112
to protect against program or patient
abuse.’’.
(2) BONA
FIDE
EMPLOYMENT
RELATION-
SHIPS.—Paragraph (2) of such section is amended—
(A) by striking ‘‘WITH HOSPITALS’’,
(B) by striking ‘‘An arrangement’’ and all
that follows through ‘‘if’’ and inserting ‘‘Any
amount paid by an employer to an employee
who has a bona fide employment relationship
with the employer for employment, or paid by
a hospital pursuant to an arrangement with a
physician (or immediate family member) for the
provision of administrative services, if’’,
(C) in subparagraphs (A), (B), and (D), by
striking ‘‘arrangement’’ and inserting ‘‘employ-
ment relationship or arrangement’’, and
(D) in subparagraph (C), by striking ‘‘to
the hospital’’.
(3) 
ADDITIONAL
EXCEPTIONS.—Such 
sub-
section is further amended by adding at the end the
following new paragraphs:
‘‘(7) PAYMENTS TO A PHYSICIAN FOR OTHER
ITEMS OR SERVICES.—
‘‘(A) IN GENERAL.—Payments made by an
entity to a physician (or family member) who is
113
not employed by the entity as compensation for
services specified in subparagraph (B), if—
‘‘(i) the compensation agreement is
set out in writing and specifies the services
to be provided by the parties, the com-
pensation for each unit of service provided
under the agreement, and the schedule for
the provision of such services,
‘‘(ii) the compensation paid over the
term of the agreement is consistent with
fair market value and is not determined in
a manner that takes into account the vol-
ume or value of any referrals or other busi-
ness generated between the parties,
‘‘(iii) the compensation is provided
pursuant to an agreement which would be
commercially reasonable even if no refer-
rals were made to the entity, and
‘‘(iv) the compensation arrangement
meets such other requirements as the Sec-
retary may impose by regulation as needed
to protect against program or patient
abuse.
114
‘‘(B) SPECIFIED SERVICES.—For purposes
of subparagraph (A), the services specified in
this subparagraph are any of the following:
‘‘(i) Consultative services that—
‘‘(I) relate to test results that
have been obtained that are outside
established parameters, or are specifi-
cally requested by the referring physi-
cian on a specified patient,
‘‘(II) are furnished by a physi-
cian other than the referring physi-
cian (or by another physician who is
a member of the same group prac-
tice), and
‘‘(III) for which the physician
furnishes a written report for that pa-
tient.
‘‘(ii) Interpretation of tissue pathology
or Pap smear slides or the provision of
other cytology services.
‘‘(iii) Phlebotomy services for pater-
nity or toxicology testing where the serv-
ices are furnished by a physician other
than the physician referring the individual
for such testing (or by another physician
115
who is a member of the same group prac-
tice).
‘‘(iv) Employment-related health care
services, including a payment by a self-in-
sured employer for services rendered to
employee applicants, employees, or their
families under the terms of a health bene-
fit plan.
‘‘(v) Services as a clinical consultant
to the entity as required for certification of
the provider under section 353 of the Pub-
lic Health Service Act.
‘‘(vi) Services required by local, State,
or Federal licensure, accreditation, or
other health and safety provisions.
‘‘(vii) Services billed in the name of a
group practice provided by a physician
under contract to the group practice for
services not otherwise available directly
through a physician who is a member of
the group.
‘‘(8) PAYMENTS BY A PHYSICIAN FOR ITEMS
AND SERVICES.—Payments made by a physician—
‘‘(A) to a laboratory in exchange for the
provision of clinical laboratory services, or
116
‘‘(B) to an entity as compensation for
other items or services if the items or services
are furnished at a price that is consistent with
fair market value and are generally available to
referrors and non-referrors alike on similar
terms and conditions.
‘‘(9) PAYMENTS FOR PATHOLOGY SERVICES OF
A GROUP PRACTICE.—Payments made to a group
practice for pathology services under an agreement
if—
‘‘(A) the agreement is set out in writing
and specifies the services to be provided by the
parties and the compensation for services pro-
vided under the agreement;
‘‘(B) the compensation paid over the
term of the agreement is consistent with
fair market value and is not determined in
a manner that takes into account the vol-
ume or value of any referrals or other busi-
ness generated between the parties,
‘‘(C) the compensation is provided
pursuant to an agreement which would be
commercially reasonable even if no refer-
rals were made to the entity; and
117
‘‘(D) the compensation arrangement be-
tween the parties meets such other require-
ments as the Secretary may impose by regula-
tion as needed to protect against program or
patient abuse.’’.
(c) TREATMENT
OF GROUP PRACTICE LABORA-
TORIES.—
(1) USE OF BILLING NUMBERS, ETC.—Section
1877 is amended—
(A) in subsection (b)(2)(B), by inserting
‘‘under a billing number assigned to the group
practice’’ after ‘‘member’’,
(B) in subsection (h)(4)(B), by inserting
‘‘and under a billing number assigned to the
group’’ after ‘‘in the name of the group’’, and
(C) in subsection (h)(4)(C), by striking
‘‘by members of the group’’.
(2) TREATMENT
OF
SERVICES
UNDER
AR-
RANGEMENTS
BETWEEN
HOSPITALS
AND
GROUP
PRACTICES.—
(A) IN GENERAL.—Section 1877(h)(4) is
amended—
(i) in subparagraph (B) (as amended
by paragraph (1)(B)), by inserting ‘‘(or
are billed in the name of a hospital for
118
which the group provides clinical labora-
tory services pursuant to an arrangement
that meets the requirements of subpara-
graph (B))’’ after ‘‘assigned to the group’’;
(ii) by redesignating subparagraphs
(A) through (D) as clauses (i) through
(iv), respectively;
(iii) by inserting ‘‘(A)’’ after ‘‘.—’’;
and
(iv) by adding at the end the following
new subparagraph:
‘‘(B) The requirements of this subparagraph,
with respect to an arrangement for clinical labora-
tory services provided by the laboratory of a group
and billed in the name of a hospital, are that—
‘‘(i) with respect to services provided to an
inpatient of the hospital, the arrangement is
pursuant to the provision of inpatient hospital
services under section 1861(b)(3);
‘‘(ii) the arrangement began before Decem-
ber 19, 1989, and has continued in effect with-
out interruption since such date;
‘‘(iii) the laboratory provides substantially
all of the clinical laboratory services to the hos-
pital’s patients;
119
‘‘(iv) the arrangement is pursuant to an
agreement that is set out in writing and that
specifies the services to be provided by the par-
ties and the compensation for services provided
under the agreement;
‘‘(v) the compensation paid over the term
of the agreement is consistent with fair market
value and the compensation per unit of services
is fixed in advance and is not determined in a
manner that takes into account the volume or
value of any referrals or other business gen-
erated between the parties,
‘‘(vi) the compensation is provided pursu-
ant to an agreement which would be commer-
cially reasonable even if no referrals were made
to the entity; and
‘‘(vii) the arrangement between the parties
meets such other requirements as the Secretary
may impose by regulation as needed to protect
against program or patient abuse.’’.
(B) CONFORMING
AMENDMENT.—Section
1877(b)(2)(B) is amended by inserting ‘‘(or by
a hospital for which such a group practice pro-
vides clinical laboratory services pursuant to an
arrangement that meets the requirements of
120
subsection (h)(4)(B))’’ after ‘‘by a group prac-
tice of which such physician is a member’’.
(3) TREATMENT OF CERTAIN FACULTY PRAC-
TICE
PLANS.—The 
last 
sentence 
of 
section
1877(h)(4)(A), as redesignated by paragraph (1)(A),
is amended by inserting ‘‘, institution of higher edu-
cation, or medical school’’ after ‘‘hospital’’.
(d) EXPANDING RURAL PROVIDER EXCEPTION TO
COVER COMPENSATION ARRANGEMENTS.—
(1) IN GENERAL.—Section 1877(b) is further
amended—
(A) by redesignating paragraph (5) as
paragraph (7), and
(B) by inserting after paragraph (4) the
following new paragraph:
‘‘(5) RURAL PROVIDERS.—In the case of clini-
cal laboratory services if—
‘‘(A) the laboratory furnishing the services
is in a rural area (as defined in section
1886(d)(2)(D)), and
‘‘(B) substantially all of the services fur-
nished by the laboratory to individuals entitled
to benefits under this title are furnished to such
individuals who reside in such a rural area.’’.
121
(2) 
CONFORMING
AMENDMENTS.—Section
1877(d) is amended—
(A) by striking paragraph (2), and
(B) by redesignating paragraph (3) as
paragraph (2).
(e) EXCEPTION FOR SHARED FACILITY SERVICES.—
(1) IN GENERAL.—Section 1877 is amended—
(A) in subsection (b), as amended by sub-
section (d)(1), by inserting after paragraph (5)
the following new paragraph:
‘‘(6) SHARED FACILITY SERVICES.—
‘‘(A) IN GENERAL.—In the case of shared
facility services of a shared facility—
‘‘(i) that are furnished—
‘‘(I) personally by the referring
physician who is a shared facility phy-
sician or personally by an individual
supervised by such a physician or by
another shared facility physician and
employed under the shared facility ar-
rangement,
‘‘(II) by a shared facility in a
building in which the referring physi-
cian furnishes physician’s services un-
122
related to the furnishing of shared fa-
cility services, and
‘‘(III) to a patient of a shared fa-
cility physician; and
‘‘(ii) that are billed by the referring
physician or by an entity that is wholly
owned by such physician.
‘‘(B) LIMITATION.—The exception under
this paragraph shall only apply to a shared fa-
cility only if the facility and the shared facility
arrangement were established as of June 26,
1992.’’; and
(B) in subsection (h), by adding at the end
the following new paragraph:
‘‘(8) SHARED
FACILITY
RELATED
DEFINI-
TIONS.—
‘‘(A) SHARED
FACILITY
SERVICES.—The
term ‘shared facility services’ means, with re-
spect to a shared facility, clinical laboratory
services furnished by the facility to patients of
shared facility physicians.
‘‘(B) 
SHARED
FACILITY.—The 
term
‘shared facility’ means an entity that furnishes
shared facility services under a shared facility
arrangement.
123
‘‘(C) SHARED FACILITY PHYSICIAN.—The
term ‘shared facility physician’ means, with re-
spect to a shared facility, a physician who has
a financial relationship under a shared facility
arrangement with the facility.
‘‘(D) SHARED FACILITY ARRANGEMENT.—
The term ‘shared facility arrangement’ means,
with respect to the provision of shared facility
services in a building, a financial arrange-
ment—
‘‘(i) which is only between physicians
who are providing services (unrelated to
shared facility services) in the same build-
ing,
‘‘(ii) in which the overhead expenses
of the facility are shared, in accordance
with methods previously determined by the
physicians in the arrangement, among the
physicians in the arrangement, and
‘‘(iii) which, in the case of a corpora-
tion, is wholly owned and controlled by
shared facility physicians.’’.
(2) GAO STUDY
OF
SHARED
FACILITY
AR-
RANGEMENTS.—
124
(A) IN GENERAL.—The Comptroller Gen-
eral shall analyze the effect on the utilization of
health services of shared facility arrangements
for which an exception is provided under the
amendments made by paragraph (1). The anal-
ysis shall include a review of the effect of the
limitation, described in section 1877(b)(6)(B) of
the Social Security Act (as added by paragraph
(1)), with respect to such exception and on the
availability of services (including hematology
services).
(B) REPORT.—Not later than January 1,
1994, the Comptroller General shall submit a
report to Congress on the analysis conducted
under subparagraph (A). The report shall in-
clude recommendations with respect to chang-
ing the limitation.
(f) EXEMPTION OF COMPENSATION ARRANGEMENTS
INVOLVING CERTAIN TYPES OF REMUNERATION.—Sec-
tion 1877(h)(1) (42 U.S.C. 1395nn(h)(1)) is amended—
(1) by striking subparagraph (B);
(2) in subparagraph (A), by inserting before the
period the following: ‘‘(other than an arrangement
involving only remuneration described in subpara-
graph (B))’’; and
125
(3) by adding at the end the following new sub-
paragraph:
‘‘(B) Remuneration described in this subpara-
graph is any remuneration consisting of any of the
following:
‘‘(i) The forgiveness of amounts owed for
inaccurate tests, mistakenly performed tests, or
the correction of minor billing errors.
‘‘(ii) The provision of items, devices, or
supplies of minor value that are used to—
‘‘(I) collect, transport, process, or
store specimens for the entity providing
the item, device, or supply, or
‘‘(II) communicate the results of tests
for such entity.
‘‘(iii) The furnishing by an entity of lab-
oratory services to a group practice affiliated
with the entity, if the entity provides all or sub-
stantially all of the clinical laboratory services
of the group practice.’’.
(g) MISCELLANEOUS
AND
TECHNICAL
CORREC-
TIONS.—Section 1877 (42 U.S.C. 1395nn) is amended—
(1) in the fourth sentence of subsection (f)—
(A) by striking ‘‘provided’’ and inserting
‘‘furnished’’, and
126
(B) by striking ‘‘provides’’ and inserting
‘‘furnish’’;
(2) in the fifth sentence of subsection (f)—
(A) by striking ‘‘providing’’ each place it
appears and inserting ‘‘furnishing’’,
(B) by striking ‘‘with respect to the provid-
ers’’ and inserting ‘‘with respect to the enti-
ties’’, and
(C) by striking ‘‘diagnostic imaging serv-
ices of any type’’ and inserting ‘‘magnetic reso-
nance imaging, computerized axial tomography
scans, and ultrasound services’’; and
(3) in subsection (a)(2)(B), by striking ‘‘sub-
section (h)(1)(A)’’ and inserting ‘‘subsection (h)(1)’’.
(h) EFFECTIVE DATE.—The amendments made by
this section shall apply to referrals made on or after Janu-
ary 1, 1992.
SEC. 302. DIRECT GRADUATE MEDICAL EDUCATION.
(a) ADJUSTMENT IN GME BASE-YEAR COSTS OF
FEDERAL INSURANCE CONTRIBUTIONS ACT.—
(1) IN GENERAL.—In determining the amount
of payment to be made under section 1886(h) of the
Social Security Act in the case of a hospital de-
scribed in subsection (b) for cost reporting periods
beginning on or after October 1, 1992, the Secretary
127
of Health and Human Services shall redetermine the
approved FTE resident amount to reflect the
amount that would have been paid the hospital if,
during the hospital’s base cost reporting period, the
hospital had been liable for FICA taxes or for con-
tributions to the retirement system of a State, a po-
litical subdivision of a State, or an instrumentality
of such a State or political subdivision with respect
to interns and residents in its medical residency
training program.
(2) HOSPITALS
AFFECTED.—A hospital de-
scribed in this subsection is a hospital that did not
pay FICA taxes with respect to interns and resi-
dents in its medical residency training program dur-
ing the hospital’s base cost reporting period, but is
required to pay FICA taxes or make contributions to
a retirement system described in paragraph (1) with
respect to such interns and residents because of the
amendments made by section 11332(b) of OBRA–
1990.
(3) DEFINITIONS.—In this subsection:
(A) the ‘‘base cost reporting period’’ for a
hospital is the hospital’s cost reporting period
that began during fiscal year 1984.
128
(B) The term ‘‘FICA taxes’’ means, with
respect to a hospital, the taxes under section
3111 of the Internal Revenue Code of 1986.
(b) PUBLICLY-FUNDED FAMILY PRACTICE RESI-
DENCY PROGRAMS.—
(1) IN
GENERAL.—Section 1886(h)(5) (42
U.S.C. 1395ww(h)(5)) is amended by adding at the
end the following new subparagraph:
‘‘(H) ADJUSTMENTS FOR CERTAIN FAMILY
PRACTICE RESIDENCY PROGRAMS.—
‘‘(i) IN GENERAL.—In the case of an
approved medical residency training pro-
gram (meeting the requirements of clause
(ii)) of a hospital which received payments
from the United States, a State, or a polit-
ical subdivision of a State or an instrumen-
tality of such a State or political subdivi-
sion (other than payments under this title
or a State plan under title XIX) for the
program during the cost reporting period
that began during fiscal year 1984, the
Secretary shall—
‘‘(I) provide for an average
amount under paragraph (2)(A) that
takes into account the Secretary’s es-
129
timate of the amount that would have
been recognized as reasonable under
this title if the hospital had not re-
ceived such payments, and
‘‘(II) reduce the payment amount
otherwise provided under this sub-
section in an amount equal to the pro-
portion of such program payments
during the cost reporting period in-
volved that is allocable to this title.
‘‘(ii) ADDITIONAL
REQUIREMENTS.—
A hospital’s approved medical residency
program meets the requirements of this
clause if—
‘‘(I) the program is limited to
training for family and community
medicine;
‘‘(II) the program is the only ap-
proved medical residency program of
the hospital; and
‘‘(III) the average amount deter-
mined under paragraph (2)(A) for the
hospital (as determined without re-
gard to the increase in such amount
130
described in clause (i)(I)) does not ex-
ceed $10,000.’’.
(2) EFFECTIVE DATE.—The amendment made
by paragraph (1) shall apply to payments under sec-
tion 1886(h) of the Social Security Act for cost re-
porting periods beginning on or after October 1,
1990.
(c) PREVENTIVE CARE SERVICES AS PART OF INI-
TIAL RESIDENCY PERIOD.—
(1) ELIGIBILITY OF PREVENTIVE CARE RESI-
DENCY
PROGRAMS
FOR
EXPANDED
INITIAL
RESI-
DENCY
PERIODS.—Section 1886(h)(5)(F)(ii) (42
U.S.C. 1395ww(h)(5)(F)(ii)) is amended by insert-
ing after ‘‘fellowship program’’ the following: ‘‘or a
preventive care residency or fellowship program’’.
(2) EFFECTIVE DATE.—The amendment made
by paragraph (1) shall apply to cost reporting peri-
ods beginning on or after October 1, 1993.
SEC. 303. END STAGE RENAL DISEASE.
(a) COVERAGE OF IMMUNOSUPPRESSIVE DRUGS.—
(1) IN
GENERAL.—Section 1861(s)(2)(J) (42
U.S.C. 1395x(s)(2)(J)) is amended by striking
‘‘title, within’’ and all that follows and inserting the
following: ‘‘title, but only in the case of drugs fur-
nished—
131
‘‘(i) before 1994, within 12 months after
the date of the transplant procedure,
‘‘(ii) during 1994, within 18 months after
the date of the transplant procedure,
‘‘(iii) during 1995, within 24 months after
the date of the transplant procedure,
‘‘(iv) during 1996, within 30 months after
the date of the transplant procedure, and
‘‘(v) during any year after 1997, within 36
months after the date of the transplant proce-
dure;’’.
(2) EFFECTIVE DATE.—The amendment made
by paragraph (1) shall take effect on the date of the
enactment of this section.
(b) PAYMENT FOR ERYTHROPOIETIN.—
(1) 
IN
GENERAL.—Section
1881(b)(11)(B)(ii)(I) 
(42 
U.S.C.
1395rr(b)(11)(B)(ii)(I)) is amended—
(A) by striking ‘‘1991’’ and inserting
‘‘1994’’; and
(B) by striking ‘‘$11’’ and inserting
‘‘$10’’.
(2) EFFECTIVE DATE.—The amendments made
by paragraph (1) shall apply to erythropoietin fur-
nished on or after January 1, 1994.
132
(c) HOME DIALYSIS DEMONSTRATION TECHNICAL
CORRECTION.—
(1) IN
GENERAL.—Section 4202 of OBRA–
1990 is amended—
(A) in subsection (b)(1)(A), by striking
‘‘home hemodialysis staff assistant’’ and insert-
ing ‘‘qualified home hemodialysis staff assistant
(as described in subsection (d))’’;
(B) in subsection (b)(2)(B)(ii)(I), by strik-
ing ‘‘(as adjusted to reflect differences in area
wage levels);
(C) in subsection (c)(1)(A), by striking
‘‘skilled’’; and
(D) in subsection (c)(1)(E), by striking
‘‘(b)(4)’’ and inserting ‘‘(b)(2)’’.
(2) EFFECTIVE DATE.—The amendments made
by paragraph (1) shall take effect as if included in
the enactment of OBRA–1990.
SEC. 304. MEDICARE SECONDARY PAYER.
(a) SECONDARY PAYER EXEMPTION FOR MEMBERS
OF RELIGIOUS ORDERS.—Effective as if included in the
enactment of OBRA–1989, section 6202(e)(2) of such Act
is amended by adding at the end the following: ‘‘Such
amendment also shall apply to items and services fur-
nished before such date with respect to secondary payor
133
cases which the Secretary of Health and Human Services
had not identified as of such date.’’.
(b) IMPROVING IDENTIFICATION OF MEDICARE SEC-
ONDARY PAYER SITUATIONS.—
(1) SURVEY OF BENEFICIARIES.—
(A) IN GENERAL.—Section 1862(b)(5) (42
U.S.C. 1395y(b)(5)) is amended by adding at
the end the following new subparagraph:
‘‘(D) 
OBTAINING
INFORMATION
FROM
BENEFICIARIES.—Before an individual applies
for benefits under part A or enrolls under part
B, the Administrator shall mail the individual a
questionnaire to obtain information on whether
the individual is covered under a primary plan
and the nature of the coverage provided under
the plan, including the name, address, and iden-
tifying number of the plan.’’.
(B) DISTRIBUTION OF QUESTIONNAIRE BY
CONTRACTOR.—The Secretary of Health and
Human Services shall enter into an agreement
with an entity not later than November 1,
1993, to distribute the questionnaire described
in section 1862(b)(5)(D) of the Social Security
Act (as added by subparagraph (A)).
134
(C) NO MEDICARE SECONDARY PAYOR DE-
NIAL BASED ON FAILURE TO COMPLETE QUES-
TIONNAIRE.—Section 1862(b)(2) (42 U.S.C.
1395y(b)(2)) is amended by adding at the end
the following new subparagraph:
‘‘(C) TREATMENT OF QUESTIONNAIRES.—
The Secretary may not fail to make payment
under subparagraph (A) solely on the ground
that an individual failed to complete a question-
naire concerning the existence of a primary
plan.’’.
(2) MANDATORY
SCREENING
BY
PROVIDERS
AND SUPPLIERS UNDER PART B.—
(A) IN
GENERAL.—Section 1862(b) (42
U.S.C. 1395y(b)) is amended by adding at the
end the following new paragraph:
‘‘(6) SCREENING REQUIREMENTS FOR PROVID-
ERS AND SUPPLIERS.—
‘‘(A) IN GENERAL.—Notwithstanding any
other provision of this title, no payment may be
made for any item or service furnished under
part B unless the entity furnishing such item or
service completes (to the best of its knowledge
and on the basis of information obtained from
the individual to whom the item or service is
135
furnished) the portion of the claim form relat-
ing to the availability of other health benefit
plans.
‘‘(B) PENALTIES.—An entity that know-
ingly, willfully, and repeatedly fails to complete
a claim form in accordance with subparagraph
(A) or provides inaccurate information relating
to the availability of other health benefit plans
on a claim form under such subparagraph shall
be subject to a civil money penalty of not to ex-
ceed $2,000 for each such incident. The provi-
sions of section 1128A (other than subsections
(a) and (b)) shall apply to a civil money penalty
under the previous sentence in the same man-
ner as such provisions apply to a penalty or
proceeding under section 1128A(a).’’.
(B) EFFECTIVE
DATE.—The amendment
made by subparagraph (A) shall apply with re-
spect to items and services furnished on or
after July 1, 1993.
(c) IMPROVEMENTS
IN RECOVERY
OF PAYMENTS
FROM PRIMARY PAYERS.—
(1) SUBMISSION OF REPORTS ON EFFORTS TO
RECOVER ERRONEOUS PAYMENTS.—
136
(A) FISCAL INTERMEDIARIES UNDER PART
A.—Section 1816 (42 U.S.C. 1396h) is amend-
ed by adding at the end the following new sub-
section:
‘‘(k) An agreement with an agency or organization
under this section shall require that such agency or orga-
nization submit an annual report to the Secretary describ-
ing the steps taken to recover payments made for items
or services for which payment has been or could be made
under 
a 
primary 
plan 
(as 
defined 
in 
section
1862(b)(2)(A)).’’.
(B) CARRIERS
UNDER
PART
B.—Section
1842(b)(3) (42 U.S.C. 1395u(b)(3)) is amend-
ed—
(i) by striking ‘‘and’’ at the end of
subparagraphs (G) and (H); and
(ii) by inserting after subparagraph
(H) the following new subparagraph:
‘‘(I) will submit annual reports to the Secretary
describing the steps taken to recover payments made
under this part for items or services for which pay-
ment has been or could be made under a primary
plan (as defined in section 1862(b)(2)(A)).’’.
(2) REQUIREMENTS UNDER CARRIER PERFORM-
ANCE EVALUATION PROGRAM.—
137
(A) FISCAL INTERMEDIARIES UNDER PART
A.—Section 
1816(f)(1)(A) 
(42 
U.S.C.
1396h(f)(1)(A)) is amended by striking ‘‘proc-
essing’’ and inserting ‘‘processing (including the
agency’s or organization’s success in recovering
payments made under this title for services for
which payment has been or could be made
under a primary plan (as defined in section
1862(b)(2)(A)))’’.
(B) CARRIERS
UNDER
PART
B.—Section
1842(b)(2) (42 U.S.C. 1395u(b)(2)) is amended
by adding at the end the following new sub-
paragraph:
‘‘(D) In addition to any other standards and criteria
established by the Secretary for evaluating carrier per-
formance under this paragraph relating to avoiding erro-
neous payments, the Secretary shall establish standards
and criteria relating to the carrier’s success in recovering
payments made under this part for items or services for
which payment has been or could be made under a pri-
mary plan (as defined in section 1862(b)(2)(A)).’’.
(3) DEADLINE FOR REIMBURSEMENT BY PRI-
MARY PLANS.—
(A) 
IN
GENERAL.—Section
1862(b)(2)(B)(i) (42 U.S.C. 1395y(b)(2)(B)(i))
138
is amended by adding at the end the following
sentence: ‘‘If reimbursement is not made to the
appropriate Trust Fund before the expiration of
the 60-day period that begins on the date such
notice or other information is received, the Sec-
retary may charge interest (beginning with the
date on which the notice or other information
is received) on the amount of the reimburse-
ment until reimbursement is made (at a rate
determined by the Secretary in accordance with
regulations of the Secretary of the Treasury ap-
plicable to charges for late payments).’’.
(B) 
CONFORMING
AMENDMENT.—The
heading of clause (i) of section 1862(b)(2)(B) is
amended to read as follows: ‘‘REPAYMENT RE-
QUIRED.—’’.
(C) EFFECTIVE DATE.—The amendments
made by this paragraph shall apply to payments
for items and services furnished on or after the
date of the enactment of this Act.
(4) EFFECTIVE DATE.—The amendments made
by paragraphs (1) and (2) shall apply to contracts
with fiscal intermediaries and carriers under title
XVIII of the Social Security Act for years beginning
with 1993.
139
(d) MISCELLANEOUS
AND
TECHNICAL
CORREC-
TIONS.—
(1) The sentence in section 1862(b)(1)(C)
added by section 4203(c)(1)(B) of OBRA–1990 is
amended—
(A) by striking ‘‘on or before January 1,
1996,’’ and inserting ‘‘before January 1,
1996’’; and
(B) by striking ‘‘clauses (i) and (ii)’’ and
inserting ‘‘this subparagraph’’.
(2) Effective as if included in the enactment of
OBRA–1989, section 1862(b)(1) is amended—
(A) 
in 
subparagraphs 
(A)(v) 
and
(B)(iv)(II), by inserting ‘‘, without regard to
section 5000(d) of such Code’’ before the period
at the end of each subparagraph;
(B) in subparagraph (A)(iii), by striking
‘‘current calendar year or the preceding cal-
endar year’’ and inserting ‘‘current calendar
year and the preceding calendar year’’; and
(C) in the matter in subparagraph (C)
after clause (ii), by striking ‘‘taking into ac-
count that’’ and inserting ‘‘paying benefits sec-
ondary to this title when’’.
140
(3) Section 4203(c)(2) of OBRA–1990 is
amended—
(A) by striking ‘‘the application of clause
(iii)’’ and inserting ‘‘the second sentence’’;
(B) by striking ‘‘on individuals’’ and all
that follows through ‘‘section 226A of such
Act’’;
(C) in clause (ii), by striking ‘‘clause’’ and
inserting ‘‘sentence’’;
(D) in clause (v), by adding ‘‘and’’ at the
end; and
(E) in clause (vi)—
(i) by inserting ‘‘of such Act’’ after
‘‘1862(b)(1)(C)’’, and
(ii) by striking the period at the end
and inserting the following: ‘‘, without re-
gard to the number of employees covered
by such plans.’’.
(4) Section 4203(d) of OBRA–1990 is amended
by striking ‘‘this subsection’’ and inserting ‘‘this sec-
tion’’.
(5) Except as provided in paragraph (2), the
amendments made by this subsection shall be effec-
tive as if included in the enactment of OBRA–1990.
141
SEC. 305. IMPROVED OUTREACH FOR QUALIFIED MEDI-
CARE BENEFICIARIES.
The Secretary of Health and Human Services shall
establish and implement a method for obtaining informa-
tion from newly eligible medicare beneficiaries that may
be used to determine whether such beneficiaries may be
eligible for medical assistance for medicare cost-sharing
under State medicaid plans as qualified medicare bene-
ficiaries, and for transmitting such information to the
State in which such a beneficiary resides.
SEC. 306. SOCIAL HEALTH MAINTENANCE ORGANIZATIONS.
(a) EXTENSION
OF CURRENT WAIVERS.—Section
4018(b) of OBRA–1987, as amended by OBRA–1990, is
amended—
(1) in paragraph (1) by striking ‘‘December 31,
1995’’ and inserting ‘‘December 31, 1997’’; and
(2) in paragraph (4) by striking ‘‘March 31,
1996’’ and inserting ‘‘March 31, 1998’’.
(b) EXPANSION
OF
DEMONSTRATIONS.—Section
2355 of the Deficit Reduction Act of 1984 is amended—
(1) in the last sentence of subsection (a) by
striking ‘‘12 months’’ and inserting ‘‘36 months’’;
and
(2) in subsection (b)(1)(B)—
(A) by striking ‘‘or’’ at the end of clause
(iii); and
142
(B) by redesignating clause (iv) as clause
(v) and inserting after clause (iii) the following
new clause:
‘‘(iv) integrating acute and chronic
care management for patients with end-
stage renal disease through expanded com-
munity care case management services
(and for purposes of a demonstration
project conducted under this clause, any
requirement under a waiver granted under
this section that a project disenroll individ-
uals who develop end-stage renal disease
shall not apply); or’’.
(c) EXPANSION
OF NUMBER
OF MEMBERS PER
SITE.—The Secretary of Health and Human Services may
not impose a limit of less than 12,000 on the number of
individuals that may participate in a project conducted
under section 2355 of the Deficit Reduction Act of 1984.
(d) MISCELLANEOUS
AND
TECHNICAL
CORREC-
TIONS.—
(1) The section following section 4206 of
OBRA–1990 is amended by striking ‘‘SEC. 4027.’’
and inserting ‘‘SEC. 4207.’’, and in this subtitle is
referred to as section 4207 of OBRA–1990.
143
(2) Section 2355(b)(1)(B) of the Deficit Reduc-
tion 
Act 
of 
1984, 
as 
amended 
by 
section
4207(b)(4)(B)(ii) of OBRA–1990, is amended—
(A) by striking ‘‘12907(c)(4)(A)’’ and in-
serting ‘‘4207(b)(4)(B)(i)’’, and
(B) by striking ‘‘feasibilitly’’ and inserting
‘‘feasibility’’.
(3) Section 4207(b)(4)(B)(iii)(III) of OBRA–
1990 is amended by striking the period at the end
and inserting a semicolon.
(4) Subsections (c)(3) and (e) of section 2355
of the Deficit Reduction Act of 1984, as amended by
section 4207(b)(4)(B) of OBRA–1990, are each
amended by striking ‘‘12907(c)(4)(A)’’ each place it
appears and inserting ‘‘4207(b)(4)(B)’’.
(5) Section 4207(c)(2) of OBRA–1990 is
amended by striking ‘‘the Committee on Ways and
Means’’ each place it appears and inserting ‘‘the
Committees on Ways and Means and Energy and
Commerce’’.
(6) Section 4207(d) of OBRA–1990 is amended
by redesignating the second paragraph (3) (relating
to effective date) as paragraph (4).
(7) Section 4207(i)(2) of OBRA–1990 is
amended—
144
(A) by striking the period at the end of
clause (iii) and inserting a semicolon, and
(B) in clause (v), by striking ‘‘residents’’
and inserting ‘‘patients’’.
(8) Section 4207(j) of OBRA–1990 is amended
by striking ‘‘title’’ each place it appears and insert-
ing ‘‘subtitle’’.
(e) EFFECTIVE DATE.—The amendments made by
this section shall take effect as if included in the enact-
ment of OBRA–90.
SEC. 307. PEER REVIEW ORGANIZATIONS.
(a) REPEAL OF PRO PRECERTIFICATION REQUIRE-
MENT FOR CERTAIN SURGICAL PROCEDURES.—
(1) IN
GENERAL.—Section 1164 (42 U.S.C.
1320c–13) is repealed.
(2) CONFORMING AMENDMENTS.—
(A) Section 1154 (42 U.S.C. 1320c–3) is
amended—
(i) in subsection (a), by striking para-
graph (12), and
(ii) in subsection (d), by striking
‘‘(and except as provided in section
1164)’’.
(B) Section 1833 (42 U.S.C. 1395l) is
amended—