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[Congressional Bills 103th Congress]
[From the U.S. Government Publishing Office]
[S. 176 Introduced in Senate (IS)]

103d CONGRESS
  1st Session
                                 S. 176

    To amend title XVIII of the Social Security Act with respect to 
   essential access community hospitals, the rural transition grant 
  program, regional referral centers, medicare-dependent small rural 
   hospitals, interpretation of electrocardiograms, payments for new 
 physicians and practitioners, prohibitions on carrier forum shopping, 
      treatment of nebulizers and aspirators, and rural hospital 
                            demonstrations.

_______________________________________________________________________

                   IN THE SENATE OF THE UNITED STATES

             January 21 (legislative day, January 5), 1993

  Mr. Dole (for himself, Mr. McCain, Mr. Danforth, Mr. Grassley, Mr. 
Durenberger, Mrs. Kassebaum, Mr. Craig, Mr. Nickles, Mr. Jeffords, Mr. 
 Bond, Mr. Packwood, Mr. Burns, Mr. McConnell, Mr. Wallop, Mr. Shelby, 
  Mr. Boren, and Mr. Baucus) introduced the following bill; which was 
          read twice and referred to the Committee on Finance

_______________________________________________________________________

                                 A BILL

 
    To amend title XVIII of the Social Security Act with respect to 
   essential access community hospitals, the rural transition grant 
  program, regional referral centers, medicare-dependent small rural 
   hospitals, interpretation of electrocardiograms, payments for new 
 physicians and practitioners, prohibitions on carrier forum shopping, 
      treatment of nebulizers and aspirators, and rural hospital 
                            demonstrations.

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

SECTION 1. SHORT TITLE; REFERENCES IN ACT.

    (a) Short Title.--This Act may be cited as the ``Medicare 
Amendments of 1993''.
    (b) References in Act.--Except as otherwise specifically provided, 
whenever in this Act, an amendment is expressed in terms of an 
amendment to or repeal of a section or other provision, the reference 
shall be considered to be made to that section or other provision of 
the Social Security Act.

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

    (a) Increasing Number of Participating States.--Section 1820(a)(1) 
(42 U.S.C. 1395i-4(a)(1)) is amended by striking ``7'' and inserting 
``9''.
    (b) Treatment of Inpatient Hospital Services Provided in Rural 
Primary Care Hospitals.--
            (1) In general.--Section 1820(f)(1)(F) (42 U.S.C. 1395i-
        4(f)(1)(F)) is amended to read as follows:
                    ``(F) subject to paragraph (4), provides not more 
                than 6 inpatient beds (meeting such conditions as the 
                Secretary may establish) for providing inpatient care 
                to patients requiring stabilization before discharge or 
                transfer to a hospital, except that the facility may 
                not provide any inpatient hospital services--
                            ``(i) to any patient whose attending 
                        physician does not certify that the patient may 
                        reasonably be expected to be discharged or 
                        transferred to a hospital within 72 hours of 
                        admission to the facility; or
                            ``(ii) consisting of surgery or any other 
                        service requiring the use of general anesthesia 
                        (other than surgical procedures specified by 
                        the Secretary under section 1833(i)(1)(A)), 
                        unless the attending physician certifies that 
                        the risk associated with transferring the 
                        patient to a hospital for such services 
                        outweighs the benefits of transferring the 
                        patient to a hospital for such services.''.
            (2) Limitation on average length of stay.--Section 1820(f) 
        (42 U.S.C. 1395i-4(f)) is amended by adding at the end the 
        following new paragraph:
            ``(4) Limitation on average length of inpatient stays.--The 
        Secretary may terminate a designation of a rural primary care 
        hospital under paragraph (1) if the Secretary finds that the 
        average length of stay for inpatients at the facility during 
        the previous year in which the designation was in effect 
        exceeded 72 hours. In determining the compliance of a facility 
        with the requirement of the previous sentence, there shall not 
        be taken into account periods of stay of inpatients in excess 
        of 72 hours to the extent such periods exceed 72 hours because 
        transfer to a hospital is precluded because of inclement 
        weather or other emergency conditions.''.
            (3) Conforming amendment.--Section 1814(a)(8) (42 U.S.C. 
        1395f(a)(8)) is amended by striking ``such services'' and all 
        that follows and inserting ``the individual may reasonably be 
        expected to be discharged or transferred to a hospital within 
        72 hours after admission to the rural primary care hospital.''.
            (4) GAO reports.--Not later than 2 years after the date of 
        the enactment of this Act, the Comptroller General shall submit 
        reports to the Congress on--
                    (A) the application of the requirements under 
                section 1820(f) of the Social Security Act (as amended 
                by this subsection) that rural primary care hospitals 
                provide inpatient care only to those individuals whose 
                attending physicians certify may reasonably be expected 
                to be discharged within 72 hours after admission and 
                maintain an average length of inpatient stay during a 
                year that does not exceed 72 hours; and
                    (B) the extent to which such requirements have 
                resulted in such hospitals providing inpatient care 
                beyond their capabilities or have limited the ability 
                of such hospitals to provide needed services.
    (c) Designation of Hospitals.--
            (1) Permitting designation of hospitals located in urban 
        areas.--
                    (A) In general.--Section 1820 (42 U.S.C. 1395i-4) 
                is amended--
                            (i) by striking paragraph (1) of subsection 
                        (e) and redesignating paragraphs (2) through 
                        (6) as paragraphs (1) through (5);
                            (ii) in subsection (e)(1)(A) (as 
                        redesignated by subparagraph (A))--
                                    (I) by striking ``is located'' and 
                                inserting ``except in the case of a 
                                hospital located in an urban area, is 
                                located''
                                    (II) by striking ``, (ii)'' and 
                                inserting ``or (ii)'', and
                                    (III) by striking ``or (iii)'' and 
                                all that follows through ``section,''; 
                                and
                            (iii) in subsection (i)(1)(B), by striking 
                        ``paragraph (3)'' and inserting ``paragraph 
                        (2)''.
                    (B) No change in medicare prospective payment.--
                Section 1886(d)(5)(D) (42 U.S.C. 1395ww(d)(5)(D)) is 
                amended--
                            (i) in clause (iii)(III), by inserting 
                        ``located in a rural area and'' after ``that 
                        is'', and
                            (ii) in clause (v), by inserting ``located 
                        in a rural area and'' after ``in the case of a 
                        hospital''.
            (2) Permitting hospitals located in adjoining states to 
        participate in state program.--
                    (A) In general.--Section 1820 (42 U.S.C. 1395i-4) 
                is amended--
                            (i) by redesignating subsection (k) as 
                        subsection (l); and
                            (ii) by inserting after subsection (j) the 
                        following new subsection:
    ``(k) Eligibility of Hospitals Not Located in Participating 
States.--Notwithstanding any other provision of this section--
            ``(1) for purposes of including a hospital or facility as a 
        member institution of a rural health network, a State may 
        designate a hospital or facility that is not located in the 
        State as an essential access community hospital or a rural 
        primary care hospital if the hospital or facility is located in 
        an adjoining State and is otherwise eligible for designation as 
        such a hospital;
            ``(2) the Secretary may designate a hospital or facility 
        that is not located in a State receiving a grant under 
        subsection (a)(1) as an essential access community hospital or 
        a rural primary care hospital if the hospital or facility is a 
        member institution of a rural health network of a State 
        receiving a grant under such subsection; and
            ``(3) a hospital or facility designated pursuant to this 
        subsection shall be eligible to receive a grant under 
        subsection (a)(2).''.
                    (B) Conforming amendments.--(i) Section 1820(c)(1) 
                (42 U.S.C. 1395i-4(c)(1)) is amended by striking 
                ``paragraph (3)'' and inserting ``paragraph (3) or 
                subsection (k)''.
                    (ii) Paragraphs (1)(A) and (2)(A) of section 
                1820(i) (42 U.S.C. 1395i-4(i)) are each amended--
                            (I) in clause (i), by striking ``(a)(1)'' 
                        and inserting ``(a)(1) (except as provided in 
                        subsection (k))'', and
                            (II) in clause (ii), by striking 
                        ``subparagraph (B)'' and inserting 
                        ``subparagraph (B) or subsection (k)''.
    (d) Skilled Nursing Services in Rural Primary Care Hospitals.--
Section 1820(f)(3) (42 U.S.C. 1395i-4(f)(3)) is amended by striking 
``because the facility'' and all that follows and inserting the 
following: ``because, at the time the facility applies to the State for 
designation as a rural primary care hospital, there is in effect an 
agreement between the facility and the Secretary under section 1883 
under which the facility's inpatient hospital facilities are used for 
the furnishing of extended care services, except that the number of 
beds used for the furnishing of such services may not exceed the total 
number of licensed inpatient beds at the time the facility applies to 
the State for such designation (minus the number of inpatient beds used 
for providing inpatient care pursuant to paragraph (1)(F)). For 
purposes of the previous sentence, the number of beds of the facility 
used for the furnishing of extended care services shall not include any 
beds of a unit of the facility that is licensed as a distinct-part 
skilled nursing facility at the time the facility applies to the State 
for designation as a rural primary care hospital.''.
    (e) Payment for Outpatient Rural Primary Care Hospital Services.--
Section 1834(g)(1) (42 U.S.C. 1395m(g)(1)) is amended by adding at the 
end the following:
        ``The amount of payment shall be determined under either method 
        without regard to the amount of the customary or other 
        charge.''.
    (f) Clarification of Physician Staffing Requirement for Rural 
Primary Care Hospitals.--Section 1820(f)(1)(H) (42 U.S.C. 1395i-
4(f)(1)(H)) is amended by striking the period and inserting the 
following: ``, except that in determining whether a facility meets the 
requirements of this subparagraph, subparagraphs (E) and (F) of that 
paragraph shall be applied as if any reference to a `physician' is a 
reference to a physician as defined in section 1861(r)(1).''.
    (g) Technical Amendments Relating to Part A Deductible, 
Coinsurance, and Spell of Illness.--(1) Section 1812(a)(1) (42 U.S.C. 
1395d(a)(1)) is amended--
            (A) by striking ``inpatient hospital services'' the first 
        place it appears and inserting ``inpatient hospital services or 
        inpatient rural primary care hospital services'';
            (B) by striking ``inpatient hospital services'' the second 
        place it appears and inserting ``such services''; and
            (C) by striking ``and inpatient rural primary care hospital 
        services''.
    (2) Sections 1813(a) and 1813(b)(3)(A) (42 U.S.C. 1395e(a), 
1395e(b)(3)(A)) are each amended by striking ``inpatient hospital 
services'' each place it appears and inserting ``inpatient hospital 
services or inpatient rural primary care hospital services''.
    (3) Section 1813(b)(3)(B) (42 U.S.C. 1395e(b)(3)(B)) is amended by 
striking ``inpatient hospital services'' and inserting ``inpatient 
hospital services, inpatient rural primary care hospital services''.
    (4) Section 1861(a) (42 U.S.C. 1395x(a)) is amended--
            (A) in paragraph (1), by striking ``inpatient hospital 
        services'' and inserting ``inpatient hospital services, 
        inpatient rural primary care hospital services''; and
            (B) in paragraph (2), by striking ``hospital'' and 
        inserting ``hospital or rural primary care hospital''.
    (h) Authorization of Appropriations.--Section 1820(l) (42 U.S.C. 
1395i-4(l)), as redesignated by subsection (c)(2), is amended by 
striking ``1990, 1991, and 1992'' and inserting ``1990 through 1995''.
    (i) Effective Date.--The amendments made by this section shall take 
effect on the date of the enactment of this Act.

SEC. 3. REAUTHORIZATION OF RURAL TRANSITION GRANT PROGRAM.

    Section 4005(e)(9) of the Omnibus Budget Reconciliation Act of 1987 
(Public Law 100-203) is amended by striking ``1992'' and inserting 
``1992 and $30,000,000 for each of fiscal years 1993 through 1997''.

SEC. 4. REGIONAL REFERRAL CENTERS.

    (a) Extension Through Fiscal Year 1994.--
            (1) In general.--Section 6003(d) of the Omnibus Budget 
        Reconciliation Act of 1989 (42 U.S.C. 1395ww note) is amended 
        by striking ``October 1, 1992'' and inserting ``October 1, 
        1994''.
            (2) Payment adjustment.--
                    (A) In general.--In the case of a hospital which 
                would have retained its status as a regional referral 
                center during the period described in subparagraph (B) 
                if the amendments made by paragraph (1) had been 
                included in the enactment of section 6003(d) of the 
                Omnibus Budget Reconciliation Act of 1989 (42 U.S.C. 
                1395ww note), the Secretary of Health and Human 
                Services shall make a lump sum payment to such hospital 
                based on the difference between the aggregate payments 
                (excluding outlier payments) such hospital would have 
                received during such period if such hospital was 
                classified as a regional referral center during such 
                period and the aggregate payments (excluding outlier 
                payments) such hospital actually received during such 
                period.
                    (B) Definition.--The period described in this 
                subparagraph is the period beginning the day after the 
                last day a hospital was classified as a regional 
                referral center under section 6003(d) of the Omnibus 
                Budget Reconciliation Act of 1989 (42 U.S.C. 1395ww 
                note) and ending on the date of the enactment of the 
                amendments made by paragraph (1)
    (b) Permitting Hospitals To Decline Reclassification.--
            (1) In general.--If any hospital fails to qualify as a 
        rural referral center under section 1886(d)(5)(C) of the Social 
        Security Act as a result of a decision by the Medicare 
        Geographic Classification Review Board under section 
        1886(d)(10) of such Act to reclassify the hospital as being 
        located in an urban area for fiscal year 1993, the Secretary of 
        Health and Human Services shall--
                    (A) notify such hospital of such failure to 
                qualify,
                    (B) provide an opportunity for such hospital to 
                decline such reclassification, and
                    (C) if the hospital declines such reclassification, 
                administer the Social Security Act (other than section 
                1886(d)(8)(D) of such Act) for fiscal year 1993 as if 
                the decision by the Review Board had not occurred.
            (2) Payment adjustment.--In the case of a hospital which 
        declines a reclassification under paragraph (1)(C), the 
        Secretary of Health and Human Services shall make a lump sum 
        payment to such hospital for any period in which such hospital 
        was reclassified under section 1886(d)(10) of the Social 
        Security Act based on the difference between the aggregate 
        payments (excluding outlier payments) such hospital would have 
        received during such period if such hospital was classified as 
        a regional referral center during such period and the aggregate 
        payments (excluding outlier payments) such hospital actually 
        received during such period.

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

    (a) In General.--Section 1886(d)(5)(G) of the Social Security Act 
(42 U.S.C. 1395ww(d)(5)(G)) is amended--
            (1) by amending clause (i) to read as follows:
    ``(i) In the case of a subsection (d) hospital which is a medicare-
dependent, small rural hospital, payment under paragraph (1)(A) for 
discharges occurring before October 1, 1994, shall be--
            ``(I) for any cost reporting period beginning on or after 
        April 1, 1990, and ending before March 31, 1994, the amount 
        determined under clause (ii); and
            ``(II) for any cost reporting period beginning on or after 
        April 1, 1993, the amount determined under clause (ii) by 
        substituting `50 percent' for `100 percent'.'',
            (2) by redesignating clauses (ii) and (iii), as clauses 
        (iii) and (iv), respectively, and
            (3) by inserting after clause (i) the following new clause:
    ``(ii) The amount determined under this clause is the sum of--
            ``(I) the amount determined under paragraph (1)(A)(iii), 
        and
            ``(II) 100 percent of the excess (if any) of--
                    ``(aa) the hospital's target amount for the cost 
                reporting period, as defined in subsection (b)(3)(D), 
                over
                    ``(bb) the amount determined under paragraph 
                (1)(A)(iii).''.
    (b) Permitting Hospitals to Decline Reclassification.--
            (1) In general.--If any hospital fails to qualify as a 
        medicare-dependent, small rural hospital under section 
        1886(d)(5)(G)(i) of the Social Security Act as a result of a 
        decision by the Medicare Geographic Classification Review Board 
        under section 1886(d)(10) of such Act to reclassify the 
        hospital as being located in an urban area for fiscal year 
        1993, the Secretary of Health and Human Services shall--
                    (A) notify such hospital of such failure to 
                qualify,
                    (B) provide an opportunity for such hospital to 
                decline such reclassification, and
                    (C) if the hospital declines such reclassification, 
                administer the Social Security Act (other than section 
                1886(d)(8)(D) of such Act) for fiscal year 1993 as if 
                the decision by the Review Board had not occurred.
            (2) Payment adjustment.--In the case of a hospital which 
        declines a reclassification under paragraph (1)(C), the 
        Secretary of Health and Human Services shall make a lump sum 
        payment to such hospital for any period in which such hospital 
        was reclassified under section 1886(d)(10) of the Social 
        Security Act based on the difference between the aggregate 
        payments (excluding outlier payments) such hospital would have 
        received during such period if such hospital was classified as 
        a medicare-dependent, small rural hospital during such period 
        and the aggregate payments (excluding outlier payments) such 
        hospital actually received during such period.

SEC. 6. SEPARATE PAYMENT FOR INTERPRETATION OF ELECTROCARDIOGRAMS.

    (a) In General.--Paragraph (3) of section 1848(b) (42 U.S.C. 1395w-
4(b)) is amended to read as follows:
            ``(3) Treatment of interpretation of electrocardiograms.--
        The Secretary--
                    ``(A) shall make separate payment under this 
                section for the interpretation of electrocardiograms 
                performed or ordered to be performed as part of or in 
                conjunction with a visit to or a consultation with a 
                physician, and
                    ``(B) shall adjust the relative values established 
                for visits and consultations under subsection (c) so as 
                not to include relative value units for interpretations 
                of electrocardiograms in the relative value for visits 
                and consultations.''.
    (b) Assuring Budget Neutrality.--Section 1848(c)(2) (42 U.S.C. 
1395w-4(c)(2)) is amended by adding at the end the following new 
subparagraph:
                    ``(E) Budget neutrality adjustments.--The 
                Secretary--
                            ``(i) shall reduce the relative values for 
                        all services (other than anesthesia services) 
                        established under this paragraph (and, in the 
                        case of anesthesia services, the conversion 
                        factor established by the Secretary for such 
                        services) by such percentage as the Secretary 
                        determines to be necessary so that, beginning 
                        in 1996, the amendment made by section 6(a) of 
                        the Medicare Amendments of 1993 would not 
                        result in expenditures under this section that 
                        exceed the amount of such expenditures that 
                        would have been made if such amendment had not 
                        been made, and
                            ``(ii) shall reduce the amounts determined 
                        under subsection (a)(2)(B)(i)(I) by such 
                        percentage as the Secretary determines to be 
                        required to assure that, taking into account 
                        the reductions made under clause (i), the 
                        amendment made by section 6(a) of the Medicare 
                        Amendments of 1993 would not result in 
                        expenditures under this section in 1993 that 
                        exceed the amount of such expenditures that 
                        would have been made if such amendment had not 
                        been made.''.
    (c) Conforming Amendments.--Section 1848 (42 U.S.C. 1395w-4) is 
amended--
            (1) in subsection (a)(2)(B)(i)(I), by inserting ``and as 
        adjusted under subsection (c)(2)(E)(ii)'' after ``for 1993'';
            (2) in subsection (c)(2)(A)(i), by adding at the end the 
        following: ``Such relative values are subject to adjustment 
        under subparagraph (E)(i).''; and
            (3) in subsection (i)(1)(B), by adding at the end 
        ``including adjustments under subsection (c)(2)(E),''.
    (d) Effective Date.--The amendments made by this section shall 
apply to services furnished on or after January 1, 1993.

SEC. 7. PAYMENTS FOR NEW PHYSICIANS AND PRACTITIONERS.

    (a) Equal Treatment of New Physicians and Practitioners.--(1) 
Section 1848(a) (42 U.S.C. 1395w-4(a)) is amended by striking paragraph 
(4).
    (2) Section 1842(b)(4) (42 U.S.C. 1395u(b)(4)) is amended by 
striking subparagraph (F).
    (b) Budget Neutrality Adjustment.--Notwithstanding any other 
provision of law, the Secretary of Health and Human Services shall 
reduce the following values and amounts for 1993 (to be applied for 
that year and subsequent years) by such uniform percentage as the 
Secretary determines to be required to assure that the amendments made 
by subsection (a) will not result in expenditures under part B of title 
XVIII of the Social Security Act in 1993 that exceed the amount of such 
expenditures that would have been made if such amendments had not been 
made:
            (1) The relative values established under section 1848(c) 
        of such Act for services (other than anesthesia services) and, 
        in the case of anesthesia services, the conversion factor 
        established under section 1848 of such Act for such services.
            (2) The amounts determined under section 
        1848(a)(2)(B)(i)(I) of such Act.
            (3) The prevailing charges or fee schedule amounts to be 
        applied under such part for services of a health care 
        practitioner (as defined in section 1842(b)(4)(F)(ii)(I) of 
        such Act, as in effect before the date of the enactment of this 
        Act).
    (c) Conforming Amendments.--Section 1848 (42 U.S.C. 1395w-4), as 
amended by section 6(c) of this subtitle, is amended--
            (1) in subsection (a)(2)(B)(i)(I), by inserting ``and 
        section 7(b) of the Medicare Amendments of 1993'' after 
        ``(c)(2)(E)(ii)'';
            (2) in subsection (c)(2)(A)(i), by inserting ``and section 
        7(b) of the Medicare Amendments of 1993'' after ``under 
        subparagraph (E)(i)''; and
            (3) in subsection (i)(1)(B), by inserting ``and section 
        7(b) of the Medicare Amendments of 1993'' after ``under 
        subsection (c)(2)(E)''.
    (d) Effective Date.--The amendments made by subsection (a) shall 
apply to services furnished on or after January 1, 1993.

SEC. 8. PROHIBITION AGAINST CARRIER FORUM SHOPPING.

    (a) In General.--Section 1834(a)(12) (42 U.S.C. 1395m(a)(12)) is 
amended to read as follows:
            ``(12) Use of carriers to process claims.--
                    ``(A) Designation of regional carriers.--The 
                Secretary may designate, by regulation under section 
                1842, one carrier for one or more entire regions to 
                process all claims within the region for covered items 
                under this section.
                    ``(B) Prohibition against carrier shopping.--(i) No 
                supplier of a covered item may present or cause to be 
                presented a claim for payment under this part unless 
                such claim is presented to the appropriate carrier.
                    ``(ii) For purposes of clause (i), the term 
                `appropriate carrier' means the carrier having 
                jurisdiction over the geographic area that includes the 
                permanent residence of the patient to whom the item is 
                furnished.''.
    (b) Effective Date.--The amendment made by subsection (a) shall 
apply to items furnished on or after July 1, 1993.
    (c) Clarification of Authority to Designate Carriers for Other 
Items and Services.--Nothing in this subsection or the amendment made 
by this subsection may be construed to restrict the authority of the 
Secretary of Health and Human Services to designate regional carriers 
or modify claims jurisdiction rules with respect to items or services 
under part B of the medicare program that are not covered items under 
section 1834(a) of the Social Security Act or prosthetic devices or 
orthotics and prosthetics under section 1834(h) of such Act.

SEC. 9. TREATMENT OF NEBULIZERS AND ASPIRATORS.

    (a) In General.--Section 1834(a)(3)(A) (42 U.S.C. 1395m(a)(3)(A)) 
is amended by striking ``ventilators, aspirators, IPPB machines, and 
nebulizers'' and inserting ``ventilators and IPPB machines''.
    (b) Payment for Accessories Relating to Nebulizers and 
Aspirators.--Section 1834(a) (42 U.S.C. 1395m(a)) is amended by 
inserting after paragraph (14) the following new paragraph:
            ``(15) Payment for accessories relating to nebulizers and 
        aspirators.--In the case of accessories to be used in 
        conjunction with a nebulizer or aspirator for which payment is 
        made under this subsection, payment shall be made in accordance 
        with paragraph (2) of this subsection.''.
    (c) Effective Date.--The amendments made by this section shall 
apply to items furnished on or after January 1, 1993.

SEC. 10. EXTENSION OF RURAL HOSPITAL DEMONSTRATION.

    Section 4008(i)(1) of the Omnibus Budget Reconciliation Act of 1990 
is amended by adding at the end the following new sentence: ``The 
Secretary shall continue any such demonstration project until at least 
December 31, 1995.''.

                                 <all>

S 176 IS----2
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