H. R. 2015—221
‘‘(G) with respect to items and services described in
section 1861(s)(10)(A), the lesser of—
‘‘(i) the reasonable cost of such services, as deter-
mined under section 1861(v), or
‘‘(ii) the customary charges with respect to such
services,
or, if such services are furnished by a public provider
of services, or by another provider which demonstrates
to the satisfaction of the Secretary that a significant portion
of its patients are low-income (and requests that payment
be made under this provision), free of charge or at nominal
charges to the public, the amount determined in accordance
with section 1814(b)(2);’’.
(B) REQUIRING PAYMENT FOR ALL ITEMS AND SERVICES
TO BE MADE TO AGENCY.—
(i) IN
GENERAL.—The first sentence of section
1842(b)(6) (42 U.S.C. 1395u(b)(6)) (as amended by sec-
tion 4432(b)(2)) is amended—
(I) by striking ‘‘and (E)’’ and inserting ‘‘(E)’’;
and
(II) by striking the period at the end and
inserting the following: ‘‘, and (F) in the case of
home health services furnished to an individual
who (at the time the item or service is furnished)
is under a plan of care of a home health agency,
payment shall be made to the agency (without
regard to whether or not the item or service was
furnished by the agency, by others under arrange-
ment with them made by the agency, or when
any other contracting or consulting arrangement,
or otherwise).’’.
(ii) CONFORMING AMENDMENT.—Section 1832(a)(1)
(42 U.S.C. 1395k(a)(1)) (as amended by section
4432(b)(5)(B)) 
is 
amended 
by 
striking 
‘‘section
1842(b)(6)(E);’’ and inserting ‘‘subparagraphs (E) and
(F) of section 1842(b)(6);’’.
(C) EXCLUSIONS FROM COVERAGE.—Section 1862(a) (42
U.S.C. 1395y(a)) (as amended by sections 4319(b), 4432(b),
4507(a)(2)(B) and 4541(b)) is amended—
(i) by striking ‘‘or’’ at the end of paragraph (19);
(ii) by striking the period at the end of paragraph
(20) and inserting ‘‘; or’’; and
(iii) by inserting after paragraph (20) the following:
‘‘(21) where such expenses are for home health services
furnished to an individual who is under a plan of care of
the home health agency if the claim for payment for such
services is not submitted by the agency.’’.
(d) EFFECTIVE
DATE.—Except as otherwise provided, the
amendments made by this section shall apply to cost reporting
periods beginning on or after October 1, 1999.
(e) CONTINGENCY.—If the Secretary of Health and Human Serv-
ices for any reason does not establish and implement the prospective
payment system for home health services described in section
1895(b) of the Social Security Act (as added by subsection (a))
for cost reporting periods described in subsection (d), for such cost
reporting periods the Secretary shall provide for a reduction by
15 percent in the cost limits and per beneficiary limits described
H. R. 2015—222
in section 1861(v)(1)(L) of such Act, as those limits would otherwise
be in effect on September 30, 1999.
SEC. 4604. PAYMENT BASED ON LOCATION WHERE HOME HEALTH
SERVICE IS FURNISHED.
(a) CONDITIONS OF PARTICIPATION.—Section 1891 (42 U.S.C.
1395bbb) is amended by adding at the end the following:
‘‘(g) PAYMENT ON BASIS OF LOCATION OF SERVICE.—A home
health agency shall submit claims for payment for home health
services under this title only on the basis of the geographic location
at which the service is furnished, as determined by the Secretary.’’.
(b) WAGE ADJUSTMENT.—Section 1861(v)(1)(L)(iii) (42 U.S.C.
1395x(v)(1)(L)(iii)) is amended by striking ‘‘agency is located’’ and
inserting ‘‘service is furnished’’.
(c) EFFECTIVE DATE.—The amendments made by this section
apply to cost reporting periods beginning on or after October 1,
1997.
Subchapter B—Home Health Benefits
SEC. 4611. MODIFICATION OF PART A HOME HEALTH BENEFIT FOR
INDIVIDUALS ENROLLED UNDER PART B.
(a) IN GENERAL.—Section 1812 (42 U.S.C. 1395d) is amended—
(1) in subsection (a)(3), by striking ‘‘home health services’’
and inserting ‘‘for individuals not enrolled in part B, home
health services, and for individuals so enrolled, post-institu-
tional home health services furnished during a home health
spell of illness for up to 100 visits during such spell of illness’’;
and
(2) in subsection (b), by adding after and below paragraph
(3) the following:
‘‘Payment under this part for post-institutional home health services
furnished an individual during a home health spell of illness may
not be made for such services beginning after such services have
been furnished for a total of 100 visits such spell.’’.
(b) POST-INSTITUTIONAL HOME HEALTH SERVICES DEFINED.—
Section 1861 (42 U.S.C. 1395x), as amended by sections 4103(a),
4104(a), 4105(a), 4106(a), and 4454, is amended by adding at the
end the following:
‘‘Post-Institutional Home Health Services; Home Health Spell of
Illness
‘‘(tt)(1) The term ‘post-institutional home health services’ means
home health services furnished to an individual—
‘‘(A) after discharge from a hospital or rural primary care
hospital in which the individual was an inpatient for not less
than 3 consecutive days before such discharge if such home
health services were initiated within 14 days after the date
of such discharge; or
‘‘(B) after discharge from a skilled nursing facility in which
the individual was provided post-hospital extended care services
if such home health services were initiated within 14 days
after the date of such discharge.
‘‘(2) The term ‘home health spell of illness’ with respect to
any individual means a period of consecutive days—
‘‘(A) beginning with the first day (not included in a previous
home health spell of illness) (i) on which such individual is
H. R. 2015—223
furnished post-institutional home health services, and (ii) which
occurs in a month for which the individual is entitled to benefits
under part A, and
‘‘(B) ending with the close of the first period of 60 consecu-
tive days thereafter on each of which the individual is neither
an inpatient of a hospital or rural primary care hospital nor
an inpatient of a facility described in section 1819(a)(1) or
subsection (y)(1) nor provided home health services.’’.
(c) MAINTAINING APPEAL RIGHTS
FOR HOME HEALTH SERV-
ICES.—Section 1869(b)(2)(B) (42 U.S.C. 1395ff(b)(2)(B)) is amended
by inserting ‘‘(or $100 in the case of home health services)’’ after
‘‘$500’’.
(d) MAINTAINING SEAMLESS ADMINISTRATION THROUGH FISCAL
INTERMEDIARIES.—Section 1842(b)(2) (42 U.S.C. 1395u(b)(2)) is
amended by adding at the end the following:
‘‘(E) With respect to the payment of claims for home health
services under this part that, but for the amendments made by
section 4611 of the Balanced Budget Act of 1997, would be payable
under part A instead of under this part, the Secretary shall continue
administration of such claims through fiscal intermediaries under
section 1816.’’.
(e) TRANSITION.—
(1) IN GENERAL.—Notwithstanding any provision of title
XVIII of the Social Security Act, the Secretary of Health and
Human Services shall establish a transition for the aggregate
amount of expenditures that are transferred from part A, to
part B, of title XVIII of the Social Security Act, as a result
of the amendments made by this section, during each of the
years during the period beginning with 1998 and ending with
2002 according to this subsection. Under the transition for
each such year, the Secretary shall effect such transfer, between
the trust funds under such parts, as will result in only the
proportion (specified in paragraph (2)) of such aggregate
expenditures for the year being transferred from such part
A to such part B.
(2) PROPORTION
SPECIFIED.—The proportion specified in
this paragraph for—
(A) 1998 is 1⁄6,
(B) 1999 is 1⁄3,
(C) 2000 is 1⁄2,
(D) 2001 is 2⁄3, and
(E) 2002 is 5⁄6.
(3) APPLICATION IN ESTABLISHING MONTHLY PREMIUMS FOR
1998 THROUGH 2003.—
(A) IN GENERAL.—For purposes only of computing the
monthly premium under section 1839 of the Social Security
Act (42 U.S.C. 1395r), the monthly actuarial rate for enroll-
ees age 65 and over shall be computed as though any
reference in paragraph (1) of this subsection to 2002 were
a reference to 2003 and as if the following proportions
were substituted for the proportions specified in paragraph
(2):
(i) For 1998, 1⁄7.
(ii) For 1999, 2⁄7.
(iii) For 2000, 3⁄7.
(iv) For 2001, 4⁄7.
(v) For 2002, 5⁄7.
H. R. 2015—224
(vi) For 2003, 6⁄7.
(B) NO
IMPACT
ON
GOVERNMENT
CONTRIBUTION.—
Subparagraph (A) does not apply in determining the
amount of the Government contribution under section 1844
of the Social Security Act (42 U.S.C. 1395w).
(f) EFFECTIVE DATE.—The amendments made by this section
apply to services furnished on or after January 1, 1998. For purpose
of applying such amendments, any home health spell of illness
that began, but not did not end, before such date shall be considered
to have begun as of such date.
SEC. 4612. CLARIFICATION OF PART-TIME OR INTERMITTENT NURSING
CARE.
(a) IN GENERAL.—Section 1861(m) (42 U.S.C. 1395x(m)) is
amended by adding at the end the following: ‘‘For purposes of
paragraphs (1) and (4), the term ‘part-time or intermittent services’
means skilled nursing and home health aide services furnished
any number of days per week as long as they are furnished (com-
bined) less than 8 hours each day and 28 or fewer hours each
week (or, subject to review on a case-by-case basis as to the need
for care, less than 8 hours each day and 35 or fewer hours per
week). For purposes of sections 1814(a)(2)(C) and 1835(a)(2)(A),
‘intermittent’ means skilled nursing care that is either provided
or needed on fewer than 7 days each week, or less than 8 hours
of each day for periods of 21 days or less (with extensions in
exceptional circumstances when the need for additional care is
finite and predictable).’’.
(b) EFFECTIVE DATE.—The amendment made by subsection (a)
applies to services furnished on or after October 1, 1997.
SEC. 4613. STUDY ON DEFINITION OF HOMEBOUND.
(a) STUDY.—The Secretary of Health and Human Services shall
conduct a study of the criteria that should be applied, and the
method of applying such criteria, in the determination of whether
an individual is homebound for purposes of qualifying for receipt
of benefits for home health services under the medicare program.
Such criteria shall include the extent and circumstances under
which a person may be absent from the home but nonetheless
qualify.
(b) REPORT.—Not later than October 1, 1998, the Secretary
shall submit a report to Congress on the study conducted under
subsection (a). The report shall include specific recommendations
on such criteria and methods.
SEC. 4614. NORMATIVE STANDARDS FOR HOME HEALTH CLAIMS
DENIALS.
(a) IN GENERAL.—Section 1862(a)(1) (42 U.S.C. 1395y(a)(1))
(as amended by section 4104(c)) is amended—
(1) by striking ‘‘and’’ at the end of subparagraph (G),
(2) by striking the semicolon at the end of subparagraph
(H) and inserting ‘‘, and’’, and
(3) by inserting after subparagraph (H) the following new
subparagraph:
‘‘(I) the frequency and duration of home health services
which are in excess of normative guidelines that the Secretary
shall establish by regulation;’’.
(b) NOTIFICATION.—The Secretary of Health and Human Serv-
ices may establish a process for notifying a physician in cases