I
106TH CONGRESS
2D SESSION
H. R. 5324
To amend the Social Security Act to make corrections and refinements in
the Medicare, Medicaid, and SCHIP health insurance programs, as re-
vised by the Balanced Budget Act of 1997 and the Medicare, Medicaid,
and SCHIP Balanced Budget Refinement Act of 1999, and for other
purposes.
IN THE HOUSE OF REPRESENTATIVES
SEPTEMBER 27, 2000
Mr. MARKEY (for himself, Mr. FRANK of Massachusetts, Mr. MOAKLEY, Mr.
NEAL of Massachusetts, Mr. MEEHAN, Mr. OLVER, Mr. TIERNEY, Mr.
DELAHUNT, Mr. MCGOVERN, Mr. CAPUANO, Ms. MILLENDER-MCDON-
ALD, Mr. DOYLE, Mr. BLUMENAUER, Mr. HILLIARD, Mr. ABERCROMBIE,
Mr. MASCARA, Mr. PAYNE, Mr. ROMERO-BARCELO´, Ms. LEE, Mr. CON-
YERS, Mr. SANDERS, Mr. CLEMENT, Ms. MCKINNEY, Mr. BLAGOJEVICH,
Mr. BARCIA, Mr. DAVIS of Illinois, Mr. HINOJOSA, Mrs. MEEK of Flor-
ida, Mr. SANDLIN, Ms. BROWN of Florida, Ms. KILPATRICK, Mr. PICK-
ETT, Ms. WATERS, Mr. REYES, Mrs. JONES of Ohio, Mr. GREEN of
Texas, Mr. BERMAN, Mr. SERRANO, and Mr. MCNULTY) introduced the
following bill; which was referred to the Committee on Commerce, and
in addition to the Committees on Ways and Means, Rules, and Education
and the Workforce, 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 the Social Security Act to make corrections and
refinements in the Medicare, Medicaid, and SCHIP
health insurance programs, as revised by the Balanced
Budget Act of 1997 and the Medicare, Medicaid, and
SCHIP Balanced Budget Refinement Act of 1999, and
for other purposes.
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled,
SECTION 1. SHORT TITLE; AMENDMENTS TO SOCIAL SECU-
RITY ACT; REFERENCES TO OTHER ACTS;
TABLE OF CONTENTS.
(a) SHORT TITLE.—This Act may be cited as the
‘‘Medicare, Medicaid, and SCHIP Balanced Budget Re-
finement Act of 2000’’.
(b) AMENDMENTS TO SOCIAL SECURITY ACT.—Ex-
cept 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.
(c) REFERENCES TO OTHER ACTS.—In this Act:
(1) THE BALANCED BUDGET ACT OF 1997.—
The term ‘‘BBA’’ means the Balanced Budget Act
of 1997 (Public Law 105–33; 111 Stat. 251).
(2) THE
MEDICARE, MEDICAID, AND
SCHIP
BALANCED
BUDGET
REFINEMENT
ACT
OF
1999.—
The term ‘‘BBRA’’ means the Medicare, Medicaid,
and SCHIP Balanced Budget Refinement Act of
1999 (113 Stat. 1501A–321), as enacted into law by
section 1000(a)(6) of Public Law 106–113.
(d) TABLE OF CONTENTS.—The table of contents of
this Act is as follows:
Sec. 1. Short title; amendments to Social Security Act; references to other Acts;
table of contents.
TITLE I—PROVISIONS RELATING TO PART A
Subtitle A—Skilled Nursing Facilities
Sec. 101. Eliminating reduction in skilled nursing facility (SNF) market basket
update.
Sec. 102. Revision of BBRA increase for skilled nursing facilities in fiscal years
2001 and 2002.
Sec. 103. MedPAC study on payment updates for skilled nursing facilities; au-
thority of Secretary to make adjustments.
Subtitle B—PPS Hospitals
Sec. 111. Revision of reduction of indirect graduate medical education pay-
ments.
Sec. 112. Eliminating reduction in PPS hospital payment update.
Sec. 113. Eliminating reduction in disproportionate share hospital (DSH) pay-
ments.
Sec. 114. Equalizing the threshold and updating payment formulas for dis-
proportionate share hospitals.
Sec. 115. Care for low-income patients.
Sec. 116. Modification of payment rate for Puerto Rico hospitals.
Sec. 117. MedPAC study on hospital area wage indexes.
Subtitle C—PPS Exempt Hospitals
Sec. 121. Treatment of certain cancer hospitals.
Sec. 122. Payment adjustment for inpatient services in rehabilitation hospitals.
Subtitle D—Hospice Care
Sec. 131. Revision in payments for hospice care.
Subtitle E—Other Provisions
Sec. 141. Hospitals required to comply with bloodborne pathogens standard.
Sec. 142. Informatics and data systems grant program.
Sec. 143. Relief from medicare part A late enrollment penalty for group buy-
in for State and local retirees.
Subtitle F—Transitional Provisions
Sec. 151. Reclassification of certain counties and areas for purposes of reim-
bursement under the medicare program.
Sec. 152. Calculation and application of wage index floor for a certain area.
Sec. 153. Reclassification of a certain county for purposes of reimbursement
under the medicare program.
TITLE II—PROVISIONS RELATING TO PART B
Subtitle A—Hospital Outpatient Services
Sec. 201. Reduction of effective HOPD coinsurance rate to 20 percent by 2014.
Sec. 202. Application of transitional corridor to certain hospitals that did not
submit a 1996 cost report.
Sec. 203. Permanent guarantee of pre-BBA payment levels for outpatient serv-
ices furnished by children’s hospitals.
Subtitle B—Provisions Relating to Physicians
Sec. 211. Loan deferment for residents.
Sec. 212. GAO studies and reports on medicare payments.
Sec. 213. MedPAC study on the resource-based practice expense system.
Subtitle C—Ambulance Services
Sec. 221. Election to forego phase-in of fee schedule for ambulance services.
Sec. 222. Prudent layperson standard for emergency ambulance services.
Sec. 223. Elimination of reduction in inflation adjustments for ambulance serv-
ices.
Sec. 224. Study and report on the costs of rural ambulance services.
Sec. 225. Interim payments for rural ground ambulance services until regula-
tion implemented.
Sec. 226. GAO study and report on the costs of emergency and medical trans-
portation services.
Subtitle D—Preventive Services
Sec. 231. Elimination of deductibles and coinsurance for preventive benefits.
Sec. 232. Counseling for cessation of tobacco use.
Sec. 233. Coverage of glaucoma detection tests.
Sec. 234. Medical nutrition therapy services for beneficiaries with diabetes, a
cardiovascular disease, or a renal disease.
Sec. 235. Studies on preventive interventions in primary care for older Ameri-
cans.
Sec. 236. Institute of Medicine 5-year medicare prevention benefit study and
report.
Sec. 237. Fast-track consideration of prevention benefit legislation.
Subtitle E—Other Services
Sec. 241. Revision of moratorium in caps for therapy services.
Sec. 242. Revision of coverage of immunosuppressive drugs.
Sec. 243. State accreditation of diabetes self-management training programs.
Sec. 244. Elimination of reduction in payment amounts for durable medical
equipment and oxygen and oxygen equipment.
Sec. 245. Standards regarding payment for certain orthotics and prosthetics.
Sec. 246. National limitation amount equal to 100 percent of national median
for new pap smear technologies and other new clinical labora-
tory test technologies.
Sec. 247. Increased medicare payments for certified nurse-midwife services.
Sec. 248. Payment for administration of drugs.
Sec. 249. MedPAC study on in-home infusion therapy nursing services.
Sec. 250. Coverage of vision rehabilitation services.
Sec. 251. Limiting medicare late enrollment penalty to 10 percent and twice
the period of no enrollment.
TITLE III—PROVISIONS RELATING TO PARTS A AND B
Subtitle A—Home Health Services
Sec. 301. Elimination of 15 percent reduction in payment rates under the pro-
spective payment system for home health services.
Sec. 302. Additional payments for outliers.
Sec. 303. Additional payments under the prospective payment system for serv-
ices furnished in rural areas and security services.
Sec. 304. Exclusion of certain nonroutine medical supplies under the PPS for
home health services.
Sec. 305. Clarification of the homebound definition for the home health benefit.
Sec. 306. Standards for home health branch offices.
Sec. 307. Treatment of home health services provided in certain counties.
Sec. 308. Rule of construction relating to telehomehealth services.
Subtitle B—Direct Graduate Medical Education
Sec. 311. Not counting certain geriatric residents against graduate medical
education limitations.
Sec. 312. Program of payments to children’s hospitals that operate graduate
medical education programs.
Sec. 313. Authority to include costs of training of clinical psychologists in pay-
ments to hospitals.
Sec. 314. Treatment of certain newly established residency programs in com-
puting medicare payments for the costs of medical education.
Sec. 315. Exception to establishing the number of residents for certain hos-
pitals.
Subtitle C—Miscellaneous Provisions
Sec. 321. Waiver of 24-month waiting period for medicare coverage of individ-
uals disabled with amyotrophic lateral sclerosis (ALS).
TITLE IV—RURAL PROVIDER PROVISIONS
Subtitle A—Critical Access Hospitals
Sec. 401. Payments to critical access hospitals for clinical diagnostic laboratory
tests.
Sec. 402. Revision of payment for professional services provided by a critical
access hospital.
Sec. 403. Permitting critical access hospitals to operate PPS exempt distinct
part psychiatric and rehabilitation units.
Subtitle B—Medicare Dependent, Small Rural Hospital Program
Sec. 411. Making the medicare dependent, small rural hospital program perma-
nent.
Sec. 412. Option to base eligibility for medicare dependent, small rural hospital
program on discharges during any of the 3 most recent audited
cost reporting periods.
Subtitle C—Sole Community Hospitals
Sec. 421. Extension of option to use rebased target amounts to all sole commu-
nity hospitals.
Sec. 422. Deeming a certain hospital as a sole community hospital.
Subtitle D—Other Rural Hospital Provisions
Sec. 431. Exemption of hospital swing-bed program from the PPS for skilled
nursing facilities.
Sec. 432. Permanent guarantee of pre-BBA payment levels for outpatient serv-
ices furnished by rural hospitals.
Sec. 433. Treatment of certain physician pathology services.
Subtitle E—Other Rural Provisions
Sec. 441. Revision of bonus payments for services furnished in health profes-
sional shortage areas.
Sec. 442. Provider-based rural health clinic cap exemption.
Sec. 443. Payment for certain physician assistant services.
Sec. 444. Exclusion of clinical social worker services and services performed
under a contract with a rural health clinic or federally qualified
health center from the PPS for SNFs.
Sec. 445. Coverage of marriage and family therapist services provided in rural
health clinics.
Sec. 446. Capital infrastructure revolving loan program.
Sec. 447. Grants for upgrading data systems.
Sec. 448. Relief for financially distressed rural hospitals.
Sec. 449. Refinement of medicare reimbursement for telehealth services.
Sec. 450. MedPAC study on low-volume, isolated rural health care providers.
TITLE 
V—PROVISIONS 
RELATING 
TO 
PART 
C
(MEDICARE+CHOICE PROGRAM) AND OTHER MEDICARE MAN-
AGED CARE PROVISIONS
Sec. 501. Restoring effective date of elections and changes of elections of
Medicare+Choice plans.
Sec. 502. Special Medigap enrollment antidiscrimination provision for certain
beneficiaries.
Sec. 503. Increase in national per capita Medicare+Choice growth percentage
in 2001 and 2002.
Sec. 504. Allowing movement to 50:50 percent blend in 2002.
Sec. 505. Delay from July to November 2000, in deadline for offering and
withdrawing Medicare+Choice plans for 2001.
Sec. 506. Amounts in medicare trust funds available for Secretary’s share of
Medicare+Choice education and enrollment-related costs.
Sec. 507. Revised terms and conditions for extension of medicare community
nursing organization (CNO) demonstration project.
Sec. 508. Modification of payment rules for certain frail elderly medicare bene-
ficiaries.
TITLE VI—PROVISIONS RELATING TO INDIVIDUALS WITH END-
STAGE RENAL DISEASE
Sec. 601. Update in renal dialysis composite rate.
Sec. 602. Revision of payment rates for ESRD patients enrolled in
Medicare+Choice plans.
Sec. 603. Permitting ESRD beneficiaries to enroll in another Medicare+Choice
plan if the plan in which they are enrolled is terminated.
Sec. 604. Coverage of certain vascular access services for ESRD beneficiaries
provided by ambulatory surgical centers.
Sec. 605. Collection and analysis of information on the satisfaction of ESRD
beneficiaries with the quality of and access to health care
under the medicare program.
TITLE VII—ACCESS TO CARE IMPROVEMENTS THROUGH
MEDICAID AND SCHIP
Sec. 701. New prospective payment system for Federally-qualified health cen-
ters and rural health clinics.
Sec. 702. Transitional medical assistance.
Sec. 703. Application of simplified SCHIP procedures under the medicaid pro-
gram.
Sec. 704. Presumptive eligibility.
Sec. 705. Improvements to the maternal and child health services block grant.
Sec. 706. Improving access to medicare cost-sharing assistance for low-income
beneficiaries.
Sec. 707. Breast and cervical cancer prevention and treatment.
TITLE VIII—OTHER PROVISIONS
Sec. 801. Appropriations for Ricky Ray Hemophilia Relief Fund.
Sec. 802. Increase in appropriations for special diabetes programs for children
with type I diabetes and Indians.
Sec. 803. Demonstration grants to improve outreach, enrollment, and coordina-
tion of programs and services to homeless individuals and fami-
lies.
Sec. 804. Protection of an HMO enrollee to receive continuing care at a facility
selected by the enrollee.
Sec. 805. Grants to develop and establish real choice systems change initiatives.
TITLE I—PROVISIONS RELATING
TO PART A
Subtitle A—Skilled Nursing
Facilities
SEC. 101. ELIMINATING REDUCTION IN SKILLED NURSING
FACILITY (SNF) MARKET BASKET UPDATE.
(a) 
ELIMINATION
OF
REDUCTION.—Section
1888(e)(4)(E)(ii) (42 U.S.C. 1395yy(e)(4)(E)(ii)) is
amended—
(1) in subclause (I), by adding ‘‘and’’ at the
end;
(2) by striking subclause (II); and
(3) by redesignating subclause (III) as sub-
clause (II).
(b) SPECIAL RULE
FOR PAYMENT
FOR SKILLED
NURSING FACILITY SERVICES FOR FISCAL YEAR 2001.—
Notwithstanding the amendments made by subsection (a),
for purposes of making payments for covered skilled nurs-
ing facility services under section 1888(e) of the Social
Security Act (42 U.S.C. 1395yy(e)) for fiscal year 2001,
the Federal per diem rate referred to in paragraph
(4)(E)(ii) of such section—
(1) for the period beginning on October 1,
2000, and ending on March 31, 2001, shall be the
rate determined in accordance with subclause (II) of
such paragraph as in effect on the day before the
date of enactment of this Act; and
(2) for the period beginning on April 1, 2001,
and ending on September 30, 2001, shall be the rate
computed for fiscal year 2000 pursuant to subclause
(I) of such paragraph increased by the skilled nurs-
ing facility market basket percentage change for fis-
cal year 2001 plus 1 percentage point.
SEC. 102. REVISION OF BBRA INCREASE FOR SKILLED
NURSING FACILITIES IN FISCAL YEARS 2001
AND 2002.
(a) REVISION.—Section 101(d) of BBRA (113 Stat.
1501A–325) is amended—
(1) in paragraph (1)—
(A) by striking ‘‘4.0 percent for each such
fiscal year’’ and inserting ‘‘the applicable per-
cent (as defined in paragraph (3)) for each
such fiscal year (or portion of such year)’’; and
(2) by adding at the end the following new
paragraph:
‘‘(3) APPLICABLE
PERCENT
DEFINED.—For
purposes of this subsection, the term ‘applicable per-
cent’ means, with respect to services provided
during—
‘‘(A) the period beginning on October 1,
2000, and ending on March 31, 2001, 4.0 per-
cent;
‘‘(B) the period beginning on April 1,
2001, and ending on September 30, 2001, 8.0
percent; and
‘‘(C) fiscal year 2002, 6.0 percent.
(b) EFFECTIVE DATE.—The amendments made by
subsection (a) shall take effect as if included in the enact-
ment of section 101 of BBRA (113 Stat. 1501A–324).
SEC. 103. MEDPAC STUDY ON PAYMENT UPDATES FOR
SKILLED NURSING FACILITIES; AUTHORITY
OF SECRETARY TO MAKE ADJUSTMENTS.
(a) STUDY.—The Medicare Payment Advisory Com-
mission established under section 1805 of the Social Secu-
rity Act (42 U.S.C. 1395b–6) (in this section referred to
as ‘‘MedPAC’’) shall conduct a study of nursing home
costs to determine the adequacy of payment rates (includ-
ing updates to such rates) under the medicare program
under title XVIII of such Act (42 U.S.C. 1395 et seq.)
(in this section referred to as the ‘‘medicare program’’)
for items and services furnished by skilled nursing facili-
ties. In conducting such study, MedPAC shall use data
on actual costs and cost increases.
(b) REPORT.—Not later than 12 months after the
date of enactment of this Act, MedPAC shall submit a
report to the Secretary of Health and Human Services and
Congress on the study conducted under subsection (a), in-
cluding a description of the methodology and calculations
used by the Health Care Financing Administration to es-
tablish the original payment level under the prospective
payment system for skilled nursing facility services under
section 1888(e) of the Social Security Act (42 U.S.C.
1395yy(e)) and to annually update payments under the
medicare program for items and services furnished by
skilled nursing facilities, together with recommendations
regarding methods to ensure that all input variables, in-
cluding the labor costs, the intensity of services, and the
changes in science and technology that are specific to such
facilities, are adequately accounted for.
(c) AUTHORITY OF SECRETARY TO MAKE ADJUST-
MENTS.—Notwithstanding any other provision of law, the
Secretary of Health and Human Services may make ad-
justments to payments under the prospective payment sys-
tem under section 1888(e) of the Social Security Act (42
U.S.C. 1395yy(e)) for covered skilled nursing facility serv-
ices to reflect any necessary adjustments to such payments
as is appropriate as a result of the study conducted under
subsection (a).
(d) PUBLICATION.—
(1) IN
GENERAL.—Not later than April 1,
2002, the Secretary of Health and Human Services
shall publish for public comment a description of—
(A) whether the Secretary will make any
adjustments pursuant to subsection (c); and
(B) if so, the form of such adjustments.
(2) FINAL FORM.—Not later than August 1,
2002, the Secretary of Health and Human Services
shall publish the description described in paragraph
(1) in final form.
Subtitle B—PPS Hospitals
SEC. 111. REVISION OF REDUCTION OF INDIRECT GRAD-
UATE MEDICAL EDUCATION PAYMENTS.
(a) REVISION.—
(1) IN
GENERAL.—Section 1886(d)(5)(B)(ii)
(42 U.S.C. 1395ww(d)(5)(B)(ii)) is amended—
(A) in subclause (IV), by adding ‘‘and’’ at
the end; and
(B) by striking subclauses (V) and (VI)
and inserting the following new subclause:
‘‘(V) on or after October 1, 2000, ‘c’
is equal to 1.6.’’.
(2) 
TECHNICAL
AMENDMENTS.—Section
1886(d)(5)(B) (42 U.S.C. 1395ww(d)(5)(B)), as
amended by paragraph (1), is amended—
(A) by realigning the left margins of
clauses (ii) and (v) so as to align with the left
margin of clause (i); and
(B) by realigning the left margins of sub-
clauses (I) through (V) of clause (ii) appro-
priately.
(b) SPECIAL ADJUSTMENT FOR PURPOSES OF MAIN-
TAINING 6.5 PERCENT IME PAYMENT FOR FISCAL YEAR
2001.—Notwithstanding paragraph (5)(B)(ii)(V) of sec-
tion 1886(d) of the Social Security Act (42 U.S.C.
1395ww(d)(5)(B)(ii)(V)), as amended by subsection (a),
for purposes of making payments for subsection (d) hos-
pitals (as defined in paragraph (1)(B) of such section)
with indirect costs of medical education, the indirect
teaching adjustment factor referred to in paragraph
(5)(B)(ii) of such section shall be determined—
(1) for discharges occurring on or after October
1, 2000, and before April 1, 2001, pursuant to such
paragraph as in effect on the day before the date of
enactment of this Act; and
(2) for discharges occurring on or after April 1,
2001, and before October 1, 2001, by substituting
‘‘1.66’’ for ‘‘1.6’’ in subclause (V) of such paragraph
(as so amended).
(c) CONFORMING AMENDMENT RELATING TO DE-
TERMINATION
OF
STANDARDIZED
AMOUNT.—Section
1886(d)(2)(C)(i) (42 U.S.C. 1395ww(d)(2)(C)(i)) is
amended—
(1) by inserting a comma after ‘‘Balanced
Budget Act of 1997’’; and
(2) by inserting ‘‘, or any payment under such
paragraph resulting from the application of section
111(b) of the Medicare, Medicaid, and SCHIP Bal-
anced Budget Refinement Act of 2000’’ after ‘‘Bal-
anced Budget Refinement Act of 1999’’.
SEC. 112. ELIMINATING REDUCTION IN PPS HOSPITAL PAY-
MENT UPDATE.
(a) IN
GENERAL.—Section 1886(b)(3)(B)(i) (42
U.S.C. 1395ww(b)(3)(B)(i)) is amended—
(1) in subclause (XV), by adding ‘‘and’’ at the
end;
(2) by striking subclauses (XVI) and (XVII);
(3) by redesignating subclause (XVIII) as sub-
clause (XVI); and
(4) in subclause (XVI), as so redesignated, by
striking ‘‘fiscal year 2003’’ and inserting ‘‘fiscal year
2001’’.
(b) SPECIAL RULE FOR PAYMENT FOR INPATIENT
HOSPITAL SERVICES FOR FISCAL YEAR 2001.—Notwith-
standing the amendments made by subsection (a), for pur-
poses of making payments for fiscal year 2001 for inpa-
tient hospital services furnished by subsection (d) hos-
pitals (as defined in section 1886(d)(1)(B) of the Social
Security Act (42 U.S.C. 1395ww(d)(1)(B))), the ‘‘applica-
ble 
percentage 
increase’’ 
referred 
to 
in 
section
1886(b)(3)(B)(i) 
of 
such 
Act 
(42 
U.S.C.
1395ww(b)(3)(B)(i))—
(1) for discharges occurring on or after October
1, 2000, and before April 1, 2001, shall be deter-
mined in accordance with subclause (XVI) of such
section as in effect on the day before the date of en-
actment of this Act; and
(2) for discharges occurring on or after April 1,
2001, and before October 1, 2001, shall be equal
to—
(A) the market basket percentage increase
plus 1.1 percentage points for hospitals (other
than sole community hospitals) in all areas; and
(B) the market basket percentage increase
for sole community hospitals.
SEC. 
113. 
ELIMINATING 
REDUCTION 
IN 
DISPROPOR-
TIONATE SHARE HOSPITAL (DSH) PAYMENTS.
(a) ELIMINATION OF REDUCTION.—
(1) IN
GENERAL.—Section 1886(d)(5)(F)(ix)
(42 U.S.C. 1395ww(d)(5)(F)(ix)) is amended—
(A) in subclause (III), by striking ‘‘during
each of fiscal years 2000 and 2001’’ and insert-
ing ‘‘during fiscal year 2000’’;
(B) by striking subclause (IV);
(C) by redesignating subclause (V) as sub-
clause (IV); and
(D) in subclause (IV), as so redesignated,
by striking ‘‘during fiscal year 2003’’ and in-
serting ‘‘during fiscal year 2001’’.
(2) EFFECTIVE DATE.—The amendments made
by this subsection shall apply to discharges occur-
ring on or after October 1, 2000.
(b) SPECIAL RULE FOR DSH PAYMENT FOR FISCAL
YEAR 2001.—Notwithstanding the amendments made by
subsection (a)(1), for purposes of making disproportionate
share payments for subsection (d) hospitals (as defined
in section 1886(d)(1)(B) of the Social Security Act (42
U.S.C. 1395ww(d)(1)(B))) for fiscal year 2001, the addi-
tional payment amount otherwise determined under clause
(ii) of section 1886(d)(5)(F) of the Social Security Act
(42 U.S.C. 1395ww(d)(5)(F))—
(1) for discharges occurring on or after October
1, 2000, and before April 1, 2001, shall be adjusted
as provided by clause (ix)(III) of such section as in
effect on the day before the date of enactment of
this Act; and
(2) for discharges occurring on or after April 1,
2001, and before October 1, 2001, shall be increased
by 3 percent.
(c) CONFORMING AMENDMENTS RELATING TO DE-
TERMINATION
OF
STANDARDIZED
AMOUNT.—Section
1886(d)(2)(C)(iv) (42 U.S.C. 1395ww(d)(2)(C)(iv)), is
amended—
(1) by striking ‘‘Act of 1989 or’’ and inserting
‘‘Act of 1989,’’; and
(2) by inserting ‘‘, or the enactment of section
113(b) of the Medicare, Medicaid, and SCHIP Bal-
anced Budget Refinement Act of 2000’’ after ‘‘Om-
nibus Budget Reconciliation Act of 1990’’.
SEC. 114. EQUALIZING THE THRESHOLD AND UPDATING
PAYMENT 
FORMULAS 
FOR 
DISPROPOR-
TIONATE SHARE HOSPITALS.
(a) APPLICATION
OF
UNIFORM
15 PERCENT
THRESHOLD.—Section 
1886(d)(5)(F)(v) 
(42 
U.S.C.
1395ww(d)(5)(F)(v)) is amended by striking ‘‘exceeds—
’’ and all that follows and inserting ‘‘exceeds 15 percent.’’.
(b) CHANGE
IN
PAYMENT
PERCENTAGE
FOR-
MULAS.—Section 
1886(d)(5)(F)(viii) 
(42 
U.S.C.
1395ww(d)(5)(F)(viii)) is amended to read as follows:
‘‘(viii) The formula used to determine the dispropor-
tionate share adjustment percentage for a cost reporting
period for a hospital described in subclause (II), (III), or
(IV) of clause (iv) is—
‘‘(I) in the case of such a hospital with a dis-
proportionate patient percentage (as defined in
clause (vi)) that does not exceed 20.2, (P–15)(.65)
+ 2.5;
‘‘(II) in the case of such a hospital with a dis-
proportionate patient percentage (as so defined) that
exceeds 20.2 but does not exceed 25.2, (P–
20.2)(.825) + 5.88;
‘‘(III) except as provided in subclause (IV), in
the case of such a hospital with a disproportionate
patient percentage (as so defined) that exceeds 25.2,
the disproportionate share adjustment percentage =
10; and
‘‘(IV) in the case of such a hospital with a dis-
proportionate patient percentage (as so defined) that
exceeds 30.0 and that is described in clause (iv)(III),
(P–30)(.6) + 10;
where ‘P’ is the hospital’s disproportionate patient per-
centage (as so defined).’’.
(c) 
CONFORMING
AMENDMENTS.—Section
1886(d)(5)(F)(iv) (42 U.S.C. 1395ww(d)(5)(F)(iv)) is
amended—
(1) in subclause (I), by striking ‘‘is described in
the second sentence of clause (v)’’ and inserting ‘‘is
located in a rural area and has 500 or more beds’’;
(2) by amending subclause (II) to read as fol-
lows:
‘‘(II) is located in an urban area and has less
than 100 beds, or is located in a rural area and has
less than 500 beds and is not described in subclause
(III) or (IV), is equal to the percent determined in
accordance with the applicable formula described in
clause (viii);’’;
(3) by striking subclauses (III) and (IV);
(4) by redesignating subclauses (V) and (VI) as
subclauses (III) and (IV), respectively;
(5) in subclause (III) (as so redesignated), by
striking ‘‘and is not classified as a sole community
hospital under subparagraph (D),’’; and
(6) in subclause (IV) (as so redesignated), by
striking ‘‘10 percent’’ and inserting ‘‘equal to the
percent determined in accordance with the applicable
formula described in clause (viii)’’.
(d) EFFECTIVE DATE.—The amendments made by
this section shall apply to discharges occurring on or after
April 1, 2001.
SEC. 115. CARE FOR LOW-INCOME PATIENTS.
(a) FREEZE IN MEDICAID DSH ALLOTMENTS.—
(1) IN GENERAL.—Section 1923(f) (42 U.S.C.
1396r–4(f)) is amended—
(A) by redesignating paragraph (4) as
paragraph (5); and
(B) by inserting after paragraph (3), the
following new paragraph:
‘‘(4) SPECIAL RULE FOR FISCAL YEARS 2001
THROUGH 2008.—With respect to each of fiscal years
2001 through 2008—
‘‘(A) paragraph (2) shall be applied—
‘‘(i) by substituting—
‘‘(I) in the heading, ‘2001’ for
‘2002’;
‘‘(II) in the matter preceding the
table, ‘2001 (and the DSH allotment
for a State for fiscal year 2001 is the
same as the DSH allotment for the
State for fiscal year 2000, as deter-
mined under the following table)’ for
‘2002’; and
‘‘(ii) without regard to the columns in
the table relating to FY 01 and FY 02
(fiscal years 2001 and 2002); and
‘‘(B) paragraph (3) shall be applied by
substituting—
‘‘(i) in the heading, ‘2002’ for ‘2003’;
‘‘(ii) in subparagraph (A), ‘2002’ for
‘2003’.’’.
(2) REPEAL; APPLICABILITY.—Effective Octo-
ber 1, 2008, the amendments made by paragraph
(1) are repealed and section 1923(f) of the Social
Security Act (42 U.S.C. 1396r–4(f)) shall be applied
and administered as if such amendments had not
been enacted.
(b) INCREASE IN DSH ALLOTMENTS FOR THE DIS-
TRICT OF COLUMBIA.—
(1) IN GENERAL.—Each of the entries in the
table in section 1923(f)(2) (42 U.S.C. 1396r–
4(f)(2)) relating to the District of Columbia for FY
98 (fiscal year 1998), for FY 99 (fiscal year 1999),
for FY 00 (fiscal year 2000), for FY 01 (fiscal year
2001), and for FY 02 (fiscal year 2002) are amend-
ed by striking the amount otherwise specified and
inserting ‘‘43.4’’.
(2) EFFECTIVE DATE.—The amendments made
by paragraph (1) shall take effect as if included in
the enactment of section 4721(a) of BBA (111 Stat.
511).
(c) OPTIONAL
ELIGIBILITY
OF
CERTAIN
ALIEN
PREGNANT WOMEN AND CHILDREN FOR MEDICAID AND
SCHIP.—
(1) MEDICAID.—Section 1903(v) (42 U.S.C.
1396b(v)) is amended—
(A) in paragraph (1), by striking ‘‘para-
graph (2)’’ and inserting ‘‘paragraphs (2) and
(4)’’; and
(B) by adding at the end the following new
paragraph:
‘‘(4)(A) A State may elect (in a plan amendment
under this title) to provide medical assistance under this
title, notwithstanding sections 401(a), 402(b), 403, and
421 of the Personal Responsibility and Work Opportunity
Reconciliation Act of 1996, for aliens who are lawfully re-
siding in the United States (including battered aliens de-
scribed in section 431(c) of such Act) and who are other-
wise eligible for such assistance, within any of the fol-
lowing eligibility categories:
‘‘(i) PREGNANT WOMEN.—Women during preg-
nancy (and during the 60-day period beginning on
the last day of the pregnancy).
‘‘(ii) CHILDREN.—Children (as defined under
such plan), including optional targeted low-income
children described in section 1905(u)(2)(B).
‘‘(B) In the case of a State that has elected to provide
medical assistance to a category of aliens under subpara-
graph (A), no action may be brought under an affidavit
of support against any sponsor of such an alien on the
basis of provision of assistance to such category.’’.
(2) SCHIP.—Section 2107(e)(1) (42 U.S.C.
1397gg(e)(1)) is amended by adding at the end the
following new subparagraph:
‘‘(D) Section 1903(v)(4)(A)(ii) (relating to
optional coverage of permanent resident alien
children), but only if the State has in effect an
election under that same eligibility category for
purposes of title XIX.’’.
(3) EFFECTIVE DATE.—The amendments made
by this section take effect on October 1, 2000, and
apply to medical assistance and child health assist-
ance furnished on or after such date.
SEC. 116. MODIFICATION OF PAYMENT RATE FOR PUERTO
RICO HOSPITALS.
(a) MODIFICATION
OF PAYMENT RATE.—Section
1886(d)(9)(A) 
(42 
U.S.C. 
1395ww(d)(9)(A)) 
is
amended—
(1) in clause (i), by striking ‘‘October 1, 1997,
50 percent (’’ and inserting ‘‘October 1, 2000, 25
percent (for discharges between October 1, 1997,
and September 30, 2000, 50 percent,’’; and
(2) in clause (ii), in the matter preceding sub-
clause (I), by striking ‘‘after October 1, 1997, 50
percent (’’ and inserting ‘‘after October 1, 2000, 75
percent (for discharges between October 1, 1997,
and September 30, 2000, 50 percent,’’.
(b) SPECIAL RULE FOR PAYMENT FOR FISCAL YEAR
2001.—
(1) IN GENERAL.—Notwithstanding the amend-
ment made by subsection (a), for purposes of mak-
ing payments for the operating costs of inpatient
hospital services of a section 1886(d) Puerto Rico
hospital for fiscal year 2001, the amount referred to
in the matter preceding clause (i) of section
1886(d)(9)(A) of the Social Security Act (42 U.S.C.
1395ww(d)(9)(A))—
(A) for discharges occurring on or after
October 1, 2000, and before April 1, 2001,
shall be determined in accordance with such
section as in effect on the day before the date
of enactment of this Act; and
(B) for discharges occurring on or after
April 1, 2001, and before October 1, 2001,
shall be determined—
(i) using 0 percent of the Puerto Rico
adjusted DRG prospective payment rate
referred to in clause (i) of such section;
and
(ii) using 100 percent of the dis-
charge-weighted average referred to in
clause (ii) of such section.
(2) SECTION 1886(d) PUERTO RICO HOSPITAL.—
For purposes of this subsection, the term ‘‘section
1886(d) Puerto Rico hospital’’ has the meaning
given the term ‘‘subsection (d) Puerto Rico hospital’’
in the last sentence of section 1886(d)(9)(A) of the
Social Security Act (42 U.S.C. 1395ww(d)(9)(A)).
SEC. 117. MEDPAC STUDY ON HOSPITAL AREA WAGE IN-
DEXES.
(a) STUDY.—
(1) IN GENERAL.—The Medicare Payment Ad-
visory Commission established under section 1805 of
the Social Security Act (42 U.S.C. 1395b–6) (in this
section referred to as ‘‘MedPAC’’) shall conduct a
study on the hospital area wage indexes used in
making payments to hospitals under section 1886(d)
of the Social Security Act (42 U.S.C. 1395ww(d)),
including an assessment of the accuracy of those in-
dexes in reflecting geographic differences in wage
and wage-related costs of hospitals.
(2) CONSIDERATIONS.—In conducting the study
under paragraph (1), MedPAC shall consider—
(A) the appropriate method for deter-
mining hospital area wage indexes;
(B) the appropriate portion of hospital
payments that should be adjusted by the appli-
cable area wage index;
(C) the appropriate method for adjusting
the wage index by occupational mix; and
(D) the feasibility and impact of making
changes 
(as 
determined 
appropriate 
by
MedPAC) to the methods used to determine
such indexes, including the need for a data sys-
tem required to implement such changes.
(b) REPORT.—Not later than 18 months after the
date of enactment of this Act, MedPAC shall submit a
report to the Secretary of Health and Human Services and
Congress on the study conducted under subsection (a) to-
gether with such recommendations for legislation and ad-
ministrative action as MedPAC determines appropriate.
Subtitle C—PPS Exempt Hospitals
SEC. 121. TREATMENT OF CERTAIN CANCER HOSPITALS.
(a) IN GENERAL.—Section 1886(d)(1)(B)(v) of the
Social Security Act (42 U.S.C. 1395ww(d)(1)(B)(v)) is
amended—
(1) in subclause (I), by striking ‘‘or’’ at the
end;
(2) in subclause (II), by striking the semicolon
at the end and inserting ‘‘, or’’; and
(3) by adding at the end the following:
‘‘(III) a hospital that was recognized as a clin-
ical cancer research center by the National Cancer
Institute of the National Institutes of Health as of
February 18, 1998, that has never been reimbursed
for inpatient hospital services pursuant to a reim-
bursement system under a demonstration project
under section 1814(b), that is a freestanding facility
organized primarily for treatment of and research on
cancer and is not a unit of another hospital, that as
of the date of enactment of this subclause, is li-
censed for 162 acute care beds, and that dem-
onstrates for the 4-year period ending on June 30,
1999, that at least 50 percent of its total discharges
have a principal finding of neoplastic disease, as de-
fined in subparagraph (E);’’.
(b) 
CONFORMING
AMENDMENT.—Section
1886(d)(1)(E) of the Social Security Act (42 U.S.C.
1395ww(d)(1)(E)) is amended by striking ‘‘For purposes
of subparagraph (B)(v)(II)’’ and inserting ‘‘For purposes
of subclauses (II) and (III) of subparagraph (B)(v)’’.
(c) PAYMENT.—
(1) APPLICATION
TO
COST
REPORTING
PERI-
ODS.—Any classification by reason of section
1886(d)(1)(B)(v)(III) of the Social Security Act (as
added by subsection (a)) shall apply to 12-month
cost reporting periods beginning on or after July 1,
1999.
(2) BASE
YEAR.—Notwithstanding the provi-
sions of section 1886(b)(3)(E) of such Act (42
U.S.C. 1395ww(b)(3)(E)) or other provisions to the
contrary, the base cost reporting period for purposes
of determining the target amount for any hospital
classified by reason of section 1886(d)(1)(B)(v)(III)
of such Act (as added by subsection (a)) shall be the
12-month cost reporting period beginning on July 1,
1995.
(3) DEADLINE FOR PAYMENTS.—Any payments
owed to a hospital by reason of this subsection shall
be made expeditiously, but in no event later than 1
year after the date of enactment of this Act.
SEC. 122. PAYMENT ADJUSTMENT FOR INPATIENT SERV-
ICES IN REHABILITATION HOSPITALS.
(a) OPTION TO APPLY PROSPECTIVE PAYMENT SYS-
TEM
DURING
TRANSITION
PERIOD.—Section
1886(j)(1)(A) (42 U.S.C. 1395ww(j)(1)(A)) is amended in
the matter preceding subclause (i) by inserting ‘‘the great-
er of the prospective payment rate determined in para-
graph (3)(A) or’’ after ‘‘is equal to’’.
(b) INCREASE IN PROSPECTIVE PAYMENT PERCENT-
AGE
DURING
TRANSITION
PERIOD.—Section
1886(j)(1)(A)(ii)(I) (42 U.S.C. 1395ww(j)(1)(A)(ii)(I)) is
amended by inserting ‘‘102 percent of’’ before ‘‘the per
unit’’.
(c) EFFECTIVE DATE.—The amendments made by
this section shall take effect as if included in the enact-
ment of section 4421 of BBA (111 Stat. 410).
Subtitle D—Hospice Care
SEC. 131. REVISION IN PAYMENTS FOR HOSPICE CARE.
(a) INCREASE.—Section 1814(i)(1)(C) of the Social
Security Act (42 U.S.C. 1395f(i)(1)(C)) is amended—
(1) in clause (i), by adding at the end the fol-
lowing new sentence: ‘‘With respect to routine home
care and other services included in hospice care fur-
nished during fiscal year 2001, the payment rates
for such care and services for such fiscal year shall
be 110 percent of such rates as would otherwise be
in effect for such fiscal year (taking into account the
increase under clause (ii) but not taking into ac-
count the increase under section 131 of the Medi-
care, Medicaid, and SCHIP Balanced Budget Re-
finement Act of 1999), and such payment rates shall
be used in determining payments for such care and
services furnished in a subsequent fiscal year under
clause (ii).’’; and
(2) in clause (ii), by striking ‘‘during a subse-
quent fiscal year’’ and inserting ‘‘during a fiscal
year beginning after September 30, 1990’’.
(b) ELIMINATING REDUCTION IN UPDATE.—Section
1814(i)(1)(C)(ii) of the Social Security Act (42 U.S.C.
1395f(i)(1)(C)(ii)) is amended—
(1) in subclause (VI), by striking ‘‘through
2002’’ and inserting ‘‘through 2000’’; and
(2) in subclause (VII), by striking ‘‘for a subse-
quent fiscal year’’ and inserting ‘‘for fiscal year
2001 and each subsequent fiscal year’’.
(c) SPECIAL RULE
FOR PAYMENT
FOR HOSPICE
CARE
FOR FISCAL YEAR 2001.—Notwithstanding the
amendments made by subsections (a) and (b), for pur-
poses of making payments under section 1814(i)(1)(C) of
the Social Security Act (42 U.S.C. 1395f(i)(1)(C)) for
routine home care and other services included in hospice
care furnished during fiscal year 2001, such payment
rates shall be determined—
(1) for the period beginning on October 1,
2000, and ending on March 31, 2001, in accordance
with such section as in effect on the day before the
date of enactment of this Act; and
(2) for the period beginning on April 1, 2001,
and ending on September 30, 2001—
(A) by substituting ‘‘120 percent’’ for
‘‘110 percent’’ in the second sentence of clause
(i) of such section (as added by subsection
(a)(1)); and
(B) as if the increase under subclause
(ii)(VII) (as amended by subsection (b)) for fis-
cal year 2001 was equal to the market basket
increase for the fiscal year plus 1.0 percentage
point.
Subtitle E—Other Provisions
SEC. 
141. 
HOSPITALS 
REQUIRED 
TO 
COMPLY 
WITH
BLOODBORNE PATHOGENS STANDARD.
(a) 
AGREEMENTS
WITH
HOSPITALS.—Section
1866(a)(1) (42 U.S.C. 1395cc(a)(1)) is amended—
(1) in subparagraph (R), by striking ‘‘and’’ at
the end;
(2) in subparagraph (S), by striking the period
at the end and inserting ‘‘, and’’; and
(3) by inserting after subparagraph (S) the fol-
lowing new subparagraph:
‘‘(T) in the case of hospitals that are not other-
wise subject to regulation by the Occupational Safe-
ty and Health Administration, to comply with the
Bloodborne 
Pathogens 
standard 
under 
section
1910.1030 of title 29 of the Code of Federal Regula-
tions.’’.
(b) EFFECTIVE DATE.—The amendments made by
this section shall apply to agreements in effect on or after
the date that is 1 year after the date of enactment of this
Act.
SEC. 142. INFORMATICS AND DATA SYSTEMS GRANT PRO-
GRAM.
(a) GRANTS TO HOSPITALS.—
(1) IN GENERAL.—The Secretary of Health and
Human Services (in this section referred to as the
‘‘Secretary’’) shall establish a program to make
grants to hospitals that have submitted applications
in accordance with subsection (c) to assist such hos-
pitals in offsetting the costs related to—
(A) developing and implementing standard-
ized clinical health care informatics systems de-
signed to improve medical care and reduce ad-
verse events and health care complications re-
sulting from medication errors; and
(B) establishing data systems to comply
with the administrative simplification require-
ments under part C of title XI of the Social Se-
curity Act (42 U.S.C. 1320d et seq.).
(2) COSTS.—For purposes of paragraph (1),
the term ‘‘costs’’ shall include costs associated
with—
(A) purchasing computer software and
hardware; and
(B) providing education and training to
hospital staff on computer information systems.
(3) DURATION.—The authority of the Secretary
to make grants under this section shall terminate on
September 30, 2011.
(4) LIMITATION.—A hospital that has received
a grant under section 1611 of the Public Health
Service Act (as added by section 447 of this Act) is
not eligible to receive a grant under this section.
(b) SPECIAL CONSIDERATION FOR LARGE URBAN
HOSPITALS.—In awarding grants under this section, the
Secretary shall give special consideration to hospitals lo-
cated in large urban areas (as defined for purposes of sec-
tion 1886(d) of the Social Security Act (42 U.S.C.
1395ww(d)).
(c) APPLICATION.—A hospital seeking a grant under
this section shall submit an application to the Secretary
at such time and in such form and manner as the Sec-
retary specifies.
(d) REPORTS.—
(1) INFORMATION.—A hospital receiving a
grant under this section shall furnish the Secretary
with such information as the Secretary may require
to—
(A) evaluate the project for which the
grant is made; and
(B) ensure that the grant is expended for
the purposes for which it is made.
(2) TIMING OF SUBMISSION.—
(A) INTERIM
REPORTS.—The Secretary
shall report to the Committee on Ways and
Means of the House of Representatives and the
Committee on Finance of the Senate at least
annually on the grant program established
under this section, including in such report in-
formation on the number of grants made, the
nature of the projects involved, the geographic
distribution of grant recipients, and such other
matters as the Secretary deems appropriate.
(B) FINAL REPORT.—The Secretary shall
submit a final report to such committees not
later than 180 days after the completion of all
of the projects for which a grant is made under
this section.
(e) AUTHORIZATION
OF APPROPRIATIONS.—There
are authorized to be appropriated from the Federal Hos-
pital Insurance Trust Fund under section 1817 of the So-
cial Security Act (42 U.S.C. 1395i) $25,000,000 for each
of the fiscal years 2001 through 2011 for the purposes
of making grants under this section.
SEC. 143. RELIEF FROM MEDICARE PART A LATE ENROLL-
MENT PENALTY FOR GROUP BUY-IN FOR
STATE AND LOCAL RETIREES.
Section 1818(d) (42 U.S.C. 1395i–2(d)) is amended
by adding at the end the following new paragraph:
‘‘(6)(A) In the case where a State, a political
subdivision of a State, or an agency or instrumen-
tality of a State or political subdivision thereof de-
termines to pay, for the life of each individual, the
monthly premiums due under paragraph (1) on be-
half of each of the individuals in a qualified State
or local government retiree group who meets the
conditions of subsection (a), the amount of any in-
crease otherwise applicable under section 1839(b)
(as modified by subsection (c)(6) of this section)
with respect to the monthly premium for benefits
under this part for an individual who is a member
of such group shall be reduced by the total amount
of taxes paid under section 3101(b) of the Internal
Revenue Code of 1986 by such individual and under
section 3111(b) by the employers of such individual
on behalf of such individual with respect to employ-
ment (as defined in section 3121(b) of such Code).
‘‘(B) For purposes of this paragraph, the term
‘qualified State or local government retiree group’
means all of the individuals who retire prior to a
specified date that is before January 1, 2002, from
employment in 1 or more occupations or other broad
classes of employees of—
‘‘(i) the State;
‘‘(ii) a political subdivision of the State; or
‘‘(iii) an agency or instrumentality of the
State or political subdivision of the State.’’.
Subtitle F—Transitional Provisions
SEC. 151. RECLASSIFICATION OF CERTAIN COUNTIES AND
AREAS FOR PURPOSES OF REIMBURSEMENT
UNDER THE MEDICARE PROGRAM.
(a) FISCAL YEARS 2002 THROUGH 2004.—Notwith-
standing any other provision of law, effective for dis-
charges occurring during fiscal years 2002, 2003, and
2004, for purposes of making payments under section
1886(d) of the Social Security Act (42 U.S.C.
1395ww(d))—
(1) Iredell County, North Carolina is deemed to
be located in the Charlotte-Gastonia-Rock Hill,
North Carolina-South Carolina Metropolitan Statis-
tical Area; and
(2) the large urban area of New York, New
York is deemed to include Orange County, New
York (including hospitals that have been reclassified
into such county).
For purposes of that section, any reclassification under
this subsection shall be treated as a decision of the Medi-
care Geographic Classification Review Board under para-
graph (10) of that section.
(b) FISCAL YEARS 2001 THROUGH 2003.—Notwith-
standing any other provision of law, effective for dis-
charges occurring during fiscal years 2001, 2002, and
2003, for purposes of making payments under section
1886(d) of the Social Security Act (42 U.S.C.
1395ww(d))—
(1) the Jackson, Michigan Metropolitan Statis-
tical Area is deemed to be located in the Ann Arbor,
Michigan Metropolitan Statistical Area;
(2) Tangipahoa Parish, Louisiana is deemed to
be located in the New Orleans, Louisiana Metropoli-
tan Statistical Area; and
(3) the large urban area of New York, New
York is deemed to include Duchess County, New
York.
For purposes of that section, any reclassification under
this subsection shall be treated as a decision of the Medi-
care Geographic Classification Review Board under para-
graph (10) of that section.
(c) TECHNICAL CORRECTION TO BBRA.—
(1) IN GENERAL.—Section 152 of BBRA (113
Stat. 1501A–334) is amended—
(A) in subsection (a)(2), by inserting ‘‘(in-
cluding hospitals that have been reclassified
into such county)’’ after ‘‘such county’’; and
(B) in subsection (b)(2), by inserting ‘‘(in-
cluding hospitals that have been reclassified
into such county)’’ after ‘‘Orange County, New
York’’; and
(2) EFFECTIVE DATE.—The amendments made
by paragraph (1) shall take effect as if included in
the enactment of section 152 of BBRA (113 Stat.
1501A–334).
SEC. 152. CALCULATION AND APPLICATION OF WAGE
INDEX FLOOR FOR A CERTAIN AREA.
Notwithstanding any other provision of section
1886(d) of the Social Security Act (42 U.S.C.
1395ww(d)), for discharges occurring during fiscal year
2000, the Secretary of Health and Human Services shall
calculate and apply the wage index for the Barnstable-
Yarmouth Metropolitan Statistical Area under that sec-
tion as if the Jordan Hospital were classified in such area
for purposes of payment under that section for such fiscal
year. Such recalculation shall not affect the wage index
for any other area.
SEC. 153. RECLASSIFICATION OF A CERTAIN COUNTY FOR
PURPOSES OF REIMBURSEMENT UNDER THE
MEDICARE PROGRAM.
(a) IN GENERAL.—Notwithstanding any other provi-
sion of law, effective for discharges occurring on or after
October 1, 2000, for purposes of making payments under
section 1886(d) of the Social Security Act (42 U.S.C.
1395ww(d)) to a covered hospital in Boston, Metropolitan
Statistical Area, such covered hospital is deemed to be lo-
cated in the Barnstable-Yarmouth, Metropolitan Statis-
tical Area.
(b) COVERED HOSPITAL DEFINED.—In subsection
(a), the term ‘‘covered hospital’’ means a subsection (d)
hospital (as defined in paragraph (1)(B) of such section
1886(d)) that—
(1) for discharges occurring during fiscal year
1999—
(A) received additional payments under
paragraph (5)(F) of such section (relating to
serving a significantly disproportionate number
of low-income patients); and
(B) received no additional payments under
paragraph (5)(B) of such section (relating to
indirect costs of medical education); and
(2) is located in Fall River, Massachusetts, New
Bedford, Massachusetts, or Wareham, Massachu-
setts.
(c) CONSTRUCTION.—For purposes of such section
1886(d), the reclassification under subsection (a) shall be
treated as a decision of the Medicare Geographic Classi-
fication Review Board under paragraph (10) of that sec-
tion.
TITLE II—PROVISIONS
RELATING TO PART B
Subtitle A—Hospital Outpatient
Services
SEC. 201. REDUCTION OF EFFECTIVE HOPD COINSURANCE
RATE TO 20 PERCENT BY 2019.
Section 
1833(t)(3)(B)(ii) 
(42 
U.S.C.
1395l(t)(3)(B)(ii)) is amended—
(1) by striking ‘‘If the’’ and inserting:
‘‘(I) IN GENERAL.—If the’’; and
(2) by adding at the end the following new sub-
clause:
‘‘(II) ACCELERATED PHASE-IN.—
The Secretary shall estimate, prior to
January 1, 2002, the unadjusted co-
payment amount for each such service
(or groups of such services). If the
Secretary estimates such unadjusted
copayment amount to be greater than
20 percent for any such service (or
group of such services) on or after
January 1, 2019, the Secretary shall,
for services furnished beginning on or
after January 1, 2002, reduce the
unadjusted copayment amount for
such service (or group of such serv-
ices) in equal increments each year,
from the amount applicable in 2001,
by an amount estimated by the Sec-
retary such that the unadjusted co-
payment amount shall equal 20 per-
cent beginning on or after January 1,
2019.’’.
SEC. 202. APPLICATION OF TRANSITIONAL CORRIDOR TO
CERTAIN HOSPITALS THAT DID NOT SUBMIT
A 1996 COST REPORT.
(a) IN GENERAL.—Section 1833(t)(7)(F)(ii)(I) (42
U.S.C. 1395l(t)(7)(F)(ii)(I)) is amended by inserting ‘‘(or,
in the case of a hospital that did not submit a cost report
for such period, during the first cost reporting period end-
ing in a year after 1996 and before 2001 for which the
hospital submitted a cost report)’’ after ‘‘1996’’.
(b) EFFECTIVE DATE.—The amendment made by
subsection (a) shall take effect as if included in the enact-
ment of section 202 of BBRA.
SEC. 203. PERMANENT GUARANTEE OF PRE-BBA PAYMENT
LEVELS FOR OUTPATIENT SERVICES FUR-
NISHED BY CHILDREN’S HOSPITALS.
(a) IN GENERAL.—Section 1833(t)(7)(D) (42 U.S.C.
1395l(t)(7)(D)), 
as 
amended 
by 
section 
432, 
is
amended—
(1) in the heading, by inserting ‘‘, CHIL-
DREN’S,’’ after ‘‘SMALL RURAL’’; and
(2) by striking ‘‘section 1886(d)(1)(B)(v)’’ and
inserting 
‘‘clause 
(iii) 
or 
(v) 
of 
section
1886(d)(1)(B)’’.
(b) EFFECTIVE DATE.—The amendments made by
subsection (a) shall apply to services provided on or after
the date that is 1 year after the date of enactment of this
Act.
Subtitle B—Provisions Relating to
Physicians
SEC. 211. LOAN DEFERMENT FOR RESIDENTS.
(a) FAIRNESS IN MEDICAL STUDENT LOAN FINANC-
ING.—
(1) 
ELIGIBILITY
REQUIREMENTS.—Section
427(a)(2)(C)(iii) of the Higher Education Act of
1965 (20 U.S.C. 1077(a)(2)(C)(iii)) is amended by
inserting before the semicolon the following: ‘‘, ex-
cept that for a medical student such period shall not
exceed the full initial residency period’’.
(2) INSURANCE PROGRAM AGREEMENTS.—Sec-
tion 428(b)(1)(M)(iii) of the Higher Education Act
of 1965 (20 U.S.C. 1078(b)(1)(M)(iii)) is amended
by inserting before the semicolon the following: ‘‘,
except that for a medical student such period shall
not exceed the full initial residency period’’.
(3) 
DEFERMENT
ELIGIBILITY.—Section
455(f)(2)(C) of the Higher Education Act of 1965
(20 U.S.C. 1087e(f)(2)(C)) is amended by inserting
before the period the following: ‘‘, except that for a
medical student such period shall not exceed the full
initial residency period’’.
(4) CONTENTS OF LOAN AGREEMENT.—Section
464(c)(2)(A)(iii) of the Higher Education Act of
1965 (20 U.S.C. 1087dd(c)(2)(A)(iii)) is amended
by inserting before the semicolon the following: ‘‘,
except that for a medical student such period shall
not exceed the full initial residency period’’.
(b) FAIRNESS IN ECONOMIC HARDSHIP DETERMINA-
TION.—Section 435(o)(1)(B) of the Higher Education Act
of 1965 (20 U.S.C. 1085(o)(1)(B)) is amended to read
as follows:
‘‘(B) such borrower is working full time
and has a Federal educational debt burden that
equals or exceeds 20 percent of such borrower’s
adjusted gross income, and the difference be-
tween such borrower’s adjusted gross income
minus such burden is less than 250 percent of
the greater of—
‘‘(i) the annual earnings of an indi-
vidual earning the minimum wage under
section 6 of the Fair Labor Standards Act
of 1938; or
‘‘(ii) the income official poverty line
(as defined by the Office of Management
and Budget, and revised annually in ac-
cordance with section 673(2) of the Com-
munity Service Block Grant Act) applica-
ble to a family of 2; or’’.
SEC. 212. GAO STUDIES AND REPORTS ON MEDICARE PAY-
MENTS.
(a) GAO STUDY ON HCFA POST-PAYMENT AUDIT
PROCESS.—
(1) STUDY.—The Comptroller General of the
United States shall conduct a study of the post-pay-
ment audit process under the medicare program
under title XVIII of the Social Security Act (42
U.S.C. 1395 et seq.) (in this section referred to as
the ‘‘medicare program’’) as such process applies to
physicians, including the proper level of resources
that the Health Care Financing Administration
should devote to educating physicians regarding—
(A) coding and billing;
(B) documentation requirements; and
(C) the calculation of overpayments.
(2) REPORT.—Not later than 18 months after
the date of enactment of this Act, the Comptroller
General shall submit a report to the Secretary of
Health and Human Services and Congress on the
study conducted under paragraph (1) together with
specific recommendations for changes or improve-
ments in the post-payment audit process described
in such paragraph.
(b) GAO STUDY ON ADMINISTRATION AND OVER-
SIGHT.—
(1) STUDY.—The Comptroller General of the
United States shall conduct a study on the aggre-
gate effects of regulatory, audit, oversight, and pa-
perwork burdens on physicians and other health care
providers participating in the medicare program.
(2) REPORT.—Not later than 18 months after
the date of enactment of this Act, the Comptroller
General shall submit a report to the Secretary of
Health and Human Services and Congress on the
study conducted under paragraph (1) together with
recommendations regarding any area in which—
(A) a reduction in paperwork, an ease of
administration, or an appropriate change in
oversight and review may be accomplished; or
(B) additional payments or education are
needed to assist physicians and other health
care providers in understanding and complying
with any legal or regulatory requirements.
SEC. 213. MEDPAC STUDY ON THE RESOURCE-BASED PRAC-
TICE EXPENSE SYSTEM.
(a) STUDY.—The Medicare Payment Advisory Com-
mission established under section 1805 of the Social Secu-
rity Act (42 U.S.C. 1395b–6) (in this section referred to
as ‘‘MedPAC’’) shall conduct a study of the refinements
to the practice expense relative value units during the
transition to a resource-based practice expense system for
physician payments under the medicare program under
title XVIII of the Social Security Act (42 U.S.C. 1395
et seq.) (in this section referred to as the ‘‘medicare pro-
gram’’).
(b) REPORT.—Not later than July 1, 2001, MedPAC
shall submit a report to the Secretary of Health and
Human Services and Congress on the study conducted
under subsection (a) together with recommendations
regarding—
(1) any change or adjustment that is appro-
priate to ensure full access to a spectrum of care for
beneficiaries under the medicare program; and
(2) the appropriateness of payments to physi-
cians.
Subtitle C—Ambulance Services
SEC. 221. ELECTION TO FOREGO PHASE-IN OF FEE SCHED-
ULE FOR AMBULANCE SERVICES.
Section 1834(l) (42 U.S.C. 1395m(l)) is amended by
adding at the end the following new paragraph:
‘‘(8) ELECTION TO FOREGO PHASE-IN OF FEE
SCHEDULE.—
‘‘(A) IN GENERAL.—If the Secretary pro-
vides for a phase-in of the fee schedule estab-
lished under this subsection, a supplier of am-
bulance services may make an election to re-
ceive payments based only on such fee schedule
at any time during such phase-in, and the Sec-
retary shall begin to make payments to the sup-
plier based only on such fee schedule not later
than the date that is 60 days after the date on
which the supplier notifies the Secretary of such
election.
‘‘(B) WAIVER OF BUDGET NEUTRALITY.—
The Secretary shall apply paragraph (3)(A) as
if this paragraph had not been enacted.’’.
SEC. 222. PRUDENT LAYPERSON STANDARD FOR EMER-
GENCY AMBULANCE SERVICES.
(a) IN GENERAL.—Section 1861(s)(7) (42 U.S.C.
1395x(s)(7)) is amended by inserting before the semicolon
at the end the following: ‘‘, except that such regulations
shall not fail to treat ambulance services as medical and
other health services solely because the ultimate diagnosis
of the individual receiving the ambulance services results
in a conclusion that ambulance services were not nec-
essary, as long as the request for ambulance services is
made after the sudden onset of a medical condition that
would be classified as an emergency medical condition (as
defined in section 1852(d)(3)(B)).’’.
(b) EFFECTIVE DATE.—The amendment made by
this section shall apply with respect to ambulance services
provided on or after October 1, 2000.
SEC. 223. ELIMINATION OF REDUCTION IN INFLATION AD-
JUSTMENTS FOR AMBULANCE SERVICES.
Subparagraphs (A) and (B) of section 1834(l)(3) (42
U.S.C. 1395m(l)(3)(A)) are each amended by striking ‘‘re-
duced in the case of 2001 and 2002 by 1.0 percentage
points’’ and inserting ‘‘increased in the case of 2001 by
1.0 percentage point’’.
SEC. 224. STUDY AND REPORT ON THE COSTS OF RURAL
AMBULANCE SERVICES.
(a) STUDY.—The Secretary of Health and Human
Services (in this section referred to as the ‘‘Secretary’’),
in consultation with the Office of Rural Health Policy,
shall conduct a study of the means by which rural areas
with low population densities can be identified for the pur-
pose of designating areas in which the cost of providing
ambulance services would be expected to be higher than
similar services provided in more heavily populated areas
because of low usage. Such study shall also include an
analysis of the additional costs of providing ambulance
services in areas designated under the previous sentence.
(b) REPORT.—Not later than June 30, 2001, the
Secretary shall submit a report to Congress on the study
conducted under subsection (a), together with a regulation
based on that study which adjusts the fee schedule pay-
ment rates for ambulance services provided in low density
rural areas based on the increased cost of providing such
services in such areas.
SEC. 225. INTERIM PAYMENTS FOR RURAL GROUND AMBU-
LANCE SERVICES UNTIL REGULATION IMPLE-
MENTED.
(a) INTERIM
PAYMENTS.—Section 1834(l) (42
U.S.C. 1395m(l)), as amended by section 221, is amended
by adding at the end the following new paragraph:
‘‘(9) INTERIM PAYMENTS FOR RURAL GROUND
AMBULANCE SERVICES.—Until such time as the fee
schedule established under this subsection is modi-
fied by the regulation described in section 224(b) of
the Medicare, Medicaid, and SCHIP Balanced
Budget Refinement Act of 2000, the amount of pay-
ment under this subsection for ground ambulance
services provided in a rural area (as defined in sec-
tion 1886(d)(2)(D)) shall be the greater of—
‘‘(A) the amount determined under the fee
schedule established under this subsection
(without regard to any phase-in established pur-
suant to paragraph (2)(E)); or
‘‘(B) the amount that would have been
paid for such services if the amendments made
by section 4531(b) of the Balanced Budget Act
of 1997 had not been enacted;
as adjusted for inflation in the manner described in
paragraph (3)(B). For purposes of this paragraph,
an ambulance trip shall be considered to have been
provided in a rural area only if the transportation of
the patient originated in a rural area.’’.
(b) 
CONFORMING
AMENDMENTS.—Section
1833(a)(1) (42 U.S.C. 1395l(a)(1)) is amended—
(1) in subparagraph (R)—
(A) by inserting ‘‘except as provided in
subparagraph (T),’’ before ‘‘with respect’’; and
(B) by striking ‘‘and’’ at the end; and
(2) in subparagraph (S), by striking the semi-
colon at the end and inserting ‘‘, and (T) with re-
spect to ambulance services described in section
1834(l)(9), the amount paid shall be 80 percent of
the lesser of the actual charge for the services or the
amount determined under such section;’’.
(c) EFFECTIVE DATE.—The amendments made by
this section shall apply with respect to services provided
on and after January 1, 2001.
SEC. 226. GAO STUDY AND REPORT ON THE COSTS OF
EMERGENCY 
AND 
MEDICAL 
TRANSPOR-
TATION SERVICES.
(a) STUDY.—The Comptroller General of the United
States shall conduct a study of the costs of providing
emergency and medical transportation services across the
range of acuity levels of conditions for which such trans-
portation services are provided.
(b) REPORT.—Not later than 18 months after the
date of enactment of this Act, the Comptroller General
shall submit a report to the Secretary of Health and
Human Services and Congress on the study conducted
under subsection (a), together with recommendations for
any changes in methodology or payment level necessary
to fairly compensate suppliers of emergency and medical
transportation services and to ensure the access of bene-
ficiaries under the medicare program under title XVIII of
the Social Security Act (42 U.S.C. 1395 et seq.) to such
services.
Subtitle D—Preventive Services
SEC. 231. ELIMINATION OF DEDUCTIBLES AND COINSUR-
ANCE FOR PREVENTIVE BENEFITS.
(a) IN GENERAL.—Section 1833 (42 U.S.C. 1395l)
is amended by inserting after subsection (o) the following
new subsection:
‘‘(p) DEDUCTIBLES AND COINSURANCE WAIVED FOR
PREVENTIVE BENEFITS.—The Secretary may not require
the payment of any deductible or coinsurance under sub-
section (a) or (b) of any individual enrolled for coverage
under this part for any of the following preventive health
care items and services:
‘‘(1) Blood-testing strips, lancets, and blood
glucose monitors for individuals with diabetes de-
scribed in section 1861(n).
‘‘(2) 
Diabetes 
outpatient 
self-management
training services (as defined in section 1861(qq)(1)).
‘‘(3) Pneumococcal, influenza, and hepatitis B
vaccines and administration described in section
1861(s)(10).
‘‘(4) Screening mammography (as defined in
section 1861(jj)).
‘‘(5) Screening pap smear and screening pelvic
exam (as defined in paragraphs (1) and (2) of sec-
tion 1861(nn), respectively).
‘‘(6) Bone mass measurement (as defined in
section 1861(rr)(1)).
‘‘(7) Prostate cancer screening test (as defined
in section 1861(oo)(1)).
‘‘(8) Colorectal cancer screening test (as de-
fined in section 1861(pp)(1)).’’.
(b) 
WAIVER
OF
COINSURANCE.—Section
1833(a)(1)(B) (42 U.S.C. 1395l(a)(1)(B)) is amended to
read as follows: ‘‘(B) with respect to preventive health care
items and services described in subsection (p), the
amounts paid shall be 100 percent of the fee schedule or
other basis of payment under this title,’’.
(c) WAIVER OF DEDUCTIBLE.—Section 1833(b)(1)
(42 U.S.C. 1395l(b)(1)) is amended to read as follows:
‘‘(1) such deductible shall not apply with respect to pre-
ventive health care items and services described in sub-
section (p),’’.
(d) ADDING ‘‘LANCET’’ TO DEFINITION OF DME.—
Section 1861(n) (42 U.S.C. 1395x(n)) is amended by
striking ‘‘blood-testing strips and blood glucose monitors’’
and inserting ‘‘blood-testing strips, lancets, and blood glu-
cose monitors’’.
(e) CONFORMING AMENDMENTS.—
(1) ELIMINATION OF COINSURANCE FOR CLIN-
ICAL DIAGNOSTIC LABORATORY TESTS.—Paragraphs
(1)(D)(i) and (2)(D)(i) of section 1833(a) (42
U.S.C. 1395l(a)) are each amended—
(A) by striking ‘‘basis or which’’ and in-
serting ‘‘basis, which’’; and
(B) by inserting ‘‘, or which are described
in subsection (p)’’ after ‘‘critical access hos-
pital’’.
(2) ELIMINATION OF COINSURANCE FOR CER-
TAIN
DME.—Section 1834(a)(1)(A) (42 U.S.C.
1395m(a)(1)(A)) is amended by inserting ‘‘(or 100
percent, in the case of such an item described in sec-
tion 1833(p))’’ after ‘‘80 percent’’.
(3) 
ELIMINATION
OF
COINSURANCE
FOR
SCREENING MAMMOGRAPHY.—Section 1834(c)(1)(C)
(42 U.S.C. 1395m(c)(1)(C)) is amended by striking
‘‘80 percent’’ and inserting ‘‘100 percent’’.
(4) ELIMINATION OF DEDUCTIBLES AND COIN-
SURANCE
FOR
COLORECTAL
CANCER
SCREENING
TESTS.—Section 1834(d) (42 U.S.C. 1395m(d)) is
amended—
(A) in paragraph (2)(C)—
(i) by striking clause (ii);
(ii) by striking ‘‘FACILITY PAYMENT
LIMIT.—’’ and all that follows through
‘‘Notwithstanding’’ and inserting ‘‘FACIL-
ITY
PAYMENT
LIMIT.—Notwithstanding’’;
and
(iii) by redesignating subclauses (I)
and (II) as clauses (i) and (ii), respec-
tively; and
(B) in paragraph (3)(C)—
(i) by striking clause (ii); and
(ii) by striking ‘‘FACILITY PAYMENT
LIMIT.—’’ and all that follows through
‘‘Notwithstanding’’ and inserting ‘‘FACIL-
ITY PAYMENT LIMIT.—Notwithstanding’’.
(f) EFFECTIVE DATE.—The amendments made by
this section shall apply to items and services furnished on
or after July 1, 2001.
SEC. 232. COUNSELING FOR CESSATION OF TOBACCO USE.
(a) COVERAGE.—Section 1861(s)(2) (42 U.S.C.
1395x(s)(2)) is amended—
(1) in subparagraph (S), by striking ‘‘and’’ at
the end;
(2) in subparagraph (T), by inserting ‘‘and’’ at
the end; and
(3) by adding at the end the following new sub-
paragraph:
‘‘(U) counseling for cessation of tobacco use (as
defined in subsection (uu)) for individuals who have
a history of tobacco use;’’.
(b) SERVICES DESCRIBED.—Section 1861 (42 U.S.C.
1395x) is amended by adding at the end the following new
subsection:
‘‘Counseling for Cessation of Tobacco Use
‘‘(uu)(1) Except as provided in paragraph (2), the
term ‘counseling for cessation of tobacco use’ means diag-
nostic, therapy, and counseling services for cessation of
tobacco use which are furnished—
‘‘(A) by or under the supervision of a physician;
or
‘‘(B) by any other health care professional who
is legally authorized to furnish such services under
State law (or the State regulatory mechanism pro-
vided by State law) of the State in which the serv-
ices are furnished, as would otherwise be covered if
furnished by a physician or as an incident to a phy-
sician’s professional service.
‘‘(2) The term ‘counseling for cessation of tobacco
use’ does not include coverage for drugs or biologicals that
are not otherwise covered under this title.’’.
(c) ELIMINATION OF COST-SHARING.—
(1) ELIMINATION
OF
COINSURANCE.—Section
1833(a)(1) (42 U.S.C. 1395l(a)(1)), as amended by
section 225(b), is amended—
(A) by striking ‘‘and’’ before ‘‘(T)’’; and
(B) by inserting before the semicolon at
the end the following: ‘‘, and (U) with respect
to counseling for cessation of tobacco use (as
defined in section 1861(uu)), the amount paid
shall be 100 percent of the lesser of the actual
charge for the services or the amount deter-
mined by a fee schedule established by the Sec-
retary for the purposes of this subparagraph’’.
(2) ELIMINATION OF DEDUCTIBLE.—The first
sentence of section 1833(b) (42 U.S.C. 1395l(b)) is
amended—
(A) by striking ‘‘and’’ before ‘‘(6)’’; and
(B) by inserting before the period the fol-
lowing: ‘‘, and (7) such deductible shall not
apply with respect to counseling for cessation of
tobacco use (as defined in section 1861(uu))’’.
(d) EFFECTIVE DATE.—The amendments made by
this section shall apply to services furnished on or after
July 1, 2001.
SEC. 233. COVERAGE OF GLAUCOMA DETECTION TESTS.
(a) IN GENERAL.—Section 1861 (42 U.S.C. 1395x),
as amended by section 232, is amended—
(1) in subsection (s)(2)—
(A) in subparagraph (T), by striking
‘‘and’’ at the end;
(B) in subparagraph (U), by inserting
‘‘and’’ at the end; and
(C) by adding at the end the following new
subparagraph:
‘‘(V) glaucoma detection tests (as defined in
subsection (vv));’’; and
(2) by adding at the end the following new sub-
section:
‘‘Glaucoma Detection Tests
‘‘(vv) The term ‘glaucoma detection test’ means all
of the following conducted for the purpose of early detec-
tion of glaucoma:
‘‘(1) A dilated eye examination with an intra-
ocular pressure measurement.
‘‘(2) Direct ophthalmoscopy or slit-lamp bio-
microscopic examination.’’.
(b) LIMITATION ON ELIGIBILITY AND FREQUENCY.—
Section 1834 (42 U.S.C. 1395m) is amended by adding
at the end the following new subsection:
‘‘(m) LIMITATION ON COVERAGE OF GLAUCOMA DE-
TECTION TESTS.—
‘‘(1) IN GENERAL.—Notwithstanding any other
provision of this part, with respect to expenses in-
curred for glaucoma detection tests (as defined in
section 1861(vv)), payment may be made only for
glaucoma detection tests conducted—
‘‘(A) for individuals described in paragraph
(2); and
‘‘(B) consistent with the frequency per-
mitted under paragraph (3).
‘‘(2) INDIVIDUALS ELIGIBLE FOR BENEFIT.—
Individuals described in this paragraph are as fol-
lows:
‘‘(A) Individuals who are 60 years of age
or older and who have a family history of glau-
coma.
‘‘(B) Other individuals who are at high
risk (as determined by the Secretary) of devel-
oping glaucoma.
‘‘(3) FREQUENCY LIMIT.—
‘‘(A) IN
GENERAL.—Subject to subpara-
graph (B), payment may not be made under
this part for a glaucoma detection test per-
formed for an individual within 23 months fol-
lowing the month in which a glaucoma detection
test was performed under this part for the indi-
vidual.
‘‘(B) EXCEPTION.—The Secretary may
permit a glaucoma detection test to be covered
on a more frequent basis than that provided
under subparagraph (A) under such cir-
cumstances as the Secretary determines to be
appropriate.’’.
(c) NO APPLICATION
OF DEDUCTIBLE.—Section
1833(b)(5) (42 U.S.C. 1395l(b)(5)) is amended by insert-
ing ‘‘or with respect to glaucoma detection tests (as de-
fined in section 1861(vv))’’ after ‘‘1861(jj))’’.
(d) CONFORMING AMENDMENTS.—Section 1862(a)
(42 U.S.C. 1395y(a)) is amended—
(1) in paragraph (1)—
(A) in subparagraph (H), by striking
‘‘and’’ at the end;
(B) in subparagraph (I), by striking the
semicolon at the end and inserting ‘‘, and’’; and
(C) by adding at the end the following new
subparagraph:
‘‘(J) in the case of glaucoma detection tests (as
defined in section 1861(vv)), which are furnished to
an individual not described in paragraph (2) of sec-
tion 1834(m) or which are performed more fre-
quently than is covered under paragraph (3) of such
section;’’; and
(2) in paragraph (7), by striking ‘‘or (H)’’ and
inserting ‘‘(H), or (I)’’.
(e) EFFECTIVE DATE.—The amendments made by
this section apply to tests provided on or after July 1,
2001.
SEC. 234. MEDICAL NUTRITION THERAPY SERVICES FOR
BENEFICIARIES WITH DIABETES, A CARDIO-
VASCULAR DISEASE, OR A RENAL DISEASE.
(a) COVERAGE.—Section 1861(s)(2) (42 U.S.C.
1395x(s)(2)), as amended by section 233(a), is amended—
(1) in subparagraph (U) by striking ‘‘and’’ at
the end;
(2) in subparagraph (V) by inserting ‘‘and’’ at
the end; and
(3) by adding at the end the following new sub-
paragraph:
‘‘(W) medical nutrition therapy services (as de-
fined in subsection (ww)(1)) in the case of a bene-
ficiary with diabetes, a cardiovascular disease (in-
cluding congestive heart failure, arteriosclerosis,
hyperlipidemia, 
hypertension, 
and
hypercholesterolemia), or a renal disease;’’.
(b) SERVICES DESCRIBED.—Section 1861 (42 U.S.C.
1395x), as amended by section 233(a), is amended by add-
ing at the end the following new subsection:
‘‘Medical Nutrition Therapy Services; Registered
Dietitian or Nutrition Professional
‘‘(ww)(1) The term ‘medical nutrition therapy serv-
ices’ means nutritional diagnostic, therapy, and counseling
services for the purpose of disease management which are
furnished by a registered dietitian or nutrition profes-
sional (as defined in paragraph (2)) pursuant to a referral
by a physician (as defined in subsection (r)(1)).
‘‘(2) Subject to paragraph (3), the term ‘registered
dietitian or nutrition professional’ means an individual
who—
‘‘(A) holds a baccalaureate or higher degree
granted by a regionally accredited college or univer-
sity in the United States (or an equivalent foreign
degree) with completion of the academic require-
ments of a program in nutrition or dietetics, as ac-
credited by an appropriate national accreditation or-
ganization recognized by the Secretary for this pur-
pose;
‘‘(B) has completed at least 900 hours of super-
vised dietetics practice under the supervision of a
registered dietitian or nutrition professional; and
‘‘(C)(i) is licensed or certified as a dietitian or
nutrition professional by the State in which the serv-
ices are performed; or
‘‘(ii) in the case of an individual in a State that
does not provide for such licensure or certification,
meets such other criteria as the Secretary estab-
lishes.
‘‘(3) Subparagraphs (A) and (B) of paragraph (2)
shall not apply in the case of an individual who, as of the
date of enactment of this subsection, is licensed or cer-
tified as a dietitian or nutrition professional by the State
in which medical nutrition therapy services are per-
formed.’’.
(c) PAYMENT.—Section 1833(a)(1) (42 U.S.C.
1395l(a)(1)), as amended by section 232(c)(1), is
amended—
(1) by striking ‘‘and’’ before ‘‘(U)’’; and
(2) by inserting before the semicolon at the end
the following: ‘‘, and (V) with respect to medical nu-
trition therapy services (as defined in section
1861(ww)), the amount paid shall be 85 percent of
the lesser of the actual charge for the services or the
amount determined under the fee schedule estab-
lished under section 1848(b) for the same services if
furnished by a physician’’.
(d) EFFECTIVE DATE.—The amendments made by
this section apply to services furnished on or after July
1, 2001.
SEC. 235. STUDIES ON PREVENTIVE INTERVENTIONS IN
PRIMARY CARE FOR OLDER AMERICANS.
(a) STUDIES.—The Secretary of Health and Human
Services, acting through the United States Preventive
Services Task Force, shall conduct a series of studies de-
signed to identify preventive interventions that can be de-
livered in the primary care setting that are most valuable
to older Americans.
(b) MISSION STATEMENT.—The mission statement of
the United States Preventive Services Task Force is
amended to include the evaluation of services that are of
particular relevance to older Americans.
(c) REPORT.—Not later than 1 year after the date
of enactment of this Act, and annually thereafter, the Sec-
retary of Health and Human Services shall submit a re-
port to Congress on the conclusions of the studies con-
ducted under subsection (a), together with recommenda-
tions for such legislation and administrative actions as the
Secretary considers appropriate.
SEC. 236. INSTITUTE OF MEDICINE 5-YEAR MEDICARE PRE-
VENTION BENEFIT STUDY AND REPORT.
(a) STUDY.—
(1) IN GENERAL.—The Secretary of Health and
Human Services shall contract with the Institute of
Medicine of the National Academy of Sciences to
conduct a comprehensive study of current literature
and best practices in the field of health promotion
and disease prevention among medicare beneficiaries
including the issues described in paragraph (2) and
to submit the report described in subsection (b).
(2) ISSUES
STUDIED.—The study required
under paragraph (1) shall include an assessment
of—
(A) whether each covered benefit is—
(i) medically effective; and
(ii) a cost-effective benefit or a cost-
saving benefit;
(B) utilization of covered benefits (includ-
ing any barriers to or incentives to increase uti-
lization); and
(C) quality of life issues associated with
both health promotion and disease prevention
benefits covered under the medicare program
and those that are not covered under such pro-
gram that would affect all medicare bene-
ficiaries.
(b) REPORT.—
(1) IN GENERAL.—Not later than 5 years after
the date of enactment of this section, and every fifth
year thereafter, the Institute of Medicine of the Na-
tional Academy of Sciences shall submit to the
President a report that contains a detailed state-
ment of the findings and conclusions of the study
conducted under subsection (a) and the rec-
ommendations for legislation described in paragraph
(2).
(2) RECOMMENDATIONS
FOR
LEGISLATION.—
The Institute of Medicine of the National Academy
of Sciences, in consultation with the Partnership for
Prevention, shall develop recommendations in legis-
lative form that—
(A) prioritize the preventive benefits under
the medicare program; and
(B) modify preventive benefits offered
under the medicare program based on the study
conducted under subsection (a).
(c) TRANSMISSION TO CONGRESS.—
(1) IN GENERAL.—On the day on which the re-
port described in subsection (b) is submitted to the
President, the President shall transmit the report
and recommendations in legislative form described in
subsection (b)(2) to Congress.
(2) DELIVERY.—Copies of the report and rec-
ommendations in legislative form required to be
transmitted to Congress under paragraph (1) shall
be delivered—
(A) to both Houses of Congress on the
same day;
(B) to the Clerk of the House of Rep-
resentatives if the House is not in session; and
(C) to the Secretary of the Senate if the
Senate is not in session.
(d) DEFINITIONS.—In this section:
(1) 
COST-EFFECTIVE
BENEFIT.—The 
term
‘‘cost-effective benefit’’ means a benefit or technique
that has—
(A) been subject to peer review;
(B) been described in scientific journals;
and
(C) demonstrated value as measured by
unit costs relative to health outcomes achieved.
(2) COST-SAVING BENEFIT.—The term ‘‘cost-
saving benefit’’ means a benefit or technique that
has—
(A) been subject to peer review;
(B) been described in scientific journals;
and
(C) caused a net reduction in health care
costs for medicare beneficiaries.
(3) MEDICALLY EFFECTIVE.—The term ‘‘medi-
cally effective’’ means, with respect to a benefit or
technique, that the benefit or technique has been—
(A) subject to peer review;
(B) described in scientific journals; and
(C) determined to achieve an intended goal
under normal programmatic conditions.
(4) 
MEDICARE
BENEFICIARY.—The 
term
‘‘medicare beneficiary’’ means any individual who is
entitled to benefits under part A or enrolled under
part B of the medicare program, including any indi-
vidual enrolled in a Medicare+Choice plan offered
by a Medicare+Choice organization under part C of
such program.
(5) MEDICARE PROGRAM.—The term ‘‘medicare
program’’ means the health benefits program under
title XVIII of the Social Security Act (42 U.S.C.
1395 et seq.).
SEC. 237. FAST-TRACK CONSIDERATION OF PREVENTION
BENEFIT LEGISLATION.
(a) RULES OF HOUSE OF REPRESENTATIVES AND
SENATE.—This section is enacted by Congress—
port shall be introduced as a bill (by request)
in the following manner:
(i) HOUSE OF REPRESENTATIVES.—In
the House of Representatives, by the Ma-
jority Leader, for himself and the Minority
Leader, or by Members of the House of
Representatives designated by the Majority
Leader and Minority Leader.
(ii) SENATE.—In the Senate, by the
Majority Leader, for himself and the Mi-
nority Leader, or by Members of the Sen-
ate designated by the Majority Leader and
Minority Leader.
(B) SPECIAL
RULE.—If either House of
Congress is not in session on the day on which
such recommendations in legislative form are
transmitted, the recommendations in legislative
form shall be introduced as a bill in that House
of Congress, as provided in subparagraph (A),
on the first day thereafter on which that House
of Congress is in session.
(2) REFERRAL.—Such bills shall be referred by
the presiding officers of the respective Houses to the
appropriate committee, or, in the case of a bill con-
taining provisions within the jurisdiction of 2 or
more committees, jointly to such committees for con-
sideration of those provisions within their respective
jurisdictions.
(c) CONSIDERATION.—After the recommendations in
legislative form have been introduced as a bill and referred
under subsection (b), such implementing bill shall be con-
sidered in the same manner as an implementing bill is con-
sidered under subsections (d), (e), (f), and (g) of section
151 of the Trade Act of 1974 (19 U.S.C. 2191).
(d) IMPLEMENTING BILL DEFINED.—In this section,
the term ‘‘implementing bill’’ means only the recommenda-
tions in legislative form of the Institute of Medicine of the
National Academy of Sciences described in section
236(b)(2), transmitted by the President to the House of
Representatives and the Senate under section 236(c), and
introduced and referred as provided in subsection (b) as
a bill of either House of Congress.
(e) COUNTING OF DAYS.—For purposes of this sec-
tion, any period of days referred to in section 151 of the
Trade Act of 1974 shall be computed by excluding—
(1) the days on which either House of Congress
is not in session because of an adjournment of more
than 3 days to a day certain or an adjournment of
Congress sine die; and
(2) any Saturday and Sunday, not excluded
under paragraph (1), when either House is not in
session.
Subtitle E—Other Services
SEC. 241. REVISION OF MORATORIUM IN CAPS FOR THER-
APY SERVICES.
(a) 
EXTENSION
OF
MORATORIUM.—Section
1833(g)(4) (42 U.S.C. 1395l(g)(4)) is amended by strik-
ing ‘‘during 2000 and 2001’’ and inserting ‘‘during the
period beginning on January 1, 2000, and ending on the
date that is 18 months after the date the Secretary sub-
mits the report required under section 4541(d)(2) of the
Balanced Budget Act of 1997 to Congress’’.
(b) EXTENSION
OF
REPORTING
DATE.—Section
4541(d)(2) of BBA (42 U.S.C. 1395l note), as amended
by section 221(c) of BBRA (113 Stat. 1501A–351), is
amended by striking ‘‘January 1, 2001’’ and inserting
‘‘January 1, 2002’’.
SEC. 
242. 
REVISION 
OF 
COVERAGE 
OF 
IMMUNO-
SUPPRESSIVE DRUGS.
(a) REVISION.—
(1) IN
GENERAL.—Section 1861(s)(2)(J) (42
U.S.C. 1395x(s)(2)(J)) is amended to read as fol-
lows:
‘‘(J) prescription drugs used in immuno-
suppressive therapy furnished—
‘‘(i) on or after the date of enactment of
the Medicare, Medicaid, and SCHIP Balanced
Budget Refinement Act of 2000 and before
January 1, 2004, to an individual who has re-
ceived an organ transplant; and
‘‘(ii) on or after January 1, 2004, to an in-
dividual who receives an organ transplant for
which payment is made under this title, but
only in the case of drugs furnished within 36
months after the date of the transplant proce-
dure.’’.
(2) CONFORMING AMENDMENTS.—
(A) EXTENDED COVERAGE.—Section 1832
(42 U.S.C. 1395k) is amended—
(i) by striking subsection (b); and
(ii) by redesignating subsection (c) as
subsection (b).
(B) 
PASS-THROUGH; 
REPORT.—Sub-
sections (c) and (d) of section 227 of BBRA
(113 Stat. 1501A–355) are repealed.
(3) EFFECTIVE DATE.—The amendments made
by this subsection shall apply to drugs furnished on
or after the date of enactment of this Act.
(b) EXTENSION OF CERTAIN SECONDARY PAYER RE-
QUIREMENTS.—Section 
1862(b)(1)(C) 
(42 
U.S.C.
1395y(b)(1)(C)) is amended by adding at the end the fol-
lowing: ‘‘With regard to immunosuppressive drugs fur-
nished on or after the date of enactment of the Medicare,
Medicaid, and SCHIP Balanced Budget Refinement Act
of 2000 and before January 1, 2004, this subparagraph
shall be applied without regard to any time limitation.’’.
SEC. 243. STATE ACCREDITATION OF DIABETES SELF-MAN-
AGEMENT TRAINING PROGRAMS.
Section 1861(qq)(2) of the Social Security Act (42
U.S.C. 1395xx(qq)(2)) is amended—
(1) in the matter preceding subparagraph (A),
by striking ‘‘paragraph (1)—’’ and inserting ‘‘para-
graph (1):’’;
(2) in subparagraph (A)—
(A) by striking ‘‘a ‘certified provider’ ’’ and
inserting ‘‘A ‘certified provider’ ’’; and
(B) by striking ‘‘; and’’ and inserting a pe-
riod; and
(3) in subparagraph (B)—
(A) by striking ‘‘a physician, or such other
individual’’ and inserting ‘‘(i) A physician, or
such other individual’’;
(B) by inserting ‘‘(I)’’ before ‘‘meets appli-
cable standards’’;
(C) by inserting ‘‘(II)’’ before ‘‘is recog-
nized’’;
(D) by inserting ‘‘, or by a program de-
scribed in clause (ii),’’ after ‘‘recognized by an
organization that represents individuals (includ-
ing individuals under this title) with diabetes’’;
and
(E) by adding at the end the following new
clause:
‘‘(ii) Notwithstanding any reference to ‘a na-
tional accreditation body’ in section 1865(b), for
purposes of clause (i), a program described in this
clause is a program operated by a State for the pur-
poses of accrediting diabetes self-management train-
ing programs, if the Secretary determines that such
State program has established quality standards
that meet or exceed the standards established by the
Secretary under clause (i) or the standards origi-
nally established by the National Diabetes Advisory
Board and subsequently revised as described in
clause (i).’’.
SEC. 244. ELIMINATION OF REDUCTION IN PAYMENT
AMOUNTS FOR DURABLE MEDICAL EQUIP-
MENT AND OXYGEN AND OXYGEN EQUIP-
MENT.
(a) 
UPDATE
FOR
COVERED
ITEMS.—Section
1834(a)(14)(C) (42 U.S.C. 1395m(a)(14)(C)) is amended
by striking ‘‘through 2002’’ and inserting ‘‘through
2000’’.
(b) 
ORTHOTICS
AND
PROSTHETICS.—Section
1834(h)(4)(A)(v) (42 U.S.C. 1395m(h)(4)(A)(v)) is
amended by striking ‘‘through 2002’’ and inserting
‘‘through 2000’’.
(c) PARENTERAL AND ENTERAL NUTRIENTS, SUP-
PLIES, AND EQUIPMENT.—Section 4551(b) of BBA (42
U.S.C. 1395m note) is amended by striking ‘‘through
2002’’ and inserting ‘‘through 2000’’.
(d) OXYGEN
AND OXYGEN EQUIPMENT.—Section
1834(a)(9)(B) (42 U.S.C. 1395m(a)(9)(B)) is amended—
(1) in clause (v), by striking ‘‘and’’ at the end;
(2) in clause (vi)—
(A) by striking ‘‘each subsequent year’’
and inserting ‘‘2000’’; and
(B) by striking the period at the end and
inserting ‘‘; and’’; and
(3) by adding at the end the following new
clause:
‘‘(vii) for 2001 and each subsequent
year, the amount determined under this
subparagraph for the preceding year in-
creased by the covered item update for
such subsequent year.’’.
(e) CONFORMING
AMENDMENT.—Section 228 of
BBRA (113 Stat. 1501A–356) is repealed.
SEC. 245. STANDARDS REGARDING PAYMENT FOR CERTAIN
ORTHOTICS AND PROSTHETICS.
(a) STANDARDS.—
(1) IN
GENERAL.—Section 1834(h)(1) (42
U.S.C. 1395m(h)(1)) is amended by adding at the
end the following:
‘‘(F) ESTABLISHMENT OF STANDARDS FOR
CERTAIN ITEMS.—
‘‘(i) IN GENERAL.—No payment shall
be made for an applicable item unless such
item is provided by a qualified practitioner
or a qualified supplier under the system es-
tablished by the Secretary under clause
(iii). For purposes of the preceding sen-
tence, if a qualified practitioner or a quali-
fied supplier contracts with an entity to
provide an applicable item, then no pay-
ment shall be made for such item unless
the entity is also a qualified supplier.
‘‘(ii) 
DEFINITIONS.—In 
this
subparagraph—
‘‘(I) 
APPLICABLE
ITEM.—The
term ‘applicable item’ means orthotics
and prosthetics that require edu-
cation, training, and experience to
custom fabricate such item. Such
term does not include shoes and shoe
inserts.
‘‘(II) 
QUALIFIED
PRACTI-
TIONER.—The term ‘qualified practi-
tioner’ means a physician or health
professional who meets any of the fol-
lowing requirements:
‘‘(aa) 
The 
physician 
or
health professional is specifically
trained and educated to provide
or manage the provision of cus-
tom-designed, fabricated, modi-
fied, and fitted orthotics and
prosthetics, and is either certified
by the American Board for Cer-
tification in Orthotics and Pros-
thetics, Inc., certified by the
Board for Orthotist/Prosthetist
Certification, or credentialed and
approved by a program that the
Secretary determines, in con-
sultation with appropriate ex-
perts in orthotics and prosthetics,
has training and education stand-
ards that are necessary to pro-
vide applicable items.
‘‘(bb) 
The 
physician 
or
health professional is licensed in
orthotics or prosthetics by the
State in which the applicable
item is supplied, but only if the
Secretary determines that the
mechanisms used by the State to
provide 
such 
licensure 
meet
standards determined appropriate
by the Secretary.
‘‘(cc) 
The 
physician 
or
health professional has completed
at least 10 years practice in the
provision of applicable items. A
physician or health professional
may not qualify as a qualified
practitioner under the preceding
sentence with respect to an appli-
cable item if the item was pro-
vided on or after January 1,
2005.
‘‘(III) QUALIFIED
SUPPLIER.—
The term ‘qualified supplier’ means
any entity that is—
‘‘(aa) 
accredited 
by 
the
American Board for Certification
in Orthotics and Prosthetics, Inc.
or the Board for Orthotist/Pros-
thetist Certification; or
‘‘(bb) accredited and ap-
proved by a program that the
Secretary determines has accredi-
tation and approval standards
that are essentially equivalent to
those of such Board.
‘‘(iii) SYSTEM.—The Secretary, in
consultation with appropriate experts in
orthotics and prosthetics, shall establish a
system under which the Secretary shall—
‘‘(I) determine which items are
applicable items and formulate a list
of such items;
‘‘(II) review the applicable items
billed under the coding system estab-
lished under this title; and
‘‘(III) limit payment for applica-
ble items pursuant to clause (i).’’.
(2) EFFECTIVE DATE.—The amendment made
by paragraph (1) shall apply to items provided on or
after January 1, 2003.
(b) REVISION OF DEFINITION OF ORTHOTICS.—
(1) IN
GENERAL.—Section 1861(s)(9) (42
U.S.C. 1395x(s)(9)) is amended by inserting ‘‘(in-
cluding such braces that are used in conjunction
with, or as components of, other medical or non-
medical equipment when provided by a qualified
practitioner (as defined in subclause (II) of section
1834(h)(1)(F))) or a qualified supplier (as defined
in subclause (III) of such section)’’ after ‘‘braces’’.
(2) EFFECTIVE DATE.—The amendment made
by paragraph (1) shall apply to items provided on or
after January 1, 2003.
SEC. 246. NATIONAL LIMITATION AMOUNT EQUAL TO 100
PERCENT OF NATIONAL MEDIAN FOR NEW
PAP SMEAR TECHNOLOGIES AND OTHER NEW
CLINICAL 
LABORATORY 
TEST 
TECH-
NOLOGIES.
Section 
1833(h)(4)(B)(viii) 
(42 
U.S.C.
1395l(h)(4)(B)(viii)) is amended by inserting before the
period at the end the following: ‘‘(or 100 percent of such
median in the case of a clinical diagnostic laboratory test
performed on or after January 1, 2001, that the Secretary
determines is a new test for which no limitation amount
has previously been established under this subpara-
graph)’’.
SEC. 247. INCREASED MEDICARE PAYMENTS FOR CER-
TIFIED NURSE-MIDWIFE SERVICES.
(a) AMOUNT OF PAYMENT.—Section 1833(a)(1)(K)
(42 U.S.C. 1395l(a)(1)(K)) is amended by striking ‘‘65
percent of the prevailing charge that would be allowed for
the same service performed by a physician, or, for services
furnished on or after January 1, 1992, 65 percent’’ and
inserting ‘‘85 percent’’.
(b) EFFECTIVE DATE.—The amendment made by
subsection (a) shall apply to services furnished on or after
January 1, 2001.
SEC. 248. PAYMENT FOR ADMINISTRATION OF DRUGS.
(a) REVIEW OF CHEMOTHERAPY ADMINISTRATION
PRACTICE EXPENSES RVUS.—The Secretary of Health
and Human Services shall review the resource-based prac-
tice expense component of relative value units under the
physician fee schedule under section 1848 of the Social
Security Act (42 U.S.C. 1395w–4) for chemotherapy ad-
ministration services to determine if such units should be
increased.
(b) MORE ACCURATE CHEMOTHERAPY DRUG PAY-
MENTS TIED TO INCREASES IN CHEMOTHERAPY ADMINIS-
TRATION PAYMENTS.—If the Secretary of Health and
Human Services determines, as a result of the review
under subsection (a), that the resource-based practice ex-
pense relative value units for chemotherapy administration
services should be increased, the Secretary—
(1) may implement such increases for such
services, but only if the Secretary simultaneously im-
plements more accurate average wholesale prices for
chemotherapy drugs (but in no case shall such si-
multaneous implementation occur prior to January
1, 2002); and
(2) if the Secretary implements such increases
for such services, shall do so without taking into ac-
count the requirement under the physician fee
schedule under section 1848(c)(2)(B)(ii)(II) of the
Social 
Security 
Act 
(42 
U.S.C. 
1395w–
4(c)(2)(B)(ii)(II)).
(c) BLOOD
CLOTTING
DRUG-RELATED
ACTIVI-
TIES.—
(1) COVERAGE.—Section 1861(s)(2)(I) (42
U.S.C. 1395x(s)(2)(I)) is amended—
(A) by striking ‘‘and’’ after ‘‘supervision,’’;
and
(B) by inserting the following before the
semicolon: ‘‘, and the costs (pursuant to section
1834(n)) incurred by suppliers of such factors’’.
(2) PAYMENTS.—Section 1834 (42 U.S.C.
1395m), as amended by section 233(b), is amended
by adding at the end the following new subsection:
‘‘(n) PAYMENT FOR BLOOD CLOTTING DRUG-RE-
LATED ACTIVITIES.—
‘‘(1) IN GENERAL.—The Secretary shall make
payments in accordance with paragraph (2) to sup-
pliers of blood clotting factors (as described in sec-
tion 1861(s)(2)(I)) to cover the costs (such as ship-
ping, storage, inventory control, or other costs speci-
fied by the Secretary) incurred by such suppliers in
furnishing such factors to individuals enrolled under
this part.
‘‘(2) PAYMENT AMOUNT.—The amount of pay-
ment for furnishing such blood clotting factors (as
so described) shall be an amount equal to 80 percent
of the lesser of—
‘‘(A) the actual charge for the furnishing
of such factors; or
‘‘(B) an amount equal to 10 cents (or such
other amount determined appropriate by the
Secretary) per unit of such factor furnished.’’.
(3) EFFECTIVE DATE.—The amendments made
by this subsection shall apply to blood clotting fac-
tors (as described in section 1861(s)(2)(I) of the So-
cial Security Act (42 U.S.C. 1395x(s)(2)(I))) fur-
nished on or after the date that the Secretary of
Health and Human Services implements more accu-
rate average wholesale prices for such factors.
SEC. 249. MEDPAC STUDY ON IN-HOME INFUSION THERAPY
NURSING SERVICES.
(a) STUDY.—The Medicare Payment Advisory Com-
mission established under section 1805 of the Social Secu-
rity Act (42 U.S.C. 1395b–6) (in this section referred to
as ‘‘MedPAC’’) shall conduct a study on the provision of
in-home infusion therapy nursing services, including a re-
view of any documentation of clinical efficacy for those
services and any costs associated with providing those
services.
(b) REPORT.—Not later than 18 months after the
date of enactment of this Act, MedPAC shall submit a
report to the Secretary of Health and Human Services and
Congress on the study and review conducted under sub-
section (a) together with recommendations regarding the
establishment of a payment methodology for in-home infu-
sion therapy nursing services that ensures the continuing
access of beneficiaries under the medicare program under
title XVIII of the Social Security Act (42 U.S.C. 1395
et seq.) to those services.
SEC. 250. COVERAGE OF VISION REHABILITATION SERV-
ICES.
(a) COVERAGE.—Section 1861(s)(2) (42 U.S.C.
1395x(s)(2)) is amended—
(1) by striking ‘‘and’’ at the end of subpara-
graph (S);
(2) by striking the period at the end of (T) and
inserting ‘‘; and’’; and
(3) by adding at the end the following new sub-
paragraph:
‘‘(U) vision rehabilitation services (as defined in
subsection (uu)(1)).’’.
(b) SERVICES DESCRIBED.—Section 1861 (42 U.S.C.
1395x), as amended by sections 232, 233(a), and 234(b),
is further amended by adding at the end the following new
subsection:
‘‘Vision Rehabilitation Services; Vision Rehabilitation
Professional
‘‘(xx)(1) The term ‘vision rehabilitation services’
means a program of restorative services (as determined
by the Secretary in regulations) furnished by a vision re-
habilitation professional (as defined in paragraph (2)) to
an individual diagnosed with a vision impairment (as de-
fined in paragraph (6)) to promote the independence and
safety of the individual notwithstanding such impairment,
such services furnished pursuant to a plan of care estab-
lished by a physician (as defined in paragraph (1) or (4)
of subsection (r)).
‘‘(2) The term ‘vision rehabilitation professional’
means any of the following individuals:
‘‘(A) An orientation and mobility specialist (as
defined in paragraph (3)).
‘‘(B) A rehabilitation teacher (as defined in
paragraph (4)).
‘‘(C) A low vision therapist (as defined in para-
graph (5)).
‘‘(3)(A) The term ‘orientation and mobility specialist’
means an individual—
‘‘(i) who holds a baccalaureate or higher degree
granted by a regionally accredited college or univer-
sity in the United States (or an equivalent foreign
degree) in rehabilitation, special education, or a
health field with a university-based program of study
and clinical experience in orientation and mobility
(as defined in subparagraph (B)); and
‘‘(ii)(I) who is licensed or certified as an ori-
entation and mobility specialist by the State in
which the orientation and mobility services are per-
formed; or
‘‘(II) in the case of an individual furnishing ori-
entation and mobility services in a State which does
not provide for licensure or certification—
‘‘(aa) who has successfully completed 350
hours of clinical practicum under the super-
vision of an orientation and mobility specialist
holding a master’s degree or higher, and who
has furnished not less than 9 months of super-
vised full-time orientation and mobility services
after obtaining a degree described in clause (i);
and
‘‘(bb) who has successfully completed a na-
tional examination in orientation and mobility
administered by a national organization specifi-
cally dedicated to performing credentialing of
orientation and mobility specialists that is rec-
ognized by the Secretary, and who meets such
other criteria as the Secretary establishes.
‘‘(B) The term ‘orientation and mobility’ means the
following services:
‘‘(i) Assessment of needs of an individual who
has a vision impairment for skills training in meth-
ods of safe movement and in strategies to gather re-
quired environmental and spatial information.
‘‘(ii) Development of appropriate integrated
service plans tailored to meet such needs identified
pursuant to an assessment under clause (i).
‘‘(iii) Provision of training in and utilization
of—
‘‘(I) equipment and adaptive devices in-
tended and designed for use by such an indi-
vidual; and
‘‘(II) specialized techniques adapted for
such individuals, including orientation, sensory
development, systems of safe movement (includ-
ing long cane techniques), resource identifica-
tion, professional referrals (as appropriate),
and, in applied settings reinforcing instruction
for the use of optical devices as prescribed by
optometrists and ophthalmologists.
‘‘(iv) Evaluation of the progress in performance
of such an individual receiving training under clause
(iii).
‘‘(4)(A) The term ‘rehabilitation teacher’ means an
individual—
‘‘(i) who holds a baccalaureate or higher degree
granted by a regionally accredited college or univer-
sity in the United States (or an equivalent foreign
degree) in rehabilitation, special education, or a
health field with a university-based program of study
and clinical experience in rehabilitation teaching (as
defined in subparagraph (B)); and
‘‘(ii)(I) who is licensed or certified as a rehabili-
tation teacher by the State in which the rehabilita-
tion teaching services are performed; or
‘‘(II) in the case of an individual furnishing re-
habilitation teaching services in a State which does
not provide for licensure or certification—
‘‘(aa) who has successfully completed 350
hours of clinical practicum under the super-
vision of a rehabilitation teacher holding a mas-
ter’s degree or higher, and who has furnished
not less than 9 months of supervised full-time
rehabilitation teaching services after obtaining a
degree described in clause (i); and
‘‘(bb) who has successfully completed a na-
tional examination in rehabilitation teaching ad-
ministered by a national organization specifi-
cally dedicated to performing credentialing of
rehabilitation teachers that is recognized by the
Secretary, and who meets such other criteria as
the Secretary establishes.
‘‘(B) The term ‘rehabilitation teaching’ means the
following services:
‘‘(i) Assessment of needs of an individual with
a vision impairment for skills training in inde-
pendent living and communications.
‘‘(ii) Development of appropriate integrated
service plans tailored to meet such needs identified
pursuant to an assessment under clause (i).
‘‘(iii) Provision of training in, and utilization
of—
‘‘(I) equipment and adaptive devices in-
tended and designed for use by such an indi-
vidual, including, in applied settings, reinforcing
instruction for the use of optical devices as pre-
scribed by optometrists or ophthalmologists;
and
‘‘(II) specialized techniques adapted for
such an individual, including braille and other
communication skills, personal self-care skills,
and home management skills.
‘‘(iv) Evaluation of the progress in performance
of such an individual receiving training under clause
(iii).
‘‘(5)(A) The term ‘low vision therapist’ means an
individual—
‘‘(i) who holds—
‘‘(I) a baccalaureate or higher degree
granted by a regionally accredited college or
university in the United States (or an equiva-
lent foreign degree) in rehabilitation, special
education, or a health field with a university-
based program of study and clinical experience
in orientation and mobility, rehabilitation teach-
ing, or teaching the visually impaired;
‘‘(II) a master’s of science degree granted
by a regionally accredited college or university
in the United States (or an equivalent foreign
degree) in low vision rehabilitation; or
‘‘(III) a baccalaureate or higher degree
granted by a regionally accredited college or
university in the United States (or an equiva-
lent foreign degree) in occupational therapy;
‘‘(ii) who after obtaining a degree described in
clause (i) has performed at least 2 years of low vi-
sion therapy (as defined in subparagraph (B)) under
the supervision of an optometrist or ophthalmologist
in an appropriate setting (as determined by the Sec-
retary); and
‘‘(iii)(I) who is licensed or certified as a low vi-
sion therapist by the State in which the services are
performed; or
‘‘(II) in the case of an individual in a State
which does not provide for licensure or certification,
who has successfully completed a national examina-
tion in low vision therapy administered by a national
organization specifically dedicated to performing
credentialing of low vision therapists that is recog-
nized by the Secretary, and who meets such other
criteria as the Secretary establishes.
‘‘(B) The term ‘low vision therapy’ means the fol-
lowing services furnished to an individual and based upon
the clinical findings of a low vision examination conducted
on the individual by an optometrist or an ophthalmologist:
‘‘(i) Assessment of the performance of an indi-
vidual diagnosed with a vision impairment with pre-
scribed optical and adaptive nonoptical devices.
‘‘(ii) In order to promote safety and maximize
use of visual ability of the individual diagnosed with
vision impairment, the provision of training in and
use of the following:
‘‘(I) Visual abilities in daily living and
other tasks.
‘‘(II) Optical devices prescribed by an op-
tometrist or ophthalmologist.
‘‘(III) Adaptive non-optical and electronic
devices.
‘‘(IV) Environmental cues and modifica-
tions.
‘‘(iii) Evaluation of the progress in performance
of such an individual receiving the training and use
under clause (ii).
‘‘(6)(A) The term ‘vision impairment’ means that an
individual is blind or partially sighted.
‘‘(B) The term ‘blind’ means blind within the mean-
ing of ‘blindness’ as that term is defined in section
216(i)(1).
‘‘(C) The term ‘partially sighted’ means functional vi-
sion impairment that constitutes a significant limitation
of visual capability resulting from disease, trauma, or con-
genital or degenerative condition, that cannot be fully
ameliorated by standard refractive correction, medication,
or surgery, and that is manifested by one or more of the
following:
‘‘(i) Insufficient visual resolution.
‘‘(ii) Inadequate field of vision.
‘‘(iii) Reduced peak contrast sensitivity.’’.
(c) PAYMENT.—Section 1833(a)(1) (42 U.S.C.
1395l(a)(1)) is amended—
(1) by striking ‘‘and’’ before ‘‘(S)’’; and
(2) by inserting before the semicolon at the end
the following: ‘‘, and (T) with respect to vision reha-
bilitation services (as defined in section 1861(xx))
furnished by a vision rehabilitation professional, the
amount paid shall be 80 percent of the lesser of the
actual charge for the services or 85 percent of the
amount determined under the fee schedule estab-
lished under section 1848(b) for the same services if
furnished by a physician’’.
(d) EFFECTIVE DATE.—The amendments made by
this section shall apply to services furnished on or after
the date of the enactment of this Act.
(e) CONSULTATION.—The Secretary shall consult
with the National Vision Rehabilitation Cooperative, the
Association for Education and Rehabilitation of the Blind
and Visually Impaired, the Academy for Certification of
Vision Rehabilitation and Education Professionals, and
such other qualified professional and consumer organiza-
tions as the Secretary determines appropriate in promul-
gating regulations to carry out this Act.
SEC. 251. LIMITING MEDICARE LATE ENROLLMENT PEN-
ALTY TO 10 PERCENT AND TWICE THE PE-
RIOD OF NO ENROLLMENT.
(a) IN GENERAL.—The first sentence of section
1839(b) (42 U.S.C. 1395r(b)) is amended by striking ‘‘10
percent of the monthly premium so determined for each
full 10 months’’ and inserting ‘‘10 percent of the monthly
premium so determined for premiums paid during a period
equal to twice the number of months in each of the full
periods of 12 months’’.
(b) CONFORMING AMENDMENTS.—
(1) Section 1818(c) (42 U.S.C. 1395i–2(c)) is
amended—
(A) by striking paragraph (6); and
(B) 
by 
redesignating 
paragraphs 
(7)
through (9) as paragraphs (6) through (8), re-
spectively.
(2) Section 1818(g)(2)(B) (42 U.S.C. 1395i–
2(g)(2)(B)) is amended by striking ‘‘by sub-
stituting’’ and all that follows and inserting the fol-
lowing: ‘‘by substituting ‘section 1818 (without any
increase resulting from the application of section
1839(b) to such section)’ for ‘section 1839 (without
any increase under subsection (b) thereof)’.’’.
(c) EFFECTIVE DATE.—
(1) The amendments made by this section shall
apply to premiums paid for months beginning after
the end of the 90-day period beginning on the date
of the enactment of this Act.
(2) In applying these amendments, months (be-
fore, during, or after the month in which this Act
is enacted) in which an individual was or is required
to pay an increased premium shall be taken into ac-
count in determining the month in which the pre-
mium will no longer be subject to an increase.
TITLE III—PROVISIONS
RELATING TO PARTS A AND B
Subtitle A—Home Health Services
SEC. 301. ELIMINATION OF 15 PERCENT REDUCTION IN
PAYMENT RATES UNDER THE PROSPECTIVE
PAYMENT SYSTEM FOR HOME HEALTH SERV-
ICES.
(a) IN GENERAL.—Section 1895(b)(3)(A) (42 U.S.C.
1395fff(b)(3)(A)) is amended to read as follows:
‘‘(A) INITIAL BASIS.—Under such system
the Secretary shall provide for computation of
a standard prospective payment amount (or
amounts). Such amount (or amounts) shall ini-
tially be based on the most current audited cost
report data available to the Secretary and shall
be computed in a manner so that the total
amounts payable under the system for the 12-
month period beginning on the date the Sec-
retary implements the system shall be equal to
the total amount that would have been made if
the system had not been in effect and if section
1861(v)(1)(L)(ix) had not been enacted. Each
such amount shall be standardized in a manner
that eliminates the effect of variations in rel-
ative case mix and area wage adjustments
among different home health agencies in a
budget neutral manner consistent with the case
mix and wage level adjustments provided under
paragraph (4)(A). Under the system, the Sec-
retary may recognize regional differences or dif-
ferences based upon whether or not the services
or agency are in an urbanized area.’’.
100
(b) EFFECTIVE DATE.—The amendment made by
subsection (a) shall take effect as if included in the enact-
ment of BBRA.
SEC. 302. ADDITIONAL PAYMENTS FOR OUTLIERS.
(a) IN GENERAL.—Section 1895(b)(5) (42 U.S.C.
1395fff(b)(5)) is amended—
(1) by striking ‘‘OUTLIERS.—The Secretary’’
and inserting the following (and conforming the in-
dentation of the succeeding matter accordingly):
‘‘OUTLIERS.—
‘‘(A) IN GENERAL.—The Secretary’’; and
(2) by adding at the end the following new sub-
paragraph:
‘‘(B) TEMPORARY ADDITIONAL PAYMENTS
FOR OUTLIERS.—For the purposes described in
the first sentence of subparagraph (A), there
are authorized to be appropriated from the
trust funds (as defined in section 1896(a)(8))
in appropriate part, as determined by the Sec-
retary, for each of fiscal years 2001 through
2005 an amount equal to $500,000,000. Such
amounts shall be in addition to amounts avail-
able for payment under this section and shall
not result in a reduction of the standard pro-
spective payment amount (or amounts). In
101
making payments under this subparagraph, the
Secretary shall use a loss-sharing ratio of 90
percent.’’.
(b) 
CONFORMING
AMENDMENT.—Section
1895(b)(3)(C) (42 U.S.C. 1395fff(b)(3)(C)) is amended
by striking ‘‘paragraph (5)’’ and inserting ‘‘paragraph
(5)(A)’’.
SEC. 303. ADDITIONAL PAYMENTS UNDER THE PROSPEC-
TIVE PAYMENT SYSTEM FOR SERVICES FUR-
NISHED IN RURAL AREAS AND SECURITY
SERVICES.
(a) INCREASE
IN PAYMENT RATES
FOR RURAL
AGENCIES.—Section 1895(b) (42 U.S.C. 1395fff(b)) is
amended by adding at the end the following new para-
graph:
‘‘(7) ADDITIONAL
PAYMENT
AMOUNT
FOR
SERVICES
FURNISHED
IN
RURAL
AREAS.—In the
case of home health services furnished in a rural
area (as defined in section 1886(d)(2)(D)), notwith-
standing any other provision of this subsection, the
amount of payment for such services is equal to 110
percent of the payment amount otherwise made
under this section (but for this paragraph) for serv-
ices furnished in a rural area.’’.
102
(b) ADDITIONAL PAYMENT
FOR SECURITY SERV-
ICES.—Section 1895(b) (42 U.S.C. 1395fff(b)(3)), as
amended by subsection (a), is further amended by adding
at the end the following paragraph:
‘‘(8) ADDITIONAL
PAYMENT
FOR
SECURITY
SERVICES.—The Secretary shall provide for an addi-
tion or adjustment to the payment amount otherwise
made under this section for the reasonable cost (as
defined in section 1861(v)(1)(A)) of furnishing pro-
tective services to individuals furnishing home health
services under this title in areas where such individ-
uals are at risk of physical harm, as determined by
the Secretary.’’.
(c) INAPPLICABILITY OF ADJUSTMENTS FOR BUDG-
ET
NEUTRALITY.—Section 
1895(b)(3) 
(42 
U.S.C.
1395fff(b)(3)) is amended by adding at the end the fol-
lowing new subparagraph:
‘‘(D) NO
ADJUSTMENT
FOR
ADDITIONAL
PAYMENTS
FOR
RURAL
SERVICES
AND
SECU-
RITY SERVICES.—The Secretary shall not re-
duce the standard prospective payment amount
(or amounts) under this paragraph applicable
to home health services furnished during a pe-
riod to offset the increase in payments resulting
from the application of paragraph (7) (relating
103
to services furnished in rural areas) and para-
graph (8) (relating to costs of security serv-
ices).’’.
(d) EFFECTIVE DATE.—The amendments made by
this section apply with respect to items and services fur-
nished on or after October 1, 2000.
SEC. 304. EXCLUSION OF CERTAIN NONROUTINE MEDICAL
SUPPLIES 
UNDER 
THE 
PPS 
FOR 
HOME
HEALTH SERVICES.
(a) EXCLUSION.—
(1) IN
GENERAL.—Section 1895 (42 U.S.C.
1395fff) is amended by adding at the end the fol-
lowing new subsection:
‘‘(e) EXCLUSION OF NONROUTINE MEDICAL SUP-
PLIES.—
‘‘(1) IN GENERAL.—Notwithstanding the pre-
ceding provisions of this section, in the case of all
nonroutine medical supplies (as defined by the Sec-
retary) furnished by a home health agency during a
year (beginning with 2001) for which payment is
otherwise made on the basis of the prospective pay-
ment amount under this section, payment under this
section shall be based instead on the lesser of—
‘‘(A) the actual charge for the nonroutine
medical supply; or
104
‘‘(B) the amount determined under the fee
schedule established by the Secretary for pur-
poses of making payment for such items under
part B for nonroutine medical supplies fur-
nished during that year.
‘‘(2) BUDGET NEUTRALITY ADJUSTMENT.—The
Secretary shall provide for an appropriate propor-
tional reduction in payments under this section so
that beginning with fiscal year 2001, the aggregate
amount of such reductions is equal to the aggregate
increase in payments attributable to the exclusion ef-
fected under paragraph (1).’’.
(2) 
CONFORMING
AMENDMENT.—Section
1895(b)(1) (42 U.S.C. 1395fff(b)(1)) is amended by
striking ‘‘The Secretary’’ and inserting ‘‘Subject to
subsection (e), the Secretary’’.
(3) EFFECTIVE DATE.—The amendments made
by this subsection shall apply to supplies furnished
on or after January 1, 2001.
(b) EXCLUSION FROM CONSOLIDATED BILLING.—
(1) IN GENERAL.—For items provided during
the applicable period, the Secretary of Health and
Human Services shall administer the medicare pro-
gram under title XVIII of the Social Security Act
(42 U.S.C. 1395 et seq.) as if—
105
(A) section 1842(b)(6)(F) of such Act (42
U.S.C. 1395u(b)(6)(F)) was amended by strik-
ing ‘‘(including medical supplies described in
section 1861(m)(5), but excluding durable med-
ical equipment to the extent provided for in
such section)’’ and inserting ‘‘(excluding med-
ical supplies and durable medical equipment de-
scribed in section 1861(m)(5))’’; and
(B) section 1862(a)(21) of such Act (42
U.S.C. 1395y(a)(21)) was amended by striking
‘‘(including medical supplies described in sec-
tion 1861(m)(5), but excluding durable medical
equipment to the extent provided for in such
section)’’ and inserting ‘‘(excluding medical
supplies and durable medical equipment de-
scribed in section 1861(m)(5))’’.
(2) APPLICABLE PERIOD DEFINED.—For pur-
poses of paragraph (1), the term ‘‘applicable period’’
means the period beginning on January 1, 2001,
and ending on the later of—
(A) the date that is 18 months after the
date of enactment of this Act; or
(B) the date determined appropriate by the
Secretary of Health and Human Services.
106
(c) STUDY ON EXCLUSION OF CERTAIN NONROUTINE
MEDICAL
SUPPLIES
UNDER
THE
PPS FOR
HOME
HEALTH SERVICES.—
(1) STUDY.—The Secretary of Health and
Human Services (in this subsection referred to as
the ‘‘Secretary’’) shall conduct a study to identify
any nonroutine medical supply that may be appro-
priately and cost-effectively excluded from the pro-
spective payment system for home health services
under section 1895 of the Social Security Act (42
U.S.C. 1395fff). Specifically, the Secretary shall
consider whether wound care and ostomy supplies
should be excluded from such prospective payment
system.
(2) REPORT.—Not later than 18 months after
the date of enactment of this Act, the Secretary
shall submit to the committees of jurisdiction of the
House of Representatives and the Senate a report on
the study conducted under paragraph (1), including
a list of any nonroutine medical supplies that should
be excluded from the prospective payment system for
home health services under section 1895 of the So-
cial Security Act (42 U.S.C. 1395fff).
(d) EXCLUSION OF OTHER NONROUTINE MEDICAL
SUPPLIES.—Upon submission of the report under sub-
107
section (c)(2), the Secretary shall (if necessary) revise the
definition of nonroutine medical supply, as defined for
purposes of section 1895(e) (as added by subsection (a)),
based on the list of nonroutine medical supplies included
in such report.
SEC. 305. CLARIFICATION OF THE HOMEBOUND DEFINI-
TION FOR THE HOME HEALTH BENEFIT.
(a) IN GENERAL.—Sections 1814(a) and 1835(a) (42
U.S.C. 1395f(a) and 1395n(a)) are each amended—
(1) in the last sentence, by striking ‘‘, and that
absences of the individual from home are infrequent
or of relatively short duration, or are attributable to
the need to receive medical treatment’’; and
(2) by adding at the end the following new sen-
tences: ‘‘Any absence of an individual from the home
attributable to the need to receive health care treat-
ment, including regular absences for the purpose of
participating for therapeutic, psychosocial, or med-
ical treatment in an adult day-care program that is
licensed or certified by a State, or accredited to fur-
nish adult day-care services in the State shall not
disqualify an individual from being considered to be
‘confined to his home’. Any other absence of an indi-
vidual from the home shall not so disqualify an indi-
vidual if the absence is of infrequent or short dura-
108
tion. For purposes of the preceding sentence, any
absence for the purpose of visiting a family member
who is unable to visit the individual or for the pur-
pose of attending a religious service shall be deemed
to be an absence of infrequent and short duration.’’.
(b) EFFECTIVE DATE.—The amendments made by
subsection (a) shall apply to items and services provided
on or after the date of enactment of this Act.
SEC. 306. STANDARDS FOR HOME HEALTH BRANCH OF-
FICES.
(a) IN
GENERAL.—Section 1861(o) (42 U.S.C.
1395x(o)) is amended by adding at the end the following
new sentences: ‘‘For purposes of this subsection, a home
health agency may provide services through a single site
or through a branch office. For purposes of the preceding
sentence, the term ‘branch office’ means a service site for
home health services that is controlled and supervised by
a home health agency.’’.
(b) ESTABLISHMENT OF STANDARDS.—
(1) IN GENERAL.—The Secretary of Health and
Human Services (in this subsection referred to as
the ‘‘Secretary’’) shall establish, using a negotiated
rulemaking process under subchapter III of chapter
5 of title 5, United States Code, standards for the
operation of a branch office (as defined in the last
109
sentence of section 1861(o) of the Social Security
Act (42 U.S.C. 1395x(o)), as added by subsection
(a)).
(2) REQUIREMENTS.—In establishing standards
under paragraph (1), the Secretary shall—
(A) provide for the special treatment of
any home health agency or branch office—
(i) that is located in a frontier area;
or
(ii) 
with 
any 
other 
special 
cir-
cumstance that the Secretary determines is
appropriate; and
(B) allow the use of technology used by the
home health agency to supervise the branch of-
fice.
(3) CONSULTATION.—The Secretary shall es-
tablish the regulations under this subsection in con-
sultation with representatives of the home health in-
dustry.
SEC. 307. TREATMENT OF HOME HEALTH SERVICES PRO-
VIDED IN CERTAIN COUNTIES.
(a) IN GENERAL.—Notwithstanding any other provi-
sion of law, effective for home health services provided
under the prospective payment system under section 1895
of the Social Security Act (42 U.S.C. 1395fff) during fis-
110
cal year 2001 in an applicable county, the geographic ad-
justment factors applicable in such year to hospitals phys-
ically located in such county under section 1886(d) of such
Act (42 U.S.C. 1395ww(d)) (including the factors applica-
ble to such hospitals by reason of any reclassification or
deemed reclassification) shall be deemed to apply to such
services instead of the area wage adjustment factors that
would otherwise be applicable to such services under sec-
tion 
1895(b)(4)(C) 
of 
such 
Act 
(42 
U.S.C.
1395fff(b)(4)(C)).
(b) APPLICABLE COUNTY DEFINED.—For purposes
of subsection (a), the term ‘‘applicable county’’ means any
of the following counties:
(1) Duchess County, New York.
(2) Orange County, New York.
(3) Clinton County, New York.
(4) Ulster County, New York.
(5) Otsego County, New York.
(6) Cayuga County, New York.
(7) St. Jefferson County, New York.
SEC. 
308. 
RULE 
OF 
CONSTRUCTION 
RELATING 
TO
TELEHOMEHEALTH SERVICES.
(a) IN
GENERAL.—Section 1895(b) (42 U.S.C.
1395fff(b)(3)), as amended by section 3, is further amend-
ed by adding at the end the following paragraph:
111
‘‘(9) RULE
OF
CONSTRUCTION
RELATING
TO
TELEHOMEHEALTH SERVICES.—
‘‘(A) IN GENERAL.—Nothing in this sec-
tion, or in section 4206(a) of the Balanced
Budget Act of 1997 (42 U.S.C. 1395l note),
shall be construed as preventing a home health
agency receiving payment under this section
from furnishing a home health service via a
telecommunications system. Each home health
agency that submits a cost report to the Sec-
retary under this section shall include, in such
cost report, data with respect to the costs in-
curred in furnishing home health services to
medicare beneficiaries via such telecommuni-
cations systems.
‘‘(B) LIMITATION.—The Secretary shall
not consider a home health service provided in
the manner described in subparagraph (A) to
be a home health visit for purposes of—
‘‘(i) determining the amount of pay-
ment to be made under this section; or
‘‘(ii) any requirement relating to the
certification of a physician required under
section 1814(a)(2)(C).’’.
112
(b) REPORT.—Not later than one year after the date
of the enactment of this Act, the Secretary of Health and
Human Services shall submit to Congress a report con-
taining the recommendations of the Secretary with respect
to the feasibility and advisability of including home health
services furnished by telecommunications systems as a
home health service for purposes of—
(1) payment for such services under section
1895 of the Social Security Act (42 U.S.C. 1395fff),
and
(2) requirements with respect to physician cer-
tification of the need for home health services under
section 1814(a)(2)(C) of such Act (42 U.S.C.
1395f(a)(2)(C)).
Subtitle B—Direct Graduate
Medical Education
SEC. 311. NOT COUNTING CERTAIN GERIATRIC RESIDENTS
AGAINST GRADUATE MEDICAL EDUCATION
LIMITATIONS.
For cost reporting periods beginning on or after Oc-
tober 1, 2000, and before October 1, 2005, in applying
the limitations regarding the total number of full-time
equivalent interns and residents in the field of allopathic
or osteopathic medicine under subsections (d)(5)(B)(v)
and (h)(4)(F) of section 1886 of the Social Security Act
113
(42 U.S.C. 1395ww) for a hospital, the Secretary of
Health and Human Services shall not take into account
a maximum of 3 interns or residents in the field of geri-
atric medicine to the extent the hospital increases the
number of geriatric interns or residents above the number
of such interns or residents for the hospital’s most recent
cost reporting period ending before October 1, 2000.
SEC. 312. PROGRAM OF PAYMENTS TO CHILDREN’S HOS-
PITALS THAT OPERATE GRADUATE MEDICAL
EDUCATION PROGRAMS.
Part A of title XI (42 U.S.C. 1301 et seq.) is amend-
ed by adding after section 1150 the following new section:
‘‘PROGRAM
OF
PAYMENTS
TO
CHILDREN’S
HOSPITALS
THAT
OPERATE
GRADUATE
MEDICAL
EDUCATION
PROGRAMS
‘‘SEC. 1150A. (a) PAYMENTS.—The Secretary shall
make 2 payments under this section to each children’s
hospital for each of fiscal years 2002 through 2005, 1 for
the direct expenses and the other for the indirect expenses
associated with operating approved graduate medical resi-
dency training programs.
‘‘(b) AMOUNT OF PAYMENTS.—
‘‘(1) IN GENERAL.—Subject to paragraph (2),
the amounts payable under this section to a chil-
dren’s hospital for an approved graduate medical
114
residency training program for a fiscal year are each
of the following amounts:
‘‘(A) DIRECT
EXPENSE
AMOUNT.—The
amount determined under subsection (c) for di-
rect expenses associated with operating ap-
proved graduate medical residency training pro-
grams.
‘‘(B) INDIRECT
EXPENSE
AMOUNT.—The
amount determined under subsection (d) for in-
direct expenses associated with the treatment of
more severely ill patients and the additional
costs relating to teaching residents in such pro-
grams.
‘‘(2) CAPPED AMOUNT.—
‘‘(A) IN GENERAL.—The total of the pay-
ments made to children’s hospitals under sub-
paragraph (A) or (B) of paragraph (1) in a fis-
cal year shall not exceed the funds appropriated
under paragraph (1) or (2), respectively, of sub-
section (f) for such payments for that fiscal
year.
‘‘(B) PRO
RATA
REDUCTIONS
OF
PAY-
MENTS
FOR
DIRECT
EXPENSES.—If the Sec-
retary determines that the amount of funds ap-
propriated under subsection (f)(1) for a fiscal
115
year is insufficient to provide the total amount
of payments otherwise due for such periods
under paragraph (1)(A), the Secretary shall re-
duce the amounts so payable on a pro rata
basis to reflect such shortfall.
‘‘(c) AMOUNT OF PAYMENT FOR DIRECT GRADUATE
MEDICAL EDUCATION.—
‘‘(1) IN
GENERAL.—The amount determined
under this subsection for payments to a children’s
hospital for direct graduate expenses relating to ap-
proved graduate medical residency training pro-
grams for a fiscal year is equal to the product of—
‘‘(A) the updated per resident amount for
direct graduate medical education, as deter-
mined under paragraph (2); and
‘‘(B) the average number of full-time
equivalent residents in the hospital’s graduate
approved medical residency training programs
(as determined under section 1886(h)(4)) dur-
ing the fiscal year.
‘‘(2) UPDATED PER RESIDENT AMOUNT FOR DI-
RECT
GRADUATE
MEDICAL
EDUCATION.—The up-
dated per resident amount for direct graduate med-
ical education for a hospital for a fiscal year is an
amount determined as follows:
116
‘‘(A) DETERMINATION OF HOSPITAL SIN-
GLE PER RESIDENT AMOUNT.—The Secretary
shall compute for each hospital operating an
approved graduate medical education program
(regardless of whether or not it is a children’s
hospital) a single per resident amount equal to
the average (weighted by number of full-time
equivalent residents) of the primary care per
resident amount and the non-primary care per
resident 
amount 
computed 
under 
section
1886(h)(2) for cost reporting periods ending
during fiscal year 1997.
‘‘(B) DETERMINATION OF WAGE AND NON-
WAGE-RELATED PROPORTION OF THE SINGLE
PER RESIDENT AMOUNT.—The Secretary shall
estimate the average proportion of the single
per resident amounts computed under subpara-
graph (A) that is attributable to wages and
wage-related costs.
‘‘(C) 
STANDARDIZING
PER
RESIDENT
AMOUNTS.—The Secretary shall establish a
standardized per resident amount for each such
hospital—
‘‘(i) by dividing the single per resident
amount computed under subparagraph (A)
117
into a wage-related portion and a non-
wage-related portion by applying the pro-
portion determined under subparagraph
(B);
‘‘(ii) by dividing the wage-related por-
tion by the factor applied under section
1886(d)(3)(E) for discharges occurring
during fiscal year 1999 for the hospital’s
area; and
‘‘(iii) by adding the non-wage-related
portion to the amount computed under
clause (ii).
‘‘(D) DETERMINATION OF NATIONAL AV-
ERAGE.—The Secretary shall compute a na-
tional average per resident amount equal to the
average of the standardized per resident
amounts computed under subparagraph (C) for
such hospitals, with the amount for each hos-
pital weighted by the average number of full-
time equivalent residents at such hospital.
‘‘(E) APPLICATION
TO
INDIVIDUAL
HOS-
PITALS.—The Secretary shall compute for each
such hospital that is a children’s hospital a per
resident amount—
118
‘‘(i) by dividing the national average
per resident amount computed under sub-
paragraph (D) into a wage-related portion
and a non-wage-related portion by applying
the proportion determined under subpara-
graph (B);
‘‘(ii) by multiplying the wage-related
portion by the factor described in subpara-
graph (C)(ii) for the hospital’s area; and
‘‘(iii) by adding the non-wage-related
portion to the amount computed under
clause (ii).
‘‘(F) UPDATING
RATE.—The Secretary
shall update such per resident amount for each
such children’s hospital by the estimated per-
centage increase in the Consumer Price Index
for all urban consumers (U.S. city average)
during the period beginning October 1997, and
ending with the midpoint of the Federal fiscal
year for which payments are made.
‘‘(d) AMOUNT OF PAYMENT FOR INDIRECT MEDICAL
EDUCATION.—
‘‘(1) IN
GENERAL.—The amount determined
under this subsection for payments to a children’s
hospital for indirect expenses associated with the
119
treatment of more severely ill patients and the addi-
tional costs related to the teaching of residents for
a fiscal year is equal to an amount determined ap-
propriate by the Secretary.
‘‘(2) FACTORS.—In determining the amount
under paragraph (1), the Secretary shall—
‘‘(A) take into account variations in case
mix and regional wage levels among children’s
hospitals and the number of full-time equivalent
residents in the hospitals’ approved graduate
medical residency training programs; and
‘‘(B) assure that the aggregate of the pay-
ments for indirect expenses associated with the
treatment of more severely ill patients and the
additional costs related to the teaching of resi-
dents under this section in a fiscal year are
equal to the amount appropriated for such ex-
penses for the fiscal year involved under sub-
section (f)(2).
‘‘(e) MAKING OF PAYMENTS.—
‘‘(1) INTERIM PAYMENTS.—The Secretary shall
determine, before the beginning of each fiscal year
involved for which payments may be made for a hos-
pital under this section, the amounts of the pay-
ments for direct graduate medical education and in-
120
direct medical education for such fiscal year and
shall (subject to paragraph (2)) make the payments
of such amounts in 26 equal interim installments
during such period. Such interim payments to each
individual hospital shall be based on the number of
residents reported in the hospital’s most recently
filed medicare cost report prior to the application
date for the Federal fiscal year for which the interim
payment amounts are established.
‘‘(2) WITHHOLDING.—
‘‘(A) IN
GENERAL.—Subject to subpara-
graph (B), the Secretary shall withhold 25 per-
cent from each interim installment for direct
and indirect graduate medical education paid
under paragraph (1).
‘‘(B) REDUCTION OF WITHHOLDING.—The
Secretary shall reduce the percent withheld
from each installment pursuant to subpara-
graph (A) if the Secretary determines that such
reduced percent will provide the Secretary with
a reasonable level of assurance that most hos-
pitals will not be overpaid on an interim basis.
‘‘(3) RECONCILIATION.—Prior to the end of
each fiscal year, the Secretary shall determine any
changes to the number of residents reported by a
121
hospital and shall use that number of residents to
determine the final amount payable to the hospital
for the current fiscal year for both direct expense
and indirect expense amounts. Based on such deter-
mination, the Secretary shall recoup any overpay-
ments made or pay any balance due to the extent
possible. In the event that a hospital’s interim pay-
ments were greater than the final amount to which
it is entitled, the Secretary shall have the option of
recouping that excess amount in determining the
amount to be paid in the subsequent year to that
hospital. The final amount so determined shall be
considered a final intermediary determination for
purposes of applying section 1878 and shall be sub-
ject to review under that section in the same manner
as the amount of payment under section 1886(d) is
subject to review under such section.
‘‘(f) AUTHORIZATION OF APPROPRIATIONS.—
‘‘(1) 
DIRECT
GRADUATE
MEDICAL
EDU-
CATION.—
‘‘(A) IN
GENERAL.—There are appro-
priated, out of any money in the Treasury not
otherwise appropriated, for payments under
subsection (b)(1)(A) for each of fiscal years
2002 through 2005, $95,000,000.
122
‘‘(B) 
CARRYOVER
OF
EXCESS.—The
amounts appropriated under subparagraph (A)
for each fiscal year shall remain available for
obligation through the end of the subsequent
fiscal year.
‘‘(2) INDIRECT
MEDICAL
EDUCATION.—There
are appropriated, out of any money in the Treasury
not otherwise appropriated, for payments under sub-
section (b)(1)(A) for each of fiscal years 2002
through 2005, $190,000,000.
‘‘(g) DEFINITIONS.—In this section:
‘‘(1) APPROVED
GRADUATE
MEDICAL
RESI-
DENCY
TRAINING
PROGRAM.—The term ‘approved
graduate medical residency training program’ has
the meaning given the term ‘approved medical resi-
dency training program’ in section 1886(h)(5)(A).
‘‘(2) CHILDREN’S HOSPITAL.—The term ‘chil-
dren’s hospital’ means a hospital with a medicare
payment agreement and which is excluded from the
medicare inpatient prospective payment system pur-
suant to section 1886(d)(1)(B)(iii) and its accom-
panying regulations.
‘‘(3) DIRECT GRADUATE MEDICAL EDUCATION
COSTS.—The term ‘direct graduate medical edu-
123
cation costs’ has the meaning given such term in
section 1886(h)(5)(C).’’.
SEC. 313. AUTHORITY TO INCLUDE COSTS OF TRAINING OF
CLINICAL PSYCHOLOGISTS IN PAYMENTS TO
HOSPITALS.
Effective for cost reporting periods beginning on or
after October 1, 1999, for purposes of payments to hos-
pitals under the medicare program under title XVIII of
the Social Security Act (42 U.S.C. 1395 et seq.) for costs
of approved educational activities (as defined in section
413.85 of title 42 of the Code of Federal Regulations),
such approved educational activities shall include the clin-
ical portion of professional educational training programs,
recognized by the Secretary, for clinical psychologists.
SEC. 314. TREATMENT OF CERTAIN NEWLY ESTABLISHED
RESIDENCY 
PROGRAMS 
IN 
COMPUTING
MEDICARE PAYMENTS FOR THE COSTS OF
MEDICAL EDUCATION.
(a) IN
GENERAL.—Section 1886(h)(4)(H) (42
U.S.C. 1395ww(h)(4)(H)) is amended by adding at the
end the following new clause:
‘‘(v) TREATMENT OF CERTAIN NEWLY
ESTABLISHED
PROGRAMS.—Any hospital
that has received payments under this sub-
section for a cost reporting period ending
124
before January 1, 1995, and that operates
an approved medical residency training
program established on or after August 5,
1997, shall be treated as meeting the re-
quirements for an adjustment under the
rules prescribed pursuant to clause (i) with
respect to such program if—
‘‘(I) such program received ac-
creditation from the American Council
of Graduate Medical Education not
later than August 5, 1998;
‘‘(II) such program was in oper-
ation (with 1 or more residents in
training) as of January 1, 2000;
‘‘(III) such hospital is located in
an area that is contiguous to a rural
area and serves individuals from such
rural area; and
‘‘(IV) such hospital serves a med-
ical service area with a population
that is less than 500,000.’’.
(b) EFFECTIVE DATE.—The amendment made by
subsection (a) shall take effect as if included in the enact-
ment of section 4623 of BBA (111 Stat. 477).
125
SEC. 315. EXCEPTION TO ESTABLISHING THE NUMBER OF
RESIDENTS FOR CERTAIN HOSPITALS.
(a) AMENDMENT TO LIMITATION ON RESIDENTS FOR
INDIRECT GRADUATE MEDICAL EDUCATION.—Section
1886(d)(5)(B)(v) (42 U.S.C. 1395ww(d)(5)(B)(v)) is
amended—
(1) by adding the following after ‘‘December
31, 1996’’ and before the period: ‘‘(except in the
case where a community health center held the ac-
creditation for an approved medical residency train-
ing program of a hospital during fiscal year 1997
and the hospital incurred all or substantially all of
the costs of training those residents at the commu-
nity health center, the total number of full-time
equivalent interns and residents for the hospital with
respect to such training program in the fields of
allopathic and osteopathic medicine may not exceed
the number of such full-time equivalent interns and
residents that trained at such hospital and such
community health center during the hospital’s cost
reporting period ending on or before December 31,
1997)’’.
(b) AMENDMENT TO LIMITATION ON RESIDENTS FOR
DIRECT
GRADUATE
MEDICAL
EDUCATION.—Section
1886(h)(4)(F) 
(42 
U.S.C. 
1395ww(h)(4)(F)) 
is
amended—
126
(1) in clause (i), by striking ‘‘Such rules’’ and
inserting ‘‘Subject to clause (iii), such rules’’; and
(2) by adding at the end the following new
clause:
‘‘(iii) SPECIAL
RULE.—In the case
where a community health center held the
accreditation for an approved medical resi-
dency training program of a hospital dur-
ing fiscal year 1997 and the hospital in-
curred all or substantially all of the costs
of training those residents at the commu-
nity health center, the total number of full-
time equivalent residents before application
of weighting factors for the hospital (as de-
termined under this paragraph) with re-
spect to such training program in the
fields of allopathic medicine and osteo-
pathic medicine may not exceed the num-
ber of such full-time equivalent residents
that trained at such hospital and such
community health center during the hos-
pital’s cost reporting period ending on or
before December 31, 1997.’’.
(c) DEFINITION OF COMMUNITY HEALTH CENTER.—
For the purposes of this section, the term ‘‘community
127
health center’’ has the meaning given the term ‘‘health
center’’ in section 330(a) of the Public Health Service Act
(42 U.S.C. 254b(a)).
(d) EFFECTIVE DATE.—The amendments made by
subsections (a) and (b) shall take effect as if included in
the enactment of the Balanced Budget Act of 1997 (Pub-
lic Law 105–33).
Subtitle C—Miscellaneous
Provisions
SEC. 321. WAIVER OF 24-MONTH WAITING PERIOD FOR
MEDICARE COVERAGE OF INDIVIDUALS DIS-
ABLED WITH AMYOTROPHIC LATERAL SCLE-
ROSIS (ALS).
(a) IN GENERAL.—Section 226 (42 U.S.C. 426) is
amended—
(1) by redesignating subsection (h) as sub-
section (j) and by moving such subsection to the end
of the section; and
(2) by inserting after subsection (g) the fol-
lowing new subsection:
‘‘(h) For purposes of applying this section in the case
of an individual medically determined to have amyotrophic
lateral sclerosis (ALS), the following special rules apply:
128
‘‘(1) Subsection (b) shall be applied as if there
were no requirement for any entitlement to benefits,
or status, for a period longer than 1 month.
‘‘(2) The entitlement under such subsection
shall begin with the first month (rather than twenty-
fifth month) of entitlement or status.
‘‘(3) Subsection (f) shall not be applied.’’.
(b) CONFORMING AMENDMENT.—Section 1837 (42
U.S.C. 1395p) is amended by adding at the end the fol-
lowing new subsection:
‘‘(j) In applying this section in the case of an indi-
vidual who is entitled to benefits under part A pursuant
to the operation of section 226(h), the following special
rules apply:
‘‘(1) The initial enrollment period under sub-
section (d) shall begin on the first day of the first
month in which the individual satisfies the require-
ment of section 1836(1).
‘‘(2) In applying subsection (g)(1), the initial
enrollment period shall begin on the first day of the
first month of entitlement to disability insurance
benefits referred to in such subsection.’’.
(c) EFFECTIVE DATE.—The amendments made by
this section shall apply to benefits for months beginning
after the date of enactment of this Act.
129
TITLE IV—RURAL PROVIDER
PROVISIONS
Subtitle A—Critical Access
Hospitals
SEC. 401. PAYMENTS TO CRITICAL ACCESS HOSPITALS FOR
CLINICAL DIAGNOSTIC LABORATORY TESTS.
(a) PAYMENT
ON COST BASIS WITHOUT BENE-
FICIARY COST-SHARING.—
(1) IN
GENERAL.—Section 1833(a)(6) (42
U.S.C. 1395l(a)(6)) is amended by inserting ‘‘(in-
cluding clinical diagnostic laboratory services fur-
nished by a critical access hospital)’’ after ‘‘out-
patient critical access hospital services’’.
(2) NO BENEFICIARY COST-SHARING.—
(A) IN
GENERAL.—Section 1834(g) (42
U.S.C. 1395m(g)) is amended by inserting
‘‘(except that in the case of clinical diagnostic
laboratory services furnished by a critical access
hospital the amount of payment shall be equal
to 100 percent of the reasonable costs of the
critical access hospital in providing such serv-
ices)’’ before the period at the end.
(B) BBRA AMENDMENT.—Section 1834(g)
(42 U.S.C. 1395m(g)), as amended by section
130
403(d) of BBRA (113 Stat. 1501A–371), is
amended—
(i) in paragraph (1), by inserting
‘‘(except that in the case of clinical diag-
nostic laboratory services furnished by a
critical access hospital the amount of pay-
ment shall be equal to 100 percent of the
reasonable costs of the critical access hos-
pital in providing such services)’’ after
‘‘such services’’; and
(ii) in paragraph (2)(A), by inserting
‘‘(except that in the case of clinical diag-
nostic laboratory services furnished by a
critical access hospital the amount of pay-
ment shall be equal to 100 percent of the
reasonable costs of the critical access hos-
pital in providing such services)’’ before
the period at the end.
(b) 
CONFORMING
AMENDMENTS.—Paragraphs
(1)(D)(i) and (2)(D)(i) of section 1833(a) (42 U.S.C.
1395l(a)(1)(D)(i); 1395l(a)(2)(D)(i)) are each amended
by striking ‘‘or which are furnished on an outpatient basis
by a critical access hospital’’.