H. R. 2015—225
in which the number of home health visits, furnished under title
XVIII of the Social Security Act pursuant to a prescription or
certification of the physician, significantly exceeds such threshold
(or thresholds) as the Secretary specifies. The Secretary may adjust
such threshold to reflect demonstrated differences in the need for
home health services among different beneficiaries.
(c) EFFECTIVE DATE.—The amendments made by this section
apply to services furnished on or after October 1, 1997.
SEC. 4615. NO HOME HEALTH BENEFITS BASED SOLELY ON DRAWING
BLOOD.
(a) IN GENERAL.—Sections 1814(a)(2)(C) and 1835(a)(2)(A) (42
U.S.C. 1395f(a)(2)(C), 1395n(a)(2)(A)) are each amended by inserting
‘‘(other than solely venipuncture for the purpose of obtaining a
blood sample)’’ after ‘‘skilled nursing care’’.
(b) EFFECTIVE DATE.—The amendments made by subsection
(a) apply to home health services furnished after the 6-month
period beginning after the date of enactment of this Act.
SEC. 4616. REPORTS TO CONGRESS REGARDING HOME HEALTH COST
CONTAINMENT.
(a) ESTIMATE.—Not later than October 1, 1997, the Secretary
of Health and Human Services shall submit to the Committees
on Commerce and Ways and Means of the House of Representatives
and the Committee on Finance of the Senate a report that includes
an estimate of the outlays that will be made under parts A and
B of title XVIII of the Social Security Act for the provision of
home health services during each of fiscal years 1998 through
2002.
(b) ANNUAL REPORT.—Not later than the end of each of years
1999 through 2002, the Secretary shall submit to such Committees
a report that compares the actual outlays under such parts for
such services during the fiscal year ending in the year, to the
outlays estimated under subsection (a) for such fiscal year. If the
Secretary finds that such actual outlays were greater than such
estimated outlays for the fiscal year, the Secretary shall include
in the report recommendations regarding beneficiary copayments
for home health services provided under the medicare program
or such other methods as will reduce the growth in outlays for
home health services under the medicare program.
CHAPTER 2—GRADUATE MEDICAL EDUCATION
Subchapter A—Indirect Medical Education
SEC. 4621. INDIRECT GRADUATE MEDICAL EDUCATION PAYMENTS.
(a) MULTIYEAR TRANSITION REGARDING PERCENTAGES.—
(1) IN
GENERAL.—Section 1886(d)(5)(B)(ii) (42 U.S.C.
1395ww(d)(5)(B)(ii)) is amended to read as follows:
‘‘(ii) For purposes of clause (i)(II), the indirect teaching
adjustment factor is equal to c × (((1+r) to the nth power)
¥ 1), where ‘r’ is the ratio of the hospital’s full-time equiva-
lent interns and residents to beds and ‘n’ equals .405.
For discharges occurring—
‘‘(I) on or after October 1, 1988, and before October
1, 1997, ‘c’ is equal to 1.89;
‘‘(II) during fiscal year 1998, ‘c’ is equal to 1.72;
‘‘(III) during fiscal year 1999, ‘c’ is equal to 1.6;
H. R. 2015—226
‘‘(IV) during fiscal year 2000, ‘c’ is equal to 1.47;
and
‘‘(V) on or after October 1, 2000, ‘c’ is equal to
1.35.’’.
(2) CONFORMING AMENDMENT RELATING TO DETERMINATION
OF STANDARDIZED AMOUNT.—Section 1886(d)(2)(C)(i) (42 U.S.C.
1395ww(d)(2)(C)(i)) is amended by adding at the end the follow-
ing: ‘‘except that the Secretary shall not take into account
any reduction in the amount of additional payments under
paragraph (5)(B)(ii) resulting from the amendment made by
section 4621(a)(1) of the Balanced Budget Act of 1997,’’.
(b) LIMITATION ON NUMBER OF RESIDENTS FOR CERTAIN FISCAL
YEARS.—
(1) 
IN
GENERAL.—Section 
1886(d)(5)(B) 
(42 
U.S.C.
1395ww(d)(5)(B)) is amended by adding after clause (iv) the
following:
‘‘(v) In determining the adjustment with respect to
a hospital for discharges occurring on or after October
1, 1997, the total number of full-time equivalent interns
and residents in the fields of allopathic and osteopathic
medicine in either a hospital or nonhospital setting may
not exceed the number of such full-time equivalent interns
and residents in the hospital with respect to the hospital’s
most recent cost reporting period ending on or before
December 31, 1996.
‘‘(vi) For purposes of clause (ii)—
‘‘(I) ‘r’ may not exceed the ratio of the number
of interns and residents, subject to the limit under
clause (v), with respect to the hospital for its most
recent cost reporting period to the hospital’s available
beds (as defined by the Secretary) during that cost
reporting period, and
‘‘(II) for the hospital’s cost reporting periods begin-
ning on or after October 1, 1997, subject to the limits
described in clauses (iv) and (v), the total number
of full-time equivalent residents for payment purposes
shall equal the average of the actual full-time equiva-
lent resident count for the cost reporting period and
the preceding two cost reporting periods.
In the case of the first cost reporting period beginning
on or after October 1, 1997, subclause (II) shall be applied
by using the average for such period and the preceding
cost reporting period.
‘‘(vii) If any cost reporting period beginning on or after
October 1, 1997, is not equal to twelve months, the Secretary
shall make appropriate modifications to ensure that the average
full-time equivalent residency count pursuant to subclause (II)
of clause (vi) is based on the equivalent of full twelve-month
cost reporting periods.
‘‘(viii) Rules similar to the rules of subsection (h)(4)(H)
shall apply for purposes of clauses (v) and (vi).’’.
(2) PAYMENT FOR INTERNS AND RESIDENTS PROVIDING OFF-
SITE
SERVICES.—Section 
1886(d)(5)(B)(iv) 
(42 
U.S.C.
1395ww(d)(5)(B)(iv)) is amended to read as follows:
‘‘(iv) Effective for discharges occurring on or after October
1, 1997, all the time spent by an intern or resident in patient
care activities under an approved medical residency training
H. R. 2015—227
program at an entity in a nonhospital setting shall be counted
towards the determination of full-time equivalency if the hos-
pital incurs all, or substantially all, of the costs for the training
program in that setting.’’.
SEC. 4622. PAYMENT TO HOSPITALS OF INDIRECT MEDICAL EDU-
CATION COSTS FOR MEDICARE+CHOICE ENROLLEES.
Section 1886(d) (42 U.S.C. 1395ww(d)) is amended by adding
at the end the following:
‘‘(11) ADDITIONAL PAYMENTS FOR MANAGED CARE ENROLL-
EES.—
‘‘(A) IN GENERAL.—For portions of cost reporting peri-
ods occurring on or after January 1, 1998, the Secretary
shall provide for an additional payment amount for each
applicable discharge of any subsection (d) hospital that
has an approved medical residency training program.
‘‘(B) APPLICABLE
DISCHARGE.—For purposes of this
paragraph, the term ‘applicable discharge’ means the dis-
charge of any individual who is enrolled under a risk-
sharing contract with an eligible organization under section
1876 and who is entitled to benefits under part A or any
individual who is enrolled with a Medicare+Choice
organization under part C.
‘‘(C) DETERMINATION OF AMOUNT.—The amount of the
payment under this paragraph with respect to any
applicable discharge shall be equal to the applicable
percentage (as defined in subsection (h)(3)(D)(ii)) of the
estimated average per discharge amount that would other-
wise have been paid under paragraph (5)(B) if the individ-
uals had not been enrolled as described in subparagraph
(B).
‘‘(D) SPECIAL RULE FOR HOSPITALS UNDER REIMBURSE-
MENT SYSTEM.—The Secretary shall establish rules for the
application of this paragraph to a hospital reimbursed
under a reimbursement system authorized under section
1814(b)(3) in the same manner as it would apply to the
hospital if it were not reimbursed under such section.’’.
Subchapter B—Direct Graduate Medical Education
SEC. 4623. LIMITATION ON NUMBER OF RESIDENTS AND ROLLING
AVERAGE FTE COUNT.
Section 1886(h)(4) (42 U.S.C. 1395ww(h)(4)) is amended by
adding after subparagraph (E) the following:
‘‘(F) 
LIMITATION
ON
NUMBER
OF
RESIDENTS
IN
ALLOPATHIC AND OSTEOPATHIC MEDICINE.—Such rules shall
provide that for purposes of a cost reporting period begin-
ning on or after October 1, 1997, the total number of
full-time 
equivalent 
residents 
before 
application 
of
weighting factors (as determined under this paragraph)
with respect to a hospital’s approved medical residency
training program in the fields of allopathic medicine and
osteopathic medicine may not exceed the number of such
full-time equivalent residents for the hospital’s most recent
cost reporting period ending on or before December 31,
1996.
H. R. 2015—228
‘‘(G) COUNTING INTERNS AND RESIDENTS FOR FY 1998
AND SUBSEQUENT YEARS.—
‘‘(i) IN GENERAL.—For cost reporting periods begin-
ning during fiscal years beginning on or after October
1, 1997, subject to the limit described in subparagraph
(F), the total number of full-time equivalent residents
for determining a hospital’s graduate medical edu-
cation payment shall equal the average of the actual
full-time equivalent resident counts for the cost report-
ing period and the preceding two cost reporting periods.
‘‘(ii) ADJUSTMENT FOR SHORT PERIODS.—If any cost
reporting period beginning on or after October 1, 1997,
is not equal to twelve months, the Secretary shall
make appropriate modifications to ensure that the
average full-time equivalent resident counts pursuant
to clause (i) are based on the equivalent of full twelve-
month cost reporting periods.
‘‘(iii) TRANSITION RULE FOR 1998.—In the case of
a hospital’s first cost reporting period beginning on
or after October 1, 1997, clause (i) shall be applied
by using the average for such period and the preceding
cost reporting period.
‘‘(H) SPECIAL
RULES
FOR
APPLICATION
OF
SUBPARA-
GRAPHS (F) AND (G).—
‘‘(i) NEW FACILITIES.—The Secretary shall, consist-
ent with the principles of subparagraphs (F) and (G),
prescribe rules for the application of such subpara-
graphs in the case of medical residency training pro-
grams established on or after January 1, 1995. In
promulgating such rules for purposes of subparagraph
(F), the Secretary shall give special consideration to
facilities that meet the needs of underserved rural
areas.
‘‘(ii) AGGREGATION.—The Secretary may prescribe
rules which allow institutions which are members of
the same affiliated group (as defined by the Secretary)
to elect to apply the limitation of subparagraph (F)
on an aggregate basis.
‘‘(iii) DATA
COLLECTION.—The Secretary may
require any entity that operates a medical residency
training program and to which subparagraphs (F) and
(G) apply to submit to the Secretary such additional
information as the Secretary considers necessary to
carry out such subparagraphs.’’.
SEC. 4624. PAYMENTS TO HOSPITALS FOR DIRECT COSTS OF GRAD-
UATE 
MEDICAL 
EDUCATION 
OF 
MEDICARE+CHOICE
ENROLLEES.
Section 1886(h)(3) (42 U.S.C. 1395ww(h)(3)) is amended by
adding after subparagraph (C) the following:
‘‘(D) PAYMENT FOR MANAGED CARE ENROLLEES.—
‘‘(i) IN GENERAL.—For portions of cost reporting
periods occurring on or after January 1, 1998, the
Secretary shall provide for an additional payment
amount under this subsection for services furnished
to individuals who are enrolled under a risk-sharing
contract with an eligible organization under section