145
(i) in subsection (a)(1)(D)(i), by strik-
ing ‘‘, or for tests furnished in connection
with obtaining a second opinion required
under section 1164(c)(2) (or a third opin-
ion, if the second opinion was in disagree-
ment with the first opinion)’’;
(ii) in subsection (a)(1), by striking
clause (G);
(iii) in subsection (a)(2)(A), by strik-
ing ‘‘to items and services (other than clin-
ical diagnostic laboratory tests) furnished
in connection with obtaining a second opin-
ion required under section 1164(c)(2) (or a
third opinion, if the second opinion was in
disagreement with the first opinion),’’;
(iv) in subsection (a)(2)(D)(i)—
(I) by striking ‘‘basis,’’ and in-
serting ‘‘basis or’’, and
(II) by striking ‘‘, or for tests
furnished in connection with obtaining
a second opinion required under sec-
tion 1164(c)(2) (or a third opinion, if
the second opinion was in disagree-
ment with the first opinion))’’;
146
(v) in subsection (a)(3), by striking
‘‘and for items and services furnished in
connection with obtaining a second opinion
required under section 1164(c)(2), or a
third opinion, if the second opinion was in
disagreement with the first opinion)’’; and
(vi) in the first sentence of subsection
(b)—
(I) by striking ‘‘(3)’’ and insert-
ing ‘‘and (3)’’, and
(II) by striking ‘‘, and (4)’’ and
all that follows up to the period at the
end.
(C) Section 1834(g)(1)(B) (42 U.S.C.
1395m(g)(1)(B)) is amended by striking ‘‘and
for items and services furnished in connection
with obtaining a second opinion required under
section 1164(c)(2), or a third opinion, if the
second opinion was in disagreement with the
first opinion)’’.
(D) Section 1862(a) (42 U.S.C. 1395y(a))
is amended—
(i) by adding ‘‘or’’ at the end of para-
graph (14),
147
(ii) by striking ‘‘; or’’ at the end of
paragraph (15) and inserting a period, and
(iii) by striking paragraph (16).
(E) 
The 
third 
sentence 
of 
section
1866(a)(2)(A) (42 U.S.C. 1395w(a)(2)(A)) is
amended by striking ‘‘, with respect to items
and services furnished in connection with ob-
taining a second opinion required under section
1164(c)(2) (or a third opinion, if the second
opinion was in disagreement with the first opin-
ion),’’.
(3) EFFECTIVE DATE.—The amendments made
by this subsection shall apply to services provided on
or after the date of the enactment of this Act.
(b) MISCELLANEOUS
AND
TECHNICAL
CORREC-
TIONS.—(1) The third sentence of section 1156(b)(1) (42
U.S.C. 1320c–5(b)(1)) is amended by striking ‘‘whehter’’
and inserting ‘‘whether’’.
(2) Section 1154(a)(9)(B) (42 U.S.C. 1320c–
3(a)(9)(B)) is amended by striking ‘‘this subsection’’ and
inserting ‘‘section 1156(a)’’.
(3) Section 4205(d)(2)(B) of OBRA–1990 is
amended by striking ‘‘amendments’’ and inserting
‘‘amendment’’.
148
(4) Section 1160(d) (42 U.S.C. 1320c–9(d)) is
amended by striking ‘‘subpena’’ and inserting ‘‘subpoena’’.
(5) Section 4205(e)(2) of OBRA–1990 is amended
by striking ‘‘amendments’’ and inserting ‘‘amendment’’
and by striking ‘‘all’’.
(6)(A) Except as provided in subparagraph (B), the
amendments made by this subsection shall take effect as
if included in the enactment of OBRA–1990.
(B) The amendment made by paragraph (2) (relating
to the requirement on reporting of information to State
licensing boards) shall take effect on the date of the enact-
ment of this Act.
SEC. 308. HOSPICE INFORMATION TO HOME HEALTH BENE-
FICIARIES.
(a) IN GENERAL.—Section 1891(a)(1) (42 U.S.C.
1395bbb(a)(1)) is amended by adding at the end the fol-
lowing new subparagraph:
‘‘(H) The right, in the case of a resident
who is entitled to benefits under this title, to be
fully informed orally and in writing (at the time
of coming under the care of the agency) of the
entitlement of individuals to hospice care under
section 1812(a)(4) (unless there is no hospice
program providing hospice care for which pay-
ment may be made under this title within the
149
geographic area of the facility and it is not the
common practice of the agency to refer patients
to hospice programs located outside such geo-
graphic area).’’.
(b) EFFECTIVE DATE.—The amendment made by
subsection (a) shall apply to services furnished on or after
the first day of the first month beginning more than one
year after the date of the enactment of this Act.
SEC. 309. INTEREST PAYMENTS.
(a) IN GENERAL.—Sections 1816(c)(2)(B)(ii)(IV)
and 1842(c)(2)(B)(ii)(IV) of the Social Security Act shall
be applied with respect to claims received in the 12-month
period beginning October 1, 1992, by substituting ‘‘30 cal-
endar days’’ for ‘‘24 calendar days’’ and ‘‘17 calendar
days’’.
(b) EFFECTIVE DATE.—Subsection (a) shall be in ef-
fect during the period that begins on the date of the enact-
ment of this Act and ends on September 30, 1993.
SEC. 310. CLARIFICATION OF JUDICIAL REVIEW RIGHTS.
(a) IN
GENERAL.—Section 1869(b) (42 U.S.C.
1395ff(b)) is amended by adding at the end the following
new paragraph:
‘‘(6) Nothing in this subsection (including paragraph
(5)) shall be construed as requiring a person to file a claim
with, or obtain findings or a decision of, the Secretary
150
prior to seeking judicial review of an issue under this sub-
section, if the issue involves no material issues of fact in
dispute and involves a challenge to the validity of a regula-
tion or instruction which relates to a method for determin-
ing the amount of payment under part B.’’.
(b) EFFECTIVE DATE.—The amendment made by
subsection (a) shall apply as if included in the enactment
of section 9313 of OBRA–1986.
SEC. 311. ADJUSTMENTS TO DISCRETIONARY SPENDING
LIMITS.
(a) ADJUSTMENTS.—Section 251(b)(2) of the Bal-
anced Budget and Emergency Deficit Control Act of 1985
is amended by redesignating subparagraphs (E) and (F)
as subparagraphs (F) and (G), respectively, and by insert-
ing after subparagraph (D) the following new subpara-
graph:
‘‘(E) 
MEDICARE
ADMINISTRATIVE
COSTS.—To the extent that appropriations are
enacted that provide additional new budget au-
thority (as compared with a base level of
$1,526,000,000 for new budget authority) for
the administration of the Medicare program by
fiscal intermediaries and carriers pursuant to
sections 1816 and 1842(a) of title XVIII of the
Social Security Act, the adjustment for that
151
year shall be that amount, but shall not ex-
ceed—
‘‘(i) 
for 
fiscal 
year 
1994,
$198,000,000 in new budget authority and
$198,000,000 in outlays; and
‘‘(ii) 
for 
fiscal 
year 
1995,
$220,000,000 in new budget authority and
$220,000,000 in outlays; and
the prior-year outlays resulting from these appro-
priations of budget authority and additional adjust-
ments equal to the sum of the maximum adjust-
ments that could have been made in preceding fiscal
years under this subparagraph.’’.
(b) CONFORMING AMENDMENTS.—
(1) Section 603(a) of the Congressional Budget
Act of 1974 is amended by striking ‘‘section
251(b)(2)(E)(i)’’ 
and 
inserting 
‘‘section
251(b)(2)(F)(i)’’.
(2) Section 606(d) of the Congressional Budget
Act of 1974 is amended—
(A) in paragraph (1)(A) by striking ‘‘sec-
tion 251(b)(2)(E)(i)’’ and inserting ‘‘section
251(b)(2)(F)(i)’’; and
(B) 
in 
paragraph 
(2), 
by 
inserting
‘‘251(b)(2)(E),’’ after ‘‘251(b)(2)(D),’’.
152
SEC. 312. HEALTH MAINTENANCE ORGANIZATIONS.
(a) ADJUSTMENT IN MEDICARE CAPITATION PAY-
MENTS TO ACCOUNT FOR REGIONAL VARIATIONS IN AP-
PLICATION OF SECONDARY PAYOR PROVISIONS.—
(1) IN
GENERAL.—Section 1876(a)(4) (42
U.S.C. 1395mm(a)(4)) is amended by adding at the
end the following new sentence: ‘‘In establishing the
adjusted average per capita cost for a geographic
area, the Secretary shall take into account the dif-
ferences between the proportion of individuals in the
area with respect to whom there is a group health
plan that is a primary payor (within the meaning of
section 1862(b)(2)(A)) compared to the proportion
of all such individuals with respect to whom there is
such a group health plan.’’.
(2) EFFECTIVE DATE.—The amendment made
by paragraph (1) shall apply to contracts entered
into for years beginning with 1994.
(b) REVISIONS
IN
THE PAYMENT METHODOLOGY
FOR RISK CONTRACTORS.—Section 4204(b) of OBRA–
1990 is amended to read as follows:
‘‘(b) REVISIONS IN THE PAYMENT METHODOLOGY
FOR RISK CONTRACTORS.—(1)(A) Not later than July 1,
1993, the Secretary of Health and Human Services (in
this subsection referred to as the ‘‘Secretary’’) shall sub-
mit a proposal to the Congress that provides for revisions
153
to the payment method to be applied in years beginning
with 1995 for organizations with a risk-sharing contract
under section 1876(g) of the Social Security Act.
‘‘(B) In proposing the revisions required under sub-
paragraph (A) the Secretary shall consider—
‘‘(i) the difference in costs associated with med-
icare beneficiaries with differing health status and
demographic characteristics; and
‘‘(ii) the effects of using alternative geographic
classifications on the determinations of costs associ-
ated with beneficiaries residing in different areas.
‘‘(2) Not later than October 1, 1993, the Comptroller
General shall review the proposal made pursuant to para-
graph (1), and shall report to Congress on the appro-
priateness of the proposed modifications.’’.
(c) MISCELLANEOUS
AND
TECHNICAL
CORREC-
TIONS.—(1) 
Section 
1876(a)(3) 
(42 
U.S.C.
1395mm(a)(3)) is amended by striking ‘‘subsection
(c)(7)’’ and inserting ‘‘subsections (c)(2)(B)(ii) and
(c)(7)’’.
(2) Section 4204(c)(3) of OBRA–1990 is amended
by striking ‘‘for 1991’’ and inserting ‘‘for years beginning
with 1991’’.
(3) Section 4204(d)(2) of OBRA–1990 is amended
by striking ‘‘amendment’’ and inserting ‘‘amendments’’.
154
(4) 
Section 
1876(a)(1)(E)(ii)(I) 
(42 
U.S.C.
1395mm(a)(1)(E)(ii)(I)) is amended by striking the
comma after ‘‘contributed to’’.
(5) Section 4204(e)(2) of OBRA–1990 is amended
by striking ‘‘(which has a risk-sharing contract under sec-
tion 1876 of the Social Security Act)’’.
(6) Section 4204(f)(4) of OBRA–1990 is amended by
striking ‘‘final’’.
(7) 
Section 
1862(b)(3)(C) 
(42 
U.S.C.
1395y(b)(3)(C)) is amended—
(A) in the heading, by striking ‘‘PLAN’’ and in-
serting ‘‘PLAN OR A LARGE GROUP HEALTH PLAN’’;
(B) by striking ‘‘group health plan’’ and insert-
ing ‘‘group health plan or a large group health
plan’’;
(C) by striking ‘‘, unless such incentive is also
offered to all individuals who are eligible for cov-
erage under the plan’’; and
(D) by striking ‘‘the first sentence of subsection
(a) and other than subsection (b)’’ and inserting
‘‘subsections (a) and (b)’’.
(8) The amendments made by this subsection shall
take effect as if included in the enactment of OBRA–1990.
155
SEC. 313. TREATMENT OF CERTAIN STATE HEALTH CARE
PROGRAMS.
Section 514(b)(5) of the Employee Retirement In-
come Security Act of 1974 (29 U.S.C. 1144(b)(5)) is
amended to read as follows:
‘‘(5)(A) Except as provided in subparagraphs
(B) and (C), subsection (a) shall not apply to the
Hawaii Prepaid Health Care Act (Haw. Rev. Stat.
§ § 393–1 through 393–51).
‘‘(B) Nothing in subparagraph (A) shall be con-
strued to exempt from subsection (a) any State tax
law relating to employee benefits plans.
‘‘(C) If the Secretary of Labor notifies the Gov-
ernor of the State of Hawaii that as the result of
an amendment to the Hawaii Prepaid Health Care
Act enacted after October 5, 1992—
‘‘(i) the proportion of the population with
health care coverage under such Act is less than
such proportion on such date, or
‘‘(ii) the level of benefit coverage provided
under such Act is less than the actuarial equiv-
alent of such level of coverage on such date,
subparagraph (A) shall not apply with respect to the
application of such amendment to such Act after the
date of such notification.’’.
156
SEC. 314. MISCELLANEOUS AND TECHNICAL CORRECTIONS.
(a) SURVEY AND CERTIFICATION REQUIREMENTS.—
(1) Section 1864 (42 U.S.C. 1395aa) is amended—
(A) in subsection (e), by striking ‘‘title’’ and in-
serting ‘‘title (other than any fee relating to section
353 of the Public Health Service Act)’’; and
(B) in the first sentence of subsection (a), by
striking ‘‘1861(s) or’’ and all that follows through
‘‘Service Act,’’ and inserting ‘‘1861(s),’’.
(2) An agreement made by the Secretary of Health
and Human Services with a State under section 1864(a)
of the Social Security Act may include an agreement that
the services of the State health agency or other appro-
priate State agency (or the appropriate local agencies) will
be utilized by the Secretary for the purpose of determining
whether a laboratory meets the requirements of section
353 of the Public Health Service Act.
(b) OTHER MISCELLANEOUS AND TECHNICAL PRO-
VISIONS.—(1) Section 1833 (42 U.S.C. 1395l) is amended
by redesignating the subsection (r) added by section
4206(b)(2) of OBRA–1990 as subsection (s).
(2) Section 1866(f)(1) (42 U.S.C. 1395cc(f)(1)) is
amended by striking ‘‘1833(r)’’ and inserting ‘‘1833(s)’’.
(3) Section 1861(s)(2) (42 U.S.C. 1395x(s)(2)) is
amended by moving subparagraph (O), as redesignated by
157
section 10149(f)(8)(B)(iii)(II) of this title, two ems to the
left.
(4) 
Section 
1881(b)(1)(C) 
(42 
U.S.C.
1395rr(b)(1)(C)) is amended by striking ‘‘1861(s)(2)(Q)’’
and inserting ‘‘1861(s)(2)(P)’’.
(5) Section 4201(d)(2) of OBRA–1990 is amended
by striking ‘‘(B) by striking’’, ‘‘(C) by striking’’, and ‘‘(3)
by adding’’ and inserting ‘‘(i) by striking’’, ‘‘(ii) by strik-
ing’’, and ‘‘(B) by adding’’, respectively.
(6)(A) Section 4207(a)(1) of OBRA–1990 is amend-
ed by adding closing quotation marks and a period after
‘‘such review.’’.
(B) Section 4207(a)(4) of OBRA–1990 is amended
by striking ‘‘this subsection’’ and inserting ‘‘paragraphs
(2) and (3)’’.
(C) Section 4207(b)(1) of OBRA–1990 is amended
by striking ‘‘section 3(7)’’ and inserting ‘‘section
601(a)(1)’’.
(c) EFFECTIVE DATE.—The amendments made by
this section shall take effect as if included in the enact-
ment of OBRA–1990.
158
TITLE IV—PROVISIONS RELAT-
ING TO MEDICARE SUPPLE-
MENTAL 
INSURANCE 
POLI-
CIES
SEC. 401. STANDARDS FOR MEDICARE SUPPLEMENTAL IN-
SURANCE POLICIES.
(a) SIMPLIFICATION OF MEDICARE SUPPLEMENTAL
POLICIES.—
(1) Section 4351 of OBRA–1990 is amended by
striking ‘‘(a) IN GENERAL.—’’.
(2) Section 1882(p) (42 U.S.C. 1395ss(p)) is
amended—
(A) in paragraph (1)(A)—
(i) by striking ‘‘promulgates’’ and in-
serting ‘‘changes the revised NAIC Model
Regulation (described in subsection (m)) to
incorporate’’,
(ii) by striking ‘‘(such limitations, lan-
guage, definitions, format, and standards
referred to collectively in this subsection as
‘NAIC standards’)’’, and
(iii) by striking ‘‘included a reference
to the NAIC standards’’ and inserting
‘‘were a reference to the revised NAIC
Model Regulation as changed under this
159
subparagraph (such changed regulation re-
ferred to in this section as the ‘1991 NAIC
Model Regulation’)’’;
(B) in paragraph (1)(B)—
(i) by striking ‘‘promulgate NAIC
standards’’ 
and 
inserting 
‘‘make 
the
changes in the revised NAIC Model Regu-
lation’’,
(ii) by striking ‘‘limitations, language,
definitions, format, and standards de-
scribed in clauses (i) through (iv) of such
subparagraph (in this subsection referred
to collectively as ‘Federal standards’)’’ and
inserting ‘‘a regulation’’, and
(iii) by striking ‘‘included a reference
to the Federal standards’’ and inserting
‘‘were a reference to the revised NAIC
Model Regulation as changed by the Sec-
retary under this subparagraph (such
changed regulation referred to in this sec-
tion as the ‘1991 Federal Regulation’)’’;
(C) in paragraph (1)(C)(i), by striking
‘‘NAIC standards or the Federal standards’’
and inserting ‘‘1991 NAIC Model Regulation or
1991 Federal Regulation’’;