semicolon and inserting the following: ‘‘, unless
the survey shows that the facility is in compli-
ance with the requirements of subsections (b),
(c), and (d) of this section;’’.
(B) EFFECTIVE
DATE.—The amendment
made by subparagraph (A) shall take effect as
if included in the enactment of OBRA–1990.
(2) REQUIREMENTS
FOR
CONSULTANTS
CON-
DUCTING REVIEWS ON USE OF DRUGS.—
(A) IN GENERAL.—Section 1819(c)(1)(D)
(42 U.S.C. 1395i–3(c)(1)(D)) is amended by
adding at the end the following sentence: ‘‘In
determining whether such a consultant is quali-
fied to conduct reviews under the preceding sen-
tence, the Secretary shall take into account the
needs of nursing facilities under this title to
have access to the services of such a consultant
on a timely basis.’’.
(B) EFFECTIVE
DATE.—The amendment
made by subparagraph (A) shall take effect as
if included in the enactment of OBRA–1987.
(3) INCREASE IN MINIMUM AMOUNT REQUIRED
FOR SEPARATE DEPOSIT OF PERSONAL FUNDS.—
(A) 
IN
GENERAL.—Section
1819(c)(6)(B)(i) 
(42 
U.S.C. 
1395i–
3(c)(6)(B)(i)) is amended by striking ‘‘$50’’
and inserting ‘‘$100’’.
(B) EFFECTIVE
DATE.—The amendment
made by subparagraph (A) shall take effect
January 1, 1995.
(4) DUE
PROCESS
PROTECTIONS
FOR
NURSE
AIDES.—
(A) PROHIBITING STATE FROM INCLUDING
UNDOCUMENTED
ALLEGATIONS
IN
NURSES
AIDE
REGISTRY.—Section 1819(e)(2)(B) (42
U.S.C. 1395i–3(e)(2)(B)) is amended by strik-
ing the period at the end of the first sentence
and inserting the following: ‘‘, but shall not in-
clude any allegations of resident abuse or ne-
glect or misappropriation of resident property
that are not specifically documented by the
State under such subsection.’’.
(B) DUE
PROCESS
REQUIREMENTS
FOR
REBUTTING
ALLEGATIONS.—Section
1819(g)(1)(C) (42 U.S.C. 1395i–3(g)(1)(C)) is
amended by striking the second sentence and
inserting the following: ‘‘The State shall, after
providing the individual involved with a written
notice of the allegations (including a statement
of the availability of a hearing for the individual
to rebut the allegations) and the opportunity
for a hearing on the record, make a written
finding as to the accuracy of the allegations.’’.
(C) EFFECTIVE DATE.—The amendments
made by this paragraph shall take effect Janu-
ary 1, 1995.
(d) CORRECTIONS RELATING TO SECTION 4008.—
(1) Section 1819(b)(5)(D) (42 U.S.C. 1395i–
3(b)(5)(D)), as amended by section 4008(h)(1)(D)
of OBRA–1990, is amended by striking the comma
before ‘‘or a new competency evaluation program.’’.
(2) Section 1819(b)(5)(G) (42 U.S.C. 1395i–
3(b)(5)(G)) is amended by striking ‘‘or licensed or
certified social worker’’ and inserting ‘‘licensed or
certified social worker, registered respiratory thera-
pist, or certified respiratory therapy technician’’.
(3) Section 1819(f)(2)(B)(i) (42 U.S.C. 1395i–
3(f)(2)(B)(i)) is amended by striking ‘‘facilities,’’
and inserting ‘‘facilities (subject to clause (iii)),’’.
(4) Section 1819(f)(2)(B)(iii)(I)(c) (42 U.S.C.
1395i–3(f)(2)(B)(iii)(I)(c)) is amended by striking
‘‘clauses’’ each place it appears and inserting
‘‘clause’’.
(5) Section 1819(g)(5)(B) (42 U.S.C. 1395i–
3(g)(5)(B)) is amended by striking ‘‘paragraphs’’
and inserting ‘‘paragraph’’.
(6) Section 4008(h)(1)(F)(ii) of OBRA–1990 is
amended—
(A) by striking ‘‘The amendments’’ and in-
serting ‘‘(I) The amendments’’;
(B) by striking ‘‘nursing facility’’ each
place it appears and inserting ‘‘skilled nursing
facility’’;
(C) 
by 
redesignating 
subclauses 
(I)
through (V) as items (aa) through (ee); and
(D) by adding at the end the following new
subclause:
‘‘(II) Notwithstanding subclause (I)
and subject to section 1819(f)(2)(B)(iii)(I)
of the Social Security Act (as amended by
clause (i)), a State may approve a training
and competency evaluation program or a
competency evaluation program offered by
or in a skilled nursing facility described in
subclause (I) if, during the previous 2
years, item (aa), (bb), (cc), (dd), or (ee) of
subclause (I) did not apply to the facil-
ity.’’.
(7) EFFECTIVE DATE.—The amendments made
by this subsection shall take effect as if included in
the enactment of OBRA–1990.
SEC. 107. NOTIFICATION OF AVAILABILITY OF HOSPICE
BENEFIT.
(a) IN
GENERAL.—Section 1861(ee)(2)(D) (42
U.S.C. 1395x(ee)(2)(D)) is amended by inserting ‘‘, in-
cluding hospice services,’’ after ‘‘post-hospital services’’.
(b) EFFECTIVE DATE.—The amendment made by
subsection (a) shall apply to services furnished on or after
the first day of the first month beginning more than one
year after the date of the enactment of this Act.
SEC. 108. CLARIFYING EXPERTISE OF INDIVIDUALS TO
SERVE ON THE PROSPECTIVE PAYMENT AS-
SESSMENT COMMISSION.
Section 1886(e)(6)(B) (42 U.S.C. 1395ww(e)(6)(B))
is amended by striking ‘‘hospital reimbursement, hospital
financial management’’ and inserting ‘‘health facility man-
agement, reimbursement of health facilities or other pro-
viders of services which reflect the scope of the Commis-
sion’s responsibilities’’.
SEC. 109. AUTHORITY FOR BUDGET NEUTRAL ADJUST-
MENTS FOR CHANGES IN PAYMENT AMOUNTS
FOR TRANSFER CASES.
Section 1886(d)(5)(I) (42 U.S.C. 1395ww(d)(5)) is
amended—
(1) by inserting ‘‘(i)’’ after ‘‘(I)’’; and
(2) by adding at the end the following new
clause:
‘‘(ii) In making adjustments under clause (i) for
transfer cases (as defined by the Secretary) in a fiscal
year, the Secretary may make adjustments to each of the
average standardized amounts determined under para-
graph (3) to assure that the aggregate payments made
under this subsection for such fiscal year are not greater
or lesser than those that would have otherwise been made
in such fiscal year.’’.
SEC. 110. CLARIFICATION OF DRG PAYMENT WINDOW EX-
PANSION; MISCELLANEOUS AND TECHNICAL
CORRECTIONS.
(a) CLARIFICATION OF DRG PAYMENT WINDOW EX-
PANSION.—The first sentence of section 1886(a)(4) (42
U.S.C. 1395ww(a)(4)) is amended by inserting ‘‘(or, in the
case of a hospital that is not a subsection (d) hospital,
during the 1 day)’’ after ‘‘3 days’’.
(b) TECHNICAL CORRECTION RELATING TO RESI-
DENT
ASSESSMENT
IN
NURSING
HOMES.—Section
1819(b)(3)(C)(i)(I) (42 U.S.C. 1395i–3(b)(3)(C)(i)(I)) is
amended by striking ‘‘not later than’’ before ‘‘14 days’’.
(c) TECHNICAL CORRECTION RELATING TO APPLICA-
BLE ADJUSTMENT FACTOR
FOR INDIRECT MEDICAL
EDUCATION
ADJUSTMENT.—Section 1886(d)(5)(B)(ii)
(42 U.S.C. 1395ww(d)(5)(B)(ii)) is amended by striking
‘‘May 1, 1986,’’ and inserting ‘‘October 1, 1988,’’.
(d) 
CLERICAL
CORRECTIONS.—(1) 
Section
1814(i)(1)(C)(i) (42 U.S.C. 1395f(i)(1)(C)(i)) is amended
by striking ‘‘September 30, 1990,,’’ and inserting ‘‘Sep-
tember 30, 1990,’’.
(2) 
Section 
1816(f)(2)(A)(ii) 
(42 
U.S.C.
1396h(f)(2)(A)(ii)) is amended by striking ‘‘such agency’’
and inserting ‘‘such agency’s’’.
Subtitle B—Provisions Relating to
Part B
PART I—PHYSICIANS’ SERVICES
SEC. 121. DEVELOPMENT AND IMPLEMENTATION OF RE-
SOURCE-BASED METHODOLOGY FOR PRAC-
TICE EXPENSES.
(a) DEVELOPMENT.—
(1) IN GENERAL.—The Secretary of Health and
Human Services shall develop a methodology for im-
plementing in 1998 a resource-based system for de-
termining practice expense relative value units for
each physicians’ service. The methodology utilized
shall recognize the staff, equipment, and supplies
used in the provision of various medical and surgical
services in various settings.
(2) REPORT.—The Secretary shall transmit a
report by June 30, 1996, on the methodology devel-
oped under paragraph (1) to the Committees on
Ways and Means and Energy and Commerce of the
House of Representatives and the Committee on Fi-
nance of the Senate. The report shall include a pres-
entation of data utilized in developing the methodol-
ogy and an explanation of the methodology.
(b) IMPLEMENTATION.—
(1) IN
GENERAL.—Section 1848(c)(2)(C)(ii)
(42 U.S.C. 1395w–4(c)(2)(C)(ii)) is amended—
(A) by inserting ‘‘for the service for years
before 1998’’ before ‘‘equal to’’,
(B) by striking the period at the end of
subclause (II) and inserting a comma, and
(C) by adding after and below subclause
(II) the following:
‘‘and for years beginning with 1998 based
on the relative practice expense resources
involved in furnishing the service.’’.
(2) 
CONFORMING
AMENDMENT.—Section
1848(c)(3)(C)(ii) (42 U.S.C. 1395w–4(c)(3)(C)(ii))
is amended by striking ‘‘The practice’’ and inserting
‘‘For years before 1998, the practice’’.
(3) APPLICATION OF CERTAIN PROVISIONS.—In
implementing the amendment made by paragraph
(1)(C), the provisions of clauses (ii)(II) and (iii) of
section 1848(c)(2)(B) of the Social Security Act
shall apply in the same manner as they apply to ad-
justments under clause (ii)(I) of such section.
SEC. 122. GEOGRAPHIC COST OF PRACTICE INDEX REFINE-
MENTS.
(a) REQUIRING CONSULTATION WITH REPRESENTA-
TIVES OF PHYSICIANS IN REVIEWING GEOGRAPHIC AD-
JUSTMENT FACTORS.—Section 1848(e)(1)(C) (42 U.S.C.
1395w–4(e)(1)(C)) is amended by striking ‘‘shall review’’
and inserting ‘‘shall, in consultation with appropriate rep-
resentatives of physicians, review’’.
(b) USE OF MOST RECENT DATA IN GEOGRAPHIC
ADJUSTMENT.—Section 1848(e)(1) (42 U.S.C. 1395w–
4(e)(1)) is amended by adding at the end the following
new subparagraph:
‘‘(D) USE OF RECENT DATA.—In estab-
lishing indices and index values under this
paragraph, the Secretary shall use the most re-
cent data available relating to practice ex-
penses, malpractice expenses, and physician
work effort in different fee schedule areas.’’.
(c) REPORT ON REVIEW PROCESS.—Not later than
1 year after the date of the enactment of this Act, the
Secretary of Health and Human Services shall study and
report to the Committee on Finance of the Senate and
the Committee on Ways and Means and the Committee
on Energy and Commerce of the House of Representatives
on—
(1) the data necessary to review and revise the
indices established under section 1848(e)(1)(A) of
the Social Security Act, including—
(A) the shares allocated to physicians’
work effort, practice expenses (other than mal-
practice expenses), and malpractice expenses;
(B) the weights assigned to the input com-
ponents of such shares; and
(C) the index values assigned to such com-
ponents;
(2) any limitations on the availability of data
necessary to review and revise such indices at least
every three years;
(3) ways of addressing such limitations, with
particular attention to the development of alternative
data sources for input components for which current
index values are based on data collected less fre-
quently than every three years; and
(4) the costs of developing more accurate and
timely data.
SEC. 123. EXTRA-BILLING LIMITS.
(a) ENFORCEMENT OF LIMITS.—Section 1848(g) (42
U.S.C. 1395w–4(g)), as amended by section 13517(a) of
OBRA–1993, is amended—
(1) by amending paragraph (1) to read as fol-
lows:
‘‘(1) LIMITATION ON ACTUAL CHARGES.—
‘‘(A) IN
GENERAL.—In the case of a
nonparticipating physician or nonparticipating
supplier or other person (as defined in section
1842(i)(2)) who does not accept payment on an
assignment-related basis for a physician’s serv-
ice furnished with respect to an individual en-
rolled under this part, the following rules apply:
‘‘(i) 
APPLICATION
OF
LIMITING
CHARGE.—No person may bill or collect an
actual charge for the service in excess of
the limiting charge described in paragraph
(2) for such service.
‘‘(ii) NO
LIABILITY
FOR
EXCESS
CHARGES.—No person is liable for pay-
ment of any amounts billed for the service
in excess of such limiting charge.
‘‘(iii) 
CORRECTION
OF
EXCESS
CHARGES.—If such a physician, supplier,
or other person bills, but does not collect,
an actual charge for a service in violation
of clause (i), the physician, supplier, or
other person shall reduce on a timely basis
the actual charge billed for the service to
an amount not to exceed the limiting
charge for the service.
‘‘(iv) REFUND
OF
EXCESS
COLLEC-
TIONS.—If such a physician, supplier, or
other person collects an actual charge for
a service in violation of clause (i), the phy-
sician, supplier, or other person shall pro-
vide on a timely basis a refund to the indi-
vidual charged in the amount by which the
amount collected exceeded the limiting
charge for the service. The amount of such
a refund shall be reduced to the extent the
individual has an outstanding balance owed
by the individual to the physician.
carrier under this part of such violation and of
the requirements of subparagraph (A).’’; and
(2) in paragraph (3)(B)—
(A) by inserting after the first sentence the
following: ‘‘No person is liable for payment of
any amounts billed for such a service in viola-
tion of the previous sentence.’’, and
(B) in the last sentence, by striking ‘‘pre-
vious sentence’’ and inserting ‘‘first sentence’’.
(b) CLARIFICATION
OF MANDATORY ASSIGNMENT
RULES FOR CERTAIN PRACTITIONERS.—
(1) IN GENERAL.—Section 1842(b) (42 U.S.C.
1395u(b)), as amended by section 126(e), is amend-
ed by adding at the end the following new para-
graph:
‘‘(18)(A) Payment for any service furnished by a
practitioner described in subparagraph (C) and for which
payment may be made under this part on a reasonable
charge or fee schedule basis may only be made under this
part on an assignment-related basis.
‘‘(B) A practitioner described in subparagraph (C) or
other person may not bill (or collect any amount from)
the individual or another person for any service described
in subparagraph (A), except for deductible and coinsur-
ance amounts applicable under this part. No person is lia-
ble for payment of any amounts billed for such a service
in violation of the previous sentence. If a practitioner or
other person knowingly and willfully bills (or collects an
amount) for such a service in violation of such sentence,
the Secretary may apply sanctions against the practitioner
or other person in the same manner as the Secretary may
apply sanctions against a physician in accordance with
subsection (j)(2) in the same manner as such section ap-
plies with respect to a physician. Paragraph (4) of sub-
section (j) shall apply in this subparagraph in the same
manner as such paragraph applies to such section.
‘‘(C) A practitioner described in this subparagraph
is any of the following:
‘‘(i) A physician assistant, nurse practitioner, or
clinical nurse specialist (as defined in section
1861(aa)(5)).
‘‘(ii) A certified registered nurse anesthetist (as
defined in section 1861(bb)(2)).
‘‘(iii) A certified nurse-midwife (as defined in
section 1861(gg)(2)).
‘‘(iv) A clinical social worker (as defined in sec-
tion 1861(hh)(1)).
‘‘(v) A clinical psychologist (as defined by the
Secretary for purposes of section 1861(ii)).
‘‘(D) For purposes of this paragraph, a service fur-
nished by a practitioner described in subparagraph (C) in-
cludes any services and supplies furnished as incident to
the service as would otherwise be covered under this part
if furnished by a physician or as incident to a physician’s
service.’’.
(2) CONFORMING AMENDMENTS.—
(A) Section 1833 (42 U.S.C. 1395l) is
amended—
(i) in subsection (l)(5), by striking
subparagraph (B) and redesignating sub-
paragraph (C) as subparagraph (B);
(ii) by striking subsection (p); and
(iii) in subsection (r), by striking
paragraph (3) and redesignating para-
graph (4) as paragraph (3).
(B) 
Section 
1842(b)(12) 
(42 
U.S.C.
1395u(b)(12)) is amended by striking subpara-
graph (C).
(c) INFORMATION ON EXTRA-BILLING LIMITS.—
(1) PART OF EXPLANATION OF MEDICARE BEN-
EFITS.—Section 
1842(h)(7) 
(42 
U.S.C.
1395u(h)(7)) is amended—
(A) by striking ‘‘and’’ at the end of sub-
paragraph (B),
(B) in subparagraph (C), by striking ‘‘shall
include’’,
(C) in subparagraph (C), by striking the
period at the end and inserting ‘‘, and’’, and
(D) by adding at the end the following new
subparagraph:
‘‘(D) in the case of services for which the billed
amount exceeds the limiting charge imposed under
section 1848(g), information regarding such applica-
ble limiting charge (including information concern-
ing 
the 
right 
to 
a 
refund 
under 
section
1848(g)(1)(A)(iv)).’’.
(2) DETERMINATIONS BY CARRIERS.—Subpara-
graph (G) of section 1842(b)(3) (42 U.S.C.
1395u(b)(3)) is amended to read as follows:
‘‘(G) will, for a service that is furnished with
respect to an individual enrolled under this part,
that is not paid on an assignment-related basis, and
that is subject to a limiting charge under section
1848(g)—
‘‘(i) determine, prior to making payment,
whether the amount billed for such service ex-
ceeds the limiting charge applicable under sec-
tion 1848(g)(2);
‘‘(ii) notify the physician, supplier, or other
person periodically (but not less often than once
every 30 days) of determinations that amounts
billed exceeded such applicable limiting charges;
and
‘‘(iii) provide for prompt response to in-
quiries of physicians, suppliers, and other per-
sons concerning the accuracy of such limiting
charges for their services;’’.
(d) REPORT ON CHARGES IN EXCESS OF LIMITING
CHARGE.—Section 1848(g)(6)(B) (42 U.S.C. 1395w–
4(g)(6)(B)) is amended by inserting ‘‘information on the
extent to which actual charges exceed limiting charges, the
number and types of services involved, and the average
amount of excess charges and information’’ after ‘‘report
to the Congress’’.
(e) MISCELLANEOUS
AND
TECHNICAL
AMEND-
MENTS.—Section 
1833(h)(5)(D) 
(42 
U.S.C.
1395l(h)(5)(D)) is amended—
(1) by striking ‘‘paragraphs (2) and (3)’’ and
by inserting ‘‘paragraph (2)’’; and
(2) by adding at the end the following: ‘‘Para-
graph (4) of such section shall apply in this sub-
paragraph in the same manner as such paragraph
applies to such section.’’.
(f) EFFECTIVE DATES.—
(1) 
ENFORCEMENT; 
MISCELLANEOUS
AND
TECHNICAL AMENDMENTS.—The amendments made
by subsections (a) and (e) shall apply to services fur-
nished on or after the date of the enactment of this
Act; except that the amendments made by sub-
section (a) shall not apply to services of a
nonparticipating supplier or other person furnished
before January 1, 1995.
(2) PRACTITIONERS.—The amendments made
by subsection (b) shall apply to services furnished on
or after January 1, 1995.
(3) EOMBS.—The amendments made by sub-
section (c)(1) shall apply to explanations of benefits
provided on or after July 1, 1995.
(4) CARRIER
DETERMINATIONS.—The amend-
ments made by subsection (c)(2) shall apply to con-
tracts as of January 1, 1995.
(5) REPORT.—The amendment made by sub-
section (d) shall apply to reports for years beginning
with 1995.
SEC. 124. RELATIVE VALUES FOR PEDIATRIC SERVICES.
(a) IN GENERAL.—The Secretary of Health and
Human Services shall fully develop, by not later than July
1, 1995, relative values for the full range of pediatric phy-