an individual enrolled under this part by tele-
phone regarding the furnishing of a covered
item to the individual (other than a covered
item the supplier has already furnished to the
individual) unless—
‘‘(i) the individual gives permission to
the supplier to make contact by telephone
for such purpose; or
‘‘(ii) the supplier has furnished a cov-
ered item under this subsection to the indi-
vidual during the 15-month period preced-
ing the date on which the supplier contacts
the individual for such purpose.
‘‘(B) PROHIBITING PAYMENT FOR ITEMS
FURNISHED
SUBSEQUENT
TO
UNSOLICITED
CONTACTS.—If a supplier knowingly contacts
an individual in violation of subparagraph (A),
no payment may be made under this part for
any item subsequently furnished to the individ-
ual by the supplier.
‘‘(C) EXCLUSION
FROM
PROGRAM
FOR
SUPPLIERS ENGAGING IN PATTERN OF UNSO-
LICITED
CONTACTS.—If a supplier knowingly
contacts individuals in violation of subpara-
graph (A) to such an extent that the supplier’s
conduct establishes a pattern of contacts in vio-
lation of such subparagraph, the Secretary shall
exclude the supplier from participation in the
programs under this Act, in accordance with
the procedures set forth in subsections (c), (f),
and (g) of section 1128.’’.
(2) REQUIRING
REFUND
OF
AMOUNTS
COL-
LECTED FOR DISALLOWED ITEMS.—Section 1834(a)
(42 U.S.C. 1395m(a)), as amended by paragraph
(1), is amended by adding at the end the following
new paragraph:
‘‘(18) REFUND OF AMOUNTS COLLECTED FOR
CERTAIN DISALLOWED ITEMS.—
‘‘(A) IN GENERAL.—If a nonparticipating
supplier furnishes to an individual enrolled
under this part a covered item for which no
payment may be made under this part by rea-
son of paragraph (17)(B), the supplier shall re-
fund on a timely basis to the patient (and shall
be liable to the patient for) any amounts col-
lected from the patient for the item, unless—
‘‘(i) the supplier establishes that the
supplier did not know and could not rea-
sonably have been expected to know that
payment may not be made for the item by
reason of paragraph (17)(B), or
‘‘(ii) before the item was furnished,
the patient was informed that payment
under this part may not be made for that
item and the patient has agreed to pay for
that item.
‘‘(B) SANCTIONS.—If a supplier knowingly
and willfully fails to make refunds in violation
of subparagraph (A), the Secretary may apply
sanctions against the supplier in accordance
with section 1842(j)(2).
‘‘(C) NOTICE.—Each carrier with a con-
tract in effect under this part with respect to
suppliers of covered items shall send any notice
of denial of payment for covered items by rea-
son of paragraph (17)(B) and for which pay-
ment is not requested on an assignment-related
basis to the supplier and the patient involved.
‘‘(D) TIMELY BASIS DEFINED.—A refund
under subparagraph (A) is considered to be on
a timely basis only if—
‘‘(i) in the case of a supplier who does
not request reconsideration or seek appeal
on a timely basis, the refund is made with-
in 30 days after the date the supplier re-
ceives a denial notice under subparagraph
(C), or
‘‘(ii) in the case in which such a re-
consideration or appeal is taken, the re-
fund is made within 15 days after the date
the supplier receives notice of an adverse
determination on reconsideration or ap-
peal.’’.
(b) CONFORMING AMENDMENT.—Section 1834(h)(3)
(42 U.S.C. 1395m(h)(3)) is amended by striking ‘‘Para-
graph (12)’’ and inserting ‘‘Paragraphs (12) and (17)’’.
(c) EFFECTIVE DATE.—The amendments made by
subsections (a) and (b) shall apply to items furnished after
the expiration of the 60-day period that begins on the date
of the enactment of this Act.
SEC. 224. KICKBACK CLARIFICATION.
(a) IN
GENERAL.—Section 1128B(b)(3)(B) (42
U.S.C. 1320a–7b(b)(3)(B)) is amended by inserting be-
fore the semicolon ‘‘(except that in the case of a contract
supply arrangement between any entity and a supplier of
medical supplies and equipment (as defined in section
1834(i)(4), but not including items described in subpara-
graph (F) of such section), such employment shall not be
considered bona fide to the extent that it includes tasks
of a clerical and cataloging nature in transmitting to sup-
pliers assignment rights of individuals eligible for benefits
under part B of title XVIII, or performance of
warehousing or stock inventory functions)’’.
(b) EFFECTIVE DATE.—The amendment made by
subsection (a) shall apply with respect to services fur-
nished on or after the first day of the first month that
begins after the expiration of the 60-day period beginning
on the date of the enactment of this Act.
SEC. 225. BENEFICIARY LIABILITY FOR NONCOVERED
SERVICES.
(a) IN GENERAL.—Section 1879 (42 U.S.C. 1395pp)
is amended by adding at the end the following new sub-
section:
‘‘(h) If a supplier of medical equipment and supplies
(as defined in section 1834(i)(4))—
‘‘(1) furnishes an item or service to a bene-
ficiary for which no payment may be made by reason
of section 1834(i)(1);
‘‘(2) furnishes an item or service to a bene-
ficiary for which payment is denied in advance under
section 1834(a)(15); or
‘‘(3) furnishes an item or service to a bene-
ficiary for which payment is denied under section
1862(a)(1);
any expenses incurred for items and services furnished to
an individual by such a supplier on an unassigned basis
shall be the responsibility of such supplier. The individual
shall have no financial responsibility for such expenses and
the supplier shall refund on a timely basis to the individual
(and shall be liable to the individual for) any amounts col-
lected from the individual for such items or services. The
provisions of section 1834(a)(18) shall apply to refunds
required under the previous sentence in the same manner
as such provisions apply to refunds under such section.’’.
(b) EFFECTIVE DATE.—The amendment made by
subsection (a) shall apply to items or services furnished
on or after October 1, 1993.
SEC. 226. ADJUSTMENTS FOR INHERENT REASONABLE-
NESS.
(a) ADJUSTMENTS
MADE
TO
FINAL
PAYMENT
AMOUNTS.—
(1) IN GENERAL.—Section 1834(a)(10)(B) (42
U.S.C. 1395m(a)(10)(B)) is amended by adding at
the end the following: ‘‘In applying such provisions
to payments for an item under this subsection, the
Secretary shall make adjustments to the payment
basis for the item described in paragraph (1)(B) if
the Secretary determines (in accordance with such
provisions and on the basis of prices and costs appli-
cable at the time the item is furnished) that such
payment basis is not inherently reasonable.’’.
(2) EFFECTIVE DATE.—The amendment made
by paragraph (1) shall take effect on the date of the
enactment of this Act.
(b) ADJUSTMENT REQUIRED FOR CERTAIN ITEMS.—
(1) IN GENERAL.—In accordance with section
1834(a)(10)(B) of the Social Security Act (as
amended by subsection (a)), the Secretary of Health
and Human Services shall determine whether the
payment amounts for the items described in para-
graph (2) are not inherently reasonable, and shall
adjust such amounts in accordance with such section
if the amounts are not inherently reasonable.
(2) ITEMS DESCRIBED.—The items referred to
in paragraph (1) are decubitus care equipment,
transcutaneous electrical nerve stimulators, and any
other items considered appropriate by the Secretary.
SEC. 227. PAYMENT FOR PARENTERAL AND ENTERAL NU-
TRIENTS, SUPPLIES, AND EQUIPMENT DUR-
ING 1993.
In determining the amount of payment under part
B of title XVIII of the Social Security Act during 1994,
the charges determined to be reasonable with respect to
parenteral and enteral nutrients, supplies, and equipment
may not exceed the charges determined to be reasonable
with respect to such nutrients, supplies, and equipment
during 1993.
SEC. 228. TREATMENT OF NEBULIZERS AND ASPIRATORS.
(a) IN GENERAL.—Section 1834(a)(3)(A) (42 U.S.C.
1395m(a)(3)(A)) is amended by striking ‘‘ventilators, as-
pirators, IPPB machines, and nebulizers’’ and inserting
‘‘ventilators and IPPB machines’’.
(b) PAYMENT
FOR
ACCESSORIES
RELATING
TO
NEBULIZERS
AND ASPIRATORS.—Section 1834(a) (42
U.S.C. 1395m(a)), as amended by section 221(a)(2), is
amended by inserting after paragraph (15) the following
new paragraph:
‘‘(16) PAYMENT FOR ACCESSORIES RELATING
TO NEBULIZERS AND ASPIRATORS.—In the case of
accessories to be used in conjunction with a
nebulizer or aspirator for which payment is made
under this subsection, payment shall be made in ac-
cordance with paragraph (2) of this subsection.’’.
(c) EFFECTIVE DATE.—The amendments made by
this section shall apply to items furnished on or after Jan-
uary 1, 1994.
SEC. 229. PAYMENT FOR OSTOMY SUPPLIES, TRACHE-
OSTOMY SUPPLIES, UROLOGICALS, AND SUR-
GICAL DRESSINGS.
(a) OSTOMY SUPPLIES, TRACHEOSTOMY SUPPLIES,
AND UROLOGICALS.—
(1) IN
GENERAL.—Section 1834(h)(1) (42
U.S.C. 1395m(h)(1)) is amended by adding at the
end the following new subparagraph:
‘‘(E) EXCEPTION FOR CERTAIN ITEMS.—
Payment for ostomy supplies, tracheostomy
supplies, and urologicals shall be made in ac-
cordance with subparagraphs (B) and (C) of
section 1834(a)(2).’’.
(2) 
CONFORMING
AMENDMENT.—Section
1834(h)(1)(B) (42 U.S.C. 1395m(h)(1)(B)) is
amended by striking ‘‘subparagraph (C),’’ and in-
serting ‘‘subparagraphs (C) and (E),’’.
(3) EFFECTIVE DATE.—The amendments made
by this subsection shall apply to items furnished on
or after January 1, 1994.
(b) SURGICAL DRESSINGS.—
(1) IN
GENERAL.—Section 1834 (42 U.S.C.
1395m), as amended by section 221(a), is amended
by adding at the end the following new subsection:
‘‘(j) PAYMENT FOR SURGICAL DRESSINGS.—
‘‘(1) IN GENERAL.—Payment under this sub-
section for surgical dressings (described in section
1861(s)(5)) shall be made in a lump sum amount
for the purchase of the item in an amount equal to
80 percent of the lesser of—
‘‘(A) the actual charge for the item; or
‘‘(B) a payment amount determined in ac-
cordance with the methodology described in
subparagraphs (B) and (C) of subsection (a)(2)
(except that in applying such methodology, the
national limited payment amount referred to in
such subparagraphs shall be initially computed
based on local payment amounts using average
reasonable charges for the 12-month period
ending December 31, 1992, increased by the
covered item updates described in such sub-
section for 1993 and 1994)
‘‘(2) EXCEPTIONS.—Paragraph (1) shall not
apply to surgical dressings that are—
‘‘(A) furnished as an incident to a physi-
cian’s professional service; or
‘‘(B) furnished by a home health agency.’’.
(2) 
CONFORMING
AMENDMENT.—Section
1833(a)(1) (42 U.S.C. 1395l(a)(1)), as amended by
sections 249(e)(2) and 205(e)(1), is amended—
(A) by striking ‘‘and’’ before ‘‘(P)’’, and
(B) by inserting before the semicolon at
the end the following: ‘‘, and (Q) with respect
to surgical dressings, the amounts paid shall be
the 
amounts 
determined 
under 
section
1834(j);’’.
(3) EFFECTIVE DATE.—The amendments made
by this subsection shall apply to items furnished on
or after January 1, 1994.
SEC. 230. PAYMENTS FOR TENS DEVICES.
(a) IN GENERAL.—Section 1834(a)(1)(D) (42 U.S.C.
1395m(a)(1)(D)) is amended by striking ‘‘15 percent’’ the
second place it appears and inserting ‘‘45 percent’’.
(b) EFFECTIVE DATE.—The amendment made by
subsection (a) shall apply to items furnished on or after
January 1, 1994.
SEC. 231. MISCELLANEOUS AND TECHNICAL CORRECTIONS.
(a) UPDATES
TO PAYMENT AMOUNTS.—Subpara-
graph 
(A) 
of 
section 
1834(a)(14) 
(42 
U.S.C.
1395m(a)(14)) is amended to read as follows:
‘‘(A) for 1991 and 1992, the percentage
increase in the consumer price index for all
urban consumers (U.S. city average) for the 12-
month period ending with June of the previous
year reduced by 1 percentage point; and’’.
(b) TREATMENT OF POTENTIALLY OVERUSED ITEMS
AND ADVANCED DETERMINATIONS OF COVERAGE.—(1)
Effective on the date of the enactment of this Act, section
1834(a)(15) (42 U.S.C. 1395m(a)(15)) is amended to
read as follows:
‘‘(15) SPECIAL TREATMENT FOR POTENTIALLY
OVERUSED ITEMS.—
‘‘(A) DEVELOPMENT OF LIST OF ITEMS BY
SECRETARY.—The Secretary shall develop and
periodically update a list of items for which
payment may be made under this subsection
that are potentially overused, and shall include
in such list seat-lift mechanisms, transcutane-
ous electrical nerve stimulators, motorized
scooters, decubitus care mattresses, and any
such other item determined by the Secretary to
be potentially overused on the basis of any of
the following criteria—
‘‘(i) the item is marketed directly to
potential patients;
‘‘(ii) the item is marketed with an
offer to potential patients to waive the
costs of coinsurance associated with the
item or is marketed as being available at
no cost to policyholders of a medicare sup-
plemental policy (as defined in section
1882(g)(1));
‘‘(iii) the item has been subject to a
consistent pattern of overutilization; or
‘‘(iv) a high proportion of claims for
payment for such item under this part may
not be made because of the application of
section 1862(a)(1).
‘‘(B) ITEMS SUBJECT TO SPECIAL CARRIER
SCRUTINY.—Payment may not be made under
this part for any item contained in the list de-
veloped by the Secretary under subparagraph
(A) unless the carrier has subjected the claim
for payment for the item to special scrutiny or
has followed the procedures described in para-
graph (11)(C) with respect to the item.’’.
(2) Effective January 1, 1994, section 1834(a)(11)
(42 U.S.C. 1395m(a)) is amended by adding at the end
the following new subparagraph:
‘‘(C) CARRIER DETERMINATIONS FOR CER-
TAIN ITEMS IN ADVANCE.—A carrier shall de-
termine in advance whether payment for an
item may not be made under this subsection be-
cause of the application of section 1862(a)(1)
if—
‘‘(i) the item is a customized item
(other than inexpensive items specified by
the Secretary); or
‘‘(ii) the item is a specified covered
item under subparagraph (B).’’.
(3) Effective for standards applied for contract years
beginning after the date of the enactment of this Act, sec-
tion 1842(c) (42 U.S.C. 1395u(c)), as amended by section
208(a), is amended by adding at the end the following new
paragraph:
‘‘(5) Each contract under this section which provides
for the disbursement of funds, as described in subsection
(a)(1)(B), shall require the carrier to meet criteria devel-
oped by the Secretary to measure the timeliness of carrier
responses to requests for payment of items described in
section 1834(a)(11)(C).’’.
(4) Section 1834(h)(3) (42 U.S.C. 1395m(h)(3)) is
amended by striking ‘‘paragraph (10) and paragraph
(11)’’ and inserting ‘‘paragraphs (10) and (11)’’.
(c) STUDY OF VARIATIONS IN DURABLE MEDICAL
EQUIPMENT SUPPLIER COSTS.—
(1) COLLECTION AND ANALYSIS OF SUPPLIER
COST
DATA.—The Administration of the Health
Care Financing Administration shall, in consultation
with appropriate organizations, collect data on sup-
plier costs of durable medical equipment for which
payment may be made under part B of the medicare
program, and shall analyze such data to determine
the proportions of such costs attributable to the
service and product components of furnishing such
equipment and the extent to which such proportions
vary by type of equipment and by the geographic re-
gion in which the supplier is located.
(2) DEVELOPMENT
OF
GEOGRAPHIC
ADJUST-
MENT INDEX; REPORTS.—Not later than January 1,
1995—
(A) the Administrator shall submit a re-
port to the Committees on Energy and Com-
merce and Ways and Means of the House of
Representatives and the Committee on Finance
of the Senate on the data collected and the
analysis conducted under paragraph (1), and
shall include in such report the Administrator’s
recommendations for a geographic cost adjust-
ment index for suppliers of durable medical
equipment under the medicare program and an
analysis of the impact of such proposed index
on payments under the medicare program; and
(B) the Comptroller General shall submit a
report to the Committees on Energy and Com-
merce and Ways and Means of the House of
Representatives and the Committee on Finance
of the Senate analyzing on a geographic basis
the supplier costs of durable medical equipment
under the medicare program.
(d) OXYGEN RETESTING.—Section 1834(a)(5)(E)
(42 U.S.C. 1395m(a)(5)(E)) is amended by striking ‘‘55’’
and inserting ‘‘56’’.
(e) 
OTHER
MISCELLANEOUS
AND
TECHNICAL
AMENDMENTS.—(1) Section 4152(a)(3) of OBRA–1990
is amended by striking ‘‘amendment made by subsection
(a)’’ and inserting ‘‘amendments made by this sub-
section’’.
(2) Section 4152(c)(2) of OBRA–1990 is amended
by 
striking 
‘‘1395m(a)(7)(A)’’ 
and 
inserting
‘‘1395m(a)(7)’’.
(3) 
Section 
1834(a)(7)(A)(iii)(II) 
(42 
U.S.C.
1395m(a)(7)(A)(iii)(II)) is amended by striking ‘‘clause
(v)’’ and inserting ‘‘clause (vi)’’.
(4) 
Section 
1834(a)(7)(C)(i) 
(42 
U.S.C.
1395m(a)(7)(C)(i)) is amended by striking ‘‘or paragraph
(3)’’.
(5) Section 1834(a)(3) (42 U.S.C. 1395m(a)(3)) is
amended by striking subparagraph (D).
(6) Section 4153(c)(1) of OBRA–1990 is amended
by striking ‘‘1834(a)’’ and inserting ‘‘1834(h)’’.
(7) Section 4153(d)(2) of OBRA–1990 is amended
by striking ‘‘Reconiliation’’ and inserting ‘‘Reconcili-
ation’’.
(8)(A) Section 1834(a) (42 U.S.C. 1395m(a)) is
amended by striking paragraph (6).
(B) Section 1834(a) (42 U.S.C. 1395m(a)) is amend-
ed—
(i) in subparagraphs (A) and (B) of paragraph
(1), by striking ‘‘(2) through (7)’’ each place it ap-
pears and inserting ‘‘(2) through (5) and (7)’’;
(ii) in paragraph (7), by striking ‘‘(2) through
(6)’’ and inserting ‘‘(2) through (5)’’;
(iii) in paragraph (8), by striking ‘‘paragraphs
(6) and (7)’’ each place it appears in the matter pre-
ceding subparagraph (A) and in subparagraph (C)
and inserting ‘‘paragraph (7)’’; and
(iv) in paragraph (8)(A)(i), by striking ‘‘de-
scribed—’’ and all that follows and inserting ‘‘de-
scribed in paragraph (7) equal to the average of the
purchase prices on the claims submitted on an as-
signment-related basis for the unused item supplied
during the 6-month period ending with December
1986.’’.
(9) The amendments made by this subsection shall
take effect as if included in the enactment of OBRA–1990.
Subtitle D—Other Provisions
SEC. 241. PAYMENT FOR MEDICALLY DIRECTED CERTIFIED
REGISTERED 
NURSE 
ANESTHETIST 
SERV-
ICES.
(a) IN GENERAL.—Section 1833(l)(4)(B) (42 U.S.C.
1395l(l)(4)(B)) is amended to read as follows:
‘‘(B) Except as provided in subparagraph (D), the
conversion factor used to determine the amount paid
under the fee schedule under this subsection for services
furnished by a certified registered nurse anesthetist who
is medically directed—
‘‘(i) in a year after 1993 and before 1997, shall
be $10.75, or
‘‘(ii) in a subsequent calendar year, shall be the
previous year’s conversion factor increased by the
update determined under section 1848(d)(3) for
physician anesthesia services for that year.’’.
(b) EFFECTIVE DATE.—The amendment made by
subsection (a) shall apply to services furnished on or after
January 1, 1994.
SEC. 242. EXTENSION OF ALZHEIMER’S DISEASE DEM-
ONSTRATION.
Section 9342 of OBRA–1986, as amended by section
4164(a)(2) of OBRA–1990, is amended—
(1) in subsection (c)(1), by striking ‘‘4 years’’
and inserting ‘‘5 years’’; and
(2) in subsection (f), —
(A) by striking ‘‘$55,000,000’’ and insert-
ing ‘‘$58,000,000’’, and
(B) by striking ‘‘$3,000,000’’ and insert-
ing ‘‘$5,000,000’’.
SEC. 243. PART B LATE ENROLLMENT PENALTY.
(a) LIMITATION ON MEDICARE PART B LATE EN-
ROLLMENT PENALTY.—
(1) IN
GENERAL.—Section 1839 (42 U.S.C.
1395r) is amended by adding at the end the follow-
ing new subsection:
‘‘(g) The percent increase in premiums under sub-
section (b) due to late enrollment under this part shall
not exceed 25 percent in the case of an individual who
is annuitant described in subparagraph (A) or (B) of sec-
tion 8901(3) of title 5, United States Code, for a month
if—
‘‘(1) during the individual’s initial enrollment
period under section 1837(d)—
‘‘(A) the individual was enrolled in a group
health 
plan 
(as 
defined 
in 
section
1862(b)(1)(A)(v)) that provided coverage of
items and services for which payment may be
made under this part, and
‘‘(B) the individual elected not to enroll (or
to be deemed enrolled) under this section, and
‘‘(2) due to a change of coverage under such
plan, there is no coverage during the month under
such plan with respect to items and services for
which payment may be made under this part unless
the individual is enrolled under this part.’’.
(2) EFFECTIVE DATE.—The amendment made
by paragraph (1) shall apply to premiums for
months beginning with January 1992.
(b) PAYMENT OF PART B PREMIUM LATE ENROLL-
MENT PENALTIES BY STATES.—Section 1839 (42 U.S.C.
1395r), as amended by subsection (a), is further amended
by adding at the end the following new subsection:
‘‘(h)(1) Upon the request of a State, the Secretary
may enter into an agreement with the State under which
the State agrees to pay on a quarterly or other periodic
basis to the Secretary (to be deposited in the Treasury
to the credit of the Federal Supplementary Medical Insur-
ance Trust Fund) an amount equal to the amount of the
part B late enrollment premium increases with respect to
the premiums for eligible individuals (as defined in para-
graph (3)(A)).
‘‘(2) No part B late enrollment premium increase
shall apply to an eligible individual for premiums for
months for which the amount of such an increase is pay-
able under an agreement under paragraph (1).
‘‘(3) In this subsection:
‘‘(A) The term ‘eligible individual’ means an in-
dividual who is enrolled under this part B and who
is within a class of individuals specified in the agree-
ment under paragraph (1).
‘‘(B) The term ‘part B late enrollment premium
increase’ means any increase in a premium as a re-
sult of the application of subsection (b).’’.
SEC. 244. ORAL CANCER DRUGS.
(a) COVERAGE
OF CERTAIN SELF-ADMINISTERED
ANTICANCER DRUGS.—Section 1861(s)(2) (42 U.S.C.
1395(s)(2)), as amended by section 249(f)(8)(B), is
amended—
(1) by striking ‘‘and’’ at the end of subpara-
graph (N);
(2) by adding ‘‘and’’ at the end of subpara-
graph (O); and
(3) by adding at the end the following new sub-
paragraph:
‘‘(P) an oral drug (which is approved by the
Federal Food and Drug Administration) prescribed
for use as an anticancer chemotherapeutic agent for
a given indication, and containing an active ingredi-
ent (or ingredients), which is the same indication
and active ingredient (or ingredients) as a drug
which the carrier determines would be covered pur-
suant to subparagraph (A) or (B) if the drug could
not be self-administered;’’.
(b) EFFECTIVE DATE.—The amendments made by
this section shall apply to items furnished on or after Jan-
uary 1, 1994.
SEC. 
245. 
SPEECH-LANGUAGE 
PATHOLOGISTS 
AND
AUDIOLOGISTS.
(a) SERVICES DEFINED.—Section 1861 (42 U.S.C.
1395x), as amended by section 249(f)(8)(E), is amended
by inserting after subsection (kk) the following new sub-
section:
‘‘Speech-Language Pathology Services; Audiology
Services
‘‘(ll)(1) The term ‘speech-language pathology serv-
ices’ means such speech, language, and related function
assessment and rehabilitation services furnished by a
petency examination in speech-language pathol-
ogy approved by the Secretary.
‘‘(B) The term ‘qualified audiologist’ means an
individual with a master’s or doctoral degree in
audiology who has performed not less than 9 months
of supervised full-time audiology services after ob-
taining such degree and who—
‘‘(i) is licensed (or is otherwise certified) as
an audiologist by the State in which the individ-
ual furnishes such services, or
‘‘(ii) in the case of an individual who fur-
nishes services in a State which does not pro-
vide for the licensing (or other form of certifi-
cation) of audiologists, has successfully com-
pleted a national clinical competency examina-
tion in audiology approved by the Secretary.’’.
(b) CONFORMING AMENDMENTS RELATING TO MED-
ICARE TREATMENT OF SPEECH AND LANGUAGE SERV-
ICES.—
(1) 
EXTENDED
CARE
SERVICES.—Section
1861(h)(3) (42 U.S.C. 1395x(h)(3)) is amended by
striking ‘‘, occupational, or speech therapy’’ and in-
serting ‘‘or occupational therapy or speech-language
pathology services’’.
(2) 
HOME
HEALTH
SERVICES.—Section
1861(m)(2) (42 U.S.C. 1395x(m)(2)) is amended by
striking ‘‘, occupational, or speech therapy’’ and in-
serting ‘‘or occupational therapy or speech-language
pathology services’’.
(3) OUTPATIENT
PHYSICAL
THERAPY
SERV-
ICES.—The fourth sentence of section 1861(p) (42
U.S.C. 1395x(p)) is amended by striking ‘‘speech
pathology services’’ and inserting ‘‘speech-language
pathology services’’.
(4) COMPREHENSIVE OUTPATIENT REHABILITA-
TION FACILITY SERVICES.—Section 1861(cc)(1)(B)
(42 U.S.C. 1395x(cc)(1)(B)) is amended by striking
‘‘speech pathology services’’ and inserting ‘‘speech-
language pathology services’’.
(5) HOSPICE
CARE.—Section 1861(dd)(1)(B)
(42 U.S.C. 1395x(dd)(1)(B)) is amended by striking
‘‘therapy or speech-language pathology’’ and insert-
ing ‘‘therapy, or speech-language pathology serv-
ices’’.
(c) EFFECTIVE DATE.—The amendments made by
this section shall apply to services furnished on or after
January 1, 1994.
SEC. 246. EXTENSION OF MUNICIPAL HEALTH SERVICE
DEMONSTRATION PROJECTS.
Section 9215 of the Consolidated Omnibus Budget
Reconciliation Act of 1985, as amended by section 6135
of OBRA–1989, is amended—
(1) by striking ‘‘December 31, 1993’’ and in-
serting ‘‘December 31, 1997’’, and
(2) in the second sentence, by inserting after
‘‘beneficiary costs,’’ the following: ‘‘costs to the med-
icaid program and other payors, access to care, out-
comes, beneficiary satisfaction, utilization differences
among the different populations served by the
projects,’’.
SEC. 247. TREATMENT OF CERTAIN INDIAN HEALTH PRO-
GRAMS 
AND 
FACILITIES 
AS 
FEDERALLY-
QUALIFIED HEALTH CENTERS.
(a) IN GENERAL.—Section 1861(aa)(4) (42 U.S.C.
1395x(aa)(4)) is amended—
(1) by striking ‘‘or’’ at the end of subparagraph
(B);
(2) by striking the period at the end of sub-
paragraph (C) and inserting ‘‘; or’’; and
(3) by adding at the end the following new sub-
paragraph:
‘‘(D) is an outpatient health program or facility
operated by a tribe or tribal organization under the
Indian Self-Determination Act or by an urban In-
dian organization receiving funds under title V of
the Indian Health Care Improvement Act.’’.
(b) EFFECTIVE DATE.—The amendment made by
subsection (a) shall take effect as if included in the enact-
ment of section 4161(a)(2)(C) of OBRA–1990.
SEC. 248. EXTENSION OF INFLUENZA VACCINATION DEM-
ONSTRATION.
(a) IN GENERAL.—Section 4071(b)(1) of OBRA–
1987 is amended by striking the period at the end and
inserting the following: ‘‘, except that the reference in
clause (ii) of paragraph (2)(B) of such subsection to ‘24
months’ shall be deemed to be a reference to ‘30
months’.’’.
(b) LIMITATION ON USE OF AMOUNTS.—The second
sentence of section 4071(b)(2) of OBRA–1987 is amended
by striking ‘‘and evaluate’’ and inserting ‘‘and (during fis-
cal years other than fiscal year 1993) evaluate’’.
SEC. 249. MISCELLANEOUS AND TECHNICAL CORRECTIONS.
(a) REVISION OF INFORMATION ON PART B CLAIMS
FORMS.—Section 1833(q)(1) (42 U.S.C. 1395l(q)(1)) is
amended—
(1) by striking ‘‘provider number’’ and inserting
‘‘unique physician identification number’’; and
(2) by striking ‘‘and indicate whether or not the
referring physician is an interested investor (within
the meaning of section 1877(h)(5))’’.
(b) CONSULTATION FOR SOCIAL WORKERS.—Effec-
tive with respect to services furnished on or after January
1, 1991, section 6113(c) of OBRA–1989 is amended—
(1) by inserting ‘‘and clinical social worker
services’’ after ‘‘psychologist services’’; and
(2) by striking ‘‘psychologist’’ the second and
third place it appears and inserting ‘‘psychologist or
clinical social worker’’.
(c) REPORTS
ON
HOSPITAL
OUTPATIENT
PAY-
MENT.—(1) OBRA–1989 is amended by striking section
6137.
(2) Section 1135(d) (42 U.S.C. 1320b–5(d)) is
amended—
(A) by striking paragraph (6); and
(B) in paragraph (7)—
(i) by striking ‘‘systems’’ each place it ap-
pears and inserting ‘‘system’’; and
(ii) by striking ‘‘paragraphs (1) and (6)’’
and inserting ‘‘paragraph (1)’’.
(d) RADIOLOGY AND DIAGNOSTIC SERVICES PRO-
VIDED IN HOSPITAL OUTPATIENT DEPARTMENTS.—(1)
Effective as if included in the enactment of OBRA–1989,
100
section 
1833(n)(1)(B)(i)(II) 
(42 
U.S.C.
1395l(n)(1)(B)(i)(II)) is amended—
(A) by striking ‘‘1989’’ and inserting ‘‘1989
and for services described in subsection (a)(2)(E)(ii)
furnished on or after January 1, 1992’’; and
(B) by striking ‘‘1842(b)’’ and inserting
‘‘1842(b) (or, in the case of services furnished on or
after January 1, 1992, under section 1848)’’.
(2) Effective as if included in the enactment of
OBRA–1989, section 1833(n)(1)(B)(i)(II) (42 U.S.C.
1395l(n)(1)(B)(i)(II)) is amended by striking ‘‘January 1,
1989’’ and inserting ‘‘April 1, 1989’’.
(e) PAYMENTS TO NURSE PRACTITIONERS IN RURAL
AREAS (SECTION 4155 OF OBRA–1990).—(1) Section
1861(s)(2)(K)(iii) (42 U.S.C. 1395x(s)(2)(K)(iii)) is
amended—
(A) by striking ‘‘subsection (aa)(3)’’ and insert-
ing ‘‘subsection (aa)(5)’’; and
(B) by striking ‘‘subsection (aa)(4)’’ and insert-
ing ‘‘subsection (aa)(6)’’.
(2) Section 1833(a)(1) (42 U.S.C. 1395l(a)(1)) is
amended—
(A) by striking ‘‘and’’ before ‘‘(N)’’; and
(B) with respect to the matter inserted by sec-
tion 4155(b)(2)(B) of OBRA–1990—
101
(i) by striking ‘‘(M)’’ and inserting ‘‘, and
(O)’’, and
(ii) by transferring and inserting it (as
amended) immediately before the semicolon at
the end.
(3) Section 1833(r)(1) (42 U.S.C. 1395l(r)(1)) is
amended—
(A) by striking ‘‘ambulatory’’ each place it ap-
pears and inserting ‘‘or ambulatory’’; and
(B) by striking ‘‘center,’’ and inserting ‘‘cen-
ter’’.
(4) Section 1833(r)(2)(A) (42 U.S.C. 1395l(r)(2)(A))
is amended by striking ‘‘subsection (a)(1)(M)’’ and insert-
ing ‘‘subsection (a)(1)(O)’’.
(5) Section 1861(b)(4) (42 U.S.C. 1395x(b)(4)) is
amended by striking ‘‘subsection (s)(2)(K)(i)’’ and insert-
ing ‘‘clauses (i) or (iii) of subsection (s)(2)(K)’’.
(6) Section 1861(aa)(5) (42 U.S.C. 1395x(aa)(5)) is
amended by striking ‘‘this Act’’ and inserting ‘‘this title’’.
(7) Section 1862(a)(14) (42 U.S.C. 1395y(a)(14)) is
amended by striking ‘‘1861(s)(2)(K)(i)’’ and inserting
‘‘1861(s)(2)(K)(i) or 1861(s)(2)(K)(iii)’’.
(8) 
Section 
1866(a)(1)(H) 
(42 
U.S.C.
1395cc(a)(1)(H)) 
is 
amended 
by 
striking
102
‘‘1861(s)(2)(K)(i)’’ and inserting ‘‘1861(s)(2)(K)(i) or
1861(s)(2)(K)(iii)’’.
(f) 
OTHER
MISCELLANEOUS
AND
TECHNICAL
AMENDMENTS.—
(1) IMMEDIATE ENROLLMENT IN PART B BY IN-
DIVIDUALS
COVERED
BY
AN
EMPLOYMENT-BASED
PLAN.—(A) Subparagraphs (A) and (B) of section
1837(i)(3) (42 U.S.C. 1395p(i)(3)) are each amend-
ed—
(i) by striking ‘‘beginning with the first
day of the first month in which the individual
is no longer enrolled’’ and inserting ‘‘including
each month during any part of which the indi-
vidual is enrolled’’; and
(ii) by striking ‘‘and ending seven months
later’’ and inserting ‘‘ending with the last day
of the eighth consecutive month in which the in-
dividual is at no time so enrolled’’.
(B) Paragraphs (1) and (2) of section 1838(e)
(42 U.S.C. 1395q(e)) are amended to read as fol-
lows:
‘‘(1) in any month of the special enrollment pe-
riod in which the individual is at any time enrolled
in a plan (specified in subparagraph (A) or (B), as
applicable, of section 1837(i)(3)) or in the first
103
month following such a month, the coverage period
shall begin on the first day of the month in which
the individual so enrolls (or, at the option of the in-
dividual, on the first day of any of the following
three months), or
‘‘(2) in any other month of the special enroll-
ment period, the coverage period shall begin on the
first day of the month following the month in which
the individual so enrolls.’’.
(C) The amendments made by subparagraphs
(A) and (B) shall take effect on the first day of the
first month that begins after the expiration of the
120-day period that begins on the date of the enact-
ment of this Act.
(2) BLEND AMOUNTS FOR AMBULATORY SUR-
GICAL CENTER PAYMENTS.—Subclauses (I) and (II)
of 
section 
1833(i)(3)(B)(ii) 
(42 
U.S.C.
1395l(i)(3)(B)(ii)) are each amended—
(A) by striking ‘‘for reporting’’ and insert-
ing ‘‘for portions of cost reporting’’; and
(B) by striking ‘‘and on or before’’ and in-
serting ‘‘and ending on or before’’.
(3) CLINICAL DIAGNOSTIC LABORATORY TESTS
(SECTION 4154 OF OBRA–1990).—Section 4154(e)(5)
104
of OBRA–1990 is amended by striking ‘‘(1)(A)’’ and
inserting ‘‘(1)(A),’’.
(4) SEPARATE PAYMENT UNDER PART B FOR
CERTAIN SERVICES (SECTION 4157 OF OBRA–1990).—
Section 4157(a) of OBRA–1990 is amended by
striking ‘‘(a) SERVICES
OF’’ and all that follows
through ‘‘Section’’ and inserting ‘‘(a) TREATMENT
OF SERVICES
OF CERTAIN HEALTH PRACTITION-
ERS.—Section’’.
(5) CERTIFIED
REGISTERED
NURSE
ANES-
THETISTS
(SECTION
4160
OF
OBRA–1990).—Section
1833(l)(4)(B)(ii)(VII) 
(42 
U.S.C.
1395l(l)(4)(B)(ii)(VII)) is amended by striking
‘‘1997’’ and inserting ‘‘1996’’.
(6) COMMUNITY HEALTH CENTERS AND RURAL
HEALTH CLINICS (SECTION 4161 OF OBRA–1990).—
(A) The fourth sentence of section 1861(aa)(2) (42
U.S.C. 1395x(aa)(2)) is amended—
(i) by striking ‘‘certification’’ the first
place it appears and inserting ‘‘approval’’; and
(ii) by striking ‘‘the Secretary’s approval
or disapproval of the certification’’ and insert-
ing ‘‘Secretary’s approval or disapproval’’.
105
(B) Section 4161(a)(7)(B) of OBRA–1990 is
amended by inserting ‘‘and to the Committee on Fi-
nance of the Senate’’ after ‘‘Representatives’’.
(7) SCREENING MAMMOGRAPHY (SECTION 4163
OF
OBRA–1990).—Section 4163 of OBRA–1990 is
amended—
(A) by adding at the end of subsection (d)
the following new paragraph:
‘‘(3) The amendment made by paragraph
(2)(A)(iv) shall apply to screening pap smears per-
formed on or after July 1, 1990.’’; and
(B) in subsection (e), by striking ‘‘The
amendments’’ and inserting ‘‘Except as pro-
vided in subsection (d)(3), the amendments.’’.
(8) INJECTABLE DRUGS FOR TREATMENT OF
OSTEOPOROSIS.—
(A) 
CLARIFICATION
OF
DRUGS
COV-
ERED.—The 
section 
1861(jj) 
(42 
U.S.C.
1395x(jj)) inserted by section 4156(a)(2) of
OBRA–1990 is amended—
(i) in the matter preceding paragraph
(1), by striking ‘‘a bone fracture related
to’’; and
(ii) in paragraph (1), by striking ‘‘pa-
tient’’ and inserting ‘‘individual has suf-
106
fered a bone fracture related to post-meno-
pausal osteoporosis and that the individ-
ual’’.
(B) LIMITING COVERAGE TO DRUGS PRO-
VIDED BY HOME HEALTH AGENCIES.—(i) The
section 1861(jj) (42 U.S.C. 1395x(jj)) inserted
by section 4156(a)(2) of OBRA–1990 is
amended by striking ‘‘if’’ and inserting ‘‘by a
home health agency if’’.
(ii) 
Section 
1861(m)(5) 
(42 
U.S.C.
1395x(m)(5)) is amended by striking ‘‘but ex-
cluding’’ 
and 
inserting 
‘‘and 
a 
covered
osteoporosis drug (as defined in subsection
(kk), but excluding other’’.
(iii) 
Section 
1861(s)(2) 
(42 
U.S.C.
1395x(s)(2)) is amended—
(I) by adding ‘‘and’’ at the end of
subparagraph (N), and
(II) by striking subparagraph (O) and
redesignating subparagraph (P) as sub-
paragraph (O).
(C) PAYMENT
BASED
ON
REASONABLE
COST.—Section 
1833(a)(2) 
(42 
U.S.C.
1395l(a)(2)) is amended—
107
(i) in subparagraph (A), by striking
‘‘health services’’ and inserting ‘‘health
services (other than covered osteoporosis
drug (as defined in section 1861(kk)))’’;
(ii) by striking ‘‘and’’ at the end of
subparagraph (D);
(iii) by striking the semicolon at the
end and inserting ‘‘; and’’; and
(iv) by adding at the end the following
new subparagraph:
‘‘(F) with respect to covered osteoporosis
drug (as defined in section 1861(kk)) furnished
by a home health agency, 80 percent of the rea-
sonable cost of such service, as determined
under section 1861(v);’’.
(D) APPLICATION
OF
PART
B
DEDUCT-
IBLE.—Section 
1833(b)(2) 
(42 
U.S.C.
1395l(b)(2)) is amended by striking ‘‘services’’
and inserting ‘‘services (other than covered
osteoporosis 
drug 
(as 
defined 
in 
section
1861(kk)))’’.
(E) COVERED OSTEOPOROSIS DRUG (SEC-
TION 4156 OF OBRA–1990).—Section 1861 (42
U.S.C. 1395x) is amended, in the subsection
(jj) inserted by section 4156(a)(2) of OBRA–
108
1990, by striking ‘‘(jj) The term’’ and inserting
‘‘(kk) The term’’.
(9) OTHER
MISCELLANEOUS
AND
TECHNICAL
CORRECTIONS (SECTION 4164 OF OBRA–1990).—
(A) OWNERSHIP
DISCLOSURE
REQUIRE-
MENTS.—(i) 
Section 
1124A(a)(2)(A) 
(42
U.S.C. 1320a–3a(a)(2)(A)) is amended by
striking ‘‘of the Social Security Act’’.
(ii) Section 4164(b)(4) of OBRA–1990 is
amended by striking ‘‘paragraph’’ and inserting
‘‘paragraphs’’.
(B) DIRECTORY
OF
UNIQUE
PHYSICIAN
IDENTIFIER
NUMBERS.—Section 4164(c) of
OBRA–1990 is amended by striking ‘‘publish’’
and inserting ‘‘publish, and shall periodically
update,’’.
(g) EFFECTIVE DATE.—Except as otherwise provided
in this section, the amendments made by this section shall
take effect as if included in the enactment of OBRA–1990.
TITLE III—PROVISIONS
RELATING TO PARTS A AND B
SEC. 301. PROVISIONS RELATING TO PHYSICIAN OWNER-
SHIP AND REFERRAL.
(a) MULTIPLE
LOCATIONS
FOR
GROUP
PRAC-
TICES.—Section 
1877(b)(2)(A)(ii)(II) 
(42 
U.S.C.
109
1395nn(b)(2)(A)(ii)(II)) is amended by striking ‘‘central-
ized provision’’ and inserting ‘‘provision of some or all’’.
(b) TREATMENT
OF
COMPENSATION
ARRANGE-
MENTS.—
(1) RENTAL
OF
OFFICE
SPACE
AND
EQUIP-
MENT.—Paragraph (1) of section 1877(e) (42
U.S.C. 1395nn(e)) is amended to read as follows:
‘‘(1) RENTAL OF OFFICE SPACE; RENTAL OF
EQUIPMENT.—
‘‘(A) OFFICE SPACE.—Payments made by
a lessee to a lessor for the use of premises if—
‘‘(i) the lease is set out in writing,
signed by the parties, and specifies the
premises covered by the lease,
‘‘(ii) the aggregate space rented or
leased is reasonable and necessary for the
legitimate business purposes of the lease or
rental,
‘‘(iii) the lease provides for a term of
rental or lease for at least one year,
‘‘(iv) in the case of a lease that is in-
tended to provide the lessee with access to
the premises for periodic intervals of time,
rather than on a full-time basis, the lease
specifies exactly the schedule of such inter-
110
vals, their length, and the rent for such in-
tervals,
‘‘(v) the rental charges over the term
of the lease are set in advance, are consist-
ent with fair market value, and are not de-
termined in a manner that takes into ac-
count the volume or value of any referrals
or other business generated between the
parties,
‘‘(vi) the lease would be commercially
reasonable even if no referrals were made
between the parties, and
‘‘(vii) the compensation arrangement
meets such other requirements as the Sec-
retary may impose by regulation as needed
to protect against program or patient
abuse.
‘‘(B) EQUIPMENT.—Payments made by a
lessee of equipment to the lessor of the equip-
ment for the use of the equipment if—
‘‘(i) the lease is set out in writing,
signed by the parties, and specifies the
equipment covered by the lease,
111
‘‘(ii) the equipment rented or leased is
reasonable and necessary for the legitimate
business purposes of the lease or rental,
‘‘(iii) the lease provides for a term of
rental or lease of at least one year,
‘‘(iv) in the case of a lease that is in-
tended to provide the lessee with use of the
equipment for periodic intervals of time,
rather than on a full-time basis, the lease
specifies exactly the schedule of such inter-
vals, their length, and the rent for such in-
tervals,
‘‘(v) the rental charges over the term
of the lease are set in advance, are consist-
ent with fair market value, and are not de-
termined in a manner that takes into ac-
count the volume or value of any referrals
or other business generated between the
parties,
‘‘(vi) the lease would be commercially
reasonable even if no referrals were made
between the parties, and
‘‘(vii) the compensation arrangement
meets such other requirements as the Sec-
retary may impose by regulation as needed