I

106TH CONGRESS

1ST SESSION H. R. 2240

To amend title XVIII of the Social Security Act to revise payment amounts

to home health agencies under the Medicare Program, and for other purposes.

IN THE HOUSE OF REPRESENTATIVES

JUNE 16, 1999

Mr. COYNE (for himself, Mr. ENGLISH, Mr. HILLIARD, Mr. LEVIN, Mr. SANDERS, Mr. SAXTON, and Mr. SMITH of New Jersey) introduced the following bill; which was referred to the Committee on Ways and Means,

and in addition to the Committee on Commerce, for a period to be subsequently determined by the Speaker, in each case for consideration of such

provisions as fall within the jurisdiction of the committee concerned

A BILL

To amend title XVIII of the Social Security Act to revise

payment amounts to home health agencies under the

Medicare Program, 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 ‘‘Medicare Home Health

5 Access Restoration Act of 1999’’.

6 SEC. 2. ADJUSTMENT TO PER BENEFICIARY LIMITS.

7 (a) INCREASE IN PAYMENT AMOUNT TO AGENCIES

8 WITH LIMITS UNDER THE NATIONAL AVERAGE.—Section
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1 1861(v)(1)(L) of the Social Security Act (42 U.S.C.

2 1395x(v)(1)(L)), as amended by section 5101(a) of the

3 Tax and Trade Relief Extension Act of 1998 (Public Law

4 105–277), is amended—

5 (1) in clause (v)(I), by inserting ‘‘, clause (ix)’’

6 after ‘‘subject to clause (viii)(I)’’;

7 (2) in clause (viii)(I), by striking ‘‘during or

8 after fiscal year 1999’’ and inserting ‘‘during fiscal

9 year 1999’’;

10 (3) by redesignating clause (ix) as clause (xii);

11 and

12 (4) by inserting after clause (viii) the following

13 new clause:

14 ‘‘(ix) In the case of a provider with a 12-month cost

15 reporting period ending in fiscal year 1994, if the limit

16 imposed under clause (v) (determined without regard to

17 this subclause) for a cost reporting period beginning after

18 fiscal year 1999 is less than the median described in

19 clause (vi)(I) (but determined as if any reference in clause

20 (v) to ‘98 percent’ were a reference to ‘100 percent’), the

21 payment limit for such provider and period shall be equal

22 to—

23 ‘‘(I) for cost reporting periods beginning during

24 fiscal year 2000, 90 percent of such median;
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1 ‘‘(II) for cost reporting periods beginning dur2 ing fiscal year 2001, 95 percent of such median; and

3 ‘‘(III) for cost reporting periods beginning dur4 ing or after fiscal year 2002, such median.

5 Each of the amounts specified in subclauses (I) through

6 (III) are such amounts as adjusted under clause (iii) to

7 reflect variations in wages among different areas.’’.

8 (b) ESTABLISHMENT OF PER BENEFICIARY CAP;

9 WAIVER.—

10 (1) IN GENERAL.—Section 1861(v)(1)(L) of

11 such Act (42 U.S.C. 1395x(v)(1)(L)), as amended in

12 subsection (a), is further amended—

13 (A) in clause (v)(I), by inserting ‘‘, and

14 clause (x)’’ after ‘‘clause (ix)’’; and

15 (B) by inserting after clause (ix), the fol16 lowing new clause:

17 ‘‘(x) In the case of a provider with a 12-month cost

18 reporting period ending in fiscal year 1994, if the limit

19 imposed under clause (v) (determined without regard to

20 this subclause) for a cost reporting period beginning after

21 fiscal year 1999 exceeds the median described in clause

22 (vi)(I) (but determined as if any reference in clause (v)

23 to ‘98 percent’ were a reference to ‘100 percent’), the pay24 ment limit for such provider and period may not exceed—
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1 ‘‘(I) for cost reporting periods beginning during

2 fiscal year 2000, an amount equal to 250 percent of

3 such median;

4 ‘‘(II) for cost reporting periods beginning dur5 ing fiscal year 2001, an amount equal to 225 per6 cent of such median; and

7 ‘‘(III) for cost reporting periods beginning dur8 ing or after fiscal year 2002, an amount equal to

9 200 percent of such median.

10 Notwithstanding the previous sentence, in the case of such

11 a provider that demonstrates to the Secretary (in such

12 form and using such data as the Secretary requires) that,

13 for a cost reporting period, the provider, or a unit of the

14 provider, specializes in the treatment of individuals who,

15 because of age, diagnosis, or other criteria specified by the

16 Secretary are substantially more costly-than-average to

17 treat, the amount of payment to that provider or unit for

18 such an individual for that period is the limitation deter19 mined under clause (v).’’.

20 (2) CONSULTATION.—The Secretary of Health

21 and Human Services shall consult with appropriate

22 organizations, including such organizations rep23 resenting providers of home health services, physi24 cians, and patients in determining the criteria re25 quired for special payment provisions under the sec-
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1 ond sentence of clause (x) and under clause (xi) of

2 section 1861(v)(1)(L) of the Social Security Act (42

3 U.S.C. 1395x(v)(1)(L)), including descriptions of

4 the type of patient, patient condition, unusual vari5 ations, and home health service that qualifies for

6 such payment.

7 (c) WAIVER OF PER BENEFICIARY LIMIT FOR

8 OUTLIERS.—

9 (1) IN GENERAL.—Section 1861(v)(1)(L) of

10 such Act (42 U.S.C. 1395x(v)(1)(L)), as amended in

11 subsections (a) and (b), is further amended by in12 serting after clause (x), the following new clause:

13 ‘‘(xi)(I) Notwithstanding the applicable limit under

14 clause (v), (vi), (viii), (ix), or (x), in the case of a provider

15 that demonstrates to the Secretary that with respect to

16 an individual to whom the provider furnishes home health

17 services that are appropriate to the individual’s condition

18 (as determined by the Secretary) at a reasonable cost (as

19 determined by the Secretary), and that such reasonable

20 cost significantly exceeded such applicable limit because

21 of unusual variations in the type or amount of medically

22 necessary care (outliers) required to treat the individual,

23 the Secretary, upon application by the provider, shall pay

24 to such provider for such individual such reasonable cost.
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1 ‘‘(II) The Secretary shall establish such criteria as

2 is required for payment under this clause, including a de3 scription of the type of patient, patient condition, unusual

4 variations, and home health service that qualifies for such

5 payment.

6 ‘‘(III) In making determinations under subclause (I),

7 the Secretary shall use data from the cost report, or from

8 other data collected by the Secretary, of the provider for

9 such year.

10 ‘‘(IV) A provider may make an application for pay11 ment under this clause for a fiscal year no earlier than

12 the end of the provider’s cost reporting period beginning

13 in such fiscal year.

14 ‘‘(V) In the case of an application for payment under

15 this clause that is approved by the Secretary, a provider

16 may elect to receive payment on a quarterly basis.’’.

17 (2) EFFECTIVE DATE.—The amendment made

18 by subsection (a) takes effect six months after the

19 date of the enactment of this Act, and applies with

20 respect to applications by home health agencies for

21 payment of reasonable costs for outliers for cost re22 porting periods ending on or after such date.

23 (d) REPORTS TO CONGRESS.—

24 (1) INITIAL REPORT.—Not later than one year

25 after the date of the enactment of this Act, the Sec-
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1 retary of Health and Human Services shall submit

2 to Congress a report describing the effect of the spe3 cial payment provisions provided for under the sec4 ond sentence of clause (x) and under clause (xi) of

5 section 1861(v)(1)(L) of the Social Security Act (42

6 U.S.C. 1395x(v)(1)(L)). Such report shall include

7 information with respect to the number of home

8 health agencies that requested payment under such

9 provisions and the number of such agencies that re10 ceived payment under such provisions.

11 (2) FINAL REPORT.—Not later than three years

12 after the date of the enactment of this Act, the Sec13 retary shall submit to Congress a report that up14 dates the report submitted under paragraph (1), in15 cluding additional information with respect to the ill16 nesses, and the characteristics of such illnesses, of

17 the patients for whom payment under such special

18 provisions was requested, and the characteristics of

19 the home health agencies furnishing home health

20 services to such patients for such illnesses.

21 SEC. 3. REVISION OF PER VISIT LIMITS.

22 Section 1861(v)(1)(L)(i) of the Social Security Act

23 (42 U.S.C. 1395x(v)(1)(L)(i)), as amended by section

24 5101(b) of the Tax and Trade Relief Extension Act of

25 1998 (Public Law 105–277), is amended—
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1 (1) in subclause (IV), by striking ‘‘or’’;

2 (2) in subclause (V)—

3 (A) by inserting ‘‘and before October 1,

4 1999,’’ after ‘‘October 1, 1998,’’; and

5 (B) by striking the period at the end and

6 inserting ‘‘, or’’; and

7 (3) by adding at the end the following new sub8 clause:

9 ‘‘(V) October 1, 1999, 110 percent of such me10 dian.’’.

11 SEC. 4. ELIMINATION OF CONTINGENT 15 PERCENT REDUC12 TION IN PAYMENT LIMITS UNDER THE IN13 TERIM PAYMENT SYSTEM.

14 Section 4603 of the Balanced Budget Act of 1997

15 (Public Law 105–33), as amended by section 5101(c)(3)

16 of the Tax and Trade Relief Extension Act of 1998 (Pub17 lic Law 105–277) (111 Stat. 471), is amended by striking

18 subsection (e).

19 SEC. 5. INFORMATIONAL MATERIALS FOR MEDICARE BENE20 FICIARIES WITH RESPECT TO HOME HEALTH

21 SERVICES.

22 (a) IN GENERAL.—The Secretary shall prepare a no23 tice of the rights of individuals entitled to benefits under

24 the medicare program (under title XVIII of the Social Se25 curity Act) to appeal a coverage determination with re-
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1 spect to items and services furnished to such individual

2 under the program. In the case of such items and services

3 consisting of home health services furnished by a home

4 health agency, the home health agency shall furnish such

5 notice to such an individual upon discharge by the agency

6 of such individual from such services.

7 (b) INFORMATION FOR PHYSICIANS.—The Secretary

8 shall provide guidance for physicians contacted by affected

9 individuals to assist such individuals, including specific

10 guidance in the case of such individuals for whom home

11 health services are discontinued before the recommended

12 treatment is complete, but on behalf of whom payment

13 under the limits established under section 1861(v)(1)(L)

14 of the Social Security Act (42 U.S.C. 1395x(v)(1)(L)) has

15 been made in full by the Secretary to the home health

16 agency. The materials shall include telephone numbers

17 and such other information to enable the physician to seek

18 further assistance or clarification from individuals within

19 the Health Care Financing Administration with appro20 priate expertise.

21 (c) REQUESTS FOR ADDITIONAL RESOURCES.—The

22 Secretary may submit to Congress an estimate of addi23 tional resources required by the Health Care Financing

24 Administration to comply with the provisions of the sec-
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1 tion. Any such estimate shall be included in the report

2 required under paragraph (1) of section 2(d).

3 (d) EFFECTIVE DATE.—By not later than six months

4 after the date of the enactment of this Act, the Secretary

5 shall begin distributing to home health agencies furnishing

6 home health services under the medicare program (under

7 title XVIII of the Social Security Act), and to physicians

8 furnishing services under such program, the information

9 prepared under this section.

10 SEC. 6. COMPTROLLER GENERAL STUDY ON MEDICARE

11 HOME HEALTH BENEFIT.

12 (a) STUDY.—

13 (1) COST OF SERVICES.—The Comptroller Gen14 eral of the United States shall conduct a study on

15 the relationship between the costs to the medicare

16 program (under title XVIII of the Social Security

17 Act) for home health services furnished by home

18 health agencies under the program, and the costs to

19 State and Federal government programs (including

20 the medicare program and the medicaid program

21 (under title XIX of such Act)) for services furnished

22 by rehabilitation agencies, public health agencies,

23 clinics, comprehensive outpatient rehabilitation fa24 cilities, skilled nursing facilities under the medicare

25 program, and for long-term care services furnished
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1 under the medicaid program (under title XIX of

2 such Act).

3 (2) DETERMINATION OF SAVING OVERALL TO

4 MEDICARE PROGRAM.—The Comptroller General

5 shall also determine whether providing home health

6 services as a benefit under the medicare program

7 has resulted in lower costs overall to the Federal

8 government.

9 (b) REPORT.—Not later than 18 months after the

10 date of the enactment of this Act, the Comptroller General

11 shall submit to Congress a report describing the results

12 of the study conducted under subsection (a).

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