1263
lating the sustainable growth rate 
under such section). 
‘‘(2) 
SECRETARIAL
FLEXIBILITY.—The 
Secretary shall establish by regulation 
reasonable limits on the categories of eli-
gible items and services for which a prior 
determination of coverage may be re-
quested under this subsection. In estab-
lishing such limits, the Secretary may 
consider the dollar amount involved with 
respect to the item or service, adminis-
trative costs and burdens, and other rel-
evant factors. 
‘‘(3) REQUEST
FOR
PRIOR
DETERMINA-
TION.—
‘‘(A) IN GENERAL.—Subject to para-
graph (2), under the process estab-
lished under this subsection an eligi-
ble requester may submit to the con-
tractor a request for a determination, 
before the furnishing of an eligible 
item or service involved as to wheth-
er the item or service is covered 
under this title consistent with the 
applicable requirements of section
1264
1862(a)(1)(A) (relating to medical ne-
cessity). 
‘‘(B) ACCOMPANYING
DOCUMENTA-
TION.—The 
Secretary 
may 
require 
that the request be accompanied by a 
description of the item or service, 
supporting documentation relating to 
the medical necessity for the item or 
service, and any other appropriate 
documentation. In the case of a re-
quest submitted by an eligible re-
quester who is described in para-
graph (1)(B)(ii), the Secretary may re-
quire that the request also be accom-
panied by a copy of the advance ben-
eficiary notice involved. 
‘‘(4) RESPONSE TO REQUEST.—
‘‘(A) 
IN
GENERAL.—Under 
such 
process, the contractor shall provide 
the eligible requester with written 
notice 
of 
a 
determination 
as 
to 
whether—
‘‘(i) the item or service is so 
covered;
1265
‘‘(ii) the item or service is not 
so covered; or 
‘‘(iii) the contractor lacks suf-
ficient information to make a cov-
erage determination. 
If the contractor makes the deter-
mination described in clause (iii), the 
contractor shall include in the notice 
a description of the additional infor-
mation required to make the cov-
erage determination. 
‘‘(B) DEADLINE TO RESPOND.—Such 
notice shall be provided within the 
same time period as the time period 
applicable to the contractor pro-
viding notice of initial determina-
tions on a claim for benefits under 
subsection (a)(2)(A). 
‘‘(C) INFORMING
BENEFICIARY
IN 
CASE
OF
PHYSICIAN
REQUEST.—In the 
case of a request in which an eligible 
requester is not the individual de-
scribed in paragraph (1)(B)(ii), the 
process shall provide that the indi-
vidual to whom the item or service is
1266
proposed to be furnished shall be in-
formed of any determination de-
scribed in clause (ii) (relating to a de-
termination of non-coverage) and the 
right (referred to in paragraph (6)(B)) 
to obtain the item or service and have 
a claim submitted for the item or 
service. 
‘‘(5) EFFECT OF DETERMINATIONS.—
‘‘(A) BINDING NATURE OF POSITIVE 
DETERMINATION.—If 
the 
contractor 
makes the determination described in 
paragraph (4)(A)(i), such determina-
tion shall be binding on the con-
tractor in the absence of fraud or evi-
dence of misrepresentation of facts 
presented to the contractor. 
‘‘(B) NOTICE
AND
RIGHT
TO
REDE-
TERMINATION IN CASE OF A DENIAL.—
‘‘(i) IN
GENERAL.—If the con-
tractor makes the determination 
described 
in 
paragraph 
(4)(A)(ii)—
‘‘(I) the eligible requester 
has the right to a redeter-
1267
mination by the contractor on 
the determination that the 
item or service is not so cov-
ered; and 
‘‘(II) the contractor shall 
include in notice under para-
graph (4)(A) a brief expla-
nation of the basis for the de-
termination, 
including 
on 
what national or local cov-
erage or noncoverage deter-
mination (if any) the deter-
mination is based, and the 
right to such a redetermina-
tion. 
‘‘(ii) DEADLINE
FOR
REDETER-
MINATIONS.—The contractor shall 
complete and provide notice of 
such redetermination within the 
same time period as the time pe-
riod applicable to the contractor 
providing notice of redetermina-
tions relating to a claim for bene-
fits under subsection (a)(3)(C)(ii). 
‘‘(6) LIMITATION ON FURTHER REVIEW.—
1268
‘‘(A) IN
GENERAL.—Contractor de-
terminations described in paragraph 
(4)(A)(ii) or (4)(A)(iii) (and redeter-
minations 
made 
under 
paragraph 
(5)(B)), relating to pre-service claims 
are not subject to further administra-
tive appeal or judicial review under 
this section or otherwise. 
‘‘(B) DECISION NOT TO SEEK PRIOR 
DETERMINATION
OR
NEGATIVE
DETER-
MINATION
DOES
NOT
IMPACT
RIGHT
TO 
OBTAIN
SERVICES, 
SEEK
REIMBURSE-
MENT, OR APPEAL RIGHTS.—Nothing in 
this subsection shall be construed as 
affecting the right of an individual 
who—
‘‘(i) decides not to seek a prior 
determination under this sub-
section with respect to items or 
services; or 
‘‘(ii) seeks such a determina-
tion and has received a deter-
mination described in paragraph 
(4)(A)(ii),
1269
from receiving (and submitting a 
claim for) such items services and 
from obtaining administrative or ju-
dicial review respecting such claim 
under the other applicable provisions 
of this section. Failure to seek a prior 
determination under this subsection 
with respect to items and services 
shall not be taken into account in 
such administrative or judicial re-
view. 
‘‘(C) 
NO
PRIOR
DETERMINATION 
AFTER RECEIPT OF SERVICES.—Once an 
individual is provided items and serv-
ices, there shall be no prior deter-
mination under this subsection with 
respect to such items or services.’’. 
(b) EFFECTIVE DATE; TRANSITION.—
(1) EFFECTIVE
DATE.—The Secretary 
shall establish the prior determination 
process under the amendment made by 
subsection (a) in such a manner as to pro-
vide for the acceptance of requests for 
determinations under such process filed
1270
not later than 18 months after the date of 
the enactment of this Act. 
(2) TRANSITION.—During the period in 
which the amendment made by sub-
section (a) has become effective but con-
tracts are not provided under section 
1874A of the Social Security Act with 
medicare administrative contractors, any 
reference in section 1869(g) of such Act 
(as added by such amendment) to such a 
contractor is deemed a reference to a fis-
cal intermediary or carrier with an 
agreement under section 1816, or con-
tract under section 1842, respectively, of 
such Act. 
(3) LIMITATION
ON
APPLICATION
TO 
SGR.—For purposes of applying section 
1848(f)(2)(D) of the Social Security Act (42 
U.S.C. 1395w–4(f)(2)(D)), the amendment 
made by subsection (a) shall not be con-
sidered to be a change in law or regula-
tion. 
(c) PROVISIONS RELATING TO ADVANCE BEN-
EFICIARY NOTICES; REPORT
ON PRIOR DETER-
MINATION PROCESS.—
1271
(1) DATA COLLECTION.—The Secretary 
shall establish a process for the collection 
of information on the instances in which 
an advance beneficiary notice (as defined 
in paragraph (5)) has been provided and 
on instances in which a beneficiary indi-
cates on such a notice that the bene-
ficiary does not intend to seek to have 
the item or service that is the subject of 
the notice furnished. 
(2) OUTREACH
AND
EDUCATION.—The 
Secretary shall establish a program of 
outreach and education for beneficiaries 
and providers of services and other per-
sons on the appropriate use of advance 
beneficiary notices and coverage policies 
under the medicare program. 
(3) GAO REPORT REPORT ON USE OF AD-
VANCE
BENEFICIARY
NOTICES.—Not later 
than 18 months after the date on which 
section 1869(g) of the Social Security Act 
(as added by subsection (a)) takes effect, 
the Comptroller General of the United 
States shall submit to Congress a report 
on the use of advance beneficiary notices
1272
under title XVIII of such Act. Such report 
shall include information concerning the 
providers of services and other persons 
that have provided such notices and the 
response of beneficiaries to such notices. 
(4) GAO REPORT ON USE OF PRIOR DE-
TERMINATION PROCESS.—Not later than 18 
months after the date on which section 
1869(g) of the Social Security Act (as 
added by subsection (a)) takes effect, the 
Comptroller General of the United States 
shall submit to Congress a report on the 
use of the prior determination process 
under such section. Such report shall in-
clude—
(A) information concerning the 
types of procedures for which a prior 
determination has been sought, deter-
minations made under the process, 
and changes in receipt of services re-
sulting from the application of such 
process; and 
(B) an evaluation of whether the 
process was useful for physicians 
(and 
other 
suppliers) 
and 
bene-
1273
ficiaries, whether it was timely, and 
whether the amount of information 
required was burdensome to physi-
cians and beneficiaries. 
(5) ADVANCE
BENEFICIARY
NOTICE
DE-
FINED.—In this subsection, the term ‘‘ad-
vance beneficiary notice’’ means a writ-
ten notice provided under section 1879(a) 
of the Social Security Act (42 U.S.C. 
1395pp(a)) to an individual entitled to 
benefits under part A or B of title XVIII 
of such Act before items or services are 
furnished under such part in cases where 
a provider of services or other person 
that would furnish the item or service be-
lieves that payment will not be made for 
some or all of such items or services 
under such title. 
Subtitle V—Miscellaneous 
Provisions 
SEC. 941. POLICY DEVELOPMENT REGARDING EVALUATION 
AND MANAGEMENT (E & M) DOCUMENTATION 
GUIDELINES. 
(a) IN GENERAL.—The Secretary may not 
implement any new documentation guidelines
1274
for, or clinical examples of, evaluation and 
management physician services under the 
title XVIII of the Social Security Act on or 
after the date of the enactment of this Act un-
less the Secretary—
(1) has developed the guidelines in 
collaboration with practicing physicians 
(including both generalists and special-
ists) and provided for an assessment of 
the proposed guidelines by the physician 
community; 
(2) has established a plan that con-
tains specific goals, including a schedule, 
for improving the use of such guidelines; 
(3) has conducted appropriate and 
representative pilot projects under sub-
section (b) to test modifications to the 
evaluation and management documenta-
tion guidelines; 
(4) finds that the objectives described 
in subsection (c) will be met in the imple-
mentation of such guidelines; and 
(5) has established, and is imple-
menting, a program to educate physi-
1277
tion of face to face encounter time 
with a patient; 
(C) at least one shall be con-
ducted for services furnished in a 
rural area and at least one for serv-
ices furnished outside such an area; 
and 
(D) at least one shall be con-
ducted in a setting where physicians 
bill under physicians’ services in 
teaching settings and at least one 
shall be conducted in a setting other 
than a teaching setting. 
(4) BANNING
OF
TARGETING
OF
PILOT 
PROJECT
PARTICIPANTS.—Data 
collected 
under this subsection shall not be used as 
the basis for overpayment demands or 
post-payment audits. Such limitation ap-
plies only to claims filed as part of the 
pilot project and lasts only for the dura-
tion of the pilot project and only as long 
as the provider is a participant in the 
pilot project. 
(5) 
STUDY
OF
IMPACT.—Each 
pilot 
project shall examine the effect of the
1278
new evaluation and management docu-
mentation guidelines on—
(A) different types of physician 
practices, including those with fewer 
than 10 full-time-equivalent employ-
ees (including physicians); and 
(B) the costs of physician compli-
ance, including education, implemen-
tation, auditing, and monitoring. 
(6) PERIODIC REPORTS.—The Secretary 
shall submit to Congress periodic reports 
on the pilot projects under this sub-
section. 
(c) OBJECTIVES FOR EVALUATION AND MAN-
AGEMENT
GUIDELINES.—The 
objectives 
for 
modified evaluation and management docu-
mentation guidelines developed by the Sec-
retary shall be to—
(1) identify clinically relevant docu-
mentation needed to code accurately and 
assess coding levels accurately; 
(2) decrease the level of non-clinically 
pertinent and burdensome documenta-
tion time and content in the physician’s 
medical record;
1279
(3) increase accuracy by reviewers; 
and 
(4) educate both physicians and re-
viewers. 
(d) STUDY OF SIMPLER, ALTERNATIVE SYS-
TEMS
OF
DOCUMENTATION
FOR
PHYSICIAN 
CLAIMS.—
(1) STUDY.—The Secretary shall carry 
out a study of the matters described in 
paragraph (2). 
(2) MATTERS DESCRIBED.—The matters 
referred to in paragraph (1) are—
(A) the development of a simpler, 
alternative system of requirements 
for 
documentation 
accompanying 
claims for evaluation and manage-
ment physician services for which 
payment is made under title XVIII of 
the Social Security Act; and 
(B) consideration of systems other 
than current coding and documenta-
tion requirements for payment for 
such physician services. 
(3) CONSULTATION
WITH
PRACTICING 
PHYSICIANS.—In designing and carrying
1280
out the study under paragraph (1), the 
Secretary shall consult with practicing 
physicians, including physicians who are 
part of group practices and including 
both generalists and specialists. 
(4) APPLICATION
OF
HIPAA
UNIFORM 
CODING REQUIREMENTS.—In developing an 
alternative system under paragraph (2), 
the Secretary shall consider require-
ments of administrative simplification 
under part C of title XI of the Social Se-
curity Act. 
(5) REPORT
TO
CONGRESS.—(A) Not 
later than October 1, 2005, the Secretary 
shall submit to Congress a report on the 
results of the study conducted under 
paragraph (1). 
(B) The Medicare Payment Advisory 
Commission shall conduct an analysis of 
the results of the study included in the 
report under subparagraph (A) and shall 
submit a report on such analysis to Con-
gress. 
(e) STUDY ON APPROPRIATE CODING OF CER-
TAIN EXTENDED OFFICE VISITS.—The Secretary
1281
shall conduct a study of the appropriateness 
of coding in cases of extended office visits in 
which there is no diagnosis made. Not later 
than October 1, 2005, the Secretary shall sub-
mit a report to Congress on such study and 
shall include recommendations on how to 
code appropriately for such visits in a manner 
that takes into account the amount of time 
the physician spent with the patient. 
(f) DEFINITIONS.—In this section—
(1) the term ‘‘rural area’’ has the 
meaning given that term in section 
1886(d)(2)(D) of the Social Security Act, 
42 U.S.C. 1395ww(d)(2)(D); and 
(2) the term ‘‘teaching settings’’ are 
those 
settings 
described 
in 
section 
415.150 of title 42, Code of Federal Regu-
lations. 
SEC. 942. IMPROVEMENT IN OVERSIGHT OF TECHNOLOGY 
AND COVERAGE. 
(a) COUNCIL FOR TECHNOLOGY AND INNOVA-
TION.—Section 1868 (42 U.S.C. 1395ee), as 
amended by section 921(a), is amended by 
adding at the end the following new sub-
section:
1282
‘‘(c) COUNCIL FOR TECHNOLOGY AND INNOVA-
TION.—
‘‘(1) ESTABLISHMENT.—The Secretary 
shall establish a Council for Technology 
and Innovation within the Centers for 
Medicare & Medicaid Services (in this 
section referred to as ‘CMS’). 
‘‘(2) COMPOSITION.—The Council shall 
be composed of senior CMS staff and cli-
nicians and shall be chaired by the Exec-
utive Coordinator for Technology and In-
novation (appointed or designated under 
paragraph (4)). 
‘‘(3) DUTIES.—The Council shall co-
ordinate the activities of coverage, cod-
ing, and payment processes under this 
title with respect to new technologies 
and procedures, including new drug 
therapies, and shall coordinate the ex-
change of information on new tech-
nologies between CMS and other entities 
that make similar decisions. 
‘‘(4) 
EXECUTIVE
COORDINATOR
FOR 
TECHNOLOGY
AND
INNOVATION.—The Sec-
retary shall appoint (or designate) a non-
1283
career appointee (as defined in section 
3132(a)(7) of title 5, United States Code) 
who shall serve as the Executive Coordi-
nator for Technology and Innovation. 
Such executive coordinator shall report 
to the Administrator of CMS, shall chair 
the Council, shall oversee the execution 
of its duties, and shall serve as a single 
point of contact for outside groups and 
entities regarding the coverage, coding, 
and payment processes under this title.’’. 
(b) METHODS
FOR DETERMINING PAYMENT 
BASIS FOR NEW LAB TESTS.—Section 1833(h) 
(42 U.S.C. 1395l(h)) is amended by adding at 
the end the following: 
‘‘(8)(A) The Secretary shall establish by 
regulation procedures for determining the 
basis for, and amount of, payment under this 
subsection for any clinical diagnostic labora-
tory test with respect to which a new or sub-
stantially revised HCPCS code is assigned on 
or after January 1, 2005 (in this paragraph re-
ferred to as ‘new tests’). 
‘‘(B) Determinations under subparagraph 
(A) shall be made only after the Secretary—
1284
‘‘(i) makes available to the public 
(through an Internet site and other ap-
propriate mechanisms) a list that in-
cludes any such test for which establish-
ment of a payment amount under this 
subsection is being considered for a year; 
‘‘(ii) on the same day such list is made 
available, causes to have published in the 
Federal Register notice of a meeting to 
receive comments and recommendations 
(and data on which recommendations are 
based) from the public on the appro-
priate basis under this subsection for es-
tablishing payment amounts for the tests 
on such list; 
‘‘(iii) not less than 30 days after publi-
cation of such notice convenes a meeting, 
that includes representatives of officials 
of the Centers for Medicare & Medicaid 
Services involved in determining pay-
ment amounts, to receive such comments 
and 
recommendations 
(and 
data 
on 
which the recommendations are based); 
‘‘(iv) taking into account the com-
ments and recommendations (and accom-
1285
panying data) received at such meeting, 
develops and makes available to the pub-
lic (through an Internet site and other 
appropriate mechanisms) a list of pro-
posed determinations with respect to the 
appropriate basis for establishing a pay-
ment amount under this subsection for 
each such code, together with an expla-
nation of the reasons for each such deter-
mination, the data on which the deter-
minations are based, and a request for 
public written comments on the proposed 
determination; and 
‘‘(v) taking into account the com-
ments received during the public com-
ment period, develops and makes avail-
able to the public (through an Internet 
site and other appropriate mechanisms) a 
list of final determinations of the pay-
ment amounts for such tests under this 
subsection, together with the rationale 
for each such determination, the data on 
which the determinations are based, and 
responses to comments and suggestions 
received from the public.
1286
‘‘(C) Under the procedures established 
pursuant to subparagraph (A), the Secretary 
shall—
‘‘(i) set forth the criteria for making 
determinations under subparagraph (A); 
and 
‘‘(ii) make available to the public the 
data (other than proprietary data) con-
sidered in making such determinations. 
‘‘(D) The Secretary may convene such fur-
ther public meetings to receive public com-
ments on payment amounts for new tests 
under this subsection as the Secretary deems 
appropriate. 
‘‘(E) For purposes of this paragraph: 
‘‘(i) The term ‘HCPCS’ refers to the 
Health Care Procedure Coding System. 
‘‘(ii) A code shall be considered to be 
‘substantially revised’ if there is a sub-
stantive change to the definition of the 
test or procedure to which the code ap-
plies (such as a new analyte or a new 
methodology for measuring an existing 
analyte-specific test).’’.
1287
(c) GAO STUDY ON IMPROVEMENTS IN EXTER-
NAL DATA COLLECTION FOR USE IN THE MEDI-
CARE INPATIENT PAYMENT SYSTEM.—
(1) STUDY.—The Comptroller General 
of the United States shall conduct a study 
that analyzes which external data can be 
collected in a shorter time frame by the 
Centers for Medicare & Medicaid Serv-
ices for use in computing payments for 
inpatient hospital services. The study 
may include an evaluation of the feasi-
bility and appropriateness of using of 
quarterly samples or special surveys or 
any other methods. The study shall in-
clude an analysis of whether other execu-
tive agencies, such as the Bureau of 
Labor Statistics in the Department of 
Commerce, are best suited to collect this 
information. 
(2) REPORT.—By not later than Octo-
ber 1, 2004, the Comptroller General shall 
submit a report to Congress on the study 
under paragraph (1). 
(d) PROCESS FOR ADOPTION OF ICD CODES 
AS DATA STANDARD.—Section 1172(f) (42 U.S.C.
1288
1320d–1(f)) is amended by inserting after the 
first sentence the following: ‘‘Notwithstanding 
the preceding sentence, if the National Com-
mittee on Vital and Health Statistics has not 
made a recommendation to the Secretary be-
fore the date of the enactment of this sen-
tence, with respect to the adoption of the 
International Classification of Diseases, 10th 
Revision, Procedure Coding System (‘ICD–10–
PCS’) and the International Classification of 
Diseases, 10th Revision, Clinical Modification 
(‘ICD–10–CM’) as a standard under this part 
for the reporting of diagnoses, the Secretary 
may adopt ICD–10–PCS and ICD–10–CM as 
such a standard on or after 1 year after such 
date without receiving such a recommenda-
tion.’’. 
SEC. 943. TREATMENT OF HOSPITALS FOR CERTAIN SERV-
ICES UNDER MEDICARE SECONDARY PAYOR 
(MSP) PROVISIONS. 
(a) IN GENERAL.—The Secretary shall not 
require a hospital (including a critical access 
hospital) to ask questions (or obtain informa-
tion) relating to the application of section 
1862(b) of the Social Security Act (relating to
1289
medicare secondary payor provisions) in the 
case of reference laboratory services de-
scribed in subsection (b), if the Secretary does 
not impose such requirement in the case of 
such services furnished by an independent 
laboratory. 
(b) REFERENCE LABORATORY SERVICES DE-
SCRIBED.—Reference laboratory services de-
scribed in this subsection are clinical labora-
tory diagnostic tests (or the interpretation of 
such tests, or both) furnished without a face-
to-face encounter between the individual en-
titled to benefits under part A or enrolled 
under part B, or both, and the hospital in-
volved and in which the hospital submits a 
claim only for such test or interpretation. 
SEC. 944. EMTALA IMPROVEMENTS. 
(a) 
PAYMENT
FOR
EMTALA-MANDATED 
SCREENING AND STABILIZATION SERVICES.—
(1) IN
GENERAL.—Section 1862 (42 
U.S.C. 1395y) is amended by inserting 
after subsection (c) the following new 
subsection: 
‘‘(d) For purposes of subsection (a)(1)(A), 
in the case of any item or service that is re-
1290
quired to be provided pursuant to section 
1867 to an individual who is entitled to bene-
fits under this title, determinations as to 
whether the item or service is reasonable and 
necessary shall be made on the basis of the in-
formation available to the treating physician 
or practitioner (including the patient’s pre-
senting symptoms or complaint) at the time 
the item or service was ordered or furnished 
by the physician or practitioner (and not on 
the patient’s principal diagnosis). When mak-
ing such determinations with respect to such 
an item or service, the Secretary shall not 
consider the frequency with which the item 
or service was provided to the patient before 
or after the time of the admission or visit.’’. 
(2) EFFECTIVE DATE.—The amendment 
made by paragraph (1) shall apply to 
items and services furnished on or after 
January 1, 2004. 
(b) NOTIFICATION
OF
PROVIDERS
WHEN 
EMTALA 
INVESTIGATION
CLOSED.—Section 
1867(d) (42 U.S.C. 42 U.S.C. 1395dd(d)) is 
amended by adding at the end the following 
new paragraph:
1291
‘‘(4) NOTICE
UPON
CLOSING
AN
INVES-
TIGATION.—The Secretary shall establish a 
procedure to notify hospitals and physi-
cians when an investigation under this 
section is closed.’’. 
(c) PRIOR REVIEW BY PEER REVIEW ORGANI-
ZATIONS IN EMTALA CASES INVOLVING TERMI-
NATION OF PARTICIPATION.—
(1) IN GENERAL.—Section 1867(d)(3) (42 
U.S.C. 1395dd(d)(3)) is amended—
(A) in the first sentence, by insert-
ing ‘‘or in terminating a hospital’s 
participation under this title’’ after 
‘‘in imposing sanctions under para-
graph (1)’’; and 
(B) by adding at the end the fol-
lowing new sentences: ‘‘Except in the 
case in which a delay would jeop-
ardize the health or safety of individ-
uals, the Secretary shall also request 
such a review before making a com-
pliance determination as part of the 
process of terminating a hospital’s 
participation under this title for vio-
lations related to the appropriateness
1292
of a medical screening examination, 
stabilizing treatment, or an appro-
priate transfer as required by this 
section, and shall provide a period of 
5 days for such review. The Secretary 
shall provide a copy of the organiza-
tion’s report to the hospital or physi-
cian consistent with confidentiality 
requirements imposed on the organi-
zation under such part B.’’. 
(2) EFFECTIVE DATE.—The amendments 
made by paragraph (1) shall apply to ter-
minations of participation initiated on or 
after the date of the enactment of this 
Act.
(d) MODIFICATION
OF
REQUIRMENT
FOR 
MEDICAL
SCREENING
EXAMINATIONS
FOR
PA-
TIENTS NOT REQUESTING EMERGENCY DEPART-
MENT SERVICES.—
(1) IN
GENERAL.—Section 1867(a) (42 
U.S.C. 1395dd(a)) is amended—
(A) by designating all that follows 
‘‘(a) 
MEDICAL
SCREENING
REQUIRE-
MENT.—’’ as paragraph (1) with the 
heading ‘‘IN GENERAL.—’’;
1293
(B) by aligning such paragraph 
with the paragraph added by para-
graph (3); and 
(C) by adding at the end the fol-
lowing new paragraph: 
‘‘(2) EXCEPTION
FOR
CERTAIN
CASES.—
The requirement for an appropriate med-
ical screening examination under para-
graph (1) shall not apply in the case of an 
individual who comes to the emergency 
department and does not request exam-
ination or treatment for an emergency 
medical condition (such as a request sole-
ly for prescription refills, blood pressure 
screening, and non-emergency laboratory 
and diagnostic tests).’’. 
(2) EFFECTIVE DATE.—The amendments 
made by paragraph (1) shall apply to ter-
minations of participation initiated on or 
after the date of the enactment of this 
Act.
1294
SEC. 945. EMERGENCY MEDICAL TREATMENT AND ACTIVE 
LABOR ACT (EMTALA) TECHNICAL ADVISORY 
GROUP. 
(a) ESTABLISHMENT.—The Secretary shall 
establish a Technical Advisory Group (in this 
section referred to as the ‘‘Advisory Group’’) 
to review issues related to the Emergency 
Medical Treatment and Labor Act (EMTALA) 
and its implementation. In this section, the 
term ‘‘EMTALA’’ refers to the provisions of 
section 1867 of the Social Security Act (42 
U.S.C. 1395dd). 
(b) MEMBERSHIP.—The Advisory Group 
shall be composed of 19 members, including 
the Administrator of the Centers for Medicare 
& Medicaid Services and the Inspector Gen-
eral of the Department of Health and Human 
Services and of which—
(1) 4 shall be representatives of hos-
pitals, including at least one public hos-
pital, that have experience with the ap-
plication of EMTALA and at least 2 of 
which have not been cited for EMTALA 
violations; 
(2) 7 shall be practicing physicians 
drawn from the fields of emergency medi-
1295
cine, cardiology or cardiothoracic sur-
gery, orthopedic surgery, neurosurgery, 
pediatrics or a pediatric subspecialty, ob-
stetrics-gynecology, and psychiatry, with 
not more than one physician from any 
particular field; 
(3) 2 shall represent patients; 
(4) 2 shall be staff involved in 
EMTALA investigations from different re-
gional offices of the Centers for Medicare 
& Medicaid Services; and 
(5) 1 shall be from a State survey of-
fice involved in EMTALA investigations 
and 1 shall be from a peer review organi-
zation, both of whom shall be from areas 
other than the regions represented under 
paragraph (4). 
In selecting members described in para-
graphs (1) through (3), the Secretary shall 
consider qualified individuals nominated by 
organizations representing providers and pa-
tients. 
(c) GENERAL RESPONSIBILITIES.—The Advi-
sory Group—
(1) shall review EMTALA regulations;
1296
(2) may provide advice and rec-
ommendations to the Secretary with re-
spect to those regulations and their ap-
plication to hospitals and physicians; 
(3) shall solicit comments and rec-
ommendations from hospitals, physicians, 
and the public regarding the implementa-
tion of such regulations; and 
(4) may disseminate information on 
the application of such regulations to 
hospitals, physicians, and the public. 
(d) ADMINISTRATIVE MATTERS.—
(1) CHAIRPERSON.—The members of 
the Advisory Group shall elect a member 
to serve as chairperson of the Advisory 
Group for the life of the Advisory Group. 
(2) MEETINGS.—The Advisory Group 
shall first meet at the direction of the 
Secretary. The Advisory Group shall then 
meet twice per year and at such other 
times as the Advisory Group may pro-
vide. 
(e) TERMINATION.—The Advisory Group 
shall terminate 30 months after the date of its 
first meeting.
1297
(f) WAIVER
OF
ADMINISTRATIVE
LIMITA-
TION.—The Secretary shall establish the Advi-
sory Group notwithstanding any limitation 
that may apply to the number of advisory 
committees that may be established (within 
the Department of Health and Human Serv-
ices or otherwise). 
SEC. 946. AUTHORIZING USE OF ARRANGEMENTS TO PRO-
VIDE CORE HOSPICE SERVICES IN CERTAIN 
CIRCUMSTANCES. 
(a) IN GENERAL.—Section 1861(dd)(5) (42 
U.S.C. 1395x(dd)(5)) is amended by adding at 
the end the following: 
‘‘(D) In extraordinary, exigent, or other 
non-routine circumstances, such as unantici-
pated periods of high patient loads, staffing 
shortages due to illness or other events, or 
temporary travel of a patient outside a hos-
pice program’s service area, a hospice pro-
gram may enter into arrangements with an-
other hospice program for the provision by 
that other program of services described in 
paragraph (2)(A)(ii)(I). The provisions of para-
graph (2)(A)(ii)(II) shall apply with respect to
1298
the services provided under such arrange-
ments. 
‘‘(E) A hospice program may provide serv-
ices described in paragraph (1)(A) other than 
directly by the program if the services are 
highly specialized services of a registered 
professional nurse and are provided non-rou-
tinely and so infrequently so that the provi-
sion of such services directly would be im-
practicable and prohibitively expensive.’’. 
(b) CONFORMING PAYMENT PROVISION.—Sec-
tion 1814(i) (42 U.S.C. 1395f(i)) is amended by 
adding at the end the following new para-
graph: 
‘‘(4) In the case of hospice care provided 
by a hospice program under arrangements 
under section 1861(dd)(5)(D) made by another 
hospice program, the hospice program that 
made the arrangements shall bill and be paid 
for the hospice care.’’. 
(c) EFFECTIVE
DATE.—The amendments 
made by this section shall apply to hospice 
care provided on or after the date of the en-
actment of this Act.
1299
SEC. 947. APPLICATION OF OSHA BLOODBORNE PATHO-
GENS STANDARD TO CERTAIN HOSPITALS. 
(a) IN GENERAL.—Section 1866 (42 U.S.C. 
1395cc) is amended—
(1) in subsection (a)(1)—
(A) in subparagraph (R), by strik-
ing ‘‘and’’ at the end; 
(B) in subparagraph (S), by strik-
ing the period at the end and insert-
ing ‘‘, and’’; and 
(C) by inserting after subpara-
graph (S) the following new subpara-
graph: 
‘‘(T) in the case of hospitals that are 
not otherwise subject to the Occupational 
Safety and Health Act of 1970, to comply 
with the Bloodborne Pathogens standard 
under section 1910.1030 of title 29 of the 
Code of Federal Regulations (or as subse-
quently redesignated).’’; and 
(2) by adding at the end of subsection 
(b) the following new paragraph: 
‘‘(4)(A) A hospital that fails to comply with 
the requirement of subsection (a)(1)(T) (relat-
ing to the Bloodborne Pathogens standard) is 
subject to a civil money penalty in an amount
1300
described in subparagraph (B), but is not sub-
ject to termination of an agreement under 
this section. 
‘‘(B) The amount referred to in subpara-
graph (A) is an amount that is similar to the 
amount of civil penalties that may be imposed 
under section 17 of the Occupational Safety 
and Health Act of 1970 for a violation of the 
Bloodborne Pathogens standard referred to in 
subsection (a)(1)(T) by a hospital that is sub-
ject to the provisions of such Act. 
‘‘(C) A civil money penalty under this 
paragraph shall be imposed and collected in 
the same manner as civil money penalties 
under subsection (a) of section 1128A are im-
posed and collected under that section.’’. 
(b) EFFECTIVE
DATE.—The amendments 
made by this subsection (a) shall apply to hos-
pitals as of July 1, 2004. 
SEC. 948. BIPA-RELATED TECHNICAL AMENDMENTS AND 
CORRECTIONS. 
(a) TECHNICAL AMENDMENTS RELATING TO 
ADVISORY
COMMITTEE
UNDER
BIPA SECTION 
522.—(1) Subsection (i) of section 1114 (42 
U.S.C. 1314)—
1301
(A) is transferred to section 1862 and 
added at the end of such section; and 
(B) is redesignated as subsection (j). 
(2) Section 1862 (42 U.S.C. 1395y) is 
amended—
(A) in the last sentence of subsection 
(a), by striking ‘‘established under section 
1114(f)’’; and 
(B) in subsection (j), as so transferred 
and redesignated—
(i) by striking ‘‘under subsection 
(f)’’; and 
(ii) by striking ‘‘section 1862(a)(1)’’ 
and inserting ‘‘subsection (a)(1)’’. 
(b) TERMINOLOGY CORRECTIONS.—(1) Sec-
tion 
1869(c)(3)(I)(ii) 
(42 
U.S.C. 
1395ff(c)(3)(I)(ii)), as amended by section 521 
of BIPA, is amended—
(A) in subclause (III), by striking ‘‘pol-
icy’’ and inserting ‘‘determination’’; and 
(B) in subclause (IV), by striking 
‘‘medical review policies’’ and inserting 
‘‘coverage determinations’’. 
(2) Section 1852(a)(2)(C) (42 U.S.C. 1395w–
22(a)(2)(C)) is amended by striking ‘‘policy’’
1302
and ‘‘POLICY’’ and inserting ‘‘determination’’ 
each place it appears and ‘‘DETERMINATION’’, 
respectively. 
(c) 
REFERENCE
CORRECTIONS.—Section 
1869(f)(4) (42 U.S.C. 1395ff(f)(4)), as added by 
section 522 of BIPA, is amended—
(1) in subparagraph (A)(iv), by strik-
ing ‘‘subclause (I), (II), or (III)’’ and in-
serting ‘‘clause (i), (ii), or (iii)’’; 
(2) in subparagraph (B), by striking 
‘‘clause (i)(IV)’’ and ‘‘clause (i)(III)’’ and 
inserting 
‘‘subparagraph 
(A)(iv)’’ 
and 
‘‘subparagraph (A)(iii)’’, respectively; and 
(3) in subparagraph (C), by striking 
‘‘clause (i)’’, ‘‘subclause (IV)’’ and ‘‘sub-
paragraph (A)’’ and inserting ‘‘subpara-
graph (A)’’, ‘‘clause (iv)’’ and ‘‘paragraph 
(1)(A)’’, respectively each place it ap-
pears. 
(d) OTHER CORRECTIONS.—Effective as if 
included in the enactment of section 521(c) of 
BIPA, section 1154(e) (42 U.S.C. 1320c–3(e)) is 
amended by striking paragraph (5). 
(e) EFFECTIVE DATE.—Except as otherwise 
provided, the amendments made by this sec-
1303
tion shall be effective as if included in the en-
actment of BIPA. 
SEC. 949. CONFORMING AUTHORITY TO WAIVE A PROGRAM 
EXCLUSION. 
The first sentence of section 1128(c)(3)(B) 
(42 U.S.C. 1320a–7(c)(3)(B)) is amended to read 
as follows: ‘‘Subject to subparagraph (G), in 
the case of an exclusion under subsection (a), 
the minimum period of exclusion shall be not 
less than five years, except that, upon the re-
quest of the administrator of a Federal health 
care program (as defined in section 1128B(f)) 
who determines that the exclusion would im-
pose a hardship on individuals entitled to 
benefits under part A of title XVIII or enrolled 
under part B of such title, or both, the Sec-
retary may waive the exclusion under sub-
section (a)(1), (a)(3), or (a)(4) with respect to 
that program in the case of an individual or 
entity that is the sole community physician or 
sole source of essential specialized services in 
a community.’’.
1304
SEC. 950. TREATMENT OF CERTAIN DENTAL CLAIMS. 
(a) IN GENERAL.—Section 1862 (42 U.S.C. 
1395y) is amended by adding after subsection 
(g) the following new subsection: 
‘‘(h)(1) Subject to paragraph (2), a group 
health 
plan 
(as 
defined 
in 
subsection 
(a)(1)(A)(v)) providing supplemental or sec-
ondary coverage to individuals also entitled 
to services under this title shall not require 
a medicare claims determination under this 
title for dental benefits specifically excluded 
under subsection (a)(12) as a condition of 
making a claims determination for such bene-
fits under the group health plan. 
‘‘(2) A group health plan may require a 
claims determination under this title in cases 
involving or appearing to involve inpatient 
dental hospital services or dental services ex-
pressly covered under this title pursuant to 
actions taken by the Secretary.’’. 
(b) EFFECTIVE
DATE.—The amendment 
made by subsection (a) shall take effect on the 
date that is 60 days after the date of the enact-
ment of this Act.