)) to

19 incorporate’’,

20 (ii) by striking ‘‘(such limitations, lan21 guage, definitions, format, and standards

22 referred to collectively in this subsection as

23 ‘NAIC standards’),’’, and

24 (iii) by striking ‘‘included a reference

25 to the NAIC standards’’ and inserting
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1 ‘‘were a reference to the revised NAIC

2 Model Regulation as changed under this

3 subparagraph (such changed regulation re4 ferred to in this section as the ‘1991 NAIC

5 Model Regulation’)’’;

6 (B) in paragraph (1)(B)—

7 (i) by striking ‘‘promulgate NAIC

8 standards’’ and inserting ‘‘make the

9 changes in the revised NAIC Model Regu10 lation’’,

11 (ii) by striking ‘‘limitations, language,

12 definitions, format, and standards de13 scribed in clauses (i) through (iv) of such

14 subparagraph (in this subsection referred

15 to collectively as ‘Federal standards’)’’ and

16 inserting ‘‘a regulation’’, and

17 (iii) by striking ‘‘included a reference

18 to the Federal standards’’ and inserting

19 ‘‘were a reference to the revised NAIC

20 Model Regulation as changed by the Sec21 retary under this subparagraph (such

22 changed regulation referred to in this sec23 tion as the ‘1991 Federal Regulation’)’’;

24 (C) in paragraph (1)(C)(i), by striking

25 ‘‘NAIC standards or the Federal standards’’
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1 and inserting ‘‘1991 NAIC Model Regulation or

2 1991 Federal Regulation’’;

3 (D) in paragraphs (1)(C)(ii)(I), (1)(E),

4 (2), and (9)(B), by striking ‘‘NAIC or Federal

5 standards’’ and inserting ‘‘1991 NAIC Model

6 Regulation or 1991 Federal Regulation’’;

7 (E) in paragraph (2)(C), by striking

8 ‘‘(5)(B)’’ and inserting ‘‘(4)(B)’’;

9 (F) in paragraph (4)(A)(i), by inserting

10 ‘‘or paragraph (6)’’ after ‘‘(B)’’;

11 (G) in paragraph (4), by striking ‘‘applica12 ble standards’’ each place it appears and insert13 ing ‘‘applicable 1991 NAIC Model Regulation

14 or 1991 Federal Regulation’’;

15 (H) in paragraph (6), by striking ‘‘in re16 gard to the limitation of benefits described in

17 paragraph (4)’’ and inserting ‘‘described in

18 clauses (i) through (iii) of paragraph (1)(A)’’;

19 (I) in paragraph (7), by striking ‘‘policy20 holder’’ and inserting ‘‘policyholders’’;

21 (J) in paragraph (8), by striking ‘‘after the

22 effective date of the NAIC or Federal standards

23 with respect to the policy, in violation of the

24 previous requirements of this subsection’’ and

25 inserting ‘‘on and after the effective date speci-
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1 fied in paragraph (1)(C) (but subject to para2 graph (10)), in violation of the applicable 1991

3 NAIC Model Regulation or 1991 Federal Regu4 lation insofar as such regulation relates to the

5 requirements of subsection (o) or (q) or clause

6 (i), (ii), or (iii) of paragraph (1)(A)’’;

7 (K) in paragraph (9), by adding at the end

8 the following new subparagraph:

9 ‘‘(D) Subject to paragraph (10), this paragraph shall

10 apply to sales of policies occurring on or after the effective

11 date specified in paragraph (1)(C).’’; and

12 (L) in paragraph (10), by striking ‘‘this

13 subsection’’ and inserting ‘‘paragraph

14 (1)(A)(i)’’.

15 (b) GUARANTEED RENEWABILITY.—Section 1882(q)

16 (42 U.S.C. 1395ss(q)) is amended—

17 (1) in paragraph (2), by striking ‘‘paragraph

18 (2)’’ and inserting ‘‘paragraph (4)’’, and

19 (2) in paragraph (4), by striking ‘‘the succeed20 ing issuer’’ and inserting ‘‘issuer of the replacement

21 policy’’.

22 (c) ENFORCEMENT OF STANDARDS.—

23 (1) Section 1882(a)(2) (42 U.S.C.

24 1395ss(a)(2)) is amended—
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1 (A) in subparagraph (A), by striking

2 ‘‘NAIC standards or the Federal standards’’

3 and inserting ‘‘1991 NAIC Model Regulation or

4 1991 Federal Regulation’’, and

5 (B) by striking ‘‘after the effective date of

6 the NAIC or Federal standards with respect to

7 the policy’’ and inserting ‘‘on and after the ef8 fective date specified in subsection (p)(1)(C)’’.

9 (2) The sentence in section 1882(b)(1) added

10 by section 4353(c)(5) of OBRA–1990 is amended—

11 (A) by striking ‘‘The report’’ and inserting

12 ‘‘Each report’’,

13 (B) by inserting ‘‘and requirements’’ after

14 ‘‘standards’’,

15 (C) by striking ‘‘and’’ after ‘‘compliance,’’,

16 and

17 (D) by striking the comma after ‘‘Commis18 sioners’’.

19 (3) Section 1882(g)(2)(B) (42 U.S.C.

20 1395ss(g)(2)(B)) is amended by striking ‘‘Panel’’

21 and inserting ‘‘Secretary’’.

22 (4) Section 1882(b)(1) (42 U.S.C.

23 1395ss(b)(1)) is amended by striking ‘‘the the Sec24 retary’’ and inserting ‘‘the Secretary’’.

25 (d) PREVENTING DUPLICATION.—
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1 (1) Section 1882(d)(3)(A) (42 U.S.C.

2 1395ss(d)(3)(A)) is amended—

3 (A) by amending the first sentence to read

4 as follows:

5 ‘‘(i) It is unlawful for a person to sell or issue to an

6 individual entitled to benefits under part A or enrolled

7 under part B of this title—

8 ‘‘(I) a health insurance policy with knowledge

9 that the policy duplicates health benefits to which

10 the individual is otherwise entitled under this title or

11 title XIX,

12 ‘‘(II) a medicare supplemental policy with

13 knowledge that the individual is entitled to benefits

14 under another medicare supplemental policy, or

15 ‘‘(III) a health insurance policy (other than a

16 medicare supplemental policy) with knowledge that

17 the policy duplicates health benefits to which the in18 dividual is otherwise entitled, other than benefits to

19 which the individual is entitled under a requirement

20 of State or Federal law.’’;

21 (B) by designating the second sentence as

22 clause (ii) and, in such clause, by striking ‘‘the

23 previous sentence’’ and inserting ‘‘clause (i)’’;

24 (C) by designating the third sentence as

25 clause (iii) and, in such clause—
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1 (i) by striking ‘‘the previous sentence’’

2 and inserting ‘‘clause (i) with respect to

3 the sale of a medicare supplemental pol4 icy’’, and

5 (ii) by striking ‘‘and the statement’’

6 and all that follows up to the period at the

7 end; and

8 (D) by striking the last sentence.

9 (2) Section 1882(d)(3)(B) (42 U.S.C.

10 1395ss(d)(3)(B)) is amended—

11 (A) in clause (ii)(II), by striking ‘‘65 years

12 of age or older’’,

13 (B) in clause (iii)(I), by striking ‘‘another

14 medicare’’ and inserting ‘‘a medicare’’,

15 (C) in clause (iii)(I), by striking ‘‘such a

16 policy’’ and inserting ‘‘a medicare supplemental

17 policy’’,

18 (D) in clause (iii)(II), by striking ‘‘another

19 policy’’ and inserting ‘‘a medicare supplemental

20 policy’’, and

21 (E) by amending subclause (III) of clause

22 (iii) to read as follows:

23 ‘‘(III) If the statement required by clause (i) is ob24 tained and indicates that the individual is entitled to any

25 medical assistance under title XIX, the sale of the policy
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1 is not in violation of clause (i) (insofar as such clause re2 lates to such medical assistance), if (aa) a State medicaid

3 plan under such title pays the premiums for the policy,

4 (bb) in the case of a qualified medicare beneficiary de5 scribed in section 1905(p)(1), the policy provides for cov6 erage of outpatient prescription drugs, or (cc) the only

7 medical assistance to which the individual is entitled under

8 the State plan is medicare cost sharing described in sec9 tion 1905(p)(3)(A)(ii).’’.

10 (3)(A) Section 1882(d)(3)(C) (42 U.S.C.

11 1395ss(d)(3)(C)) is amended—

12 (i) by striking ‘‘the selling’’ and inserting

13 ‘‘(i) the sale or issuance’’, and

14 (ii) by inserting before the period at the

15 end the following: ‘‘, (ii) the sale or issuance of

16 a policy or plan described in subparagraph

17 (A)(i)(I) (other than a medicare supplemental

18 policy to an individual entitled to any medical

19 assistance under title XIX) under which all the

20 benefits are fully payable directly to or on be21 half of the individual without regard to other

22 health benefit coverage of the individual but

23 only if (for policies sold or issued more than 60

24 days after the date the statements are pub25 lished or promulgated under subparagraph (D))
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1 there is disclosed in a prominent manner as

2 part of (or together with) the application the

3 applicable statement (specified under subpara4 graph (D)) of the extent to which benefits pay5 able under the policy or plan duplicate benefits

6 under this title, or (iii) the sale or issuance of

7 a policy or plan described in subparagraph

8 (A)(i)(III) under which all the benefits are fully

9 payable directly to or on behalf of the individual

10 without regard to other health benefit coverage

11 of the individual’’.

12 (B) Section 1882(d)(3) (42 U.S.C.

13 1395ss(d)(3)) is amended by adding at the end the

14 following:

15 ‘‘(D)(i) If—

16 ‘‘(I) within the 90-day period beginning on the

17 date of the enactment of this subparagraph, the Na18 tional Association of Insurance Commissioners devel19 ops (after consultation with consumer and insurance

20 industry representatives) and submits to the Sec21 retary a statement for each of the types of health in22 surance policies (other than medicare supplemental

23 policies and including, but not limited to, as sepa24 rate types of policies, policies paying directly to the

25 beneficiary fixed, cash benefits, and policies that
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1 limit benefit payments to specific diseases) which are

2 sold or issued to persons entitled to health benefits

3 under this title, of the extent to which benefits pay4 able under the policy or plan duplicate benefits

5 under this title, and

6 ‘‘(II) the Secretary approves all the statements

7 submitted as meeting the requirements of subclause

8 (I),

9 each such statement shall be (for purposes of subpara10 graph (C)) the statement specified under this subpara11 graph for the type of policy involved. The Secretary shall

12 review and approve (or disapprove) all the statements sub13 mitted under subclause (I) within 30 days after the date

14 of their submittal. Upon approval of such statements, the

15 Secretary shall publish such statements.

16 ‘‘(ii) If the Secretary does not approve the statements

17 under clause (i) or the statements are not submitted with18 in the 90-day period specified in such clause, the Secretary

19 shall promulgate (after consultation with consumer and

20 insurance industry representatives and not later than 90

21 days after the date of disapproval or the end of such 90-

22 day period (as the case may be)) a statement for each

23 of the types of health insurance policies (other than medi24 care supplemental policies and including, but not limited

25 to, as separate types of policies, policies paying directly
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1 to the beneficiary fixed, cash benefits, and policies that

2 limit benefit payments to specific diseases) which are sold

3 or issued to persons entitled to health benefits under this

4 title, of the extent to which benefits payable under the pol5 icy or plan duplicate benefits under this title, and each

6 such statement shall be (for purposes of subparagraph

7 (C)) the statement specified under this subparagraph for

8 the type of policy involved.’’.

9 (C) The requirement of a disclosure under sec10 tion 1882(d)(3)(C)(ii) of the Social Security Act

11 shall not apply to an application made for a policy

12 or plan before 60 days after the date the Secretary

13 of Health and Human Services publishes or promul14 gates all the statements under section

15 1882(d)(3)(D) of such Act.

16 (4) Subparagraphs (A) and (B) of section

17 1882(q)(5) are amended by striking ‘‘of the Social

18 Security Act’’.

19 (e) LOSS RATIOS AND REFUNDS OF PREMIUMS.—

20 (1) Section 1882(r) (42 U.S.C. 1395ss(r)) is

21 amended—

22 (A) in paragraph (1), by striking ‘‘or sold’’

23 and inserting ‘‘or renewed (or otherwise provide

24 coverage after the date described in subsection

25 (p)(1)(C))’’;
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1 (B) in paragraph (1)(A), by inserting ‘‘for

2 periods after the effective date of these provi3 sions’’ after ‘‘the policy can be expected’’;

4 (C) in paragraph (1)(A), by striking

5 ‘‘Commissioners,’’ and inserting ‘‘Commis6 sioners)’’;

7 (D) in paragraph (1)(B), by inserting be8 fore the period at the end the following: ‘‘,

9 treating policies of the same type as a single

10 policy for each standard package’’;

11 (E) by adding at the end of paragraph (1)

12 the following: ‘‘For the purpose of calculating

13 the refund or credit required under paragraph

14 (1)(B) for a policy issued before the date speci15 fied in subsection (p)(1)(C), the refund or cred16 it calculation shall be based on the aggregate

17 benefits provided and premiums collected under

18 all such policies issued by an insurer in a State

19 (separated as to individual and group policies)

20 and shall be based only on aggregate benefits

21 provided and premiums collected under such

22 policies after the date specified in section

23 171(m)(4) of the Social Security Act Amend24 ments of 1993.’’;
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1 (F) in the first sentence of paragraph

2 (2)(A), by striking ‘‘by policy number’’ and in3 serting ‘‘by standard package’’;

4 (G) by striking the second sentence of

5 paragraph (2)(A) and inserting the following:

6 ‘‘Paragraph (1)(B) shall not apply to a policy

7 until 12 months following issue.’’;

8 (H) in the last sentence of paragraph

9 (2)(A), by striking ‘‘in order’’ and all that fol10 lows through ‘‘are effective’’;

11 (I) by adding at the end of paragraph

12 (2)(A), the following new sentence: ‘‘In the case

13 of a policy issued before the date specified in

14 subsection (p)(1)(C), paragraph (1)(B) shall

15 not apply until 1 year after the date specified

16 in section 171(m)(4) of the Social Security Act

17 Amendments of 1993.’’;

18 (J) in paragraph (2), by striking ‘‘policy

19 year’’ each place it appears and inserting ‘‘cal20 endar year’’;

21 (K) in paragraph (4), by striking ‘‘Feb22 ruary’’, ‘‘disllowance’’, ‘‘loss-ratios’’ each place

23 it appears, and ‘‘loss-ratio’’ and inserting ‘‘Oc24 tober’’, ‘‘disallowance’’, ‘‘loss ratios’’, and ‘‘loss

25 ratio’’, respectively;
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1 (L) in paragraph (6)(A), by striking ‘‘is2 sues a policy in violation of the loss ratio re3 quirements of this subsection’’ and ‘‘such viola4 tion’’ and inserting ‘‘fails to provide refunds or

5 credits as required in paragraph (1)(B)’’ and

6 ‘‘policy issued for which such failure occurred’’,

7 respectively; and

8 (M) in paragraph (6)(B), by striking ‘‘to

9 policyholders’’ and inserting ‘‘to the policy10 holder or, in the case of a group policy, to the

11 certificate holder’’.

12 (2) Section 1882(b)(1) (42 U.S.C.

13 1395ss(b)(1)) is amended, in the matter after sub14 paragraph (H), by striking ‘‘subsection (F)’’ and in15 serting ‘‘subparagraph (F)’’.

16 (3) Section 4355(d) of OBRA–1990 is amended

17 by striking ‘‘sold or issued’’ and all that follows and

18 inserting ‘‘issued or renewed (or otherwise providing

19 coverage after the date described in section

20 1882(p)(1)(C) of the Social Security Act) on or after

21 the date specified in section 1882(p)(1)(C) of the

22 Social Security Act.’’.

23 (f) TREATMENT OF HMO’S.—

24 (1) Section 1882(g)(1) (42 U.S.C.

25 1395ss(g)(1)) is amended by striking ‘‘a health
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1 maintenance organization or other direct service or2 ganization’’ and all that follows through ‘‘1833’’ and

3 inserting ‘‘an eligible organization (as defined in sec4 tion 1876(b)) if the policy or plan provides benefits

5 pursuant to a contract under section 1876 or an ap6 proved demonstration project described in section

7 603(c) of the Social Security Amendments of 1983,

8 section 2355 of the Deficit Reduction Act of 1984,

9 or section 9412(b) of the Omnibus Budget Reconcili10 ation Act of 1986, or, during the period beginning

11 on the date specified in subsection (p)(1)(C) and

12 ending on December 31, 1994, a policy or plan of

13 an organization if the policy or plan provides bene14 fits pursuant to an agreement under section

15 1833(a)(1)(A)’’.

16 (2) Section 4356(b) of OBRA–1990 is amended

17 by striking ‘‘on the date of the enactment of this

18 Act’’ and inserting ‘‘on the date specified in section

19 1882(p)(1)(C) of the Social Security Act’’.

20 (g) PRE-EXISTING CONDITION LIMITATIONS.—Sec21 tion 1882(s) (42 U.S.C. 1395ss(s)) is amended—

22 (1) in paragraph (2)(A), by striking ‘‘for which

23 an application is submitted’’ and inserting ‘‘in the

24 case of an individual for whom an application is sub25 mitted prior to or’’,
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1 (2) in paragraph (2)(A), by striking ‘‘in which

2 the individual (who is 65 years of age or older) first

3 is enrolled for benefits under part B’’ and inserting

4 ‘‘as of the first day on which the individual is 65

5 years of age or older and is enrolled for benefits

6 under part B’’, and

7 (3) in paragraph (2)(B), by striking ‘‘before it’’

8 and inserting ‘‘before the policy’’.

9 (h) MEDICARE SELECT POLICIES.—

10 (1) Section 1882(t) (42 U.S.C. 1395ss(t)) is

11 amended—

12 (A) in paragraph (1), by inserting ‘‘medi13 care supplemental’’ after ‘‘If a’’,

14 (B) in paragraph (1), by striking ‘‘NAIC

15 Model Standards’’ and inserting ‘‘1991 NAIC

16 Model Regulation or 1991 Federal Regulation’’,

17 (C) in paragraph (1)(A), by inserting ‘‘or

18 agreements’’ after ‘‘contracts’’,

19 (D) in subparagraphs (E)(i) and (F) of

20 paragraph (1), by striking ‘‘NAIC standards’’

21 and inserting ‘‘standards in the 1991 NAIC

22 Model Regulation or 1991 Federal Regulation’’,

23 and
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1 (E) in paragraph (2), by inserting ‘‘the is2 suer’’ before ‘‘is subject to a civil money pen3 alty’’.

4 (2) Section 1154(a)(4)(B) (42 U.S.C. 1320c–

5 3(a)(4)(B)) is amended—

6 (A) by inserting ‘‘that is’’ after ‘‘(or’’, and

7 (B) by striking ‘‘1882(t)’’ and inserting

8 ‘‘1882(t)(3)’’.

9 (i) HEALTH INSURANCE COUNSELING.—Section

10 4360 of OBRA–1990 is amended—

11 (1) in subsection (b)(2)(A)(ii), by striking

12 ‘‘Act’’ and inserting ‘‘Act)’’;

13 (2) in subsection (b)(2)(D), by striking ‘‘serv14 ices’’ and inserting ‘‘counseling’’;

15 (3) in subsection (b)(2)(I), by striking ‘‘assist16 ance’’ and inserting ‘‘referrals’’;

17 (4) in subsection (c)(1), by striking ‘‘and that

18 such activities will continue to be maintained at such

19 level’’;

20 (5) in subsection (d)(3), by striking ‘‘to the

21 rural areas’’ and inserting ‘‘eligible individuals resid22 ing in rural areas’’;

23 (6) in subsection (e)—

24 (A) by striking ‘‘subsection (c) or (d)’’ and

25 inserting ‘‘this section’’,
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1 (B) by striking ‘‘and annually thereafter,

2 issue an annual report’’ and inserting ‘‘and an3 nually thereafter during the period of the grant,

4 issue a report’’, and

5 (C) in paragraph (1), by striking ‘‘State6 wide’’;

7 (7) in subsection (f), by striking paragraph (2)

8 and by redesignating paragraphs (3) through (5) as

9 paragraphs (2) through (4), respectively; and

10 (8) in the second subsection (f) (relating to au11 thorization of appropriations for grants)—

12 (A) by striking ‘‘and 1993’’ and inserting

13 ‘‘1993, 1994, 1995, and 1996’’; and

14 (B) by redesignating such subsection as

15 subsection (g).

16 (j) TELEPHONE INFORMATION SYSTEM.—

17 (1) Section 1804 (42 U.S.C. 1395b–2) is

18 amended—

19 (A) by adding at the end of the heading

20 the following: ‘‘; MEDICARE AND MEDIGAP IN21 FORMATION’’,

22 (B) by inserting ‘‘(a)’’ after ‘‘1804.’’, and

23 (C) by adding at the end the following new

24 subsection:
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1 ‘‘(b) The Secretary shall provide information via a

2 toll-free telephone number on the programs under this

3 title.’’.

4 (2) Section 1882(f) (42 U.S.C. 1395ss(f)) is

5 amended by adding at the end the following new

6 paragraph:

7 ‘‘(3) The Secretary shall provide information via a

8 toll-free telephone number on medicare supplemental poli9 cies (including the relationship of State programs under

10 title XIX to such policies).’’.

11 (3) Section 1889 is repealed.

12 (k) MAILING OF POLICIES.—Section 1882(d)(4) (42

13 U.S.C. 1395ss(d)(4)) is amended—

14 (1) in subparagraph (D), by striking ‘‘, if such

15 policy’’ and all that follows up to the period at the

16 end, and

17 (2) by adding at the end the following new sub18 paragraph:

19 ‘‘(E) Subparagraph (A) shall not apply in the case

20 of an issuer who mails or causes to be mailed a policy,

21 certificate, or other matter solely to comply with the re22 quirements of subsection (q).’’.

23 (l) EFFECTIVE DATE.—The amendments made by

24 this section shall be effective as if included in the enact25 ment of OBRA–1990; except that—
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1 (1) the amendments made by subsection (d)(1)

2 shall take effect on the date of the enactment of this

3 Act, but no penalty shall be imposed under section

4 1882(d)(3)(A) of the Social Security Act (for an ac5 tion occurring after the effective date of the amend6 ments made by section 4354 of OBRA–1990 and be7 fore the date of the enactment of this Act) with re8 spect to the sale or issuance of a policy which is not

9 unlawful under section 1882(d)(3)(A)(i)(II) of the

10 Social Security Act (as amended by this section);

11 (2) the amendments made by subsection

12 (d)(2)(A) and by subparagraphs (A), (B), and (E)

13 of subsection (e)(1) shall be effective on the date

14 specified in subsection (m)(4); and

15 (3) the amendment made by subsection (g)(2)

16 shall take effect on July 1, 1994, and shall apply to

17 individuals who attain 65 years of age or older on

18 or after the effective date of section 1882(s)(2) of

19 the Social Security Act (and, in the case of individ20 uals who attained 65 years of age after such effec21 tive date and before July 1, 1994, and who were not

22 covered under such section before July 1, 1994, the

23 6-month period specified in that section shall begin

24 July 1, 1994).

25 (m) TRANSITION PROVISIONS.—
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1 (1) IN GENERAL.—If the Secretary of Health

2 and Human Services identifies a State as requiring

3 a change to its statutes or regulations to conform its

4 regulatory program to the changes made by this sec5 tion, the State regulatory program shall not be con6 sidered to be out of compliance with the require7 ments of section 1882 of the Social Security Act due

8 solely to failure to make such change until the date

9 specified in paragraph (4).

10 (2) NAIC STANDARDS.—If, within 6 months

11 after the date of the enactment of this Act, the Na12 tional Association of Insurance Commissioners (in

13 this subsection referred to as the ‘‘NAIC’’) modifies

14 its 1991 NAIC Model Regulation (adopted in July

15 1991) to conform to the amendments made by this

16 section and to delete from section 15C the exception

17 which begins with ‘‘unless’’, such revised regulation

18 incorporating the modifications shall be considered

19 to be the 1991 Regulation for the purposes of sec20 tion 1882 of the Social Security Act.

21 (3) SECRETARY STANDARDS.—If the NAIC

22 does not make the modifications described in para23 graph (2) within the period specified in such para24 graph, the Secretary of Health and Human Services

25 shall make the modifications described in such para-
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1 graph and such revised regulation incorporating the

2 modifications shall be considered to be the 1991

3 Regulation for the purposes of section 1882 of the

4 Social Security Act.

5 (4) DATE SPECIFIED.—

6 (A) IN GENERAL.—Subject to subpara7 graph (B), the date specified in this paragraph

8 for a State is the earlier of—

9 (i) the date the State changes its stat10 utes or regulations to conform its regu11 latory program to the changes made by

12 this section, or

13 (ii) 1 year after the date the NAIC or

14 the Secretary first makes the modifications

15 under paragraph (2) or (3), respectively.

16 (B) ADDITIONAL LEGISLATIVE ACTION RE17 QUIRED.—In the case of a State which the Sec18 retary identifies as—

19 (i) requiring State legislation (other

20 than legislation appropriating funds) to

21 conform its regulatory program to the

22 changes made in this section, but

23 (ii) having a legislature which is not

24 scheduled to meet in 1994 in a legislative
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1 session in which such legislation may be

2 considered,

3 the date specified in this paragraph is the first

4 day of the first calendar quarter beginning after

5 the close of the first legislative session of the

6 State legislature that begins on or after Janu7 ary 1, 1994. For purposes of the previous sen8 tence, in the case of a State that has a 2-year

9 legislative session, each year of such session

10 shall be deemed to be a separate regular session

11 of the State legislature.

12 TITLE II—MEDICAID

13 PROVISIONS

14 Subtitle A—Substantive Provisions

15 PART I—MANAGED CARE PROVISIONS

16 SEC. 201. MEDICAID MANAGED CARE ANTIFRAUD PROVI17 SIONS.

18 (a) PROHIBITING AFFILIATIONS WITH INDIVIDUALS

19 DEBARRED BY FEDERAL AGENCIES.—

20 (1) IN GENERAL.—Section 1903(m) (42 U.S.C.

21 1396b(m)) is amended—

22 (A) in paragraph (2)(A)—

23 (i) by striking ‘‘and’’ at the end of

24 clause (x),
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1 (ii) by striking the period at the end

2 of clause (xi) and inserting ‘‘; and’’, and

3 (iii) by adding at the end the follow4 ing new clause:

5 ‘‘(xii) the entity complies with the requirements

6 of paragraph (3) (relating to certain protections

7 against fraud and abuse).’’;

8 (B) in paragraph (2)(B), as amended by

9 section 249, by striking ‘‘clause (ix)’’ and in10 serting ‘‘clauses (ix) and (xii)’’; and

11 (C) by inserting after paragraph (2) the

12 following new paragraph:

13 ‘‘(3)(A)(i) An entity with a contract under this sub14 section may not have a person described in clause (iv) as

15 a director, officer, partner, or person with beneficial own16 ership of more than 5 percent of the entity’s equity.

17 ‘‘(ii) An entity with a contract under this subsection

18 may not have an employment, consulting, or other agree19 ment with a person described in clause (iv) for the provi20 sion of goods and services that are significant and material

21 to the entity’s obligations under its contract with the State

22 described in paragraph (2)(A)(iii).

23 ‘‘(iii) If an entity with a contract under this sub24 section is not in compliance with clause (i) or (ii)—
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1 ‘‘(I) a State may continue an existing agree2 ment with the entity unless the Secretary (in con3 sultation with the Inspector General of the Depart4 ment of Health and Human Services) directs other5 wise; and

6 ‘‘(II) a State may not renew or otherwise ex7 tend the duration of an existing agreement with the

8 entity unless the State provides a written statement

9 to the Secretary describing compelling reasons that

10 exist for renewing or extending the agreement and

11 the Secretary (in consultation with the Inspector

12 General of the Department of Health and Human

13 Services) approves such statement.

14 ‘‘(iv) A person described in this clause is a person

15 that—

16 ‘‘(I) is debarred or suspended by the Federal

17 Government, pursuant to the Federal acquisition

18 regulation, from Government contracting and sub19 contracting, or

20 ‘‘(II) is an affiliate (within the meaning of the

21 Federal acquisition regulation) of a person described

22 in subclause (I).’’.

23 (2) EFFECTIVE DATE.—The amendments made

24 by paragraph (1) shall apply to agreements between

25 a State and an entity under section 1903(m) of the
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1 Social Security Act entered into or renewed on or

2 after January 1, 1994, without regard to whether

3 regulations to carry out such amendments are pro4 mulgated by such date.

5 (b) REQUIREMENT FOR STATE CONFLICT-OF-INTER6 EST SAFEGUARDS IN MEDICAID RISK CONTRACTING.—

7 (1) IN GENERAL.—Section 1903(m)(2)(A) (42

8 U.S.C. 1396b(m)(2)(A)), as amended by subsection

9 (a)(1)(A), is amended—

10 (A) by striking ‘‘and’’ at the end of clause

11 (xi),

12 (B) by striking the period at the end of

13 clause (xii) and inserting ‘‘; and’’, and

14 (C) by adding at the end the following new

15 clause:

16 ‘‘(xiii) the State certifies to the Secretary and

17 the Secretary finds that the State has in effect con18 flict-of-interest safeguards with respect to officers

19 and employees of the State who have responsibilities

20 with respect to contracts with organizations under

21 this subsection that are at least as effective as the

22 Federal conflicts-of-interest safeguards provided

23 under section 27 of the Office of Federal Procure24 ment Policy Act that apply with respect to Federal
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1 procurement officials who have comparable respon2 sibilities with respect to such contracts.’’.

3 (2) EFFECTIVE DATE.—The amendments made

4 by paragraph (1) shall apply as of July 1, 1994,

5 without regard to whether regulations to carry out

6 such amendments are promulgated by such date.

7 (c) REQUIRING DISCLOSURE OF FINANCIAL INFOR8 MATION.—

9 (1) IN GENERAL.—Section 1903(m)(3), as in10 serted by subsection (a)(1)(C), is amended by add11 ing at the end the following new subparagraph:

12 ‘‘(B) The contract between the State and an entity

13 referred to in paragraph (2)(A)(iii) shall provide that—

14 ‘‘(i) the entity agrees to report to the State

15 such financial information as the Secretary or the

16 State may require to demonstrate that the entity has

17 a fiscally sound operation; and

18 ‘‘(ii) the entity agrees to make available to its

19 enrollees upon reasonable request—

20 ‘‘(I) the information reported under clause

21 (i),

22 ‘‘(II) the information required to be dis23 closed under sections 1124 and 1126, and

24 ‘‘(III) a description of each transaction,

25 described in subparagraphs (A) through (C) of
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1 section 1318(a)(3) of the Public Health Service

2 Act, between the entity and a party in interest

3 (as defined in section 1318(b) of such Act).’’.

4 (2) EFFECTIVE DATE.—The amendment made

5 by paragraph (1) shall apply to contract years begin6 ning on or after April 1, 1994, without regard to

7 whether regulations to carry out such amendments

8 are promulgated by such date, with respect to infor9 mation reported or required to be disclosed, or

10 transactions occurring, before, on, or after such

11 date.

12 (d) PROHIBITING MARKETING FRAUD.—

13 (1) IN GENERAL.—Section 1903(m)(3), as in14 serted by subsection (a)(1) and as amended by sub15 section (c)(1), is amended by adding at the end the

16 following new subparagraph:

17 ‘‘(C) The contract between the State and an entity

18 referred to in paragraph (2)(A)(iii) shall provide that the

19 entity agrees to comply with such procedures and condi20 tions as the Secretary prescribes in order to ensure that,

21 before an individual is enrolled or reenrolled with the en22 tity, the individual is provided accurate and sufficient in23 formation to make an informed decision whether or not

24 to enroll or reenroll.’’.
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1 (2) EFFECTIVE DATE.—The amendment made

2 by paragraph (1) shall apply to contract years that

3 begin on or after April 1, 1994.

4 (e) REQUIRING ADEQUATE PROVISION AGAINST RISK

5 OF INSOLVENCY.—

6 (1) IN GENERAL.—Section 1903(m)(1)(A)(ii)

7 (42 U.S.C. 1396b(m)(1)(A)(ii)) is amended by in8 serting ‘‘, which meets such standards as the Sec9 retary shall prescribe,’’ after ‘‘satisfactory to the

10 State’’.

11 (2) EFFECTIVE DATE.—The amendment made

12 by paragraph (1) shall apply to contract years begin13 ning on or after January 1, 1995.

14 (f) REQUIRING REPORT ON NET EARNINGS AND AD15 DITIONAL BENEFITS.—

16 (1) IN GENERAL.—Section 1903(m)(3), as in17 serted by subsection (a)(1) and as amended by sub18 sections (c)(1) and (d)(1) is amended by adding at

19 the end the following new subparagraph:

20 ‘‘(D) The contract between the State and an entity

21 referred to in paragraph (2)(A)(iii) shall provide that the

22 entity shall submit a report to the State and the Secretary

23 not later than 12 months after the close of a contract year

24 containing—
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1 ‘‘(i) a financial statement of the entity’s net

2 earnings under the contract during the contract

3 year, which statement has been audited using audit4 ing standards established by the Secretary in con5 sultation with the States; and

6 ‘‘(ii) a description of any benefits that are in

7 addition to the benefits required to be provided

8 under the contract that were provided during the

9 contract year to members enrolled with the entity

10 and entitled to medical assistance under the plan.’’.

11 (2) EFFECTIVE DATE.—The amendment made

12 by paragraph (1) shall apply to contract years begin13 ning on or after January 1, 1994.

14 SEC. 202. EXTENSION OF MEDICAID WAIVER FOR TEN15 NESSEE PRIMARY CARE NETWORK.

16 Section 6411(f) of OBRA–1989, as amended by sec17 tion 1 of Public Law 102–317, is amended by striking

18 ‘‘January 31, 1994’’ and inserting ‘‘December 31, 1995’’.

19 SEC. 203. WAIVER OF APPLICATION OF MEDICAID ENROLL20 MENT MIX REQUIREMENT TO DISTRICT OF

21 COLUMBIA CHARTERED HEALTH PLAN, INC.

22 (a) IN GENERAL.—The Secretary of Health and

23 Human Services shall waive the application of the require24 ment described in section 1903(m)(2)(A)(ii) of the Social

25 Security Act (42 U.S.C. 1396b(m)(2)(A)(ii)) to the entity
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1 known as the District of Columbia Chartered Health Plan,

2 Inc., for the period described in subsection (b), if the Sec3 retary determines that the entity is making continuous ef4 forts and progress toward achieving compliance with such

5 requirement.

6 (b) PERIOD OF APPLICABILITY.—The period referred

7 to in subsection (a) is the period that begins on October

8 1, 1992, and ends on December 31, 1995.

9 SEC. 204. WAIVER OF APPLICATION OF MEDICAID ENROLL10 MENT MIX REQUIREMENT TO MANAGED

11 HEALTH SERVICES INSURANCE CORPORA12 TION OF MILWAUKEE, WISCONSIN.

13 The Secretary of Health and Human Services shall

14 waive the application of the requirement described in sec15 tion 1903(m)(2)(A)(ii) of the Social Security Act (42

16 U.S.C. 1396b(m)(2)(A)(ii)) to the entity known as the

17 Managed Health Services Insurance Corporation of Mil18 waukee, Wisconsin until December 31, 1995, if the Sec19 retary determines that the entity is making continuous ef20 forts and progress toward achieving compliance with such

21 requirement.

22 SEC. 205. EXTENSION OF MINNESOTA PREPAID MEDICAID

23 DEMONSTRATION PROJECT.

24 (a) IN GENERAL.—Section 507 of the Family Sup25 port Act of 1988 (Public Law 100–485), as amended by
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1 section 6411(j) of OBRA–1989 and by section 4733 of

2 OBRA–1990, is amended by striking ‘‘1996’’ and insert3 ing ‘‘1998’’.

4 (b) AUTHORITY TO IMPOSE PREMIUM.—

5 (1) IN GENERAL.—Notwithstanding section

6 1916 of the Social Security Act and subject to para7 graph (2), the State of Minnesota may impose a pre8 mium on individuals receiving medical assistance

9 under the Minnesota Prepaid Demonstration Project

10 operated under a waiver granted by the Secretary of

11 Health and Human Services under section 1115(a)

12 of the Social Security Act and other individuals eligi13 ble under the State’s plan for medical assistance

14 under title XIX of such Act.

15 (2) LIMITATION ON AMOUNT OF PREMIUM.—In

16 no case may the amount of any premium imposed on

17 an individual receiving medical assistance under the

18 State plan or under the Demonstration Project de19 scribed in paragraph (1) exceed 10 percent of the

20 amount by which the family income (less expenses

21 for the care of a dependent child) of the individual

22 exceeds 110 percent of the income official poverty

23 line (as defined by the Office of Management and

24 Budget, and revised annually in accordance with sec25 tion 673(2) of the Omnibus Budget Reconciliation
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1 Act of 1981) applicable to a family of the size in2 volved.

3 PART II—HOME AND COMMUNITY-BASED

4 SERVICES WAIVER PROVISIONS

5 SEC. 211. ELIMINATION OF REQUIREMENT OF PRIOR INSTI6 TUTIONALIZATION WITH RESPECT TO HA7 BILITATION SERVICES FURNISHED UNDER A

8 WAIVER FOR HOME OR COMMUNITY-BASED

9 SERVICES.

10 (a) IN GENERAL.—Section 1915(c)(5) (42 U.S.C.

11 1396n(c)(5)) is amended in the matter preceding subpara12 graph (A) by striking ‘‘, with respect to individuals who

13 receive such services after discharge from a nursing facil14 ity or intermediate care facility for the mentally retarded’’.

15 (b) EFFECTIVE DATE.—The amendments made by

16 this section shall apply to services furnished on or after

17 January 1, 1994.

18 SEC. 212. RELIEF FROM THIRD PARTY LIABILITY REQUIRE19 MENTS WHEN COST-EFFECTIVE.

20 (a) IN GENERAL.—Section 1902(a)(25)(B) (42

21 U.S.C. 1396a(a)(25)(B)) is amended to read as follows—

22 ‘‘(B) that in any case where such a legal liabil23 ity is found to exist after medical assistance has

24 been made available, the State or local agency will
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1 seek reimbursement for such assistance to the extent

2 of such legal liability, unless—

3 ‘‘(i) the amount of reimbursement the

4 State can reasonably expect to recover for medi5 cal assistance furnished to an individual does

6 not exceed the costs of such recovery, or

7 ‘‘(ii) with respect to case management

8 services (as defined in section 1915(g)(2)), the

9 State demonstrates to the satisfaction of the

10 Secretary that it is not cost-effective in the ag11 gregate to seek such recovery with respect to

12 such services furnished to individuals covered

13 under the State plan, using methods specified

14 by the Secretary which may include a dem15 onstration that such services are not generally

16 covered by health insurers in the State;’’.

17 (b) EFFECTIVE DATE.—The amendments made by

18 this section shall become effective on January 1, 1994.

19 SEC. 213. STATE EXPENDITURES FOR MEDICAL ASSIST20 ANCE WITH RESPECT TO HOME AND COMMU21 NITY-BASED SERVICES PROVIDED UNDER A

22 WAIVER.

23 (a) IN GENERAL.—Section 1915(d)(5)(B) (42 U.S.C.

24 1396n(d)(5)(B)) is amended—
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1 (1) in clause (i), by striking ‘‘times the number

2 of years’’ and inserting ‘‘compounded annually for

3 years’’;

4 (2) in clause (ii), by striking ‘‘times the number

5 of years’’ and inserting ‘‘compounded annually for

6 years’’; and

7 (3) in clause (iv), by striking ‘‘December 22,

8 1987’’ and inserting ‘‘the date of the enactment of

9 the Omnibus Budget Reconciliation Act of 1986’’.

10 (b) EFFECTIVE DATE.—The amendments made by

11 subsection (a) shall be effective as if included in the enact12 ment of OBRA–1987.

13 PART III—OTHER PROVISIONS

14 SEC. 221. PRESUMPTIVE ELIGIBILITY FOR PREGNANT

15 WOMEN.

16 (a) QUALIFIED PROVIDER.—Section 1920(b)(2) (42

17 U.S.C. 1396r–1(b)(2)) is amended to read as follows:

18 ‘‘(2) the term ‘qualified provider’ means—

19 ‘‘(A) any provider that—

20 ‘‘(i) is eligible for payments under a

21 State plan approved under this title;

22 ‘‘(ii) provides services of the type de23 scribed in subparagraph (A) or (B) of sec24 tion 1905(a)(2) or in section 1905(a)(9);
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1 ‘‘(iii) is determined by the State agen2 cy to be capable of making determinations

3 of the type described in paragraph (1)(A);

4 and

5 ‘‘(iv)(I) receives funds under section

6 329, 330, 340, or 340A of the Public

7 Health Service Act, title V of this Act, or

8 title V of the Indian Health Care Improve9 ment Act;

10 ‘‘(II) participates in a program estab11 lished under section 17 of the Child Nutri12 tion Act of 1966 or section 4(a) of the Ag13 riculture and Consumer Protection Act of

14 1973;

15 ‘‘(III) participates in a State perinatal

16 program; or

17 ‘‘(IV) is the Indian Health Service or

18 is a health program or facility operated by

19 a tribe or tribal organization under the In20 dian Self-Determination Act (Public Law

21 93-638); and

22 ‘‘(B) at the option of the State, any indi23 vidual who is employed by the State and who is

24 determined by the State agency to be capable of
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1 making determinations of the type described in

2 paragraph (1)(A).’’.

3 (b) EFFECTIVE DATE.—The amendments made by

4 this section shall apply to payments under title XIX of

5 the Social Security Act for calendar quarters beginning

6 on or after January 1, 1994.

7 SEC. 222. CRITERIA FOR DETERMINING THE AMOUNT OF

8 DISALLOWANCES.

9 (a) IN GENERAL.—

10 (1) CRITERIA FOR INITIAL DETERMINATIONS.—

11 Section 1903 (42 U.S.C. 1396b) is amended by add12 ing at the end the following new subsection:

13 ‘‘(x) If the Secretary determines that a disallowance

14 of Federal financial participation should be made under

15 this title with respect to any item or class of items, the

16 Secretary shall, in making a determination with respect

17 to the amount of such disallowance, take into account (to

18 the extent the State makes a showing) factors which shall

19 include—

20 ‘‘(1) whether the amount of the disallowance is

21 reasonably related to the act or omission by the

22 State which is the basis for the disallowance; and

23 ‘‘(2) whether the act or omission by the State

24 which is the basis for the disallowance was based on

25 a reasonable interpretation of Federal statutes, Fed-
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1 eral regulations, or any written guidance provided by

2 the Secretary.’’.

3 (2) CRITERIA FOR REDETERMINATIONS.—Sec4 tion 1116(d) (42 U.S.C. 1316(d)) is amended—

5 (A) by striking ‘‘(d)’’ and inserting

6 ‘‘(d)(1)’’; and

7 (B) by adding at the end the following new

8 paragraph:

9 ‘‘(2) In conducting any reconsideration of a disallow10 ance of Federal financial participation by the Secretary

11 under title XIX, the Departmental Appeals Board of the

12 Department of Health and Human Services (or another

13 entity designated by the Secretary), shall, if such Board

14 or entity upholds the basis for the disallowance, determine

15 whether the amount of the disallowance properly takes

16 into account the factors listed in section 1903(x). If the

17 amount of the disallowance does not properly take into

18 account such factors, the Board shall adjust such amount

19 in accordance with such factors.’’.

20 (b) EFFECTIVE DATE.—The amendment made by

21 subsection (a) shall apply to disallowances made after the

22 date of the enactment of this Act and shall take effect

23 without regard to the promulgation of implementing regu24 lations.
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1 SEC. 223. INTERMEDIATE SANCTIONS FOR KICKBACK VIO2 LATIONS.

3 (a) PENALTY FOR KICKBACK VIOLATIONS.—Section

4 1128A(a) (42 U.S.C. 1320a–7a(a)) is amended—

5 (1) by striking ‘‘or’’ at the end of paragraphs

6 (1) and (2);

7 (2) by adding ‘‘or’’ at the end of paragraph (3);

8 (3) by inserting after paragraph (3) the follow9 ing new paragraph:

10 ‘‘(4) carries out any activity in violation of

11 paragraph (1) or (2) of section 1128B(b) with re12 spect to remuneration relating to a State health care

13 program;’’;

14 (4) by striking ‘‘given).’’ at the end of the first

15 sentence and inserting ‘‘given or, in cases under

16 paragraph (4), $10,000 for each such violation).’’;

17 (5) in the second sentence, by inserting ‘‘in

18 cases under paragraphs (1), (2), and (3),’’ after ‘‘In

19 addition,’’; and

20 (6) by inserting after the second sentence the

21 following new sentence: ‘‘In cases under paragraph

22 (4), such a person shall be subject to an assessment

23 of not more than twice the total amount of the re24 muneration offered, paid, solicited, or received in

25 violation of section 1128B(b), determined without

26 regard to whether a portion of such remuneration
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1 was offered, paid, solicited, or received for a lawful

2 purpose.’’.

3 (b) AUTHORIZATION TO ACT.—The first sentence of

4 section 1128A(c)(1) (42 U.S.C. 1320a–7a(c)(1)) is

5 amended by striking the period at the end and inserting

6 ‘‘, except that with respect to a proceeding relating to a

7 State health program, the Secretary may initiate such a

8 proceeding at such time and under such procedures as the

9 Secretary determines appropriate unless, within 1 year

10 after the date the Secretary presents a case to the Attor11 ney General for consideration, the Attorney General brings

12 an action in a district court of the United States.’’.

13 (c) EFFECTIVE DATES.—

14 (1) The amendments made by subsection (a)

15 shall apply to remuneration offered, paid, solicited,

16 or received before, on, or after the date of the enact17 ment of this Act.

18 (2) The amendment made by subsection (b)

19 shall apply to cases presented by the Secretary of

20 Health and Human Services for consideration on or

21 after the date of the enactment of this Act.
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1 SEC. 224. TECHNICAL AMENDMENT RELATED TO TAXES ON

2 CERTAIN HEALTH CARE ITEMS AND SERV3 ICES.

4 (a) IN GENERAL.—Section 1903(w)(7)(A)(viii) (42

5 U.S.C. 1396b(w)(7)(A)(viii)) is amended by striking the

6 period at the end and inserting ‘‘not otherwise subject to

7 a tax described in this subsection.’’.

8 (b) EFFECTIVE DATE.—(1) Except as provided in

9 paragraph (2), the amendment made by subsection (a)

10 shall be effective January 1, 1994.

11 (2) In the case of a State which the Secretary of

12 Health and Human Services determines requires State

13 legislation in order to avoid a reduction in Federal finan14 cial participation under section 1903(a) of the Social Se15 curity Act as a result of the amendment made by sub16 section (a), the State shall not be subject to such a reduc17 tion before the first day of the first calendar quarter be18 ginning after the close of the first regular session of the

19 State legislature that begins after the date of the enact20 ment of this Act. For purposes of the preceding sentence,

21 in the case of a State that has a 2-year legislative session,

22 each year of such session shall be deemed to be a separate

23 regular session of the State legislature.
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1 SEC. 225. APPLICATION OF MAMMOGRAPHY CERTIFI2 CATION REQUIREMENTS UNDER THE MEDIC3 AID PROGRAM.

4 (a) IN GENERAL.—Section 1902(a)(9) (42 U.S.C.

5 1396a(a)(9)) is amended—

6 (1) by striking ‘‘and’’ at the end of subpara7 graph (B),

8 (2) by striking the semicolon at the end of sub9 paragraph (C) and inserting ‘‘, and’’, and

10 (3) by adding at the end the following new sub11 paragraph:

12 ‘‘(D) that any mammography paid for

13 under such plan must be conducted by a facility

14 that has a certificate (or provisional certificate)

15 issued under section 354 of the Public Health

16 Service Act;’’.

17 (b) EFFECTIVE DATE.—(1) Except as provided in

18 paragraph (2), the amendments made by subsection (a)

19 shall apply to mammography furnished by a facility during

20 calendar quarters beginning on or after the first date that

21 the certificate requirements of section 354(b) of the Public

22 Health Service Act apply to such mammography con23 ducted by such facility, without regard to whether or not

24 final regulations to carry out such amendments have been

25 promulgated by such date.
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1 (2) In the case of a State plan for medical assistance

2 under title XIX of the Social Security Act which the Sec3 retary of Health and Human Services determines requires

4 State legislation (other than legislation appropriating

5 funds) in order for the plan to meet the additional require6 ment imposed by the amendment made by subsection

7 (a)(3), the State plan shall not be regarded as failing to

8 comply with the requirements of such title solely on the

9 basis of its failure to meet this additional requirement be10 fore the first day of the first calendar quarter beginning

11 after the close of the first regular session of the State leg12 islature that begins after the date of the enactment of this

13 Act. For purposes of the preceding sentence, in the case

14 of a State that has a 2-year legislative session, each year

15 of such session shall be deemed to be a separate regular

16 session of the State legislature.

17 SEC. 226. NURSING HOME REFORM.

18 (a) SUSPENSION OF DECERTIFICATION OF NURSE

19 AIDE TRAINING AND COMPETENCY EVALUATION PRO20 GRAMS BASED ON EXTENDED SURVEYS.—

21 (1) IN GENERAL.—Section

22 1919(f)(2)(B)(iii)(I)(b) (42 U.S.C.

23 1396r(f)(2)(B)(iii)(I)(b)) is amended by striking the

24 semicolon and inserting the following: ‘‘, unless the

25 survey shows that the facility is in compliance with
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1 the requirements of subsections (b), (c), and (d) of

2 this section;’’.

3 (2) EFFECTIVE DATE.—The amendment made

4 by paragraph (1) shall take effect as if included in

5 the enactment of OBRA–1990.

6 (b) REQUIREMENTS FOR CONSULTANTS CONDUCT7 ING REVIEWS ON USE OF DRUGS.—

8 (1) IN GENERAL.—Section 1919(c)(1)(D) (42

9 U.S.C. 1396r(c)(1)(D)) is amended by adding at the

10 end the following sentence: ‘‘In determining whether

11 such a consultant is qualified to conduct reviews

12 under the preceding sentence, the Secretary shall

13 take into account the needs of nursing facilities

14 under this title to have access to the services of such

15 a consultant on a timely basis.’’.

16 (2) EFFECTIVE DATE.—The amendment made

17 by paragraph (1) shall take effect as if included in

18 the enactment of OBRA–1987.

19 (c) INCREASE IN MINIMUM AMOUNT REQUIRED FOR

20 SEPARATE DEPOSIT OF PERSONAL FUNDS.—

21 (1) IN GENERAL.—Section 1919(c)(6)(B)(i) (42

22 U.S.C. 1396r(c)(6)(B)(i)) is amended by striking

23 ‘‘$50’’ and inserting ‘‘$100’’.

24 (2) EFFECTIVE DATE.—The amendment made

25 by paragraph (1) shall take effect January 1, 1994.
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1 (d) DUE PROCESS PROTECTIONS FOR NURSE

2 AIDES.—

3 (1) PROHIBITING STATE FROM INCLUDING UN4 DOCUMENTED ALLEGATIONS IN NURSE AIDE REG5 ISTRY.—Section 1919(e)(2)(B) (42 U.S.C.

6 1396r(e)(2)(B)) is amended by striking the period at

7 the end of the first sentence and inserting the fol8 lowing: ‘‘, but shall not include any allegations of

9 resident abuse or neglect or misappropriation of

10 resident property that are not specifically docu11 mented by the State under such subsection.’’.

12 (2) DUE PROCESS REQUIREMENTS FOR REBUT13 TING ALLEGATIONS.—Section 1919(g)(1)(C) (42

14 U.S.C. 1396r(g)(1)(C)) is amended by striking the

15 second sentence and inserting the following: ‘‘The

16 State shall, after providing the individual involved

17 with a written notice of the allegations (including a

18 statement of the availability of a hearing for the in19 dividual to rebut the allegations) and the oppor20 tunity for a hearing on the record, make a written

21 finding as to the accuracy of the allegations.’’.

22 (3) EFFECTIVE DATE.—The amendments made

23 by this subsection shall take effect January 1, 1994.
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1 SEC. 227. INCREASE IN AUTHORIZATION OF APPROPRIA2 TIONS FOR THE MATERNAL AND CHILD

3 HEALTH SERVICES BLOCK GRANT PROGRAM.

4 Section 501(a) (42 U.S.C. 701(a)) is amended by

5 striking ‘‘$686,000,000 for fiscal year 1990’’ and insert6 ing ‘‘$705,000,000 for fiscal year 1994’’.

7 Subtitle B—Miscellaneous and

8 Technical Corrections Relating

9 to OBRA–1990

10 SEC. 241. EFFECTIVE DATE.

11 Except as otherwise provided, the amendments made

12 by this subtitle shall take effect as if included in the enact13 ment of OBRA–1990.

14 SEC. 242. CORRECTIONS RELATING TO SECTION 4401 (DRUG

15 REBATE PROGRAM).

16 (a) SECTION 1927.—(1) Section 1927(a) (42 U.S.C.

17 1396r–8(a)), as inserted by section 4401(a)(3) of OBRA–

18 1990, is amended—

19 (A) in paragraph (1)—

20 (i) by amending the second sentence to

21 read as follows: ‘‘Any such agreement entered

22 into prior to May 1, 1991, shall be deemed to

23 have been entered into on January 1, 1991, and

24 the amount of the rebate to be paid by the

25 manufacturer under such agreement shall be
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1 calculated as if the agreement had been entered

2 into on January 1, 1991.’’, and

3 (ii) in the third sentence, by striking

4 ‘‘March’’ and inserting ‘‘May’’;

5 (B) in paragraph (2)—

6 (i) by striking ‘‘first’’, and

7 (ii) by striking the period at the end and

8 inserting the following: ‘‘, except that such

9 paragraph (and section 1903(i)(10)(A)) shall

10 not apply to drugs dispensed before May 1,

11 1991, if the Secretary determines that there

12 were extenuating circumstances with respect to

13 the first calendar quarter of 1991.’’;

14 (C) by amending paragraph (3) to read as fol15 lows:

16 ‘‘(3) AUTHORIZING PAYMENT FOR DRUGS NOT

17 COVERED UNDER REBATE AGREEMENTS.—Para18 graph (1) and section 1903(i)(10) shall not apply to

19 the dispensing of a covered outpatient drug if—

20 ‘‘(A) the State has made a determination

21 that the availability of such drug is essential to

22 the health of beneficiaries under the State plan;

23 ‘‘(B) the drug has been given a rating of

24 1–A or 1–P by the Food and Drug Administra25 tion; and
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1 ‘‘(C)(i) the physician has obtained approval

2 for the use of the drug in advance of dispensing

3 such drug in accordance with a prior authoriza4 tion program described in subsection (d)(5), or

5 ‘‘(ii) the Secretary has reviewed and ap6 proved the State’s determination under sub7 paragraph (A).’’; and

8 (D) in paragraph (4)—

9 (i) by striking ‘‘In the case’’ and inserting

10 ‘‘(A) In the case’’,

11 (ii) by striking ‘‘in compliance with’’ and

12 inserting ‘‘in effect under’’,

13 (iii) by striking ‘‘such agreement provides

14 for a minimum aggregate rebate of 10 percent

15 of the State’s total expenditures under the

16 State plan for coverage of the manufacturer’s

17 drugs under this title’’ and inserting ‘‘such

18 agreement provides for a minimum aggregate

19 rebate of 10 percent of the sum of the amounts

20 determined under subparagraph (B) for all of

21 the manufacturer’s drugs paid for by the State

22 under the agreement’’, and

23 (iv) by adding at the end the following new

24 subparagraph:
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1 ‘‘(B) The amount determined under this sub2 paragraph with respect to a manufacturer’s drug

3 paid for by a State under an agreement described in

4 the first sentence of subparagraph (A) is an amount

5 equal to the product of—

6 ‘‘(i) the average manufacturer’s price for

7 such drug; and

8 ‘‘(ii) the number of dosage units of such

9 drug paid for by the State under such agree10 ment.’’.

11 (2) Section 1927(b) (42 U.S.C. 1396r–8(b)), as in12 serted by section 4401(a)(3) of OBRA–1990, is amend13 ed—

14 (A) in paragraph (2)(A), by striking ‘‘during’’

15 and inserting ‘‘for’’;

16 (B) in paragraph (3)(A)—

17 (i) in clause (i), by striking the open pa18 renthesis before ‘‘for’’ and the close parenthesis

19 after ‘‘drugs’’,

20 (ii) in clause (i), by striking ‘‘subsection

21 (c)(2)(B)) for covered outpatient drugs’’ and in22 serting ‘‘subsection (c)(1)(C)) for each covered

23 outpatient drug’’, and

24 (iii) in clause (ii), by inserting a comma

25 after ‘‘this section’’ and after ‘‘1990’’;
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1 (C) in paragraph (3)(B)—

2 (i) by striking ‘‘$100,000’’ and inserting

3 ‘‘$10,000’’,

4 (ii) by striking ‘‘about charges or prices’’,

5 and

6 (iii) by striking ‘‘or knowingly provides

7 false information’’;

8 (D) in paragraph (3)(C)—

9 (i) in clause (i)—

10 (I) by striking ‘‘increased by’’, and

11 (II) by striking ‘‘, and, if’’ and insert12 ing ‘‘. If’’,

13 (ii) in clause (ii), by striking ‘‘under this

14 section’’ and inserting ‘‘under this section, or a

15 wholesaler or direct seller,’’,

16 (iii) in clause (ii), by inserting ‘‘under sub17 paragraph (A) or (B)’’ after ‘‘provides false in18 formation’’, and

19 (iv) in clause (ii), by striking ‘‘Such civil

20 money penalties are’’ and inserting ‘‘Any such

21 civil money penalty shall be’’;

22 (E) in paragraph (3)(D), by striking ‘‘whole23 saler,’’ the first time it appears and inserting

24 ‘‘wholesaler or the’’; and
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1 (F) in paragraph (4)(B)(i), by adding at the

2 end the following new sentence: ‘‘Failure of a State

3 to provide any advance notice of such a termination

4 as required by regulation shall not affect the State’s

5 right to terminate coverage of the drugs affected by

6 such termination as of the effective date of such ter7 mination.’’.

8 (3) Section 1927(d)(3) (42 U.S.C. 1396r–8(d)(3)), as

9 inserted by section 4401(a)(3) of OBRA–1990 and as

10 amended by section 13602 of OBRA–1993, is amended

11 to read as follows:

12 ‘‘(3) ADDITIONS TO DRUG LISTINGS.—The Sec13 retary shall, by regulation, periodically update the

14 list of drugs or classes of drugs described in para15 graph (2), or their medical uses, which the Secretary

16 has determined to be subject to clinical abuse or in17 appropriate use.’’.

18 (4) Section 1927(h)(2)(A) (42 U.S.C. 1396r–

19 8(h)(2)(A)), as inserted by section 4401(a)(3) of OBRA–

20 1990, is amended by inserting ‘‘develops or’’ before ‘‘ac21 quires’’.

22 (5) Section 1927(i) (42 U.S.C. 1396r–8(i)), as in23 serted by section 4401(a)(3) of OBRA–1990, is amend24 ed—
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1 (A) in paragraph (1), by striking ‘‘the the oper2 ation’’ and inserting ‘‘the operation’’; and

3 (B) in paragraph (2),

4 (i) by striking subparagraph (C); and

5 (ii) by redesignating subparagraphs (D),

6 (E), and (F) as subparagraphs (C), (D), and

7 (E), respectively.

8 (6) Section 1927(j) (42 U.S.C. 1396r–8(j)), as in9 serted by section 4401(a)(3) of OBRA–1990, is amended

10 to read as follows:

11 ‘‘(j) EXEMPTION FOR CERTAIN HEALTH MAINTE12 NANCE ORGANIZATIONS AND HOSPITALS.—

13 ‘‘(1) IN GENERAL.—Except as provided in para14 graph (2), the requirements of this section shall not

15 apply with respect to covered outpatient drugs dis16 pensed by—

17 ‘‘(A) a health maintenance organization; or

18 ‘‘(B) a hospital that dispenses covered out19 patient drugs using a drug formulary system

20 and bills the State no more than the hospital’s

21 purchasing costs for covered outpatient drugs.

22 ‘‘(2) CONSTRUCTION IN DETERMINING BEST

23 PRICE.—Nothing in paragraph (1) shall be con24 strued as excluding amounts paid by the entities de25 scribed in such paragraph for covered outpatient
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1 drugs from the determination of the best price (as

2 defined in subsection (c)(1)(C)) for such drugs.’’.

3 (7) Section 1927(k) (42 U.S.C. 1396r–8(k)), as in4 serted by section 4401(a)(3) of OBRA–1990, is amend5 ed—

6 (A) in paragraph (2)—

7 (i) in the matter preceding clause (i) of

8 subparagraph (A), by striking ‘‘paragraph (5)’’

9 and inserting ‘‘subparagraph (D)’’;

10 (ii) in subparagraph (A)—

11 (I) in clause (i), by striking ‘‘for safe12 ty and effectiveness’’ and by striking ‘‘or

13 which is approved under section 505(j) of

14 such Act’’; and

15 (II) by striking ‘‘and’’ at the end;

16 (iii) in subparagraph (B)—

17 (I) in clause (i), by striking ‘‘prescrip18 tion,’’ and inserting ‘‘prescription;’’;

19 (II) in clause (ii), by striking ‘‘, and’’

20 and inserting ‘‘; and’’; and

21 (III) by striking ‘‘and’’ at the end;

22 (iv) by striking the period at the end of

23 subparagraph (C) and inserting ‘‘; and’’; and

24 (v) by adding at the end the following new

25 subparagraph:
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1 ‘‘(D) a drug which may be sold without a

2 prescription (commonly referred to as an ‘over3 the-counter drug’), if the drug is prescribed by

4 a physician (or other person authorized to pre5 scribe under State law).’’;

6 (B) in subparagraph (H) of paragraph (3), by

7 inserting ‘‘services’’ after ‘‘dialysis’’;

8 (C) by striking paragraph (4) and redesignating

9 paragraphs (5), (6), (7), (8), and (9) as paragraphs

10 (4), (5), (6), (7), and (8), respectively;

11 (D) by amending paragraph (4), as so redesig12 nated, to read as follows:

13 ‘‘(4) MANUFACTURER.—The term ‘manufac14 turer’ means, with respect to a covered outpatient

15 drug, the entity holding legal title to or possession

16 of the National Drug Code number for such drug.’’;

17 and

18 (E) in paragraph (6), as so redesignated—

19 (i) in subparagraph (A)(i), by striking

20 ‘‘paragraph (5)’’ and inserting ‘‘paragraph

21 (2)(D)’’,

22 (ii) in subparagraph (A)(ii), by inserting

23 ‘‘or product licensing application’’ after ‘‘appli24 cation’’,
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1 (iii) in subparagraph (A)(iv), by inserting

2 ‘‘or product licensing application’’ after ‘‘appli3 cation’’,

4 (iv) in subparagraph (A)(iv), by striking

5 ‘‘distributers’’ and inserting ‘‘distributors’’,

6 (v) in subparagraph (C)(i), by striking

7 ‘‘pharmaceuutically’’ and inserting ‘‘pharma8 ceutically’’, and

9 (vi) in subparagraph (C)(iii), by striking ‘‘,

10 provided that’’ and inserting ‘‘if’’.

11 (b) SECTION 1903.—

12 (1) ENHANCED MATCH.—Section 1903(a) (42

13 U.S.C. 1396b(a)) is amended—

14 (A) by striking the period at the end of

15 paragraph (7) and inserting ‘‘; plus’’; and

16 (B) by adding at the end the following new

17 paragraph:

18 ‘‘(8) 75 per centum of so much of the sums ex19 pended under the State plan during calendar years

20 1991 through 1993 as the Secretary determines at21 tributable to the statewide adoption of a drug use

22 review program which conforms to the requirements

23 of section 1927(g).’’.

24 (2) CONFORMING AMENDMENTS.—Section

25 1903(a)(3) (42 U.S.C. 1396b(a)(3)) is amended—
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1 (A) by striking ‘‘and’’ at the end of sub2 paragraph (C) and inserting ‘‘plus’’; and

3 (B) by striking subparagraph (D).

4 (c) FUNDING.—Section 4401(b)(2) of OBRA–1990 is

5 amended by striking the semicolon and all that follows and

6 inserting a period.

7 (d) DEMONSTRATION PROJECTS.—Section

8 4401(c)(1) of OBRA–1990 is amended—

9 (1) in subparagraph (A), by striking ‘‘1992’’

10 and inserting ‘‘1993’’;

11 (2) in subparagraph (A), by striking ‘‘10’’ and

12 inserting ‘‘5’’;

13 (3) in subparagraph (C), by striking ‘‘regi14 ment’’ and inserting ‘‘regimen’’; and

15 (4) in subparagraph (D), by striking ‘‘1994’’

16 and inserting ‘‘1995’’.

17 (e) STUDIES.—Section 4401(d) of OBRA–1990 is

18 amended—

19 (1) in paragraph (1)(A), by striking ‘‘other in20 stitutional facilities,’’ and inserting ‘‘nursing facili21 ties, intermediate care facilities for the mentally re22 tarded,’’;

23 (2) in paragraph (1)(B), by striking ‘‘under

24 this subsection’’ and inserting ‘‘under this para25 graph’’;
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1 (3) in paragraph (1)(B)(i), by striking ‘‘under

2 this section’’ and inserting ‘‘under section 1927 of

3 the Social Security Act’’;

4 (4) in paragraph (1)(B)(ii)—

5 (A) by striking ‘‘drug use review’’ the sec6 ond time it appears and inserting ‘‘the type of

7 drug use review that is’’; and

8 (B) by striking ‘‘under this section’’ and

9 inserting ‘‘under such section’’;

10 (5) in paragraph (1)(B)(iii), by striking ‘‘under

11 this title’’ and inserting ‘‘under title XIX of the So12 cial Security Act’’;

13 (6) in paragraph (1)(C)—

14 (A) by striking ‘‘May 1, 1991’’ and insert15 ing ‘‘May 1, 1992’’, and

16 (B) by striking ‘‘Committees on Aging of

17 the Senate and the House of Representatives’’

18 and inserting ‘‘Committee on Aging of the Sen19 ate’’;

20 (7) in paragraph (2)—

21 (A) by striking ‘‘By not later than May 1

22 of each year, the Comptroller’’ and inserting

23 ‘‘The Comptroller’’;
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1 (B) by striking ‘‘Committees on Aging of

2 the Senate and House of Representatives’’ and

3 inserting ‘‘Committee on Aging of the Senate’’;

4 (C) by striking ‘‘an annual report’’ and in5 serting ‘‘a report’’; and

6 (D) by striking ‘‘retail and’’;

7 (8) in paragraph (3)—

8 (A) in subparagraph (A), by striking ‘‘,

9 acting in consultation with the Comptroller

10 General,’’,

11 (B) by indenting subparagraph (B) an ad12 ditional 2 ems;

13 (C) in subparagraph (B), by striking ‘‘De14 cember 31, 1991, the Secretary and the Comp15 troller General’’ and inserting ‘‘June 1, 1993,

16 the Secretary’’; and

17 (D) by striking ‘‘Committees on Aging of

18 the Senate and the House of Representatives’’

19 and inserting ‘‘Committee on Aging of the Sen20 ate’’;

21 (9) in paragraph (4)—

22 (A) in subparagraph (A), by striking

23 ‘‘each’’ and by striking the semicolon and in24 serting a comma;
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1 (B) in subparagraph (B), by striking ‘‘De2 cember 31, 1991’’ and inserting ‘‘January 1,

3 1993’’; and

4 (C) in subparagraph (B), by striking

5 ‘‘Committees on Aging of the Senate and the

6 House of Representatives’’ and inserting ‘‘Com7 mittee on Aging of the Senate’’;

8 (10) in paragraph (5)—

9 (A) by striking ‘‘Secretary of Health and

10 Human Services’’ and inserting ‘‘Comptroller

11 General’’,

12 (B) by striking ‘‘under this title’’ and in13 serting ‘‘under State medicaid programs’’, and

14 (C) by striking the second sentence and in15 serting the following new sentence: ‘‘The Comp16 troller General shall report to the Congress on

17 the study not later than January 1, 1993.’’;

18 and

19 (11) by striking paragraph (6).

20 SEC. 243. CORRECTIONS RELATING TO SECTION 4402 (EN21 ROLLMENT UNDER GROUP HEALTH PLANS).

22 Section 4402(b) of OBRA–1990 is amended by strik23 ing ‘‘1903(u)(1)(C)(iv) (42 U.S.C. 1396b(u)(1)(C)(iv))’’

24 and inserting ‘‘1903(u)(1)(D)(iv) (42 U.S.C.

25 1396b(u)(1)(D)(iv))’’.
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1 SEC. 244. CORRECTIONS RELATING TO SECTION 4501 (LOW2 INCOME MEDICARE BENEFICIARIES).

3 (a) Section 1902(a)(10)(E)(iii) (42 U.S.C.

4 1396a(a)(10)(E)(iii)), as added by section 4501(b)(3) of

5 OBRA–1990, is amended by striking ‘‘cost sharing’’ and

6 inserting ‘‘cost-sharing’’.

7 (b) Section 1905(p)(4)(B) (42 U.S.C.

8 1396d(p)(4)(B)), as amended by section 4501(c)(1) of

9 OBRA–1990, is amended by striking

10 ‘‘1902(a)(10)(E)(iii)’’ and inserting ‘‘section

11 1902(a)(10)(E)(iii)’’.

12 SEC. 245. CORRECTIONS RELATING TO SECTION 4601

13 (CHILD HEALTH).

14 (a) Section 1902(a)(10)(A)(i)(VII) (42 U.S.C.

15 1396a(a)(10)(A)(i)(VII)), as added by section

16 4601(a)(10)(A)(iii) of OBRA–1990, is amended by strik17 ing ‘‘family;’’ and inserting ‘‘family; and’’.

18 (b) Section 1902(l) (42 U.S.C. 1396a(l)), as amended

19 by section 4601(a)(1)(C) of OBRA–1990, is amended—

20 (1) in paragraph (1)(C), by striking ‘‘children’’

21 after ‘‘(C)’’;

22 (2) in paragraph (3), by striking

23 ‘‘(a)(10)(A)(i)(VII),,’’ and inserting

24 ‘‘(a)(10)(A)(i)(VII),’’; and

25 (3) in paragraph (4)(B), by inserting a comma

26 before ‘‘(a)(10)(A)(i)(VI),’’.
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1 (c) Section 1925 (42 U.S.C. 1396r–6), as amended

2 by section 4601(a) of OBRA–1990, is amended—

3 (1) in subsection (a)(3)(C), by striking

4 ‘‘(i)(VI)’’ and inserting ‘‘(i)(VI),’’, and

5 (2) in subsection (b)(3)(C)(i), by striking

6 ‘‘(i)(IV) (i)(VI) (i)(VII), ,’’ and inserting ‘‘(i)(IV),

7 (i)(VI), (i)(VII),’’.

8 SEC. 246. CORRECTIONS RELATING TO SECTION 4602 (OUT9 REACH LOCATIONS).

10 (a) Section 1902(a)(55) (42 U.S.C. 1396a(a)(55)),

11 as added by section 4602(a)(3) of OBRA–1990, is amend12 ed—

13 (1) in the matter preceding subparagraph (A)—

14 (A) by striking ‘‘subsection’’ and inserting

15 ‘‘paragraph’’, and

16 (B) by striking ‘‘(a)’’ each place it ap17 pears; and

18 (2) in subparagraph (A), by striking

19 ‘‘1905(1)(2)(B)’’ and inserting ‘‘1905(l)(2)(B)’’.

20 (b) Section 1902(l)(1) (42 U.S.C. 1396a(l)(1)) is

21 amended by striking ‘‘who are not described in any of

22 subclauses (I) through (III) of subsection (a)(10)(A)(i)

23 and’’.
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1 SEC. 247. CORRECTIONS RELATING TO SECTION 4604 (PAY2 MENT FOR HOSPITAL SERVICES FOR CHIL3 DREN UNDER 6 YEARS OF AGE).

4 (a) Section 1902(a)(10) (42 U.S.C. 1396a(a)(10)) is

5 amended in clause (X) in the matter following subpara6 graph (F) by striking ‘‘under one year of age’’ and insert7 ing ‘‘under 6 years of age’’.

8 (b) Section 1902(s) (42 U.S.C. 1396a(s)), as added

9 by section 4604(a) of OBRA–1990, is amended to read

10 as follows:

11 ‘‘(s) In order to meet the requirements of subsection

12 (a)(56), the State plan must provide that payments to hos13 pitals under the plan for inpatient services furnished to

14 infants who have not attained the age of 1 year (or, in

15 the case of such an individual who is an inpatient on his

16 first birthday, until such individual is discharged) shall—

17 ‘‘(1) if made on a prospective basis (whether

18 per diem, per case, or otherwise), provide for an

19 outlier adjustment in payment amounts for medi20 cally necessary inpatient hospital services involving

21 exceptionally high costs or exceptionally long lengths

22 of stay;

23 ‘‘(2) not be limited by the imposition of day

24 limits; and

25 ‘‘(3) not be limited by the imposition of dollar

26 limits (other than dollar limits resulting from pro-
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1 spective payments as adjusted pursuant to para2 graph (1)).’’.

3 (c) Section 1923(a)(2)(C) (42 U.S.C. 1396r–

4 4(a)(2)(C)) is amended by striking ‘‘provided on or after

5 July 1, 1989,’’ and all that follows and inserting the fol6 lowing: ‘‘involving exceptionally high costs or exceptionally

7 long lengths of stay—

8 ‘‘(i) for individuals under 1 year of age, in the

9 case of services provided on or after July 1, 1989,

10 and on or before June 30, 1991; and

11 ‘‘(ii) for individuals under 6 years of age, in the

12 case of services provided on or after July 1, 1991.’’.

13 SEC. 248. CORRECTIONS RELATING TO SECTION 4703 (PAY14 MENT ADJUSTMENTS FOR DISPROPORTION15 ATE SHARE HOSPITALS).

16 (a) Section 1923(c) (42 U.S.C. 1396r–4(c)) is

17 amended—

18 (1) in paragraph (2), by striking ‘‘paragraph

19 (b)(3)’’ and inserting ‘‘subsection (b)(3)’’;

20 (2) by striking the period at the end of para21 graph (3)(B) and inserting a comma; and

22 (3) in the third sentence, by striking ‘‘the pay23 ment adjustment described in paragraph (2)’’ and

24 inserting ‘‘a payment adjustment described in para25 graph (2) or (3)’’.
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1 (b) Effective December 22, 1987, section

2 1923(d)(2)(A)(ii) (42 U.S.C. 1396r–4(d)(2)(A)(ii)) is

3 amended by striking ‘‘the date of the enactment of this

4 Act’’ and inserting ‘‘December 22, 1987’’.

5 (c) Section 4703(d) of OBRA–1990 is amended by

6 striking ‘‘412(a)(2)’’ and inserting ‘‘4112(a)(2)’’.

7 SEC. 249. CORRECTIONS RELATING TO SECTION 4704 (FED8 ERALLY-QUALIFIED HEALTH CENTERS).

9 (a) Clause (ix) of section 1903(m)(2)(A) (42 U.S.C.

10 1396b(m)(2)(A)), as added by section 4704(b)(1)(C) of

11 OBRA–1990, is amended—

12 (1) by striking ‘‘of such center’’ the first place

13 it appears;

14 (2) by striking ‘‘federally qualified’’ and insert15 ing ‘‘Federally-qualified’’;

16 (3) by inserting ‘‘section’’ before

17 ‘‘1905(a)(2)(C)’’; and

18 (4) by moving such clause 2 ems to the left.

19 (b) Section 1903(m)(2)(B) (42 U.S.C.

20 1396b(m)(2)(B)), as amended by section 4704(b)(2) of

21 OBRA–1990, is amended in the matter preceding clause

22 (i) by striking ‘‘except with respect to clause (ix) of sub23 paragraph (A),’’ and inserting ‘‘(except with respect to

24 clause (ix) of such subparagraph)’’.
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1 (c) Section 1905(l)(2) (42 U.S.C. 1396d(l)(2)), as

2 amended by section 4704(c) of OBRA–1990 and sections

3 13606(a) and 13631(f)(2)(B) of OBRA–1993, is amend4 ed—

5 (1) in subparagraph (A)—

6 (A) by striking ‘‘Federally-qualififed’’ and

7 inserting ‘‘Federally-qualified’’, and

8 (B) by striking ‘‘an patient’’ and inserting

9 ‘‘a patient’’, and

10 (2) in subparagraph (B)—

11 (A) in the matter preceding clause (i), by

12 striking ‘‘a entity’’ and inserting ‘‘an entity’’,

13 (B) by striking ‘‘or’’ at the end of clause

14 (iii),

15 (C) by striking the semicolon at the end of

16 clause (iv) and inserting ‘‘, or’’, and

17 (D) by striking ‘‘and includes an out18 patient health program’’ and all that follows

19 through ‘‘for good cause shown.’’ and inserting

20 the following:

21 ‘‘(v) is an outpatient health program or facility

22 operated by a tribe or tribal organization under the

23 Indian Self-Determination Act (Public Law 93–638)

24 or by an urban Indian organization receiving funds

25 under title V of the Indian Health Care Improve-
200

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1 ment Act for the provision of primary health serv2 ices.

3 In applying clause (ii), the Secretary may waive any re4 quirement referred to in such clause for up to 2 years for

5 good cause shown.’’.

6 SEC. 250. CORRECTIONS RELATING TO SECTION 4708 (SUB7 STITUTE PHYSICIANS).

8 (a) Section 1902(a)(32) (42 U.S.C. 1396a(a)(32)),

9 as added by section 4708(a)(3) of OBRA–1990 and as

10 amended by section 13631(e)(1) of OBRA–1993, is

11 amended—

12 (1) in the matter preceding subparagraph (A),

13 by striking ‘‘except that’’ and inserting ‘‘except that

14 (subject to section 1903(i)(12))’’; and

15 (2) by amending subparagraph (C) to read as

16 follows:

17 ‘‘(C) payment may be made to a physician

18 for physicians’ services (and services furnished

19 incident to such services) furnished by a second

20 physician to patients of the first physician if (i)

21 the first physician is unavailable to provide the

22 services; (ii) the services are furnished pursuant

23 to an arrangement between the two physicians

24 that (I) is informal and reciprocal, or (II) in25 volves per diem or other fee-for-time compensa-
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1 tion for such services; (iii) the services are not

2 provided by the second physician over a contin3 uous period of more than 60 days; and (iv) the

4 claim form submitted to the State for such

5 services includes the second physician’s unique

6 identifier (provided under the system estab7 lished under subsection (x)) and indicates that

8 the claim meets the requirements of this sub9 paragraph for payment to the first physician;

10 and’’.

11 (b) The amendments made by subsection (a) shall

12 apply to services furnished on or after the first day of the

13 first month beginning more than 60 days after the date

14 of the enactment of this Act.

15 SEC. 251. CORRECTIONS RELATING TO SECTION 4711

16 (HOME AND COMMUNITY CARE FOR FRAIL

17 ELDERLY).

18 (a) Section 1929 (42 U.S.C. 1396t), as added by sec19 tion 4711(b) of OBRA–1990, is amended—

20 (1) in subsection (c)(2)(F), by moving the sec21 ond sentence 2 ems to the right;

22 (2) in subsection (d)(2)(F)(ii), by striking ‘‘they

23 manage’’ and inserting ‘‘it manages’’;

24 (3) in subsection (d)(2)(F)(iii), by inserting

25 ‘‘the agency or organization’’ after ‘‘(iii)’’;
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1 (4) in subsection (e)(2)(B), by striking ‘‘fiscal

2 year 1989’’ and inserting ‘‘fiscal year 1990’’;

3 (5) in subsection (f)(1), by striking ‘‘Commu4 nity care’’ and inserting ‘‘community care’’;

5 (6) in subsection (g)(1)—

6 (A) by striking ‘‘SETTINGS’’ and inserting

7 ‘‘SETTING’’; and

8 (B) in subparagraph (B), by striking ‘‘set9 ting.’’ and inserting ‘‘setting in which home and

10 community care under this section is pro11 vided.’’;

12 (7) in subsection (g)(2), by striking ‘‘commu13 nity care’’ the second, third, and fourth place it ap14 pears and inserting ‘‘home and community care’’;

15 (8) in subsection (h)(1)—

16 (A) by amending subparagraph (A) to read

17 as follows:

18 ‘‘(A) a nonresidential setting that serves 8

19 or more individuals; or’’; and

20 (B) in subparagraph (B)—

21 (i) by striking ‘‘more than 8’’ and in22 serting ‘‘8 or more’’; and

23 (ii) by inserting ‘‘(other than merely

24 board)’’ after ‘‘personal services’’;
203

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1 (9) in subsection (h)(2), by striking ‘‘commu2 nity care’’ the second and third place it appears and

3 inserting ‘‘home and community care’’;

4 (10) in the first sentence of subsection

5 (j)(1)(A), by striking ‘‘the State may terminate the

6 provider’s participation under the State plan and

7 may provide in addition for a civil money penalty’’

8 and inserting ‘‘the State may provide for a civil

9 money penalty and, in addition, may terminate the

10 provider’s participation under the State plan’’;

11 (11) in the first sentence of subsection

12 (j)(2)(B), by striking ‘‘the Secretary may terminate

13 the provider’s participation under the State plan and

14 may provide, in addition, for a civil money penalty

15 under subparagraph (C)’’ and inserting ‘‘the Sec16 retary may provide for a civil money penalty under

17 subparagraph (C) and, in addition, terminate the

18 provider’s participation under the State plan’’;

19 (12) in subsection (k)(1)(A)(i)—

20 (A) by striking ‘‘(d)(2)(E)’’ and inserting

21 ‘‘(d)(2)’’, and

22 (B) by striking ‘‘settings,’’ and inserting

23 ‘‘settings),’’;

24 (13) in subsection (l), by striking ‘‘State wide25 ness’’ and inserting ‘‘Statewideness’’;
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1 (14) in paragraph (2) of subsection (m) by

2 striking ‘‘Individual Community Care Plan’’ and in3 serting ‘‘individual community care plan’’; and

4 (15) by adding at the end the following new

5 subsection:

6 ‘‘(n) COMMUNITY CARE SETTING DEFINED.—In this

7 section, the term ‘community care setting’ means a small

8 community care setting (as defined in subsection (g)(1))

9 or a large community care setting (as defined in sub10 section (h)(1)).’’.

11 (b) Section 1905(r)(5) (42 U.S.C. 1396d(r)(5)) is

12 amended by striking ‘‘section 1905(a)’’ and inserting

13 ‘‘subsection (a) (other than services described in para14 graph (22) or (23) of such subsection)’’.

15 (c) Section 4711(f) of OBRA–1990 is amended by

16 striking ‘‘Act’’ each place it appears and inserting ‘‘sec17 tion’’.

18 SEC. 252. CORRECTIONS RELATING TO SECTION 4712 (COM19 MUNITY SUPPORTED LIVING ARRANGE20 MENTS).

21 (a) Section 1930 (42 U.S.C. 1396u), as added by sec22 tion 4712(b)(2) of OBRA–1990, is amended—

23 (1) in subsection (b)—

24 (A) by striking ‘‘title the term,’’ and in25 serting ‘‘title, the term’’,
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1 (B) by striking ‘‘guardian’’ and inserting

2 ‘‘guardian or’’, and

3 (C) by striking ‘‘3 other’’ and inserting

4 ‘‘3’’;

5 (2) in subsection (d)—

6 (A) in the matter preceding paragraph (1),

7 by striking ‘‘program,’’ and inserting ‘‘pro8 gram’’, and

9 (B) in the second sentence, by striking

10 ‘‘plan’’ each place it appears and inserting

11 ‘‘program’’; and

12 (3) in subsection (i), by striking ‘‘FUNDS’’ and

13 inserting ‘‘FUNDS’’.

14 (b) Section 4712(c) of OBRA–1990 is amended—

15 (1) in paragraph (1), by inserting ‘‘of section

16 1930 of the Social Security Act’’ after ‘‘subsection

17 (h)’’; and

18 (2) in paragraph (2), by striking ‘‘this section’’

19 and inserting ‘‘such section’’.

20 SEC. 253. CORRECTION RELATING TO SECTION 4713 (COBRA

21 CONTINUATION COVERAGE).

22 (a) Section 1902(a)(10) (42 U.S.C. 1396a(a)(10)) is

23 amended in the matter following subparagraph (F) by

24 striking ‘‘COBRA continuation premiums’’ and inserting

25 ‘‘COBRA premiums’’.
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1 (b) Section 1902(u)(3) (42 U.S.C. 1396a(u)(3)), as

2 added by section 4713(a)(2) of OBRA–1990, is amended

3 by striking ‘‘title VI’’ and inserting ‘‘part 6 of subtitle B

4 of title I’’.

5 SEC. 254. CORRECTION RELATING TO SECTION 4716 (MED6 ICAID TRANSITION FOR FAMILY ASSIST7 ANCE).

8 Section 4716(a) of OBRA–1990 is amended by strik9 ing ‘‘AMENDMENTS.—Subsection (f) of section’’ and in10 serting ‘‘IN GENERAL.—Section’’.

11 SEC. 255. CORRECTIONS RELATING TO SECTION 4718 (MEDI12 CALLY NEEDY INCOME LEVELS FOR CERTAIN

13 1-MEMBER FAMILIES).

14 Section 4718(b) of OBRA–1990 is amended by strik15 ing ‘‘June 1, 1989’’ and inserting ‘‘July 1, 1989’’.

16 SEC. 256. CORRECTIONS RELATING TO SECTION 4723 (MED17 ICAID SPEND-DOWN OPTION).

18 Section 1903(f)(2) (42 U.S.C. 1396b(f)(2)), as

19 amended by section 4723(a) of OBRA–1990, is amended

20 by striking ‘‘to the State, provided that’’ and inserting ‘‘to

21 the State if’’.
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1 SEC. 257. CORRECTIONS RELATING TO SECTION 4724 (OP2 TIONAL STATE DISABILITY DETERMINA3 TIONS).

4 Section 1902(v) (42 U.S.C. 1396a(v)), as added by

5 section 4724 of OBRA–1990, is amended—

6 (1) by striking ‘‘(v)(1)’’ and inserting ‘‘(v)’’;

7 and

8 (2) by striking ‘‘of the Social Security Act’’.

9 SEC. 258. CORRECTION RELATING TO SECTION 4732 (SPE10 CIAL RULES FOR HEALTH MAINTENANCE OR11 GANIZATIONS).

12 Section 1903(m)(2)(F)(i) (42 U.S.C.

13 1396b(m)(2)(F)(i)), as amended by section 4732(b)(2)(B)

14 of OBRA–1990, is amended by striking ‘‘or’’ before ‘‘with

15 an eligible organization’’.

16 SEC. 259. CORRECTIONS RELATING TO SECTION 4747 (COV17 ERAGE OF HIV-POSITIVE INDIVIDUALS).

18 Section 4747 of OBRA–1990 is amended—

19 (1) in subsection (a)—

20 (A) by striking ‘‘services described in sub21 section (c)’’ and inserting ‘‘services described in

22 subsection (b)(1) (and may provide coverage for

23 services described in subsection (b)(2))’’, and

24 (B) by striking ‘‘to individuals’’ and insert25 ing ‘‘to individuals who are not otherwise eligi26 ble for medical assistance under such title,’’;
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1 (2) by amending subsection (b) to read as fol2 lows:

3 ‘‘(b) SERVICES AVAILABLE UNDER A DEMONSTRA4 TION PROJECT.—

5 ‘‘(1) REQUIRED SERVICES.—

6 ‘‘(A) IN GENERAL.—Services described in

7 this paragraph are the following:

8 ‘‘(i) General and preventive medical

9 care services, including outpatient care,

10 physician visits, and clinic visits.

11 ‘‘(ii) Other laboratory and X-ray serv12 ices.

13 ‘‘(iii) Prescription drugs (including

14 costs associated with the intravenous ad15 ministration of prescription drugs).

16 ‘‘(iv) Case management services.

17 ‘‘(B) SCOPE OF SERVICES.—The services

18 described in subparagraph (A) may be limited

19 under a demonstration project only on the basis

20 of medical necessity or the appropriateness of

21 such services.

22 ‘‘(2) OPTIONAL SERVICES.—

23 ‘‘(A) IN GENERAL.—Services described in

24 this paragraph are the following:

25 ‘‘(i) Counseling and social services.
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1 ‘‘(ii) Substance abuse treatment.

2 ‘‘(iii) Health education services.

3 ‘‘(iv) Dental services.

4 ‘‘(B) SCOPE OF SERVICES.—A demonstra5 tion project may limit the amount, duration, or

6 scope of services described in subparagraph

7 (A).’’;

8 (3) in subsection (c)—

9 (A) in paragraph (1)—

10 (i) by striking ‘‘with a hospital’’ and

11 all that follows through ‘‘other entity

12 have’’ and inserting ‘‘with an entity which

13 has’’, and

14 (ii) by striking ‘‘and have access’’ and

15 all that follows through the end and insert16 ing ‘‘and has access to data on comparable

17 patients who have so tested and who are

18 not participating in the demonstration

19 project.’’, and

20 (B) by striking paragraphs (2) and (3) and

21 redesignating paragraph (4) as paragraph (2);

22 (4) in subsection (d), by striking ‘‘paragraph

23 (3)’’ and ‘‘paragraph (1)’’ and inserting ‘‘subsection

24 (b)’’ and ‘‘subsection (a)’’, respectively; and
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1 (5) in subsection (f), by adding at the end the

2 following new sentence: ‘‘Such sums as may be avail3 able under the limitation set forth in this paragraph

4 for fiscal year 1993 shall be available until ex5 pended.’’.

6 SEC. 260. CORRECTION RELATING TO SECTION 4751 (AD7 VANCED DIRECTIVES).

8 Section 1903(m)(1)(A) (42 U.S.C. 1396b(m)(1)(A)),

9 as amended by section 4751(b)(1) of OBRA–1990, is

10 amended—

11 (1) by striking ‘‘1902(w)’’ and inserting

12 ‘‘1902(w) and’’; and

13 (2) by striking ‘‘1902(a)’’ and inserting

14 ‘‘1902(w)’’.

15 SEC. 261. CORRECTIONS RELATING TO SECTION 4752 (PHY16 SICIANS’ SERVICES).

17 (a) Paragraph (59) of section 1902(a) (42 U.S.C.

18 1396a(a)), as added by section 4752(c)(1)(C) of OBRA–

19 1990 and as redesignated by section 13623(a)(6) of

20 OBRA–1993, is amended by striking ‘‘subsection (v)’’ and

21 inserting ‘‘subsection (x)’’.

22 (b) Section 1903(i)(12) (42 U.S.C. 1396b(i)(12)), as

23 inserted by section 4752(e) of OBRA–1990 and as redes24 ignated by section 13631(c)(3) of OBRA–1993, is amend25 ed—
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1 (1) by amending clause (i) of subparagraph (A)

2 to read as follows:

3 ‘‘(i) is certified in family practice or

4 pediatrics by the medical specialty board

5 recognized by the American Board of Med6 ical Specialties for family practice or pedi7 atrics or is certified in general practice or

8 pediatrics by the medical specialty board

9 recognized by the American Osteopathic

10 Association,’’;

11 (2) by amending clause (i) of subparagraph (B)

12 to read as follows:

13 ‘‘(i) is certified in family practice or

14 obstetrics by the medical specialty board

15 recognized by the American Board of Med16 ical Specialties for family practice or ob17 stetrics or is certified in general practice or

18 obstetrics by the Medical Specialty Board

19 recognized by the American Osteopathic

20 Association,’’; and

21 (3) in subparagraphs (A) and (B)—

22 (A) by striking ‘‘or’’ at the end of clause

23 (v);

24 (B) by redesignating clause (vi) as clause

25 (vii); and
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1 (C) by inserting after clause (v) the follow2 ing new clause:

3 ‘‘(vi) delivers such services in the

4 emergency department of a hospital par5 ticipating in the State plan approved under

6 this title, or’’.

7 SEC. 262. CORRECTIONS RELATING TO SECTION 4801

8 (NURSING HOME REFORM).

9 (a) Section 1919(b)(3)(C)(i)(I) (42 U.S.C.

10 1396r(b)(3)(C)(i)(I)), as amended by section 4801(e)(3)

11 of OBRA–1990, is amended by striking ‘‘not to exceed’’

12 before ‘‘14 days’’.

13 (b) Section 1919(b)(5)(D) (42 U.S.C.

14 1396r(b)(5)(D)), as amended by section 4801(a)(4) of

15 OBRA–1990, is amended by striking the comma before

16 ‘‘or a new competency evaluation program.’’.

17 (c) Section 1919(b)(5)(G) (42 U.S.C.

18 1396r(b)(5)(G)) is amended by striking ‘‘or licensed or

19 certified social worker’’ and inserting ‘‘licensed or certified

20 social worker, registered respiratory therapist, or certified

21 respiratory therapy technician’’.

22 (d) Section 1919(f)(2)(B)(i) (42 U.S.C.

23 1396r(f)(2)(B)(i)) is amended by striking ‘‘facilities,’’ and

24 inserting ‘‘facilities (subject to clause (iii)),’’.
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1 (e) Section 1919(f)(2)(B)(iii)(I)(c) (42 U.S.C.

2 1396r(f)(2)(B)(iii)(I)(c)) is amended by striking ‘‘clauses’’

3 each place it appears and inserting ‘‘clause’’.

4 (f) Section 1919(g)(5)(B) (42 U.S.C.

5 1396r(g)(5)(B)) is amended by striking ‘‘paragraphs’’ and

6 inserting ‘‘paragraph’’.

7 (g) Section 4801(a)(6)(B) of OBRA–1990 is amend8 ed—

9 (1) by striking ‘‘The amendments’’ and insert10 ing ‘‘(i) The amendments’’;

11 (2) by redesignating clauses (i) through (v) as

12 subclauses (I) through (V); and

13 (3) by adding at the end the following new

14 clause:

15 ‘‘(ii) Notwithstanding clause (i) and sub16 ject to section 1919(f)(2)(B)(iii)(I) of the Social

17 Security Act (as amended by subparagraph

18 (A)), a State may approve a training and com19 petency evaluation program or a competency

20 evaluation program offered by or in a nursing

21 facility described in clause (i) if, during the pre22 vious 2 years, none of the subclauses of clause

23 (i) applied to the facility.’’.
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1 SEC. 263. OTHER TECHNICAL CORRECTIONS.

2 (a) Section 1905(o)(1)(A) (42 U.S.C.

3 1396d(o)(1)(A)) is amended—

4 (1) in the first sentence, by striking ‘‘intermedi5 ate care facility services’’ and inserting ‘‘for nursing

6 facility services or intermediate care facility services

7 for the mentally retarded’’; and

8 (2) in the second sentence, by striking ‘‘or in9 termediate care facility’’ and inserting ‘‘(for pur10 poses of title XVIII), a nursing facility, or an inter11 mediate care facility for the mentally retarded’’.

12 (b) Section 1915(d) (42 U.S.C. 1396n(d)) is amend13 ed—

14 (1) by striking ‘‘skilled nursing facility or inter15 mediate care facility’’ each place it appears in para16 graphs (1), (2)(B), and (2)(C) and inserting ‘‘nurs17 ing facility’’;

18 (2) in paragraph (2)(B)(i), by striking ‘‘skilled

19 nursing or intermediate care facility’’ and inserting

20 ‘‘nursing facility’’;

21 (3) in paragraph (5)(A), by striking ‘‘under’’

22 the second place it appears and inserting ‘‘(or, in the

23 case of waiver years beginning on or after October

24 1, 1990, with respect to nursing facility services and

25 home and community-based services) under’’; and

26 (4) in paragraph (5)(B)—
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1 (A) in clause (i), by striking ‘‘furnished’’

2 and inserting ‘‘(or, with respect to waiver years

3 beginning on or after October 1, 1990, for

4 nursing facility services) furnished’’; and

5 (B) in clause (iii)(I), by striking ‘‘(regard6 less’’ and inserting ‘‘(or, with respect to waiver

7 years beginning on or after October 1, 1990,

8 which comprise nursing facility services) (re9 gardless’’.

10 (c)(1) Section 1924(h)(1)(A) (42 U.S.C. 1396r–

11 5(h)(1)(A)) is amended to read as follows:

12 ‘‘(A)(i) is in a medical institution or nurs13 ing facility; or

14 ‘‘(ii) is described in section

15 1902(a)(10)(A)(ii)(VI) (except that for pur16 poses of subsection (d), such term shall include

17 such individual only if the State elects to apply

18 such subsection to the individual); and’’.

19 (2) The amendments made by this subsection shall

20 apply to home or community-based services furnished on

21 or after January 1, 1994.
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1 Subtitle C—Miscellaneous and

2 Technical Corrections Relating

3 to OBRA–1993

4 SEC. 271. EFFECTIVE DATE.

5 Except as otherwise provided, the amendments made

6 by this part shall take effect as if included in the enact7 ment of OBRA–1993.

8 SEC. 272. CORRECTIONS RELATING TO SECTION 13601 (PER9 SONAL CARE SERVICES).

10 Section 13601(a)(3) of OBRA–1993 is amended by

11 striking ‘‘comma’’ and inserting ‘‘period’’.

12 SEC. 273. CORRECTIONS RELATING TO SECTION 13604

13 (EMERGENCY SERVICES FOR ALIENS).

14 Section 13604(b)(2) of OBRA–1993 is amended to

15 read as follows:

16 ‘‘(2) The Secretary of Health and Human Services

17 shall not disallow expenditures made under section

18 1903(v)(2) of the Social Security Act for care and services

19 relating to organ transplant procedures furnished before

20 the date of the enactment of this Act.’’.

21 SEC. 274. CORRECTIONS RELATING TO SECTION 13611

22 (TRANSFERS OF ASSETS; TREATMENT OF

23 CERTAIN TRUSTS).

24 (a) Section 1917(c)(2)(C)(iii) (42 U.S.C.

25 1396p(c)(2)(C)(iii)), as added by section
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1 13611(a)(2)(C)(iv) of OBRA–1993, is amended by strik2 ing ‘‘all’’.

3 (b) Section 1917(c)(4) (42 U.S.C. 1396p(c)(4)), as

4 amended by section 13611(a)(2)(F), is amended by strik5 ing ‘‘resources’’ and inserting ‘‘assets’’.

6 (c) Section 13611(e)(3) of OBRA–1993 is amend7 ed—

8 (1) by striking ‘‘amendment made by subsection

9 (b)’’ and inserting ‘‘amendments made by sub10 sections (a) and (b)’’; and

11 (2) by striking ‘‘such amendment’’ and insert12 ing ‘‘such amendments’’.

13 SEC. 275. CORRECTIONS RELATING TO SECTION 13612

14 (MEDICAID ESTATE RECOVERIES).

15 Section 1917(b)(1) (42 U.S.C 1396p(b)(1)), as

16 amended by section 13612(a) of OBRA–1993, is amend17 ed—

18 (1) by amending the matter preceding subpara19 graph (A) to read as follows:

20 ‘‘(b)(1) No adjustment or recovery of any medical as21 sistance correctly paid on behalf of an individual under

22 the State plan may be made, except that the State shall

23 comply with the following:’’;

24 (2) by amending subparagraph (A) to read as

25 follows:
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1 ‘‘(A) In the case of an individual described in

2 subsection (a)(1)(B), the State—

3 ‘‘(i) shall seek adjustment or recovery upon

4 the sale of property subject to a lien imposed on

5 account of medical assistance paid on behalf of

6 the individual, and

7 ‘‘(ii) may seek adjustment or recovery from

8 the individual’s estate.’’; and

9 (3) in subparagraph (B)—

10 (A) in clause (i), by striking ‘‘or’’ at the

11 end and inserting ‘‘and’’; and

12 (B) in clause (ii), by inserting ‘‘additional’’

13 after ‘‘any’’.

14 SEC. 276. CORRECTIONS RELATING TO SECTION 13622 (LI15 ABILITY OF THIRD PARTIES TO PAY FOR

16 CARE AND SERVICES).

17 (a) Section 1902(a)(25)(A) (42 U.S.C.

18 1396a(a)(25)(A)), as amended by section 13622(a) of

19 OBRA–1993, is amended by striking ‘‘(as defined in sec20 tion 607(1)’’ and inserting ‘‘(including any such plan

21 meeting the definition of section 607(1)’’.

22 (b) Section 1902(a)(25)(I) (42 U.S.C.

23 1396a(a)(25)(I)), as added by section 13622(c) of OBRA–

24 1993, is amended to read as follows:
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1 ‘‘(I) assurances satisfactory to the Sec2 retary that the State has in effect laws provid3 ing that, to the extent that payment has been

4 made under the State plan of that or any other

5 State for medical assistance for health care

6 items or services furnished to an individual, the

7 State paying such medical assistance is consid8 ered to have acquired the rights of such individ9 ual to payment by any third party legally liable

10 to pay for such items or services;’’.

11 SEC. 277. CORRECTIONS RELATING TO SECTION 13623

12 (MEDICAL CHILD SUPPORT).

13 (a)(1) Title XIX (42 U.S.C. 1396 et seq.) is amended

14 by redesignating section 1908, as added by section

15 13623(b) of OBRA–1993, as section 1909.

16 (2) Paragraph (60) of section 1902(a) (42 U.S.C.

17 1396a(a)), as added by section 13623(a) of OBRA–1993,

18 is amended by striking ‘‘section 1908’’ and inserting ‘‘sec19 tion 1909’’.

20 (b) Subsection (b) of section 1909, as redesignated

21 by subsection (a), is amended by striking ‘‘as defined in

22 section 607(1)’’ and inserting ‘‘including any such plan

23 meeting the definition of section 607(1)’’.
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1 SEC. 278. CORRECTIONS RELATING TO SECTION 13624 (PHY2 SICIAN REFERRALS).

3 Section 13624(b) of OBRA–1993 is amended by

4 striking ‘‘on or’’.

5 SEC. 279. CORRECTIONS RELATING TO SECTION 13631

6 (MEDICAID PEDIATRIC IMMUNIZATION PRO7 VISIONS).

8 (a) Section 1902(a)(32)(D) (42 U.S.C.

9 1396(a)(32)(D)), as added by section 13631(e)(1) of

10 OBRA–1993, is amended by striking ‘‘(which price in11 cludes a reasonable amount to cover shipping and the han12 dling of returns)’’ and inserting ‘‘plus a reasonable

13 amount to cover shipping and the handling of returns’’.

14 (b) Section 1928(d)(3)(B) (42 U.S.C.

15 1396s(d)(3)(B)), as added by section 13631(b)(2) of

16 OBRA–1993, is amended by striking ‘‘and any applicable

17 excise tax established under section 4131 of the Internal

18 Revenue Code of 1986’’.

19 SEC. 280. CORRECTIONS RELATING TO SECTION 13643

20 (DEMONSTRATION PROJECTS).

21 Effective as if included in the enactment of OBRA–

22 1990, section 4745 of such Act is amended in subsection

23 (d) by striking ‘‘shall commence not later than July 1,

24 1991 and’’.
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1 TITLE III—INCOME SECURITY,

2 HUMAN RESOURCES, AND RE3 LATED PROGRAMS

4 Subtitle A—Child Welfare, Foster

5 Care, Adoption

6 SEC. 301. REQUIRED PROTECTIONS FOR FOSTER CHIL7 DREN.

8 (a) IN GENERAL.—Section 422(b) (42 U.S.C.

9 622(b)) is amended—

10 (1) by striking ‘‘and’’ at the end of paragraph

11 (7);

12 (2) by striking the period at the end of para13 graph (8) and inserting ‘‘; and’’; and

14 (3) by adding at the end the following:

15 ‘‘(9) provide assurances that the State—

16 ‘‘(A) since June 17, 1980, has completed

17 an inventory of all children who, before the in18 ventory, had been in foster care under the re19 sponsibility of the State for 6 months or more,

20 which determined—

21 ‘‘(i) the appropriateness of, and neces22 sity for, the foster care placement;

23 ‘‘(ii) whether the child could or should

24 be returned to the parents of the child or
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1 should be freed for adoption or other per2 manent placement; and

3 ‘‘(iii) the services necessary to facili4 tate the return of the child or the place5 ment of the child for adoption or legal

6 guardianship;

7 ‘‘(B) is operating, to the satisfaction of the

8 Secretary—

9 ‘‘(i) a statewide information system

10 from which can be readily determined the

11 status, demographic characteristics, loca12 tion, and goals for the placement of every

13 child who is (or, within the immediately

14 preceding 12 months, has been) in foster

15 care;

16 ‘‘(ii) a case review system (as defined

17 in section 475(5)) for each child receiving

18 foster care under the supervision of the

19 State;

20 ‘‘(iii) a service program designed to

21 help children—

22 ‘‘(I) where appropriate, return to

23 families from which they have been

24 removed; or
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1 ‘‘(II) be placed for adoption, with

2 a legal guardian, or, if adoption or

3 legal guardianship is determined not

4 to be appropriate for a child, in some

5 other planned, permanent living ar6 rangement; and

7 ‘‘(iv) a preplacement preventive serv8 ices program designed to help children at

9 risk of foster care placement remain with

10 their families; and

11 ‘‘(C)(i) has reviewed (or within 12 months

12 after the date of the enactment of this para13 graph will review) State policies and adminis14 trative and judicial procedures in effect for chil15 dren abandoned at or shortly after birth (in16 cluding policies and procedures providing for

17 legal representation of such children); and

18 ‘‘(ii) is implementing (or within 24 months

19 after the date of the enactment of this para20 graph will implement) such policies and proce21 dures as the State determines, on the basis of

22 the review described in clause (i), to be nec23 essary to enable permanent decisions to be

24 made expeditiously with respect to the place25 ment of such children.’’.
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1 (b) RESTRICTION ON REALLOTMENT.—Section 424

2 (42 U.S.C. 624) is amended—

3 (1) in the first sentence, by striking ‘‘The

4 amount’’ and inserting the following:

5 ‘‘(a) IN GENERAL.—Subject to subsection (b), the

6 amount’’; and

7 (2) by adding at the end the following:

8 ‘‘(b) EXCEPTION RELATING TO FOSTER CHILD PRO9 TECTIONS.—The Secretary shall not reallot under sub10 section (a) of this section any amount that is withheld or

11 recovered from a State due to the failure of the State to

12 meet the requirements of section 422(b)(9).’’.

13 (c) REPEAL.—Section 427 (42 U.S.C. 627) is hereby

14 repealed.

15 (d) CONFORMING AMENDMENTS.—

16 (1) Section 423(a) (42 U.S.C. 623(a)) is

17 amended by striking ‘‘and in section 427’’.

18 (2) Section 425(a)(2) (42 U.S.C. 625(a)(2)) is

19 amended by striking ‘‘the statistical report required

20 by section’’ and inserting ‘‘section 422(b)(9) or’’.

21 (3) Section 472(d) (42 U.S.C. 672(d)) is

22 amended by striking ‘‘427(b)’’ and inserting

23 ‘‘422(b)(9)’’.
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1 (e) EFFECTIVE DATE.—The amendments and repeal

2 made by this section shall be effective with respect to fiscal

3 years beginning on or after October 1, 1995.

4 SEC. 302. CONFORMITY REVIEWS.

5 (a) IN GENERAL.—Part A of title XI (42 U.S.C.

6 1301–1320b–13) is amended by inserting after section

7 1122 the following:

8 ‘‘REVIEWS OF CHILD AND FAMILY SERVICES PROGRAMS,

9 AND OF FOSTER CARE AND ADOPTION ASSISTANCE

10 PROGRAMS, FOR CONFORMITY WITH STATE PLAN RE11 QUIREMENTS

12 ‘‘SEC. 1123. (a) IN GENERAL.—The Secretary, in

13 consultation with the State agencies administering the

14 State programs under parts B and E of title IV, shall pro15 mulgate regulations for the review of such programs to

16 determine whether such programs are in substantial con17 formity with—

18 ‘‘(1) State plan requirements under such parts

19 B and E,

20 ‘‘(2) implementing regulations promulgated by

21 the Secretary, and

22 ‘‘(3) the relevant approved State plans.

23 ‘‘(b) ELEMENTS OF REVIEW SYSTEM.—The regula24 tions referred to in subsection (a) shall—

25 ‘‘(1) specify the timetable for conformity re26 views of State programs, including—
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1 ‘‘(A) an initial review of each State pro2 gram;

3 ‘‘(B) a timely review of a State program

4 following a review in which such program was

5 found not to be in substantial conformity; and

6 ‘‘(C) less frequent reviews of State pro7 grams which have been found to be in substan8 tial conformity, but such regulations shall per9 mit the Secretary to reinstate more frequent re10 views based on information which indicates that

11 a State program may not be in conformity;

12 ‘‘(2) specify the requirements subject to review,

13 and the criteria to be used to measure conformity

14 with such requirements and to determine whether

15 there is a substantial failure to so conform;

16 ‘‘(3) specify the method to be used to determine

17 the amount of any Federal matching funds to be

18 withheld (subject to paragraph (4)) due to the State

19 program’s failure to so conform, which ensures

20 that—

21 ‘‘(A) such funds will not be withheld with

22 respect to a program, unless it is determined

23 that the program fails substantially to so con24 form;
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1 ‘‘(B) such funds will not be withheld for a

2 failure to so conform resulting from the State’s

3 reliance upon and correct use of formal written

4 statements of Federal law or policy provided to

5 the State by the Secretary; and

6 ‘‘(C) the amount of such funds withheld is

7 related to the extent of the failure to so con8 form; and

9 ‘‘(4) require the Secretary, with respect to any

10 State program found to have failed substantially to

11 so conform—

12 ‘‘(A) to afford the State an opportunity to

13 adopt and implement a corrective action plan,

14 approved by the Secretary, designed to end the

15 failure to so conform;

16 ‘‘(B) to make technical assistance available

17 to the State to the extent feasible to enable the

18 State to develop and implement such a correc19 tive action plan;

20 ‘‘(C) to suspend the withholding of any

21 Federal matching funds under this section while

22 such a corrective action plan is in effect; and

23 ‘‘(D) to rescind any such withholding if the

24 failure to so conform is ended by successful

25 completion of such a corrective action plan.
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1 ‘‘(c) PROVISIONS FOR ADMINISTRATIVE AND JUDI2 CIAL REVIEW.—The regulations referred to in subsection

3 (a) shall—

4 ‘‘(1) require the Secretary, not later than 10

5 days after a final determination that a program of

6 the State is not in conformity, to notify the State

7 of—

8 ‘‘(A) the basis for the determination; and

9 ‘‘(B) the amount of the Federal matching

10 funds (if any) to be withheld from the State;

11 ‘‘(2) afford the State an opportunity to appeal

12 the determination to the Departmental Appeals

13 Board within 60 days after receipt of the notice de14 scribed in paragraph (1) (or, if later, after failure to

15 continue or to complete a corrective action plan);

16 and

17 ‘‘(3) afford the State an opportunity to obtain

18 judicial review of an adverse decision of the Board,

19 within 60 days after the State receives notice of the

20 decision of the Board, by appeal to the district court

21 of the United States for the judicial district in which

22 the principal or headquarters office of the agency re23 sponsible for administering the program is located.’’.
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1 (b) CONFORMING AMENDMENT.—Section 471(b) (42

2 U.S.C. 671(b)) is amended by striking all that follows the

3 first sentence.

4 (c) EFFECTIVE DATES.—

5 (1) IN GENERAL.—Except as provided in para6 graph (2), the amendment made by subsection (a)

7 shall take effect on the date of the enactment of this

8 Act.

9 (2) CONFORMING AMENDMENT.—The amend10 ment made by subsection (b) shall take effect on Oc11 tober 1, 1995.

12 (3) REGULATIONS.—The Secretary shall pro13 mulgate the regulations referred to in section

14 1123(a) of the Social Security Act (as added by this

15 section) not later than January 1, 1995, to take ef16 fect on October 1, 1995.

17 SEC. 303. STATES REQUIRED TO REPORT ON MEASURES

18 TAKEN TO COMPLY WITH THE INDIAN CHILD

19 WELFARE ACT.

20 (a) STATE PLAN REQUIREMENT.—Section 422(b)

21 (42 U.S.C. 622(b)), as amended by section 301(a), is

22 amended—

23 (1) by striking ‘‘and’’ at the end of paragraph

24 (8);
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1 (2) by striking the period at the end of para2 graph (9) and inserting ‘‘; and’’; and

3 (3) by adding at the end the following:

4 ‘‘(10) contain a description, developed after

5 consultation with tribal organizations (as defined in

6 section 4 of the Indian Self-Determination and Edu7 cation Assistance Act) in the State, of the specific

8 measures taken by the State to comply with the In9 dian Child Welfare Act.’’.

10 (b) EFFECTIVE DATE.—The amendments made by

11 subsection (a) shall be effective with respect to fiscal years

12 beginning on or after October 1, 1994.

13 SEC. 304. CHILD WELFARE TRAINEESHIPS.

14 (a) IN GENERAL.—Subpart 1 of part B of title IV

15 (42 U.S.C. 620–628) is amended by inserting after section

16 428 the following:

17 ‘‘CHILD WELFARE TRAINEESHIPS

18 ‘‘SEC. 429. The Secretary may approve an applica19 tion for a grant to a public or nonprofit institution for

20 higher learning to provide traineeships with stipends

21 under section 426(a)(1)(C) only if the application—

22 ‘‘(1) provides assurances that each individual

23 who receives a stipend with such traineeship (in this

24 section referred to as a ‘recipient’) will enter into an

25 agreement with the institution under which the re26 cipient agrees—
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1 ‘‘(A) to participate in training at a public

2 or private nonprofit child welfare agency on a

3 regular basis (as determined by the Secretary)

4 for the period of the traineeship;

5 ‘‘(B) to be employed for a period of years

6 equivalent to the period of the traineeship, in a

7 public or private nonprofit child welfare agency

8 in any State, within a period of time (deter9 mined by the Secretary in accordance with reg10 ulations) after completing the postsecondary

11 education for which the traineeship was

12 awarded;

13 ‘‘(C) to furnish to the institution and the

14 Secretary evidence of compliance with subpara15 graphs (A) and (B); and

16 ‘‘(D) if the recipient fails to comply with

17 subparagraph (A) or (B) and does not qualify

18 for any exception to this subparagraph which

19 the Secretary may prescribe in regulations, to

20 repay to the Secretary all (or an appropriately

21 prorated part) of the amount of the stipend,

22 plus interest, and, if applicable, reasonable col23 lection fees (in accordance with regulations pro24 mulgated by the Secretary);
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1 ‘‘(2) provides assurances that the institution

2 will—

3 ‘‘(A) enter into agreements with child wel4 fare agencies for onsite training of recipients;

5 ‘‘(B) permit an individual who is employed

6 in the field of child welfare services to apply for

7 a traineeship with a stipend if the traineeship

8 furthers the progress of the individual toward

9 the completion of degree requirements; and

10 ‘‘(C) develop and implement a system that,

11 for the 3-year period that begins on the date

12 any recipient completes a child welfare services

13 program of study, tracks the employment

14 record of the recipient, for the purpose of deter15 mining the percentage of recipients who secure

16 employment in the field of child welfare services

17 and remain employed in the field.’’.

18 (b) CONFORMING AMENDMENT.—Section

19 426(a)(1)(C) (42 U.S.C. 626(a)(1)(C)) is amended by in20 serting ‘‘described in section 429’’ after ‘‘including

21 traineeships’’.

22 (c) APPLICABILITY.—The amendments made by this

23 section shall apply to grants awarded on or after October

24 1, 1994.
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1 SEC. 305. DISPOSITIONAL HEARING.

2 (a) MOST APPROPRIATE SETTING.—Section

3 475(5)(A) (42 U.S.C. 675(5)(A)) is amended by inserting

4 ‘‘and most appropriate’’ after ‘‘(most family like)’’.

5 (b) TIMING OF SUBSEQUENT REVIEW.—Section

6 475(5)(C) (42 U.S.C. 675(5)(C)) is amended by striking

7 ‘‘periodically’’ and inserting ‘‘not less frequently than

8 every 12 months’’.

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

10 this section shall take effect on October 1, 1994.

11 SEC. 306. ELIMINATION OF FOSTER CARE CEILINGS AND

12 OF AUTHORITY TO TRANSFER UNUSED FOS13 TER CARE FUNDS TO CHILD WELFARE SERV14 ICES PROGRAMS.

15 (a) REPEAL.—Subsections (b) and (c) of section 474

16 (42 U.S.C. 674 (b) and (c)) are hereby repealed.

17 (b) CONFORMING AMENDMENTS.—Section 474 (42

18 U.S.C. 674) is amended—

19 (1) in subsection (d)(1)—

20 (A) by striking ‘‘subsections (a), (b), and

21 (c)’’ and inserting ‘‘subsection (a)’’; and

(B) by striking ‘‘the provisions of such

subsections’’ and inserting ‘‘subsection (a)’’;

and

(2) by redesignating subsection (d) as subsection (b).
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(c) EFFECTIVE DATE.—The amendments and repeals made by this section shall apply to payments for

calendar quarters beginning on or after October 1, 1993.

SEC. 307. DEMONSTRATION PROJECTS.

Part A of title XI (42 U.S.C. 1301–1320b–13) is

amended by inserting after section 1128B the following:

‘‘DEMONSTRATION PROJECTS

‘‘SEC. 1129. (a) IN GENERAL.—The Secretary may

authorize not more than 10 States to conduct demonstration projects pursuant to this section which the Secretary

finds are likely to promote the objectives of part B or E

of title IV.

‘‘(b) WAIVER AUTHORITY.—The Secretary may

waive compliance with any requirement of part B or E

of title IV which (if applied) would prevent a State from

carrying out a demonstration project under this section

or prevent the State from effectively achieving the purpose of such a project, except that the Secretary may not

waive—

‘‘(1) any provision of section 427 (as in effect

before October 1, 1995), section 422(b)(9) (as in effect after such date), or section 479; or

‘‘(2) any provision of such part E, to the extent

that the waiver would impair the entitlement of any

qualified child or family to benefits under a State

plan approved under such part E.
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‘‘(c) TREATMENT AS PROGRAM EXPENDITURES.—

For purposes of parts B and E of title IV, the Secretary

shall consider the expenditures of any State to conduct

a demonstration project under this section to be expenditures under subpart 1 or 2 of such part B, or under such

part E, as the State may elect.

‘‘(d) DURATION OF DEMONSTRATION.—A demonstration project under this section may be conducted

for not more than 5 years.

‘‘(e) APPLICATION.—Any State seeking to conduct a

demonstration project under this section shall submit to

the Secretary an application, in such form as the Secretary may require, which includes—

‘‘(1) a description of the proposed project, the

geographic area in which the proposed project would

be conducted, the children or families who would be

served by the proposed project, and the services

which would be provided by the proposed project

(which shall provide, where appropriate, for random

assignment of children and families to groups served

under the project and to control groups);

‘‘(2) a statement of the period during which the

proposed project would be conducted;

‘‘(3) a discussion of the benefits that are expected from the proposed project (compared to a
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continuation of activities under the approved plan or

plans of the State);

‘‘(4) an estimate of the costs or savings of the

proposed project;

‘‘(5) a statement of program requirements for

which waivers would be needed to permit the proposed project to be conducted;

‘‘(6) a description of the proposed evaluation

design; and

‘‘(7) such additional information as the Secretary may require.

‘‘(f) EVALUATIONS; REPORT.—Each State authorized to conduct a demonstration project under this section shall—

‘‘(1) obtain an evaluation by an independent

contractor of the effectiveness of the project, using

an evaluation design approved by the Secretary

which provides for—

‘‘(A) comparison of methods of service delivery under the project, and such methods

under a State plan or plans, with respect to efficiency, economy, and any other appropriate

measures of program management;

‘‘(B) comparison of outcomes for children

and families (and groups of children and fami-
237

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lies) under the project, and such outcomes

under a State plan or plans, for purposes of assessing the effectiveness of the project in

achieving program goals; and

‘‘(C) any other information that the Secretary may require; and

‘‘(2) provide interim and final evaluation reports to the Secretary, at such times and in such

manner as the Secretary may require.

‘‘(g) COST NEUTRALITY.—The Secretary may not

authorize a State to conduct a demonstration project

under this section unless the Secretary determines that

the total amount of Federal funds that will be expended

under (or by reason of) the project over its approved

term (or such portion thereof or other period as the Secretary may find appropriate) will not exceed the amount

of such funds that would be expended by the State under

the State plans approved under parts B and E of title

IV if the project were not conducted.’’.

SEC. 308. PLACEMENT ACCOUNTABILITY.

(a) CASE PLAN REQUIREMENTS.—Section

475(5)(A) (42 U.S.C. 675(5)(A)), as amended by section

305(a), is amended by adding at the end the following:

‘‘which—
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‘‘(i) if the child has been placed in a

foster family home or child-care institution

a substantial distance from the home of

the parents of the child, or in a State different from the State in which such home

is located, sets forth the reasons why such

placement is in the best interests of the

child, and

‘‘(ii) if the child has been placed in

foster care outside the State in which the

home of the parents of the child is located,

requires that, periodically, but not less frequently than every 12 months, a caseworker on the staff of the State agency of

the State in which the home of the parents

of the child is located, or of the State in

which the child has been placed, visit such

child in such home or institution and submit a report on such visit to the State

agency of the State in which the home of

the parents of the child is located,’’.

(b) DISPOSITIONAL HEARING.—Section 475(5)(C)

(42 U.S.C. 675(5)(C)), as amended by section 305(b), is

amended by inserting ‘‘and, in the case of a child described in subparagraph (A)(ii), whether the out-of-State
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placement continues to be appropriate and in the best interests of the child,’’ after ‘‘long-term basis)’’.

1 (c) DATA COLLECTION.—Section 479(c)(3)(C) (42

2 U.S.C. 679(c)(3)(C)) is amended—

3 (1) by striking ‘‘and’’ at the end of clause (i);

4 and

5 (2) by adding at the end the following:

6 ‘‘(iii) children placed in foster care

7 outside the State which has placement and

8 care responsibility, and’’.

9 (d) EFFECTIVE DATES.—The amendments made by

10 this section shall be effective with respect to fiscal years

11 beginning on or after October 1, 1994.

12 SEC. 309. PAYMENTS OF STATE CLAIMS FOR FOSTER CARE

13 AND ADOPTION ASSISTANCE.

14 (a) IN GENERAL.—Section 474(b) (42 U.S.C.

15 674(b)), as redesignated by section 306(b)(2), is amended

16 by adding at the end the following:

17 ‘‘(4)(A) Within 60 days after receipt of a State claim

18 for expenditures pursuant to subsection (a), the Secretary

19 shall allow, disallow, or defer such claim.

20 ‘‘(B) Within 15 days after a decision to defer such

21 a State claim, the Secretary shall notify the State of the

22 reasons for the deferral and of the additional information

23 necessary to determine the allowability of the claim.
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1 ‘‘(C) Within 90 days after receiving such necessary

2 information (in readily reviewable form), the Secretary

3 shall—

4 ‘‘(i) disallow the claim, if able to complete the

5 review and determine that the claim is not allowable,

6 or

7 ‘‘(ii) in any other case, allow the claim, subject

8 to disallowance (as necessary)—

9 ‘‘(I) upon completion of the review, if it is

10 determined that the claim is not allowable; or

11 ‘‘(II) on the basis of findings of an audit

12 or financial management review.’’.

13 (b) EFFECTIVE DATE.—The amendment made by

14 subsection (a) shall be effective with respect to claims

15 made on or after the date of the enactment of this Act.

16 SEC. 310. EFFECT OF FAILURE TO CARRY OUT STATE

17 PLAN.

18 (a) IN GENERAL.—Part A of title XI (42 U.S.C.

19 1301–1320b–13), as amended by section 307, is amended

20 by inserting after section 1129 the following:

21 ‘‘EFFECT OF FAILURE TO CARRY OUT STATE PLAN

22 ‘‘SEC. 1130. In an action brought to enforce a provi23 sion of the Social Security Act, such provision is not to

24 be deemed unenforceable because of its inclusion in a sec25 tion of the Act requiring a State plan or specifying the

26 required contents of a State plan. This section is not in-
241

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1 tended to limit or expand the grounds for determining the

2 availability of private actions to enforce State plan re3 quirements other than by overturning any such grounds

4 applied in Suter v. Artist M., 112 S. Ct. 1360 (1992),

5 but not applied in prior Supreme Court decisions respect6 ing such enforceability: Provided, however, That this sec7 tion is not intended to alter the holding in Suter v. Artist

8 M. that section 471(a)(15) of the Act is not enforceable

9 in a private right of action.’’.

10 (b) APPLICABILITY.—The amendment made by sub11 section (a) shall apply to actions pending on the date of

12 the enactment of this Act and to actions brought on or

13 after such date of enactment.

14 Subtitle B—Child Support

15 Enforcement

16 SEC. 311. REPORTS TO CREDIT BUREAUS ON PERSONS DE17 LINQUENT IN CHILD SUPPORT PAYMENTS.

18 (a) IN GENERAL.—Section 466(a)(7) (42 U.S.C.

19 666(a)(7)) is amended—

20 (1) by striking ‘‘Procedures’’ and all that fol21 lows through ‘‘request of such agency’’ and inserting

22 ‘‘Procedures which require the State to periodically

23 report to consumer reporting agencies (as defined in

24 section 603(f) of the Fair Credit Reporting Act (15

25 U.S.C. 1681a(f))) the name of any parent residing
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1 in the State who owes overdue support and is at

2 least 2 months delinquent in the payment of such

3 support and the amount of such delinquency unless

4 the agency requests not to receive such informa5 tion’’; and

6 (2) by striking ‘‘(C) a fee’’ and all that follows

7 through ‘‘by the State’’ and inserting ‘‘(C) such in8 formation shall not be made available to (i) a

9 consumer reporting agency which the State deter10 mines does not have sufficient capability to system11 atically and timely make accurate use of such infor12 mation, or (ii) an entity which has not furnished evi13 dence satisfactory to the State that the entity is a

14 consumer reporting agency’’.

15 (b) EFFECTIVE DATE.—The amendments made by

16 subsection (a) shall take effect on October 1, 1995.

17 SEC. 312. TECHNICAL AMENDMENTS TO PROVISION ON

18 STATE PATERNITY ESTABLISHMENT PRO19 GRAMS.

20 Section 452(g)(2)(A) (42 U.S.C. 652(g)(2)(A)), as

21 amended by section 13721(a) of OBRA–1993, is amend22 ed—

23 (1) in clause (i), by striking ‘‘during the fiscal

24 year’’;
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1 (2) in subclause (I) of clause (ii), by striking

2 ‘‘as of the end of the fiscal year’’ and inserting ‘‘in

3 the fiscal year or, at the option of the State, as of

4 the end of such year’’;

5 (3) in subclause (II) of clause (ii), by striking

6 ‘‘or (E) as of the end of the fiscal year’’ and insert7 ing ‘‘in the fiscal year or, at the option of the State,

8 as of the end of such year’’;

9 (4) in clause (iii), by striking ‘‘during the fiscal

10 year’’; and

11 (5) in the matter following clause (iii)—

12 (A) by striking ‘‘who were born out of wed13 lock during the immediately preceding fiscal

14 year’’ and inserting ‘‘born out of wedlock’’;

15 (B) by striking ‘‘such preceding fiscal

16 year’’ both places it appears and inserting ‘‘the

17 preceding fiscal year’’; and

18 (C) by striking ‘‘or E’’ the second place it

19 appears.

20 SEC. 313. AGREEMENT TO ASSIST IN LOCATING MISSING

21 CHILDREN UNDER THE PARENT LOCATOR

22 SERVICE.

23 (a) IN GENERAL.—Section 463 (42 U.S.C. 663) is

24 amended by adding at the end the following new sub25 section:
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1 ‘‘(f) The Secretary shall enter into an agreement with

2 the Attorney General of the United States, under which

3 the services of the Parent Locator Service established

4 under section 453 shall be made available to the Office

5 of Juvenile Justice and Delinquency Prevention upon its

6 request to locate any parent or child on behalf of such

7 Office for the purpose of—

8 ‘‘(1) enforcing any State or Federal law with

9 respect to the unlawful taking or restraint of a child,

10 or

11 ‘‘(2) making or enforcing a child custody deter12 mination.

13 The Parent Locator Service shall charge no fees for serv14 ices requested pursuant to this subsection.’’.

15 (b) CONFORMING AMENDMENT.—Section 463(c) (42

16 U.S.C. 663(c)) is amended by striking ‘‘(a), (b), or (e)’’

17 and inserting ‘‘(a), (b), (e), or (f)’’.

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

19 this section shall take effect on October 1, 1994.
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1 Subtitle C—Supplemental Security

2 Income

3 SEC. 321. DEFINITION OF DISABILITY FOR CHILDREN

4 UNDER AGE 18 APPLIED TO ALL INDIVIDUALS

5 UNDER AGE 18.

6 (a) IN GENERAL.—Section 1614(a)(3) (42 U.S.C.

7 1382c(a)(3)) is amended—

8 (1) in subparagraphs (A) and (H), by striking

9 ‘‘a child’’ each place it appears and inserting ‘‘an in10 dividual’’; and

11 (2) in subparagraph (H), by striking ‘‘child’’

12 the second and third place it appears and inserting

13 ‘‘individual’’.

14 (b) EFFECTIVE DATE.—The amendments made by

15 subsection (a) shall apply to determinations made on or

16 after the date of the enactment of this Act.

17 SEC. 322. COMMISSION ON CHILDHOOD DISABILITY.

18 (a) ESTABLISHMENT OF COMMISSION.—The Sec19 retary of Health and Human Services (in this section re20 ferred to as the ‘‘Secretary’’) shall appoint a Commission

21 on the Evaluation of Disability in Children (in this section

22 referred to as the ‘‘Commission’’).

23 (b) APPOINTMENT OF MEMBERS.—(1) The Secretary

24 shall appoint not less than 9 but not more than 15 mem25 bers to the Commission, including—
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1 (A) recognized experts in the field of medicine,

2 whose work involves—

3 (i) the evaluation and treatment of disabil4 ity in children,

5 (ii) the study of congenital, genetic, or

6 perinatal disorders in children, or

7 (iii) the measurement of developmental

8 milestones and developmental deficits in chil9 dren; and

10 (B) recognized experts in the fields of—

11 (i) psychology,

12 (ii) education and rehabilitation,

13 (iii) law,

14 (iv) the administration of disability pro15 grams,

16 (v) social insurance (including health in17 surance), and

18 (vi) other fields of expertise that the Sec19 retary determines to be appropriate.

20 (2) Members shall be appointed within 90 days after

21 the date of the enactment of this Act, without regard to

22 the provisions of title 5, United States Code, governing

23 appointments to competitive service.
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1 (3) Members appointed under this subsection shall

2 serve for a term equivalent to the duration of the Commis3 sion.

4 (4) The Secretary shall designate a member of the

5 Commission to serve as Chair of the Commission for a

6 term equivalent to the duration of the Commission.

7 (c) ADMINISTRATIVE PROVISIONS.—(1) Service as a

8 member of the Commission by an individual who is not

9 otherwise a Federal employee shall not be considered serv10 ice in an appointive or elective position in the Federal Gov11 ernment for the purposes of any provision of title 5, Unit12 ed States Code.

13 (2) Each member of the Commission who is not a

14 full-time Federal employee shall be paid compensation at

15 a rate equal to the daily equivalent of the rate of basic

16 pay in effect for Level IV of the Executive Schedule for

17 each day (including travel time) the member attends meet18 ings or otherwise performs the duties of the Commission.

19 (3) While away from their homes or regular places

20 of business on the business of the Commission, each mem21 ber who is not a full-time Federal employee may be al22 lowed travel expenses, including per diem in lieu of sub23 sistence, as authorized by section 5703 of title 5, United

24 States Code, for persons employed intermittently in the

25 Government service.
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1 (d) ASSISTANCE TO COMMISSION.—The Commission

2 may engage such technical assistance from individuals

3 skilled in medical and other aspects of childhood disability

4 as may be necessary to carry out the functions of the Com5 mission. The Secretary shall make available to the Com6 mission such secretarial, clerical, and other assistance as

7 the Commission may require to carry out the functions

8 of the Commission.

9 (e) STUDY BY THE COMMISSION.—(1) The Commis10 sion shall conduct a study, in consultation with the Na11 tional Academy of Sciences, of the effects of the definition

12 of ‘‘disability’’ under title XVI of the Social Security Act

13 (42 U.S.C. 1382 et seq.) in effect on the date of enactment

14 of this Act, as such definition applies to determining

15 whether a child under the age of 18 is eligible to receive

16 benefits under such title, the appropriateness of such defi17 nition, and the advantages and disadvantages of using any

18 alternative definition of disability in determining whether

19 a child under age 18 is eligible to receive benefits under

20 such title.

21 (2) The study described in paragraph (1) shall in22 clude issues of—

23 (A) whether the need by families for assistance

24 in meeting high costs of medical care for children

25 with serious physical or mental impairments, wheth-
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1 er or not they are eligible for disability benefits

2 under title XVI of the Social Security Act, might ap3 propriately be met through expansion of Federal

4 health assistance programs (including the program

5 of medical assistance under title XIX of such Act);

6 and

7 (B) such other issues that the Secretary deter8 mines to be appropriate.

9 (f) REPORT.—Not later than September 1, 1995, the

10 Commission shall prepare a report and submit such report

11 to the Committee on Ways and Means of the House of

12 Representatives and the Committee on Finance of the

13 Senate which shall summarize the results of the study de14 scribed in subsection (e) and include any recommendations

15 that the Commission determines to be appropriate.

16 (g) TERMINATION OF COMMISSION.—The Commis17 sion shall terminate on September 30, 1995.

18 SEC. 323. EXEMPTION FROM PASS-ALONG REQUIREMENTS.

19 (a) IN GENERAL.—Section 1618 (42 U.S.C. 1382g)

20 is amended by adding at the end the following new sub21 section:

22 ‘‘(h) For purposes of determining under subsection

23 (b) of this section whether a State’s expenditures for sup24 plementary payments in the twelve-month period begin25 ning on the effective date of any increase in the level of
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1 supplemental security income benefits are not less than

2 its expenditures for such payments in the preceding

3 twelve-month period, the Secretary, in computing the

4 State’s expenditures, shall disregard, pursuant to the one5 time election of such State, all expenditures by such State

6 for retroactive supplementary payments that are required

7 to be made in connection with the retroactive supplemental

8 security income benefits referred to in section 5041 of the

9 Omnibus Budget Reconciliation Act of 1990.’’.

10 (b) EFFECTIVE DATE.—The amendment made by

11 subsection (a) shall be effective on, before, and after the

12 date of the enactment of this Act.

13 Subtitle D—Aid to Families With

14 Dependent Children

15 SEC. 331. SIMPLIFICATION OF INCOME AND ELIGIBILITY

16 VERIFICATION SYSTEM.

17 Paragraph (1)(A) of section 1137(d) (42 U.S.C.

18 1320b–7(d)) is amended to read as follows:

19 ‘‘(1)(A) The State shall require, as a condition

20 of an individual’s eligibility for benefits under a pro21 gram listed in subsection (b), a declaration in writ22 ing, under penalty of perjury—

23 ‘‘(i) by the individual,

24 ‘‘(ii) in the case in which eligibility for pro25 gram benefits is determined on a family or
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1 household basis, by any adult member of such

2 individual’s family or household (as applicable),

3 or

4 ‘‘(iii) in the case of an individual born into

5 a family or household receiving benefits under

6 such program, by any adult member of such

7 family or household no later than the next rede8 termination of eligibility of such family or

9 household following the birth of such individual,

10 stating whether the individual is a citizen or national

11 of the United States, and, if that individual is not

12 a citizen or national of the United States, that the

13 individual is in a satisfactory immigration status.’’.

14 SEC. 332. MEASUREMENT AND REPORTING OF WELFARE

15 RECEIPT.

16 (a) CONGRESSIONAL POLICY.—The Congress hereby

17 declares that—

18 (1) it is the policy and responsibility of the

19 Federal Government to reduce the rate at which and

20 the degree to which families depend on income from

21 welfare programs and the duration of welfare re22 ceipt, consistent with other essential national goals;

23 (2) it is the policy of the United States to

24 strengthen families, to ensure that children grow up

25 in families that are economically self-sufficient and
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1 that the life prospects of children are improved, and

2 to underscore the responsibility of parents to sup3 port their children;

4 (3) the Federal Government should help welfare

5 recipients as well as individuals at risk of welfare re6 ceipt to improve their education and job skills, to ob7 tain child care and other necessary support services,

8 and to take such other steps as may be necessary to

9 assist them to become financially independent; and

10 (4) it is the purpose of this section to provide

11 the public with generally accepted measures of wel12 fare receipt so that it can track such receipt over

13 time and determine whether progress is being made

14 in reducing the rate at which and, to the extent fea15 sible, the degree to which, families depend on income

16 from welfare programs and the duration of welfare

17 receipt.

18 (b) DEVELOPMENT OF WELFARE INDICATORS AND

19 PREDICTORS.—The Secretary of Health and Human Serv20 ices (in this section referred to as the ‘‘Secretary’’) in con21 sultation with the Secretary of Agriculture shall—

22 (1) develop—

23 (A) indicators of the rate at which and, to

24 the extent feasible, the degree to which, families
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1 depend on income from welfare programs and

2 the duration of welfare receipt; and

3 (B) predictors of welfare receipt;

4 (2) assess the data needed to report annually

5 on the indicators and predictors, including the abil6 ity of existing data collection efforts to provide such

7 data and any additional data collection needs; and

8 (3) not later than 2 years after the date of the

9 enactment of this section, provide an interim report

10 containing conclusions resulting from the develop11 ment and assessment described in paragraphs (1)

12 and (2), to—

13 (A) the Committee on Ways and Means of

14 the House of Representatives;

15 (B) the Committee on Education and

16 Labor of the House of Representatives;

17 (C) the Committee on Agriculture of the

18 House of Representatives;

19 (D) the Committee on Energy and Com20 merce of the House of Representatives;

21 (E) the Committee on Finance of the Sen22 ate;

23 (F) the Committee on Labor and Human

24 Resources of the Senate; and
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1 (G) the Committee on Agriculture, Nutri2 tion, and Forestry of the Senate.

3 (c) ADVISORY BOARD ON WELFARE INDICATORS.—

4 (1) ESTABLISHMENT.—There is established an

5 Advisory Board on Welfare Indicators (in this sub6 section referred to as the ‘‘Board’’).

7 (2) COMPOSITION.—The Board shall be com8 posed of 12 members with equal numbers to be ap9 pointed by the House of Representatives, the Senate,

10 and the President. The Board shall be composed of

11 experts in the fields of welfare research and welfare

12 statistical methodology, representatives of State and

13 local welfare agencies, and organizations concerned

14 with welfare issues.

15 (3) VACANCIES.—Any vacancy occurring in the

16 membership of the Board shall be filled in the same

17 manner as the original appointment for the position

18 being vacated. The vacancy shall not affect the

19 power of the remaining members to execute the du20 ties of the Board.

21 (4) DUTIES.—Duties of the Board shall in22 clude—

23 (A) providing advice and recommendations

24 to the Secretary on the development of indica25 tors of the rate at which and, to the extent fea-
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1 sible, the degree to which, families depend on

2 income from welfare programs and the duration

3 of welfare receipt; and

4 (B) providing advice on the development

5 and presentation of annual reports required

6 under subsection (d).

7 (5) TRAVEL EXPENSES.—Members of the

8 Board shall not be compensated, but shall receive

9 travel expenses, including per diem in lieu of subsist10 ence, at rates authorized for employees of agencies

11 under subchapter I of chapter 57 of title 5, United

12 States Code, for each day the member is engaged in

13 the performance of duties away from the home or

14 regular place of business of the member.

15 (6) DETAIL OF FEDERAL EMPLOYEES.—The

16 Secretary shall detail, without reimbursement, any

17 of the personnel of the Department of Health and

18 Human Services to the Board to assist the Board in

19 carrying out its duties. Any detail shall not interrupt

20 or otherwise affect the civil service status or privi21 leges of the Federal employee.

22 (7) VOLUNTARY SERVICE.—Notwithstanding

23 section 1342 of title 31, United States Code, the

24 Board may accept the voluntary services provided by

25 a member of the Board.
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1 (8) TERMINATION OF BOARD.—The Board shall

2 be terminated at such time as the Secretary deter3 mines the duties described in paragraph (4) have

4 been completed, but in any case prior to the submis5 sion of the first report required under subsection

6 (d).

7 (d) ANNUAL WELFARE INDICATORS REPORT.—

8 (1) PREPARATION.—The Secretary shall pre9 pare annual reports on welfare receipt in the United

10 States.

11 (2) COVERAGE.—The report shall include anal12 ysis of families and individuals receiving assistance

13 under means-tested benefit programs, including the

14 program of aid to families with dependent children

15 under part A of title IV of the Social Security Act

16 (42 U.S.C. 601 et seq.), the food stamp program

17 under the Food Stamp Act of 1977 (7 U.S.C. 2011

18 et seq.), and the Supplemental Security Income pro19 gram under title XVI of the Social Security Act (42

20 U.S.C. 1381 et seq.), or as general assistance under

21 programs administered by State and local govern22 ments.

23 (3) CONTENTS.—Each report shall set forth for

24 each of the means-tested benefit programs described

25 in paragraph (2)—
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1 (A) indicators of—

2 (i) the rate at which and, to the ex3 tent feasible, the degree to which, families

4 depend on income from welfare programs,

5 and

6 (ii) the duration of welfare receipt;

7 (B) trends in indicators;

8 (C) predictors of welfare receipt;

9 (D) the causes of welfare receipt;

10 (E) patterns of multiple program receipt;

11 (F) such other information as the Sec12 retary deems relevant; and

13 (G) such recommendations for legislation,

14 which shall not include proposals to reduce eli15 gibility levels or impose barriers to program ac16 cess, as the Secretary may determine to be nec17 essary or desirable to reduce—

18 (i) the rate at which and the degree to

19 which families depend on income from wel20 fare programs, and

21 (ii) the duration of welfare receipt.

22 (4) SUBMISSION.—The Secretary shall submit

23 such a report not later than 3 years after the date

24 of the enactment of this section and annually there25 after, to the committees specified in subsection
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1 (b)(3)(C). Each such report shall be transmitted

2 during the first 60 days of each regular session of

3 Congress.

4 (e) SHORT TITLE.—This section may be cited as the

5 ‘‘Welfare Indicators Act of 1993’’.

6 SEC. 333. NEW HOPE DEMONSTRATION PROJECT.

7 (a) IN GENERAL.—The Secretary of Health and

8 Human Services (in this section referred to as the ‘‘Sec9 retary’’) shall provide for a demonstration project for a

10 qualified program to be conducted in Milwaukee, Wiscon11 sin, in accordance with this section.

12 (b) PAYMENTS.—For each calendar quarter in which

13 there is a qualified program approved under this sub14 section, the Secretary shall pay to the operator of the

15 qualified program, for no more than 20 calendar quarters,

16 an amount equal to the aggregate amount that would oth17 erwise have been payable to the State with respect to par18 ticipants in the program for such calendar quarter, in the

19 absence of the program, for cash assistance and child care

20 under part A of title IV of the Social Security Act, for

21 medical assistance under title XIX of such Act, and for

22 administrative expenses related to such assistance. The

23 amount payable to the operator of the program under this

24 section shall not include the costs of evaluating the effects

25 of the program.
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1 (c) DEMONSTRATION PROJECT DESCRIBED.—For

2 purposes of this section, the term ‘‘qualified program’’

3 means a program operated—

4 (1) by The New Hope Project, Inc., a private,

5 not-for-profit corporation incorporated under the

6 laws of the State of Wisconsin (in this section re7 ferred to as the ‘‘operator’’), which offers low-income

8 residents of Milwaukee, Wisconsin, employment,

9 wage supplements, child care, health care, and coun10 seling and training for job retention or advancement;

11 and

12 (2) in accordance with an application submitted

13 by the operator of the program and approved by the

14 Secretary based on the Secretary’s determination

15 that the application satisfies the requirements of

16 subsection (d).

17 (d) CONTENTS OF APPLICATION.—The operator of

18 the qualified program shall provide, in its application to

19 conduct a demonstration project for the program, that the

20 following terms and conditions will be met:

21 (1) The operator will develop and implement an

22 evaluation plan designed to provide valid and reliable

23 information on the impact and implementation of

24 the program. The evaluation plan will include ade-
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1 quately sized groups of project participants and con2 trol groups assigned at random.

3 (2) The operator will develop and implement a

4 plan addressing the services and assistance to be

5 provided by the program, the timing and determina6 tion of payments from the Secretary to the operator

7 of the program, and the roles and responsibilities of

8 the Secretary and the operator with respect to meet9 ing the requirements of this paragraph.

10 (3) The operator will specify a reliable meth11 odology for determining expenditures to be paid to

12 the operator by the Secretary, with assistance from

13 the Secretary in calculating the amount that would

14 otherwise have been payable to the State in the ab15 sence of the program, pursuant to subsection (b).

16 (4) The operator will issue an interim and final

17 report on the results of the evaluation described in

18 paragraph (1) to the Secretary at such times as re19 quired by the Secretary.

20 (e) EFFECTIVE DATE.—This section shall take effect

21 on the first day of the first calendar quarter that begins

22 after the date of the enactment of this Act.
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1 SEC. 334. DELAY IN REQUIREMENT THAT OUTLYING

2 AREAS OPERATE AN AFDC–UP PROGRAM.

3 (a) IN GENERAL.—Section 401(g)(2) of the Family

4 Support Act of 1988 (42 U.S.C. 602 note; 102 Stat.

5 2396) is amended by striking ‘‘October 1, 1992’’ and in6 serting ‘‘the date of the repeal of the limitations contained

7 in section 1108(a) of the Social Security Act on payments

8 to such jurisdictions for purposes of making maintenance

9 payments under parts A and E of title IV of such Act’’.

10 (b) EFFECTIVE DATE.—The amendment made by

11 subsection (a) shall take effect as if included in the provi12 sion of the Family Support Act of 1988 to which the

13 amendment relates at the time such provision became law.

14 SEC. 335. NEW YORK STATE CHILD SUPPORT DEMONSTRA15 TION PROGRAM.

16 (a) EXTENSION.—Section 9122(g)(1) of OBRA–

17 1987 is amended by striking ‘‘five’’ and inserting ‘‘10’’.

18 (b) PAYMENT OF EVALUATION COSTS.—Section

19 9122(b) of OBRA–1987 is amended by adding at the end

20 the following new flush sentence: ‘‘Payment to the State

21 under this section shall not include the costs of evaluating

22 the effects of the program.’’.

23 (c) EFFECTIVE DATES.—

24 (1) EXTENSION.—The amendment made by

25 subsection (a) shall take effect on the date of the en26 actment of this Act.
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1 (2) PAYMENT.—The amendment made by sub2 section (b) shall take effect on April 1, 1994.

3 SEC. 336. STATE OPTION TO USE RETROSPECTIVE BUDG4 ETING WITHOUT MONTHLY REPORTING.

5 (a) IN GENERAL.—Section 402(a)(13) (42 U.S.C.

6 602(a)(13)) is amended—

7 (1) by striking all that precedes subparagraph

8 (A) and inserting the following:

9 ‘‘(13) provide, at the option of the State and

10 with respect to such category or categories as the

11 State may select and identify in the State plan,

12 that—’’; and

13 (2) in each of subparagraphs (A) and (B), by

14 striking ‘‘, in the case of families who are required

15 to report monthly to the State agency pursuant to

16 paragraph (14)’’.

17 (b) EFFECTIVE DATE.—The amendment made by

18 subsection (a) shall take effect on October 1, 1993, and

19 shall apply to payments under part A of title IV of the

20 Social Security Act for fiscal year 1993 and such pay21 ments for succeeding fiscal years.

22 Subtitle E—JOBS Program

23 SEC. 341. EXPANSION OF COVERAGE FOR INDIAN TRIBES.

24 (a) IN GENERAL.—Section 482(i)(2)(A) (42 U.S.C.

25 682(i)(2)(A)) is amended by striking ‘‘members of such
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1 Indian tribe receiving aid to families with dependent chil2 dren’’ and inserting ‘‘Indians receiving aid to families with

3 dependent children who reside on the reservation or within

4 the designated service area’’.

5 (b) EFFECTIVE DATE.—The amendment made by

6 subsection (a) shall take effect on October 1, 1994.

7 SEC. 342. REPORT TO THE CONGRESS WITH RESPECT TO

8 PERFORMANCE STANDARDS IN THE JOBS

9 PROGRAM.

10 Section 487(a) (42 U.S.C. 687(a)) is amended—

11 (1) by striking ‘‘3’’ and inserting ‘‘4’’;

12 (2) in paragraph (1), by inserting ‘‘criteria for’’

13 after ‘‘develop’’;

14 (3) in paragraph (2), by striking ‘‘for’’ and in15 serting ‘‘with respect to’’; and

16 (4) in the second sentence, by striking ‘‘under

17 this subsection’’ and inserting ‘‘with respect to the

18 program under this part’’.

19 Subtitle F—Unemployment

20 Insurance

21 SEC. 351. EXTENSION OF REPORTING DATE FOR ADVISORY

22 COUNCIL.

23 In the case of the first Advisory Council on Unem24 ployment Compensation established under section 908 of
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1 the Social Security Act (42 U.S.C. 1108), subsection (f)

2 of such section 908 shall be applied—

3 (1) by substituting ‘‘3rd year’’ for ‘‘second

4 year’’ in paragraph (1), and

5 (2) by substituting ‘‘February 1, 1995’’ for

6 ‘‘February 1, 1994’’ in paragraph (2).

7 SEC. 352. TECHNICAL AMENDMENT TO UNEMPLOYMENT

8 TRUST FUND.

9 Paragraph (1) of section 905(b) (42 U.S.C. 1105(b))

10 is amended to read as follows:

11 ‘‘(b)(1) Except as provided in paragraph (3), the Sec12 retary of the Treasury shall transfer (as of the close of

13 each month), from the employment security administra14 tion account to the extended unemployment compensation

15 account established by subsection (a), an amount equal to

16 20 percent of the amount by which—

17 ‘‘(A) the transfers to such account pursuant to

18 section 901(b)(2) during such month, exceed

19 ‘‘(B) the payments during such month from the

20 employment security administration account pursu21 ant to section 901(b)(3) and (d).

22 If for any month the payments referred to in subpara23 graph (B) exceed the transfers referred to in subpara24 graph (A), proper adjustments shall be made in the

25 amounts subsequently transferred.’’.
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1 Subtitle G—Other Provisions

2 SEC. 361. EXTENSION OF DEMONSTRATION TO EXPAND

3 JOB OPPORTUNITIES.

4 (a) IN GENERAL.—Section 505 of the Family Sup5 port Act of 1988 (42 U.S.C. 1315 note; 102 Stat. 2404)

6 is amended—

7 (1) in subsection (e), by striking ‘‘3-year pe8 riod’’ and inserting ‘‘5-year period’’,

9 (2) in subsection (f)(2), by striking ‘‘January 1,

10 1993’’ and inserting ‘‘January 1, 1995’’, and

11 (3) in subsection (g), by striking ‘‘1991, and

12 1992’’ and inserting ‘‘1991, 1992, 1993, 1994, and

13 1995’’.

14 (b) EFFECTIVE DATE.—The amendments made by

15 subsection (a) shall take effect on October 1, 1993.

16 SEC. 362. EARLY CHILDHOOD DEVELOPMENT PROJECTS.

17 Section 501(a) of the Family Support Act of 1988

18 (42 U.S.C. 1315 note; 102 Stat. 2400) is amended by add19 ing at the end the following:

20 ‘‘(4) For grants to States to conduct demonstration

21 projects under this subsection, there are authorized to be

22 appropriated not to exceed $3,000,000 for each of the fis23 cal years 1994 through 1998.’’.
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1 SEC. 363. REALLOCATION OF FUNDS UNDER TITLE XX FOR

2 EMPOWERMENT AND ENTERPRISE GRANTS.

3 Section 2007 (42 U.S.C. 1397f), as added by section

4 13761 of OBRA–1993, is amended—

5 (1) by redesignating subsection (e) as sub6 section (f); and

7 (2) by inserting after subsection (d) the follow8 ing new subsection:

9 ‘‘(e) REALLOCATION OF REMAINING FUNDS.—

10 ‘‘(1) REMITTED AMOUNTS.—The amount speci11 fied in section 2003(c) for any fiscal year is hereby

12 increased by the total of the amounts remitted dur13 ing the fiscal year pursuant to subsection (d) of this

14 section.

15 ‘‘(2) AMOUNTS NOT PAID TO THE STATES.—

16 The amount specified in section 2003(c) for fiscal

17 year 1998 is hereby increased by the amount made

18 available for grants under this section that has not

19 been paid to any State by the end of fiscal year

20 1997.’’.

21 SEC. 364. CORRECTIONS RELATED TO THE INCOME SECU22 RITY AND HUMAN RESOURCES PROVISIONS

23 OF THE OBRA–1990.

24 (a) AMENDMENT RELATED TO SECTION

25 5035(a)(2).—Section 5035(a)(2) of OBRA–1990 is
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1 amended by striking ‘‘a semicolon’’ and inserting

2 ‘‘ ‘; and’ ’’.

3 (b) AMENDMENT RELATED TO SECTION 5040.—Sec4 tion 1631(n) (42 U.S.C. 1383(n)) is amended by striking

5 ‘‘subsection’’ and inserting ‘‘section’’.

6 (c) AMENDMENT RELATED TO SECTION 5051(a).—

7 Section 402(a)(14) (42 U.S.C. 602(a)(14)) is amended to

8 read as follows:

9 ‘‘(14) at the option of the State and with re10 spect to such category or categories as the State

11 may select and identify in the plan, provide that—

12 ‘‘(A) the State agency will require each

13 family to which the State provides (or, but for

14 paragraph (22) or (32), would provide) aid to

15 families with dependent children, as a condition

16 to the continued receipt of such aid (or to con17 tinuing to be deemed to be a recipient of such

18 aid), to report to the State agency monthly (or

19 less frequently in the case of such categories of

20 recipients as the State may select) on—

21 ‘‘(i) the income of the family, the

22 composition of the family, and other rel23 evant circumstances during the prior

24 month; and
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1 ‘‘(ii) the income and resources the

2 family expects to receive, or any changes in

3 circumstances affecting continued eligi4 bility for, or amount of benefits, the family

5 expects to occur, in that month or in fu6 ture months; and

7 ‘‘(B) in addition to any action that may be

8 appropriate based on other reports or informa9 tion received by the State agency, the State

10 agency will—

11 ‘‘(i) take prompt action to adjust the

12 amount of assistance payable, as may be

13 appropriate, on the basis of the informa14 tion contained in the report (or upon the

15 failure of the family to submit a timely re16 port); and

17 ‘‘(ii) give the family an appropriate

18 explanatory notice concurrent with any ac19 tion taken under clause (i);’’.

20 (d) REPEAL OF PROVISION INADVERTENTLY IN21 CLUDED.—Section 5057 of OBRA–1990, and the amend22 ment made by such section, are hereby repealed, and sec23 tion 1139(d) of the Social Security Act shall be applied

24 and administered as if such section 5057 had never been

25 enacted.
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1 (e) AMENDMENT RELATED TO SECTION

2 5105(d)(1)(B).—Subparagraphs (E) and (F) of section

3 1631(a)(2) (42 U.S.C. 1383(a)(2)) are amended to read

4 as follows:

5 ‘‘(E) In cases where the negligent failure of the Sec6 retary to investigate or monitor a representative payee re7 sults in misuse of benefits by the representative payee, the

8 Secretary shall make payment to the beneficiary or the

9 beneficiary’s representative payee of an amount equal to

10 such misused benefits. The Secretary shall make a good

11 faith effort to obtain restitution from the terminated rep12 resentative payee.

13 ‘‘(F) The Secretary shall include as a part of the an14 nual report required under section 704 information with

15 respect to the implementation of the preceding provisions

16 of this paragraph, including—

17 ‘‘(i) the number of cases in which the represent18 ative payee was changed;

19 ‘‘(ii) the number of cases discovered where

20 there has been a misuse of funds;

21 ‘‘(iii) how any such cases were dealt with by the

22 Secretary;

23 ‘‘(iv) the final disposition of such cases (includ24 ing any criminal penalties imposed); and
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1 ‘‘(v) such other information as the Secretary

2 determines to be appropriate.’’.

3 (f) AMENDMENT RELATED TO SECTION

4 5105(a)(1)(B).—The second paragraph of section 1631(a)

5 (42 U.S.C. 1383(a)) is amended by striking ‘‘(A)(i) Pay6 ments’’ and inserting ‘‘(2)(A)(i) Payments’’.

7 (g) AMENDMENTS RELATED TO SECTION 5105(b).—

8 Section 1631(a)(2)(C) (42 U.S.C. 1383(a)(2)(C)) is

9 amended—

10 (1) in clause (i), by striking ‘‘to representative’’

11 and inserting ‘‘to a representative’’;

12 (2) by striking clause (ii);

13 (3) by redesignating clauses (iii), (iv), and (v)

14 as clauses (ii), (iii), and (iv), respectively; and

15 (4) in clause (iv) (as so redesignated), by strik16 ing ‘‘(iii), and (iv)’’ and inserting ‘‘and (iii)’’.

17 (h) AMENDMENTS RELATED TO SECTION

18 5107(a)(2)(B).—Section 1631(c)(1)(B) (42 U.S.C.

19 1383(c)(1)(B)) is amended by striking ‘‘paragraph (1)’’

20 each place such term appears and inserting ‘‘subpara21 graph (A)’’.

22 (i) AMENDMENT RELATED TO SECTION

23 5109(a)(2).—Section 1631 (42 U.S.C. 1383) is amended

24 by redesignating the subsection (n) added by section

25 5109(a)(2) of OBRA–1990, as subsection (o).
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1 (j) AMENDMENTS RELATED TO SECTION

2 11115(b)(2).—Section 11115(b)(2) of OBRA–1990 is

3 amended—

4 (1) in subparagraph (A), by striking ‘‘para5 graph (8)’’ and inserting ‘‘paragraph (9)’’;

6 (2) in subparagraph (B), by striking ‘‘para7 graph (9)’’ and inserting ‘‘paragraph (10)’’; and

8 (3) in subparagraph (C), by redesignating the

9 new paragraph added thereby as paragraph (11).

10 (k) EFFECTIVE DATE.—Each amendment made by

11 this section shall take effect as if included in the provision

12 of OBRA–1990 to which the amendment relates at the

13 time such provision became law.

14 SEC. 365. TECHNICAL CORRECTIONS RELATED TO THE

15 HUMAN RESOURCE AND INCOME SECURITY

16 PROVISIONS OF THE OBRA–1989.

17 (a) AMENDMENT RELATING TO SECTION 8004(a).—

18 Section 408(m)(2)(A) (42 U.S.C. 608(m)(2)(A)) is

19 amended by striking ‘‘a fiscal’’ and inserting ‘‘the fiscal’’.

20 (b) AMENDMENT RELATING TO SECTION 8006(a).—

21 Section 473(a)(6)(B) (42 U.S.C. 673(a)(6)(B)) is amend22 ed by striking ‘‘474(a)(3)(B)’’ and inserting

23 ‘‘474(a)(3)(C)’’.

24 (c) AMENDMENT RELATING TO SECTION

25 8007(b)(3).—Subparagraph (D) of section 475(5) (42
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1 U.S.C. 675(5)(D)) is amended by moving such subpara2 graph 2 ems to the right so that the left margin of such

3 subparagraph is aligned with the left margin of subpara4 graph (C) of such section.

5 (d) EFFECTIVE DATE.—Each amendment made by

6 this section shall take effect as if the amendment had been

7 included in the provision of OBRA–1989 to which the

8 amendment relates, at the time the provision became law.

9 SEC. 366. TECHNICAL CORRECTION RELATED TO THE

10 HUMAN RESOURCE AND INCOME SECURITY

11 PROVISIONS OF THE OBRA–1993.

12 (a) AMENDMENT RELATING TO SECTION

13 13713(a).—Section 473(a)(6)(B) (42 U.S.C.

14 673(a)(6)(B)) is amended by striking ‘‘474(a)(3)(C)’’ and

15 inserting ‘‘474(a)(3)(E)’’.

16 (b) EFFECTIVE DATE.—The amendment made by

17 this section shall take effect as if the amendment had been

18 included in the provision of OBRA–1993 to which the

19 amendment relates, at the time the provision became law.

20 SEC. 367. ELIMINATION OF OBSOLETE PROVISIONS RELAT21 ING TO TREATMENT OF THE EARNED IN22 COME TAX CREDIT.

23 (a) TREATMENT OF EITC AS EARNED INCOME.—

24 Section 1612(a)(1) (42 U.S.C. 1382a(a)(1)) is amended

25 by striking subparagraph (C) and by redesignating sub-
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1 paragraphs (D) and (E) as subparagraphs (C) and (D),

2 respectively.

3 (b) ADJUSTMENT OF BENEFITS DUE TO TREAT4 MENT OF EITC AS EARNED INCOME.—Section 1631(b)

5 (42 U.S.C. 1383(b)) is amended by striking paragraph (3)

6 and by redesignating paragraphs (4) and (5) as para7 graphs (3) and (4), respectively.

8 SEC. 368. REDESIGNATION OF CERTAIN PROVISIONS.

9 Section 1631(e)(6) (42 U.S.C. 1383(e)(6)) is amend10 ed by redesignating subparagraphs (1) and (2) as sub11 paragraphs (A) and (B), respectively.

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