H. R. 5252
One Hundred Third Congress
of the
United States of America
AT THE SECOND SESSION
Begun and held at the City of Washington on Tuesday,
the twenty-fifth day of January, one thousand nine hundred and ninety-four
An Act
To amend the Social Security Act and related Acts to make miscellaneous and
technical amendments, and for other purposes.
Be it enacted by the Senate and House of Representatives of
the United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ‘‘Social Security Act Amendments
of 1994’’.
SEC. 2. REFERENCES IN ACT; TABLE OF CONTENTS.
(a) AMENDMENTS TO SOCIAL SECURITY ACT.—Except as other-
wise specifically provided, whenever in this Act an amendment
is expressed in terms of an amendment to or repeal of a section
or other provision, the reference shall be considered to be made
to that section or other provision of the Social Security Act.
(b) REFERENCES TO OBRA.—In this Act, the terms ‘‘OBRA–
1986’’, ‘‘OBRA–1987’’, ‘‘OBRA–1989’’, ‘‘OBRA–1990’’, and ‘‘OBRA–
1993’’ refer to the Omnibus Budget Reconciliation Act of 1986
(Public Law 99–509), the Omnibus Budget Reconciliation Act of
1987 (Public Law 100–203), the Omnibus Budget Reconciliation
Act of 1989 (Public Law 101–239), the Omnibus Budget Reconcili-
ation Act of 1990 (Public Law 101–508), and the Omnibus Budget
Reconciliation Act of 1993 (Public Law 103–66), respectively.
(c) TABLE OF CONTENTS.—The table of contents is as follows:
Sec. 1. Short title.
Sec. 2. References in Act; table of contents.
TITLE I—MEDICARE PROVISIONS
Subtitle A—Provisions Relating to Part A
Sec. 101. Provisions relating to adjustments to standardized amounts for wages
and wage-related costs.
Sec. 102. Essential access community hospital (EACH) amendments.
Sec. 103. Provisions relating to rural health transition grant program.
Sec. 104. Psychology services in hospitals.
Sec. 105. Medicare-dependent, small rural hospitals and sole community hospitals.
Sec. 106. Skilled nursing facilities.
Sec. 107. Notification of availability of hospice benefit.
Sec. 108. Clarifying expertise of individuals to serve on the Prospective Payment
Assessment Commission.
Sec. 109. Authority for budget neutral adjustments for changes in payment
amounts for transfer cases.
Sec. 110. Clarification of DRG payment window expansion; miscellaneous and tech-
nical corrections.
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Subtitle B—Provisions Relating to Part B
PART I—PHYSICIANS’ SERVICES
Sec. 121. Development and implementation of resource-based methodology for prac-
tice expenses.
Sec. 122. Geographic cost of practice index refinements.
Sec. 123. Extra-billing limits.
Sec. 124. Relative values for pediatric services.
Sec. 125. Administration of claims relating to physicians’ services.
Sec. 126. Miscellaneous and technical corrections.
PART II—DURABLE MEDICAL EQUIPMENT
Sec. 131. Certification of suppliers.
Sec. 132. Restrictions on certain marketing and sales activities.
Sec. 133. Beneficiary liability for noncovered services.
Sec. 134. Adjustments for inherent reasonableness.
Sec. 135. Miscellaneous and technical corrections.
PART III—OTHER ITEMS AND SERVICES
Sec. 141. Ambulatory surgical center services.
Sec. 142. Study of medicare coverage of patient care costs associated with clinical
trials of new cancer therapies.
Sec. 143. Study of annual cap on amount of medicare payment for outpatient phys-
ical therapy and occupational therapy services.
Sec. 144. Payment of part B premium late enrollment penalties by States.
Sec. 145. Application of mammography certification requirements.
Sec. 146. Coverage of services of speech-language pathologists and audiologists.
Sec. 147. Miscellaneous and technical corrections.
Subtitle C—Provisions Relating to Parts A and B
Sec. 151. Medicare secondary payer reforms.
Sec. 152. Physician ownership and referral.
Sec. 153. Definition of FMGEMS examination for payment of direct graduate medi-
cal education.
Sec. 154. Qualified medicare beneficiary outreach.
Sec. 155. Hospital agreements with organ procurement organizations.
Sec. 156. Peer review organizations.
Sec. 157. Health maintenance organizations.
Sec. 158. Home health agencies.
Sec. 159. Permanent extension of authority to contract with fiscal intermediaries
and carriers on other than a cost basis.
Sec. 160. Miscellaneous and technical corrections.
Subtitle D—Provisions Relating to Medicare Supplemental Insurance Policies
Sec. 171. Standards for medicare supplemental insurance policies.
Sec. 172. 6-month extension of period for issuance of medicare select policies.
TITLE II—MATERNAL AND CHILD HEALTH SERVICES BLOCK GRANT PRO-
GRAM, INCOME SECURITY, HUMAN RESOURCES, AND RELATED PRO-
GRAMS
Sec. 201. Increase in authorization of appropriations for the Maternal and Child
Health Services Block Grant Program.
Subtitle A—Child Welfare, Foster Care, Adoption
Sec. 202. Required protections for foster children.
Sec. 203. Conformity reviews.
Sec. 204. States required to report on measures taken to comply with the Indian
Child Welfare Act.
Sec. 205. Child welfare traineeships.
Sec. 206. Dispositional hearing.
Sec. 207. Elimination of foster care ceilings and of authority to transfer unused fos-
ter care funds to child welfare services programs.
Sec. 208. Demonstration projects.
Sec. 209. Placement accountability.
Sec. 210. Payments of State claims for foster care and adoption assistance.
Sec. 211. Effect of failure to carry out State plan.
Subtitle B—Child Support Enforcement
Sec. 212. Reports to credit bureaus on persons delinquent in child support
payments.
Sec. 213. Technical amendments to provision on State paternity establishment
programs.
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Sec. 214. Agreement to assist in locating missing children under the parent locator
service.
Subtitle C—Supplemental Security Income
Sec. 221. Definition of disability for children under age 18 applied to all individuals
under age 18.
Subtitle D—Aid to Families With Dependent Children
Sec. 231. Simplification of income and eligibility verification system.
Sec. 232. Measurement and reporting of welfare receipt.
Sec. 233. New Hope demonstration project.
Sec. 234. Delay in requirement that outlying areas operate an AFDC–UP Program.
Sec. 235. State option to use retrospective budgeting without monthly reporting.
Subtitle E—JOBS Program
Sec. 241. Expansion of coverage for Indian tribes.
Sec. 242. Report to the Congress with respect to performance standards in the
JOBS program.
Subtitle F—Other Provisions
Sec. 261. Extension of demonstration to expand job opportunities.
Sec. 262. Early childhood development projects.
Sec. 263. Reallocation of funds under title XX for empowerment and enterprise
grants.
Sec. 264. Corrections related to the income security and human resources provi-
sions of OBRA–1990.
Sec. 265. Technical corrections related to the human resource and income security
provisions of OBRA–1989.
Sec. 266. Technical correction related to the human resource and income security
provisions of OBRA–1993.
Sec. 267. Elimination of obsolete provisions relating to treatment of the earned in-
come tax credit.
Sec. 268. Redesignation of certain provisions.
TITLE I—MEDICARE PROVISIONS
Subtitle A—Provisions Relating to Part A
SEC. 101. PROVISIONS RELATING TO ADJUSTMENTS TO STANDARD-
IZED AMOUNTS FOR WAGES AND WAGE-RELATED COSTS.
(a) USE OF OCCUPATIONAL MIX IN GUIDELINES FOR DETERMINA-
TION OF AREA WAGE INDEX.—
(1) IN
GENERAL.—Section 1886(d)(10)(D)(i)(I) (42 U.S.C.
1395ww(d)(10)(D)(i)(I)) is amended by inserting ‘‘(to the extent
the Secretary determines appropriate)’’ after ‘‘taking into
account’’.
(2) EFFECTIVE DATE.—The amendment made by paragraph
(1) shall take effect as if included in the enactment of OBRA–
1989.
(b) CONFORMING AMENDMENTS RELATING TO GEOGRAPHIC AREA
USED TO DETERMINE WAGE INDEX APPLICABLE TO HOSPITAL.—(1)
Section 1886(d)(8)(C) (42 U.S.C. 1395ww(d)(8)(C)), as amended by
section 13501(b)(1) of OBRA–1993, is amended—
(A) in clause (iv), by striking ‘‘paragraph (1)’’ and inserting
‘‘paragraph (10)’’; and
(B) by adding at the end the following new clause:
‘‘(v) This subparagraph shall apply with respect to discharges
occurring in a fiscal year only if the Secretary uses a method
for making adjustments to the DRG prospective payment rate for
area differences in hospital wage levels under paragraph (3)(E)
for the fiscal year that is based on the use of Metropolitan Statistical
Area classifications.’’.
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(2) Section 1886(d)(10) (42 U.S.C. 1395ww(d)(10)) is amended—
(A) in subparagraph (C)(i)(II), by striking ‘‘the area wage
index applicable’’ and inserting ‘‘the factor used to adjust the
DRG prospective payment rate for area differences in hospital
wage levels that applies’’; and
(B) in subparagraph (D)—
(i) by redesignating clause (ii) as clause (iii), and
(ii) by inserting after clause (i) the following new
clause:
‘‘(ii) Notwithstanding clause (i), if the Secretary uses a method
for making adjustments to the DRG prospective payment rate for
area differences in hospital wage levels under paragraph (3)(E)
that is not based on the use of Metropolitan Statistical Area classi-
fications, the Secretary may revise the guidelines published under
clause (i) to the extent such guidelines are used to determine
the appropriateness of the geographic area in which the hospital
is determined to be located for purposes of making such
adjustments.’’.
(c) ADJUSTMENT
OF LABOR
AND NON-LABOR PORTIONS
OF
STANDARDIZED
AMOUNTS.—Section 1886(d)(3)(A)(iii) (42 U.S.C.
1395ww(d)(3)(A)(iii)) is amended by adding at the end the following:
‘‘For discharges occurring on or after October 1, 1994, the Secretary
shall adjust the ratio of the labor portion to non-labor portion
of each average standardized amount to equal such ratio for the
national average of all standardized amounts.’’.
SEC. 102. ESSENTIAL 
ACCESS 
COMMUNITY 
HOSPITAL 
(EACH)
AMENDMENTS.
(a) TREATMENT
OF INPATIENT HOSPITAL SERVICES PROVIDED
IN RURAL PRIMARY CARE HOSPITALS.—
(1) IN GENERAL.—Section 1820(f)(1)(F) (42 U.S.C. 1395i–
4(f)(1)(F)) is amended to read as follows:
‘‘(F) subject to paragraph (4), provides not more than
6 inpatient beds (meeting such conditions as the Secretary
may establish) for providing inpatient care to patients
requiring stabilization before discharge or transfer to a
hospital, except that the facility may not provide any
inpatient hospital services—
‘‘(i) to any patient whose attending physician does
not certify that the patient may reasonably be expected
to be discharged or transferred to a hospital within
72 hours of admission to the facility; or
‘‘(ii) consisting of surgery or any other service
requiring the use of general anesthesia (other than
surgical procedures specified by the Secretary under
section 1833(i)(1)(A)), unless the attending physician
certifies that the risk associated with transferring the
patient to a hospital for such services outweighs the
benefits of transferring the patient to a hospital for
such services.’’.
(2) LIMITATION
ON
AVERAGE
LENGTH
OF
STAY.—Section
1820(f) (42 U.S.C. 1395i–4(f)) is amended by adding at the
end the following new paragraph:
‘‘(4) LIMITATION ON AVERAGE LENGTH OF INPATIENT STAYS.—
The Secretary may terminate a designation of a rural primary
care hospital under paragraph (1) if the Secretary finds that
the average length of stay for inpatients at the facility during
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the previous year in which the designation was in effect
exceeded 72 hours. In determining the compliance of a facility
with the requirement of the previous sentence, there shall
not be taken into account periods of stay of inpatients in excess
of 72 hours to the extent such periods exceed 72 hours because
transfer to a hospital is precluded because of inclement weather
or other emergency conditions.’’.
(3) CONFORMING
AMENDMENT.—Section 1814(a)(8) (42
U.S.C. 1395f(a)(8)) is amended by striking ‘‘such services’’ and
all that follows and inserting ‘‘the individual may reasonably
be expected to be discharged or transferred to a hospital within
72 hours after admission to the rural primary care hospital.’’.
(4) GAO REPORTS.—Not later than 2 years after the date
of the enactment of this Act, the Comptroller General shall
submit reports to Congress on—
(A) the application of the requirements under section
1820(f) of the Social Security Act (as amended by this
subsection) that rural primary care hospitals provide
inpatient care only to those individuals whose attending
physicians certify may reasonably be expected to be dis-
charged within 72 hours after admission and maintain
an average length of inpatient stay during a year that
does not exceed 72 hours; and
(B) the extent to which such requirements have
resulted in such hospitals providing inpatient care beyond
their capabilities or have limited the ability of such hos-
pitals to provide needed services.
(b) DESIGNATION OF HOSPITALS.—
(1) PERMITTING
DESIGNATION
OF
HOSPITALS
LOCATED
IN
URBAN AREAS.—
(A) IN
GENERAL.—Section 1820 (42 U.S.C. 1395i–4)
is amended—
(i) by striking paragraph (1) of subsection (e) and
redesignating paragraphs (2) through (6) as paragraphs
(1) through (5);
(ii) in subsection (e)(1)(A) (as redesignated by
subparagraph (A))—
(I) by striking ‘‘is located’’ and inserting
‘‘except in the case of a hospital located in an
urban area, is located’’,
(II) by striking ‘‘, (ii)’’ and inserting ‘‘or (ii)’’,
and
(III) by striking ‘‘or (iii)’’ and all that follows
through ‘‘section,’’; and
(iii) in subsection (i)(1)(B), by striking ‘‘paragraph
(3)’’ and inserting ‘‘paragraph (2)’’.
(B) NO CHANGE IN MEDICARE PROSPECTIVE PAYMENT.—
Section 1886(d)(5)(D) (42 U.S.C. 1395ww(d)(5)(D)) is
amended—
(i) in clause (iii)(III), by inserting ‘‘located in a
rural area and’’ after ‘‘that is’’, and
(ii) in clause (v), by inserting ‘‘located in a rural
area and’’ after ‘‘in the case of a hospital’’.
(2) PERMITTING HOSPITALS LOCATED IN ADJOINING STATES
TO PARTICIPATE IN STATE PROGRAM.—
(A) IN
GENERAL.—Section 1820 (42 U.S.C. 1395i–4)
is amended—
H. R. 5252—6
(i) by redesignating subsection (k) as subsection
(l); and
(ii) by inserting after subsection (j) the following
new subsection:
‘‘(k) ELIGIBILITY OF HOSPITALS NOT LOCATED IN PARTICIPATING
STATES.—Notwithstanding any other provision of this section—
‘‘(1) for purposes of including a hospital or facility as a
member institution of a rural health network, a State may
designate a hospital or facility that is not located in the State
as an essential access community hospital or a rural primary
care hospital if the hospital or facility is located in an adjoining
State and is otherwise eligible for designation as such a hos-
pital;
‘‘(2) the Secretary may designate a hospital or facility that
is not located in a State receiving a grant under subsection
(a)(1) as an essential access community hospital or a rural
primary care hospital if the hospital or facility is a member
institution of a rural health network of a State receiving a
grant under such subsection; and
‘‘(3) a hospital or facility designated pursuant to this sub-
section shall be eligible to receive a grant under subsection
(a)(2).’’.
(B) CONFORMING AMENDMENTS.—(i) Section 1820(c)(1)
(42 U.S.C. 1395i–4(c)(1)) is amended by striking ‘‘paragraph
(3)’’ and inserting ‘‘paragraph (3) or subsection (k)’’.
(ii) Paragraphs (1)(A) and (2)(A) of section 1820(i) (42
U.S.C. 1395i–4(i)) are each amended—
(I) in clause (i), by striking ‘‘(a)(1)’’ and inserting
‘‘(a)(1) (except as provided in subsection (k))’’, and
(II) in clause (ii), by striking ‘‘subparagraph (B)’’
and inserting ‘‘subparagraph (B) or subsection (k)’’.
(c) SKILLED NURSING SERVICES IN RURAL PRIMARY CARE HOS-
PITALS.—Section 1820(f)(3) (42 U.S.C. 1395i–4(f)(3)) is amended by
striking ‘‘because the facility’’ and all that follows and inserting
the following: ‘‘because, at the time the facility applies to the
State for designation as a rural primary care hospital, there is
in effect an agreement between the facility and the Secretary under
section 1883 under which the facility’s inpatient hospital facilities
are used for the furnishing of extended care services, except that
the number of beds used for the furnishing of such services may
not exceed the total number of licensed inpatient beds at the time
the facility applies to the State for such designation (minus the
number of inpatient beds used for providing inpatient care pursuant
to paragraph (1)(F)). For purposes of the previous sentence, the
number of beds of the facility used for the furnishing of extended
care services shall not include any beds of a unit of the facility
that is licensed as a distinct-part skilled nursing facility at the
time the facility applies to the State for designation as a rural
primary care hospital.’’.
(d) DEADLINE
FOR DEVELOPMENT
OF PROSPECTIVE PAYMENT
SYSTEM FOR INPATIENT RURAL PRIMARY CARE HOSPITAL SERVICES.—
Section 1814(l)(2) (42 U.S.C. 1395f(l)(2)) is amended by striking
‘‘January 1, 1993’’ and inserting ‘‘January 1, 1996’’.
(e) PAYMENT FOR OUTPATIENT RURAL PRIMARY CARE HOSPITAL
SERVICES.—
(1) IMPLEMENTATION OF PROSPECTIVE PAYMENT SYSTEM.—
Section 1834(g) (42 U.S.C. 1395m(g)) is amended—
H. R. 5252—7
(A) in paragraph (1), by striking ‘‘during a year before
1993’’ and inserting ‘‘during a year before the prospective
payment system described in paragraph (2) is in effect’’;
and
(B) in paragraph (2), by striking ‘‘January 1, 1993,’’
and inserting ‘‘January 1, 1996,’’.
(2) NO USE OF CUSTOMARY CHARGE IN DETERMINING PAY-
MENT.—Section 1834(g)(1) (42 U.S.C. 1395m(g)(1)) is amended
by adding at the end the following new flush sentence:
‘‘The amount of payment shall be determined under either
method without regard to the amount of the customary or
other charge.’’.
(f) CLARIFICATION OF PHYSICIAN STAFFING REQUIREMENT FOR
RURAL PRIMARY CARE HOSPITALS.—Section 1820(f)(1)(H) (42 U.S.C.
1395i–4(f)(1)(H)) is amended by striking the period and inserting
the following: ‘‘, except that in determining whether a facility meets
the requirements of this subparagraph, subparagraphs (E) and (F)
of that paragraph shall be applied as if any reference to a ‘physician’
is a reference to a physician as defined in section 1861(r)(1).’’.
(g) TECHNICAL AMENDMENTS RELATING TO PART A DEDUCTIBLE,
COINSURANCE, AND SPELL OF ILLNESS.—(1) Section 1812(a)(1) (42
U.S.C. 1395d(a)(1)) is amended—
(A) by striking ‘‘inpatient hospital services’’ the first place
it appears and inserting ‘‘inpatient hospital services or inpatient
rural primary care hospital services’’;
(B) by striking ‘‘inpatient hospital services’’ the second
place it appears and inserting ‘‘such services’’; and
(C) by striking ‘‘and inpatient rural primary care hospital
services’’.
(2) Sections 1813(a) and 1813(b)(3)(A) (42 U.S.C. 1395e(a),
1395e(b)(3)(A)) are each amended by striking ‘‘inpatient hospital
services’’ each place it appears and inserting ‘‘inpatient hospital
services or inpatient rural primary care hospital services’’.
(3) Section 1813(b)(3)(B) (42 U.S.C. 1395e(b)(3)(B)) is amended
by striking ‘‘inpatient hospital services’’ and inserting ‘‘inpatient
hospital services, inpatient rural primary care hospital services’’.
(4) Section 1861(a) (42 U.S.C. 1395x(a)) is amended—
(A) in paragraph (1), by striking ‘‘inpatient hospital serv-
ices’’ and inserting ‘‘inpatient hospital services, inpatient rural
primary care hospital services’’; and
(B) in paragraph (2), by striking ‘‘hospital’’ and inserting
‘‘hospital or rural primary care hospital’’.
(h) AUTHORIZATION
OF APPROPRIATIONS.—Section 1820(l) (42
U.S.C. 1395i–4(l)), as redesignated by subsection (b)(2)(A), is
amended by striking ‘‘1990, 1991, and 1992’’ and inserting ‘‘1990
through 1997’’.
(i) EFFECTIVE DATE.—The amendments made by this section
shall take effect on the date of the enactment of this Act.
SEC. 103. PROVISIONS RELATING TO RURAL HEALTH TRANSITION
GRANT PROGRAM.
(a) ELIGIBILITY
OF
RURAL
PRIMARY
CARE
HOSPITALS
FOR
GRANTS.—
(1) IN
GENERAL.—Section 4005(e)(2) of OBRA–1987 is
amended in the matter preceding subparagraph (A) by inserting
‘‘any rural primary care hospital designated by the Secretary
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under section 1820(i)(2) of the Social Security Act, or’’ after
‘‘means’’.
(2) EFFECTIVE DATE.—The amendment made by paragraph
(1) shall apply to grants made on or after October 1, 1994.
(b) EXTENSION OF AUTHORIZATION OF APPROPRIATIONS.—Section
4005(e)(9) of OBRA–1987 is amended—
(1) by striking ‘‘1989 and’’ and inserting ‘‘1989,’’; and
(2) by striking ‘‘1992’’ and inserting ‘‘1992 and $30,000,000
for each of fiscal years 1993 through 1997’’.
(c) FREQUENCY OF REQUIRED REPORTS.—Section 4008(e)(8)(B)
of OBRA–1987 is amended by striking ‘‘every 6 months’’ and insert-
ing ‘‘every 12 months’’.
SEC. 104. PSYCHOLOGY SERVICES IN HOSPITALS.
Section 1861(e)(4) (42 U.S.C. 1395x(e)(4)) is amended by strik-
ing ‘‘physician;’’ and inserting ‘‘physician, except that a patient
receiving qualified psychologist services (as defined in subsection
(ii)) may be under the care of a clinical psychologist with respect
to such services to the extent permitted under State law;’’.
SEC. 105. MEDICARE-DEPENDENT, SMALL RURAL HOSPITALS AND
SOLE COMMUNITY HOSPITALS.
(a) MEDICARE DEPENDENT, SMALL RURAL HOSPITALS.—
(1) CLARIFICATION
OF
ADDITIONAL
PAYMENT.—Section
1886(d)(5)(G)(ii)(I) 
(42 
U.S.C. 
1395ww(d)(5)(G)(ii)(I)), 
as
amended by section 13501(e)(1) of OBRA–1993, is amended
by striking ‘‘the first 3 12-month cost reporting periods that
begin’’ and inserting ‘‘the 36-month period beginning with the
first day of the cost reporting period that begins’’.
(2) CONFORMING TARGET AMOUNTS TO EXTENSION OF ADDI-
TIONAL
PAYMENTS.—Section 
1886(b)(3)(D) 
(42 
U.S.C.
1395ww(b)(3)(D)) is amended in the matter preceding clause
(i) by striking ‘‘March 31, 1993’’ and inserting ‘‘September 30,
1994’’.
(b) CLARIFICATION
OF UPDATES.—Section 1886(b)(3)(B)(iv)(II)
(42 U.S.C. 1395ww(b)(3)(B)(iv)(II)), as added by section 13501(a)(2)
of OBRA–1993, is amended by striking ‘‘(taking into account’’ and
all that follows through ‘‘1994)’’ and inserting ‘‘(adjusted to exclude
any portion of a cost reporting period beginning during fiscal year
1993 for which the applicable percentage increase is determined
under subparagraph (I))’’.
SEC. 106. SKILLED NURSING FACILITIES.
(a) CONSTRUCTION OF WAGE INDEX.—Not later than 1 year
after the date of the enactment of this Act, the Secretary of Health
and Human Services shall begin to collect data on employee com-
pensation and paid hours of employment in skilled nursing facilities
for the purpose of constructing a skilled nursing facility wage index
adjustment to the routine service cost limits required under section
1888(a)(4) of the Social Security Act.
(b) 
CLARIFICATION
OF
REPEAL
OF
UTILIZATION
REVIEW
REQUIREMENTS.—
(1) IN
GENERAL.—(A) Section 1814(a)(5) (42 U.S.C.
1395f(a)(5)) is amended—
(i) by striking ‘‘and with respect’’ and all that follows
through ‘‘regulations’’;
(ii) by striking ‘‘or skilled nursing facility, as the case
may be’’; and
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(iii) by striking ‘‘or facility’’.
(B) Section 1866(d) (42 U.S.C. 1395cc(d)) is amended—
(i) by striking ‘‘or skilled nursing facility’’;
(ii) by striking ‘‘or facility’’ each place it appears;
(iii) by striking ‘‘or for post-hospital’’ and all that fol-
lows through ‘‘the case may be’’; and
(iv) by striking ‘‘, or (in the case of’’ and all that
follows through ‘‘transfer agreement,’’.
(2) EFFECTIVE DATE.—The amendments made by paragraph
(1) shall take effect as if included in the enactment of OBRA–
1987.
(c) CONFORMING AMENDMENTS TO NURSING HOME REFORM.—
(1) SUSPENSION OF DECERTIFICATION OF NURSES AIDE TRAIN-
ING
AND
COMPETENCY
EVALUATION
PROGRAMS
BASED
ON
EXTENDED SURVEYS.—
(A) IN
GENERAL.—Section 1819(f)(2)(B)(iii)(I)(b) (42
U.S.C. 1395i–3(f)(2)(B)(iii)(I)(b)) is amended by striking the
semicolon and inserting the following: ‘‘, unless the survey
shows that the facility is in compliance with the require-
ments 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 CONDUCTING 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 consult-
ant is qualified to conduct reviews under the preceding
sentence, 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 insert-
ing ‘‘$100’’.
(B) EFFECTIVE
DATE.—The amendment made by
subparagraph (A) shall take effect January 1, 1995.
(4) DUE PROCESS PROTECTIONS FOR NURSES AIDES.—
(A) PROHIBITING
STATE
FROM
INCLUDING
UNDOCU-
MENTED ALLEGATIONS IN NURSES AIDE REGISTRY.—Section
1819(e)(2)(B) (42 U.S.C. 1395i–3(e)(2)(B)) is amended by
striking the period at the end of the first sentence and
inserting the following: ‘‘, but shall not include any allega-
tions of resident abuse or neglect 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 allega-
tions (including a statement of the availability of a hearing
H. R. 5252—10
for the individual to rebut the allegations) and the oppor-
tunity 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 January 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 
therapist, 
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 inserting ‘‘(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 com-
petency 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 facility.’’.
(7) EFFECTIVE DATE.—The amendments made by this sub-
section 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 ‘‘, including hospice serv-
ices,’’ 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 ASSESSMENT COMMISSION.
Section 1886(e)(6)(B) (42 U.S.C. 1395ww(e)(6)(B)) is amended
by striking ‘‘hospital reimbursement, hospital financial manage-
ment’’ and inserting ‘‘health facility management, reimbursement
H. R. 5252—11
of health facilities or other providers of services which reflect the
scope of the Commission’s responsibilities’’.
SEC. 109. AUTHORITY FOR BUDGET NEUTRAL ADJUSTMENTS 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 paragraph (3) to assure that the aggregate pay-
ments 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 EXPANSION;
MISCELLANEOUS AND TECHNICAL CORRECTIONS.
(a) CLARIFICATION OF DRG PAYMENT WINDOW EXPANSION.—
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 RESIDENT ASSESS-
MENT 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 APPLICABLE ADJUST-
MENT 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 ‘‘September 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 RESOURCE-
BASED METHODOLOGY FOR PRACTICE EXPENSES.
(a) DEVELOPMENT.—
(1) IN
GENERAL.—The Secretary of Health and Human
Services shall develop a methodology for implementing in 1998
a resource-based system for determining practice expense rel-
ative 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 developed under paragraph (1)
to the Committees on Ways and Means and Energy and Com-
merce of the House of Representatives and the Committee
on Finance of the Senate. The report shall include a presen-
tation of data utilized in developing the methodology and an
explanation of the methodology.
H. R. 5252—12
(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 rel-
ative 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 prac-
tice’’ 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 adjustments under clause (ii)(I) of such section.
SEC. 122. GEOGRAPHIC COST OF PRACTICE INDEX REFINEMENTS.
(a) REQUIRING
CONSULTATION
WITH
REPRESENTATIVES
OF
PHYSICIANS IN REVIEWING GEOGRAPHIC ADJUSTMENT 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 representatives 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 establishing indices
and index values under this paragraph, the Secretary shall
use the most recent data available relating to practice
expenses, 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, prac-
tice expenses (other than malpractice expenses), and mal-
practice expenses;
(B) the weights assigned to the input components of
such shares; and
(C) the index values assigned to such components;
(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 frequently than every three years; and
(4) the costs of developing more accurate and timely data.
H. R. 5252—13
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 follows:
‘‘(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 service
furnished with respect to an individual enrolled 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 per-
son is liable for payment 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 COLLECTIONS.—If such a
physician, supplier, or other person collects an actual
charge for a service in violation of clause (i), the physi-
cian, supplier, or other person shall provide on a timely
basis a refund to the individual 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.
‘‘(B) SANCTIONS.—If a physician, supplier, or other
person—
‘‘(i) knowingly and willfully bills or collects for
services in violation of subparagraph (A)(i) on a
repeated basis, or
‘‘(ii) fails to comply with clause (iii) or (iv) of
subparagraph (A) on a timely basis,
the Secretary may apply sanctions against the physician,
supplier, or other person in accordance with paragraph
(2) of section 1842(j). In applying this subparagraph, para-
graph (4) of such section applies in the same manner
as such paragraph applies to such section and any reference
in such section to a physician is deemed also to include
a reference to a supplier or other person under this
subparagraph.
‘‘(C) TIMELY BASIS.—For purposes of this paragraph,
a correction of a bill for an excess charge or refund of
an amount with respect to a violation of subparagraph
(A)(i) in the case of a service is considered to be provided
‘on a timely basis’, if the reduction or refund is made
not later than 30 days after the date the physician, sup-
H. R. 5252—14
plier, or other person is notified by the carrier under this
part of such violation and of the requirements of subpara-
graph (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 violation of the previous sentence.’’,
and
(B) in the last sentence, by striking ‘‘previous sentence’’
and inserting ‘‘first sentence’’.
(b) CLARIFICATION OF MANDATORY ASSIGNMENT RULES FOR CER-
TAIN PRACTITIONERS.—
(1) IN GENERAL.—Section 1842(b) (42 U.S.C. 1395u(b)), as
amended by section 126(e), is amended by adding at the end
the following new paragraph:
‘‘(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 coinsurance amounts applicable under
this part. No person is liable for payment of any amounts billed
for such a service in violation of the previous sentence. If a practi-
tioner 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 applies with respect to a physician.
Paragraph (4) of subsection (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 section
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 furnished by
a practitioner described in subparagraph (C) includes 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 subparagraph (C) as subpara-
graph (B);
(ii) by striking subsection (p); and
H. R. 5252—15
(iii) in subsection (r), by striking paragraph (3)
and redesignating paragraph (4) as paragraph (3).
(B) Section 1842(b)(12) (42 U.S.C. 1395u(b)(12)) is
amended by striking subparagraph (C).
(c) INFORMATION ON EXTRA-BILLING LIMITS.—
(1) PART OF EXPLANATION OF MEDICARE BENEFITS.—Section
1842(h)(7) (42 U.S.C. 1395u(h)(7)) is amended—
(A) by striking ‘‘and’’ at the end of subparagraph (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 applicable limiting charge (includ-
ing information concerning the right to a refund under section
1848(g)(1)(A)(iv)).’’.
(2) DETERMINATIONS BY CARRIERS.—Subparagraph (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 exceeds the limiting charge
applicable under section 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 inquiries of physi-
cians, suppliers, and other persons 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 AMENDMENTS.—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: ‘‘Paragraph (4)
of such section shall apply in this subparagraph in the same
manner as such paragraph applies to such section.’’.
(f) EFFECTIVE DATES.—
(1) ENFORCEMENT; MISCELLANEOUS AND TECHNICAL AMEND-
MENTS.—The amendments made by subsections (a) and (e) shall
apply to services furnished on or after the date of the enactment
of this Act; except that the amendments made by subsection
(a) shall not apply to services of a nonparticipating supplier
or other person furnished before January 1, 1995.
H. R. 5252—16
(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 subsection (c)(1)
shall apply to explanations of benefits provided on or after
July 1, 1995.
(4) CARRIER DETERMINATIONS.—The amendments made by
subsection (c)(2) shall apply to contracts as of January 1, 1995.
(5) REPORT.—The amendment made by subsection (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 physicians’ services which are consist-
ent with the relative values developed for other physicians’ services
under section 1848(c) of the Social Security Act. In developing
such values, the Secretary shall conduct such refinements as may
be necessary to produce appropriate estimates for such relative
values.
(b) STUDY.—
(1) IN GENERAL.—The Secretary shall conduct a study of
the relative values for pediatric and other services to determine
whether there are significant variations in the resources used
in providing similar services to different populations. In
conducting such study, the Secretary shall consult with appro-
priate organizations representing pediatricians and other physi-
cians and physical and occupational therapists.
(2) REPORT.—Not later than July 1, 1995, the Secretary
shall submit to Congress a report on the study conducted under
paragraph (1). Such report shall include any appropriate rec-
ommendations regarding needed changes in coding or other
payment policies to ensure that payments for pediatric services
appropriately reflect the resources required to provide these
services.
SEC. 125. ADMINISTRATION OF CLAIMS RELATING TO PHYSICIANS’
SERVICES.
(a) LIMITATION ON CARRIER USER FEES.—Section 1842(c) (42
U.S.C. 1395u(c)) is amended by adding at the end the following
new paragraph:
‘‘(4) Neither a carrier nor the Secretary may impose a fee
under this title—
‘‘(A) for the filing of claims related to physicians’ services,
‘‘(B) for an error in filing a claim relating to physicians’
services or for such a claim which is denied,
‘‘(C) for any appeal under this title with respect to physi-
cians’ services,
‘‘(D) for applying for (or obtaining) a unique identifier under
subsection (r), or
‘‘(E) for responding to inquiries respecting physicians’ serv-
ices or for providing information with respect to medical review
of such services.’’.
(b) CLARIFICATION
OF
PERMISSIBLE
SUBSTITUTE
BILLING
ARRANGEMENTS.—
(1) IN GENERAL.—Clause (D) of section 1842(b)(6) (42 U.S.C.
1395u(b)(6)) is amended to read as follows: ‘‘(D) payment may
be made to a physician for physicians’ services (and services
H. R. 5252—17
furnished incident to such services) furnished by a second physi-
cian to patients of the first physician if (i) the first physician
is unavailable to provide the services; (ii) the services are
furnished pursuant to an arrangement between the two physi-
cians that (I) is informal and reciprocal, or (II) involves per
diem or other fee-for-time compensation for such services; (iii)
the services are not provided by the second physician over
a continuous period of more than 60 days; and (iv) the claim
form submitted to the carrier for such services includes the
second physician’s unique identifier (provided under the system
established under subsection (r)) and indicates that the claim
meets the requirements of this subparagraph for payment to
the first physician’’.
(2) EFFECTIVE DATE.—The amendment made by paragraph
(1) shall apply to services furnished on or after the first day
of the first month beginning more than 60 days after the
date of the enactment of this Act.
SEC. 126. MISCELLANEOUS AND TECHNICAL CORRECTIONS.
(a) OVERVALUED PROCEDURES.—(1) Section 1842(b)(16)(B)(iii)
(42 U.S.C. 1395u(b)(16)(B)(iii)) is amended—
(A) by striking ‘‘, simple and subcutaneous’’,
(B) by striking ‘‘; small’’ and inserting ‘‘and small’’,
(C) by striking ‘‘treatments;’’ the first place it appears
and inserting ‘‘and’’,
(D) by striking ‘‘lobectomy;’’,
(E) by striking ‘‘enterectomy; colectomy; cholecystectomy;’’,
(F) by striking ‘‘; transurerethral resection’’ and inserting
‘‘and resection’’, and
(G) by striking ‘‘sacral laminectomy;’’.
(2) Section 4101(b)(2) of OBRA–1990 is amended—
(A) in the matter before subparagraph (A), by striking
‘‘1842(b)(16)’’ and inserting ‘‘1842(b)(16)(B)’’, and
(B) in subparagraph (B)—
(i) by striking ‘‘, simple and subcutaneous’’,
(ii) by striking ‘‘(HCPCS codes 19160 and 19162)’’ and
inserting ‘‘(HCPCS code 19160)’’, and
(iii) by striking all that follows ‘‘(HCPCS codes 92250’’
and inserting ‘‘and 92260).’’.
(b) RADIOLOGY SERVICES.—(1) Section 1834(b)(4) (42 U.S.C.
1395m(b)(4)) is amended by redesignating the subparagraphs (E)
and (F) redesignated by section 4102(a)(1) of OBRA–1990 as sub-
paragraphs (F) and (G), respectively.
(2) 
Section 
1834(b)(4)(D) 
(42 
U.S.C. 
1395m(b)(4)(D)) 
is
amended—
(A) in the matter before clause (i), by striking ‘‘shall be
determined as follows:’’ and inserting ‘‘shall, subject to clause
(vii), be reduced to the adjusted conversion factor for the locality
determined as follows:’’,
(B) in clause (iv), by striking ‘‘LOCAL ADJUSTMENT.—Subject
to clause (vii), the conversion factor to be applied to’’ and
inserting 
‘‘ADJUSTED
CONVERSION
FACTOR.—The 
adjusted
conversion factor for’’,
(C) in clause (vii), by striking ‘‘under this subparagraph’’,
and
(D) in clause (vii), by inserting ‘‘reduced under this subpara-
graph by’’ after ‘‘shall not be’’.
H. R. 5252—18
(3) Section 4102(c)(2) of OBRA–1990 is amended by striking
‘‘radiology services’’ and all that follows and inserting ‘‘nuclear
medicine services.’’.
(4) Section 4102(d) of OBRA–1990 is amended by striking ‘‘new
paragraph’’ and inserting ‘‘new subparagraph’’.
(5) Section 1834(b)(4)(E) (42 U.S.C. 1395m(b)(4)(E)) is amended
by inserting ‘‘RULE FOR CERTAIN SCANNING SERVICES.—’’ after ‘‘(E)’’.
(6) Section 1848(a)(2)(D)(iii) (42 U.S.C. 1395w–4(a)(2)(D)(iii))
is amended by striking ‘‘that are subject to section 6105(b) of
the Omnibus Budget Reconciliation Act of 1989’’ and by striking
‘‘provided under such section’’ and inserting ‘‘provided under section
6105(b) of the Omnibus Budget Reconciliation Act of 1989’’.
(c) ANESTHESIA SERVICES.—(1) Section 4103(a) of OBRA–1990
is amended by striking ‘‘REDUCTION IN FEE SCHEDULE’’ and insert-
ing ‘‘REDUCTION IN PREVAILING CHARGES’’.
(2) 
Section 
1842(q)(1)(B) 
(42 
U.S.C. 
1395u(q)(1)(B)) 
is
amended—
(A) in the matter before clause (i), by striking ‘‘shall be
determined as follows:’’ and inserting ‘‘shall, subject to clause
(iv), be reduced to the adjusted prevailing charge conversion
factor for the locality determined as follows:’’, and
(B) in clause (iii), by striking ‘‘Subject to clause (iv), the
prevailing charge conversion factor to be applied in’’ and insert-
ing ‘‘The adjusted prevailing charge conversion factor for’’.
(d) ASSISTANTS AT SURGERY.—(1) Section 4107(c) of OBRA–
1990 is amended by inserting ‘‘(a)(1)’’ after ‘‘subsection’’.
(2) Section 4107(a)(2) of OBRA–1990 is amended by adding
at the end the following: ‘‘In applying section 1848(g)(2)(D) of the
Social Security Act for services of an assistant-at-surgery furnished
during 1991, the recognized payment amount shall not exceed the
maximum amount specified under section 1848(i)(2)(A) of such Act
(as applied under this paragraph in such year).’’.
(e) TECHNICAL COMPONENTS OF DIAGNOSTIC SERVICES.—Section
1842(b) (42 U.S.C. 1395u(b)) is amended by redesignating paragraph
(18), as added by section 4108(a) of OBRA–1990, as paragraph
(17) and, in such paragraph, by inserting ‘‘, tests specified in para-
graph (14)(C)(i),’’ after ‘‘diagnostic laboratory tests’’.
(f) STATEWIDE FEE SCHEDULES.—Section 4117 of OBRA–1990
is amended—
(1) in subsection (a)—
(A) by striking ‘‘(a) IN GENERAL.—’’, and
(B) by striking ‘‘, if the’’ and all that follows through
‘‘1991,’’; and
(2) by striking subsections (b), (c), and (d).
(g) OTHER MISCELLANEOUS
AND TECHNICAL AMENDMENTS.—
(1) The heading of section 1834(f) (42 U.S.C. 1395m(f)) is amended
by striking ‘‘FISCAL YEAR’’.
(2)(A) Section 4105(b) of OBRA–1990 is amended—
(i) in paragraph (2), by striking ‘‘amendments’’ and insert-
ing ‘‘amendment’’, and
(ii) in paragraph (3), by striking ‘‘amendments made by
paragraphs (1) and (2)’’ and inserting ‘‘amendment made by
paragraph (1)’’.
(B) Section 1848(f)(2)(C) (42 U.S.C. 1395w–4(f)(2)(C)) is
amended by inserting ‘‘PERFORMANCE STANDARD RATES OF INCREASE
FOR FISCAL YEAR 1991.—’’ after ‘‘(C)’’.
H. R. 5252—19
(C) Section 4105(d) of OBRA–1990 is amended by inserting
‘‘PUBLICATION OF PERFORMANCE STANDARD RATES.—’’ after ‘‘(d)’’.
(3) Section 4106(c) of OBRA–1990 is amended by inserting
‘‘of the Social Security Act’’ after ‘‘1848(d)(1)(B)’’.
(4) Section 4114 of OBRA–1990 is amended by striking
‘‘patients’’ the second place it appears.
(5) Section 1848(e)(1)(C) (42 U.S.C. 1395w–4(e)(1)(C)) is
amended by inserting ‘‘date of the’’ after ‘‘since the’’.
(6) Section 4118(f)(1)(D) of OBRA–1990 is amended by striking
‘‘is amended’’.
(7) Section 4118(f)(1)(N)(ii) of OBRA–1990 is amended by strik-
ing ‘‘subsection (f)(5)(A)’’ and inserting ‘‘subsection (f)(5)(A))’’.
(8) Section 1845(e) (42 U.S.C. 1395w–1(e)) is amended—
(A) by striking paragraph (2); and
(B) by redesignating paragraphs (3), (4), and (5) as para-
graphs (2), (3), and (4).
(9) Section 4118(j)(2) of OBRA–1990 is amended by striking
‘‘In section’’ and inserting ‘‘Section’’.
(10)(A) Section 1848(i)(3) (42 U.S.C. 1395w–4(i)(3)) is amended
by striking the space before the period at the end.
(B) Section 1834(a)(10)(B) (42 U.S.C. 1395m(a)(10)(B)) is
amended—
(i) by striking ‘‘apply to’’ and inserting ‘‘would otherwise
apply to’’, and
(ii) by inserting before the period at the end ‘‘but for the
application of section 1848(i)(3)’’.
(h) OTHER CORRECTIONS.—(1) Effective on the date of the enact-
ment of this Act, section 6102(d)(4) of OBRA–1989 is amended
by striking all that follows the first sentence.
(2) Effective for payments for fiscal years beginning with fiscal
year 1994, section 1842(c)(1) (42 U.S.C. 1395u(c)(1)) is amended—
(A) in subparagraph (A), by striking ‘‘(A) Any contract’’
and inserting ‘‘Any contract’’; and
(B) by striking subparagraph (B).
(i) EFFECTIVE DATE.—Except as provided in subsection (h),
the amendments made by this section and the provisions of this
section shall take effect as if included in the enactment of OBRA–
1990.
PART II—DURABLE MEDICAL EQUIPMENT
SEC. 131. CERTIFICATION OF SUPPLIERS.
(a) REQUIREMENTS.—
(1) IN
GENERAL.—Section 1834 (42 U.S.C. 1395m), as
amended by section 13544(b)(1) of OBRA–1993, is amended
by adding at the end the following new subsection:
‘‘(j) REQUIREMENTS FOR SUPPLIERS OF MEDICAL EQUIPMENT AND
SUPPLIES.—
‘‘(1) ISSUANCE AND RENEWAL OF SUPPLIER NUMBER.—
‘‘(A) PAYMENT.—Except as provided in subparagraph
(C), no payment may be made under this part after the
date of the enactment of the Social Security Act Amend-
ments of 1994 for items furnished by a supplier of medical
equipment and supplies unless such supplier obtains (and
renews at such intervals as the Secretary may require)
a supplier number.
‘‘(B) STANDARDS FOR POSSESSING A SUPPLIER NUMBER.—
A supplier may not obtain a supplier number unless—
H. R. 5252—20
‘‘(i) for medical equipment and supplies furnished
on or after the date of the enactment of the Social
Security Act Amendments of 1994 and before January
1, 1996, the supplier meets standards prescribed by
the Secretary in regulations issued on June 18, 1992;
and
‘‘(ii) for medical equipment and supplies furnished
on or after January 1, 1996, the supplier meets revised
standards prescribed by the Secretary (in consultation
with representatives of suppliers of medical equipment
and supplies, carriers, and consumers) that shall
include requirements that the supplier—
‘‘(I) comply with all applicable State and Fed-
eral licensure and regulatory requirements;
‘‘(II) maintain a physical facility on an appro-
priate site;
‘‘(III) have proof of appropriate liability insur-
ance; and
‘‘(IV) meet such other requirements as the Sec-
retary may specify.
‘‘(C) EXCEPTION FOR ITEMS FURNISHED AS INCIDENT TO
A PHYSICIAN’S SERVICE.—Subparagraph (A) shall not apply
with respect to medical equipment and supplies furnished
incident to a physician’s service.
‘‘(D) PROHIBITION
AGAINST
MULTIPLE
SUPPLIER
NUM-
BERS.—The Secretary may not issue more than one supplier
number to any supplier of medical equipment and supplies
unless the issuance of more than one number is appropriate
to identify subsidiary or regional entities under the suppli-
er’s ownership or control.
‘‘(E) PROHIBITION
AGAINST
DELEGATION
OF
SUPPLIER
DETERMINATIONS.—The Secretary may not delegate (other
than by contract under section 1842) the responsibility
to determine whether suppliers meet the standards nec-
essary to obtain a supplier number.
‘‘(2) CERTIFICATES OF MEDICAL NECESSITY.—
‘‘(A) LIMITATION ON INFORMATION PROVIDED BY SUPPLI-
ERS ON CERTIFICATES OF MEDICAL NECESSITY.—
‘‘(i) IN GENERAL.—Effective 60 days after the date
of the enactment of the Social Security Act Amend-
ments of 1994, a supplier of medical equipment and
supplies may distribute to physicians, or to individuals
entitled to benefits under this part, a certificate of
medical necessity for commercial purposes which con-
tains no more than the following information completed
by the supplier:
‘‘(I) An identification of the supplier and the
beneficiary to whom such medical equipment and
supplies are furnished.
‘‘(II) A description of such medical equipment
and supplies.
‘‘(III) Any product code identifying such medi-
cal equipment and supplies.
‘‘(IV) Any other administrative information
(other than information relating to the bene-
ficiary’s medical condition) identified by the
Secretary.
H. R. 5252—21
‘‘(ii) INFORMATION
ON
PAYMENT
AMOUNT
AND
CHARGES.—If a supplier distributes a certificate of
medical necessity containing any of the information
permitted to be supplied under clause (i), the supplier
shall also list on the certificate of medical necessity
the fee schedule amount and the supplier’s charge
for the medical equipment or supplies being furnished
prior to distribution of such certificate to the physician.
‘‘(iii) PENALTY.—Any supplier of medical equip-
ment and supplies who knowingly and willfully distrib-
utes a certificate of medical necessity in violation of
clause (i) or fails to provide the information required
under clause (ii) is subject to a civil money penalty
in an amount not to exceed $1,000 for each such certifi-
cate of medical necessity so distributed. The provisions
of section 1128A (other than subsections (a) and (b))
shall apply to civil money penalties under this subpara-
graph in the same manner as they apply to a penalty
or proceeding under section 1128A(a).
‘‘(B) DEFINITION.—For purposes of this paragraph, the
term ‘certificate of medical necessity’ means a form or
other document containing information required by the
carrier to be submitted to show that an item is reasonable
and necessary for the diagnosis or treatment of illness
or injury or to improve the functioning of a malformed
body member.
‘‘(3) COVERAGE AND REVIEW CRITERIA.—The Secretary shall
annually review the coverage and utilization of items of medical
equipment and supplies to determine whether such items
should be made subject to coverage and utilization review cri-
teria, and if appropriate, shall develop and apply such criteria
to such items.
‘‘(4) DEFINITION.—The term ‘medical equipment and sup-
plies’ means—
‘‘(A) durable medical equipment (as defined in section
1861(n));
‘‘(B) prosthetic devices (as described in section
1861(s)(8));
‘‘(C) orthotics and prosthetics (as described in section
1861(s)(9));
‘‘(D) surgical dressings (as described in section
1861(s)(5));
‘‘(E) such other items as the Secretary may determine;
and
‘‘(F) for purposes of paragraphs (1) and (3)—
‘‘(i) home dialysis supplies and equipment (as
described in section 1861(s)(2)(F)),
‘‘(ii) immunosuppressive drugs (as described in sec-
tion 1861(s)(2)(J)),
‘‘(iii) therapeutic shoes for diabetics (as described
in section 1861(s)(12)),
‘‘(iv) oral drugs prescribed for use as an anticancer
therapeutic 
agent 
(as 
described 
in 
section
1861(s)(2)(Q)), and
‘‘(v) self-administered erythropoetin (as described
in section 1861(s)(2)(P)).’’.
H. R. 5252—22
(2) CONFORMING AMENDMENT.—Effective 60 days after the
date of enactment of the Social Security Act Amendments of
1994, paragraph (16) of section 1834(a) (42 U.S.C. 1395m(a))
is repealed.
(b) USE OF COVERED ITEMS BY DISABLED BENEFICIARIES.—
(1) IN
GENERAL.—The Secretary of Health and Human
Services, in consultation with representatives of suppliers of
durable medical equipment under part B of the medicare pro-
gram and individuals entitled to benefits under such program
on the basis of disability, shall conduct a study of the effects
of the methodology for determining payments for items of such
equipment under such part on the ability of such individuals
to obtain items of such equipment, including customized items.
(2) REPORT.—Not later than one year after the date of
the enactment of this Act, the Secretary shall submit a report
to Congress on the study conducted under paragraph (1), and
shall include in the report such recommendations as the Sec-
retary considers appropriate to assure that disabled medicare
beneficiaries have access to items of durable medical equipment.
(c) CRITERIA FOR TREATMENT OF ITEMS AS PROSTHETIC DEVICES
OR ORTHOTICS AND PROSTHETICS.—Not later than one year after
the date of the enactment of this Act, the Secretary of Health
and Human Services shall submit a report to the Committees
on Ways and Means and Energy and Commerce of the House
of Representatives and the Committee on Finance of the Senate
describing prosthetic devices or orthotics and prosthetics covered
under part B of the medicare program that do not require individ-
ualized or custom fitting and adjustment to be used by a patient.
Such report shall include recommendations for an appropriate meth-
odology for determining the amount of payment for such items
under such program.
SEC. 132. RESTRICTIONS 
ON 
CERTAIN 
MARKETING 
AND 
SALES
ACTIVITIES.
(a) PROHIBITING UNSOLICITED TELEPHONE CONTACTS FROM
SUPPLIERS OF DURABLE MEDICAL EQUIPMENT TO MEDICARE BENE-
FICIARIES.—
(1) IN GENERAL.—Section 1834(a) (42 U.S.C. 1395m(a)) is
amended by adding at the end the following new paragraph:
‘‘(17) PROHIBITION AGAINST UNSOLICITED TELEPHONE CON-
TACTS BY SUPPLIERS.—
‘‘(A) IN GENERAL.—A supplier of a covered item under
this subsection may not contact an individual enrolled
under this part by telephone regarding the furnishing of
a covered item to the individual unless 1 of the following
applies:
‘‘(i) The individual has given written permission
to the supplier to make contact by telephone regarding
the furnishing of a covered item.
‘‘(ii) The supplier has furnished a covered item
to the individual and the supplier is contacting the
individual only regarding the furnishing of such cov-
ered item.
‘‘(iii) If the contact is regarding the furnishing
of a covered item other than a covered item already
furnished to the individual, the supplier has furnished
at least 1 covered item to the individual during the
H. R. 5252—23
15-month period preceding the date on which the sup-
plier makes such contact.
‘‘(B) PROHIBITING PAYMENT FOR ITEMS FURNISHED SUB-
SEQUENT TO UNSOLICITED CONTACTS.—If a supplier know-
ingly contacts an individual in violation of subparagraph
(A), no payment may be made under this part for any
item subsequently furnished to the individual by the sup-
plier.
‘‘(C) EXCLUSION FROM PROGRAM FOR SUPPLIERS ENGAG-
ING IN PATTERN OF UNSOLICITED CONTACTS.—If a supplier
knowingly contacts individuals in violation of subparagraph
(A) to such an extent that the supplier’s conduct establishes
a pattern of contacts in violation 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 COLLECTED FOR DIS-
ALLOWED
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 DIS-
ALLOWED ITEMS.—
‘‘(A) IN GENERAL.—If a nonparticipating supplier fur-
nishes to an individual enrolled under this part a covered
item for which no payment may be made under this part
by reason of paragraph (17)(B), the supplier shall refund
on a timely basis to the patient (and shall be liable to
the patient for) any amounts collected from the patient
for the item, unless—
‘‘(i) the supplier establishes that the supplier did
not know and could not reasonably 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 contract in effect
under this part with respect to suppliers of covered items
shall send any notice of denial of payment for covered
items by reason 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 subpara-
graph (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 within 30 days after the date the
supplier receives a denial notice under subparagraph
(C), or
‘‘(ii) in the case in which such a reconsideration
or appeal is taken, the refund is made within 15 days
H. R. 5252—24
after the date the supplier receives notice of an adverse
determination on reconsideration or appeal.’’.
(b) CONFORMING AMENDMENT.—Section 1834(h)(3) (42 U.S.C.
1395m(h)(3)) is amended by striking ‘‘Paragraph (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. 133. BENEFICIARY LIABILITY FOR NONCOVERED SERVICES.
(a) UNASSIGNED CLAIMS.—
(1) IN GENERAL.—Section 1834(j) (42 U.S.C. 1395m(i)), as
added by section 131(a)(1), is amended—
(A) by redesignating paragraph (4) as paragraph (5),
and
(B) by inserting after paragraph (3) the following new
paragraph:
‘‘(4) LIMITATION ON PATIENT LIABILITY.—If a supplier of
medical equipment and supplies (as defined in paragraph (5))—
‘‘(A) furnishes an item or service to a beneficiary for
which no payment may be made by reason of paragraph
(1);
‘‘(B) furnishes an item or service to a beneficiary for
which payment is denied in advance under subsection
(a)(15); or
‘‘(C) furnishes an item or service to a beneficiary 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 not on an assigned basis shall
be the responsibility of such supplier. The individual shall
have no financial responsibility for such expenses and the sup-
plier shall refund on a timely basis to the individual (and
shall be liable to the individual for) any amounts collected
from the individual for such items or services. The provisions
of subsection (a)(18) shall apply to refunds required under
the previous sentence in the same manner as such provisions
apply to refunds under such subsection.’’.
(2) CONFORMING AMENDMENT.—Section 1128B(b)(3)(B) (42
U.S.C. 1320a–7b(b)(3)(B)), as amended by section 134(a), is
amended by striking ‘‘1834(j)(4)’’ and inserting ‘‘1834(j)(5)’’.
(b) ASSIGNED CLAIMS.—Section 1879 (42 U.S.C. 1395pp) is
amended by adding at the end the following new subsection:
‘‘(h) If a supplier of medical equipment and supplies (as defined
in section 1834(j)(5))—
‘‘(1) furnishes an item or service to a beneficiary for which
no payment may be made by reason of section 1834(j)(1);
‘‘(2) furnishes an item or service to a beneficiary for which
payment is denied in advance under section 1834(a)(15); or
‘‘(3) furnishes an item or service to a beneficiary for which
no payment may be made by reason of section 1834(a)(17)(B),
any expenses incurred for items and services furnished to an
individual by such a supplier on an assignment-related 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 collected from the individual
H. R. 5252—25
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.’’.
(c) EFFECTIVE DATE.—The amendments made by this section
shall apply to items or services furnished on or after January
1, 1995.
SEC. 134. ADJUSTMENTS FOR INHERENT REASONABLENESS.
(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 applicable 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. 135. MISCELLANEOUS AND TECHNICAL CORRECTIONS.
(a) UPDATES
TO PAYMENT AMOUNTS.—(1) Subparagraph (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’’.
(2) The amendment made by paragraph (1) shall be effective
on the date of the enactment of this Act.
(b) ADVANCE 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) ADVANCE DETERMINATIONS OF COVERAGE FOR CERTAIN
ITEMS.—
‘‘(A) DEVELOPMENT OF LISTS OF ITEMS BY SECRETARY.—
The Secretary may develop and periodically update a list
of items for which payment may be made under this sub-
section that the Secretary determines, on the basis of prior
payment experience, are frequently subject to unnecessary
utilization throughout a carrier’s entire service area or
a portion of such area.
‘‘(B) DEVELOPMENT
OF
LISTS
OF
SUPPLIERS
BY
SEC-
RETARY.—The Secretary may develop and periodically
H. R. 5252—26
update a list of suppliers of items for which payment may
be made under this subsection with respect to whom—
‘‘(i) the Secretary has found that a substantial
number of claims for payment under this part for items
furnished by the supplier have been denied on the
basis of the application of section 1862(a)(1); or
‘‘(ii) the Secretary has identified a pattern of
overutilization resulting from the business practice of
the supplier.
‘‘(C) DETERMINATIONS OF COVERAGE IN ADVANCE.—A
carrier shall determine in advance of delivery of an item
whether payment for the item may not be made because
the item is not covered or because of the application of
section 1862(a)(1) if—
‘‘(i) the item is included on the list developed by
the Secretary under subparagraph (A);
‘‘(ii) the item is furnished by a supplier included
on the list developed by the Secretary under subpara-
graph (B); or
‘‘(iii) the item is a customized item (other than
inexpensive items specified by the Secretary) and the
patient to whom the item is to be furnished or the
supplier requests that such advance determination be
made.’’.
(2) Effective for standards applied for contract years beginning
after the date of the enactment of this Act, section 1842(c) (42
U.S.C. 1395u(c)), as amended by section 125(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 developed by the Secretary
to measure the timeliness of carrier responses to requests for pay-
ment of items described in section 1834(a)(15)(C).’’.
(3) Effective on the date of the enactment of this Act, section
1834(h)(3) (42 U.S.C. 1395m(h)(3)), as amended by section 133(b),
is amended by striking ‘‘(12) and (17)’’ and inserting ‘‘(12), (15),
and (17)’’.
(c) STUDY OF VARIATIONS IN DURABLE MEDICAL EQUIPMENT
SUPPLIER COSTS.—
(1) COLLECTION AND ANALYSIS OF SUPPLIER COST DATA.—
The Administrator of the Health Care Financing Administra-
tion shall, in consultation with appropriate organizations, col-
lect data on supplier 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 propor-
tions 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 region in which the supplier is located.
(2) DEVELOPMENT
OF
GEOGRAPHIC
ADJUSTMENT
INDEX;
REPORTS.—Not later than July 1, 1995—
(A) the Administrator shall submit a report to the
Committees on Energy and Commerce 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
H. R. 5252—27
a geographic cost adjustment 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 Commerce 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.—(1) Section 1834(a)(5)(E) (42 U.S.C.
1395m(a)(5)(E)) is amended by striking ‘‘55’’ and inserting ‘‘56’’.
(2) The amendment made by paragraph (1) shall be effective
on the date of the enactment of this Act.
(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 subsection’’.
(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 ‘‘Reconciliation’’.
(8) The amendments made by this subsection shall take effect
as if included in the enactment of OBRA–1990.
PART III—OTHER ITEMS AND SERVICES
SEC. 141. AMBULATORY SURGICAL CENTER SERVICES.
(a) PAYMENT AMOUNTS FOR SERVICES FURNISHED IN AMBULA-
TORY SURGICAL CENTERS.—
(1) USE OF SURVEY TO DETERMINE INCURRED COSTS.—Sec-
tion 1833(i)(2)(A)(i) (42 U.S.C. 1395l(i)(2)(A)(i)) is amended by
striking the comma at the end and inserting the following:
‘‘, as determined in accordance with a survey (based upon
a representative sample of procedures and facilities) taken not
later than January 1, 1995, and every 5 years thereafter, of
the actual audited costs incurred by such centers in providing
such services,’’.
(2) AUTOMATIC APPLICATION OF INFLATION ADJUSTMENT.—
Section 1833(i)(2) (42 U.S.C. 1395l(i)(2)) is amended—
(A) in the second sentence of subparagraph (A) and
the second sentence of subparagraph (B), by striking ‘‘and
may be adjusted by the Secretary, when appropriate,’’;
and
(B) by adding at the end the following new
subparagraph:
‘‘(C) Notwithstanding the second sentence of subparagraph (A)
or the second sentence of subparagraph (B), if the Secretary has
H. R. 5252—28
not updated amounts established under such subparagraphs with
respect to facility services furnished during a fiscal year (beginning
with fiscal year 1996), such amounts shall be increased by the
percentage increase in the consumer price index for all urban
consumers (U.S. city average) as estimated by the Secretary for
the 12-month period ending with the midpoint of the year involved.’’.
(3) CONSULTATION REQUIREMENT.—The second sentence of
section 1833(i)(1) (42 U.S.C. 1395l(i)(1)) is amended by striking
the period and inserting the following: ‘‘, in consultation with
appropriate trade and professional organizations.’’.
(b) ADJUSTMENTS TO PAYMENT AMOUNTS FOR NEW TECHNOLOGY
INTRAOCULAR LENSES.—
(1) ESTABLISHMENT OF PROCESS FOR REVIEW OF AMOUNTS.—
Not later than 1 year after the date of the enactment of this
Act, the Secretary of Health and Human Services (in this
subsection referred to as the ‘‘Secretary’’) shall develop and
implement a process under which interested parties may
request review by the Secretary of the appropriateness of the
reimbursement amount provided under section 1833(i)(2)(A)(iii)
of the Social Security Act with respect to a class of new tech-
nology intraocular lenses. For purposes of the preceding sen-
tence, an intraocular lens may not be treated as a new
technology lens unless it has been approved by the Food and
Drug Administration.
(2) FACTORS CONSIDERED.—In determining whether to pro-
vide an adjustment of payment with respect to a particular
lens under paragraph (1), the Secretary shall take into account
whether use of the lens is likely to result in reduced risk
of intraoperative or postoperative complication or trauma, accel-
erated postoperative recovery, reduced induced astigmatism,
improved postoperative visual acuity, more stable postoperative
vision, or other comparable clinical advantages.
(3) NOTICE AND COMMENT.—The Secretary shall publish
notice in the Federal Register from time to time (but no less
often than once each year) of a list of the requests that the
Secretary has received for review under this subsection, and
shall provide for a 30-day comment period on the lenses that
are the subjects of the requests contained in such notice. The
Secretary shall publish a notice of the Secretary’s determina-
tions with respect to intraocular lenses listed in the notice
within 90 days after the close of the comment period.
(4) EFFECTIVE DATE OF ADJUSTMENT.—Any adjustment of
a payment amount (or payment limit) made under this sub-
section shall become effective not later than 30 days after
the date on which the notice with respect to the adjustment
is published under paragraph (3).
(c) TECHNICAL CORRECTION RELATING TO BLEND AMOUNTS FOR
AMBULATORY SURGICAL CENTER PAYMENTS.—
(1) IN
GENERAL.—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 inserting ‘‘for por-
tions of cost reporting’’; and
(B) by striking ‘‘and on or before’’ and inserting ‘‘and
ending on or before’’.
(2) EFFECTIVE DATE.—The amendments made by paragraph
(1) shall take effect as if included in the enactment of OBRA–
1990.
H. R. 5252—29
(d) TECHNICAL CORRECTION RELATED TO CATARACT SURGERY.—
Effective as if included in the enactment of OBRA–1990, section
4151(c)(3) of such Act is amended by striking ‘‘for the insertion
of an intraocular lens’’ and inserting ‘‘for an intraocular lens
inserted’’.
SEC. 142. STUDY OF MEDICARE COVERAGE OF PATIENT CARE COSTS
ASSOCIATED WITH CLINICAL TRIALS OF NEW CANCER
THERAPIES.
(a) STUDY.—The Secretary of Health and Human Services shall
conduct a study of the effects of expressly covering under the
medicare program the patient care costs for beneficiaries enrolled
in clinical trials of new cancer therapies, where the protocol for
the trial has been approved by the National Cancer Institute or
meets similar scientific and ethical standards, including approval
by an institutional review board. The study shall include—
(1) an estimate of the cost of such coverage, taking into
account the extent to which medicare currently pays for such
patient care costs in practice;
(2) an assessment of the extent to which such clinical
trials represent the best available treatment for the patients
involved and of the effects of participation in the trials on
the health of such patients;
(3) an assessment of whether progress in developing new
anticancer therapies would be assisted by medicare coverage
of such patient care costs; and
(4) an evaluation of whether there should be special criteria
for the admission of medicare beneficiaries (on account of their
age or physical condition) to clinical trials for which medicare
would pay the patient care costs.
(b) REPORT.—Not later than 2 years after the date of the
enactment of this Act, the Secretary of Health and Human Services
shall submit a report on the study conducted under subsection
(a) to the Committee on Ways and Means and the Committee
on Energy and Commerce of the House of Representatives and
the Committee on Finance of the Senate. Such report shall include
recommendations as to the coverage under the medicare program
of patient care costs of beneficiaries enrolled in clinical trials of
new cancer therapies.
SEC. 143. STUDY OF ANNUAL CAP ON AMOUNT OF MEDICARE PAY-
MENT 
FOR 
OUTPATIENT 
PHYSICAL 
THERAPY 
AND
OCCUPATIONAL THERAPY SERVICES.
(a) STUDY.—The Secretary of Health and Human Services shall
conduct a study of the appropriateness of continuing an annual
limitation on the amount of payment for outpatient services of
independently practicing physical and occupational therapists under
the medicare program.
(b) REPORT.—By not later than January 1, 1996, the Secretary
shall submit to the Committees on Energy and Commerce and
Ways and Means of the House of Representatives and the Commit-
tee on Finance of the Senate a report on the study conducted
under subsection (a). Such report shall include such recommenda-
tions for changes in such annual limitation as the Secretary finds
appropriate.
H. R. 5252—30
SEC. 144. PAYMENT OF PART B PREMIUM LATE ENROLLMENT PEN-
ALTIES BY STATES.
Section 1839 (42 U.S.C. 1395r) is amended by adding at the
end the following new subsection:
‘‘(g)(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 Supple-
mentary Medical Insurance 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
paragraph (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 payable under an agreement under
paragraph (1).
‘‘(3) In this subsection:
‘‘(A) The term ‘eligible individual’ means an individual
who is enrolled under this part B and who is within a class
of individuals specified in the agreement under paragraph (1).
‘‘(B) The term ‘part B late enrollment premium increase’
means any increase in a premium as a result of the application
of subsection (b).’’.
SEC. 145. APPLICATION 
OF 
MAMMOGRAPHY 
CERTIFICATION
REQUIREMENTS.
(a) SCREENING MAMMOGRAPHY.—Section 1834(c) (42 U.S.C.
1395m(c)) is amended—
(1) in paragraph (1)(B), by striking ‘‘meets the quality
standards established under paragraph (3)’’ and inserting ‘‘is
conducted by a facility that has a certificate (or provisional
certificate) issued under section 354 of the Public Health Service
Act’’;
(2) in paragraph (1)(C)(iii), by striking ‘‘paragraph (4)’’ and
inserting ‘‘paragraph (3)’’;
(3) by striking paragraph (3); and
(4) by redesignating paragraphs (4) and (5) as paragraphs
(3) and (4).
(b) DIAGNOSTIC MAMMOGRAPHY.—Section 1861(s)(3) (42 U.S.C.
1395x(s)(3)) is amended by inserting ‘‘and including diagnostic
mammography if conducted by a facility that has a certificate
(or provisional certificate) issued under section 354 of the Public
Health Service Act’’ after ‘‘necessary’’.
(c) CONFORMING AMENDMENTS.—(1) Section 1862(a)(1)(F) (42
U.S.C. 1395y(a)(1)(F)) is amended by striking ‘‘or which does not
meet the standards established under section 1834(c)(3)’’ and insert-
ing ‘‘or which is not conducted by a facility described in section
1834(c)(1)(B)’’.
(2) Section 1863 (42 U.S.C. 1395z) is amended by striking
‘‘or whether screening mammography meets the standards estab-
lished under section 1834(c)(3),’’.
(3) The first sentence of section 1864(a) (42 U.S.C. 1395aa(a))
is amended by striking ‘‘, or whether screening mammography
meets the standards established under section 1834(c)(3)’’.
(4) The third sentence of section 1865(a) (42 U.S.C. 1395bb(a))
is amended by striking ‘‘1834(c)(3),’’.
H. R. 5252—31
(d) EFFECTIVE DATE.—The amendments made by this section
shall apply to mammography furnished by a facility on and after
the first date that the certificate requirements of section 354(b)
of the Public Health Service Act apply to such mammography
conducted by such facility.
SEC. 146. COVERAGE OF SERVICES OF SPEECH-LANGUAGE PATHOLO-
GISTS AND AUDIOLOGISTS.
(a) SERVICES DEFINED.—Section 1861 (42 U.S.C. 1395x), as
amended by section 148(f)(6)(E), is amended by inserting after
subsection (kk) the following new subsection:
‘‘Speech-Language Pathology Services; Audiology Services
‘‘(ll)(1) The term ‘speech-language pathology services’ means
such speech, language, and related function assessment and
rehabilitation services furnished by a qualified speech-language
pathologist as the speech-language pathologist is legally authorized
to perform under State law (or the State regulatory mechanism
provided by State law) as would otherwise be covered if furnished
by a physician.
‘‘(2) The term ‘audiology services’ means such hearing and
balance assessment services furnished by a qualified audiologist
as the audiologist is legally authorized to perform under State
law (or the State regulatory mechanism provided by State law),
as would otherwise be covered if furnished by a physician.
‘‘(3) In this subsection:
‘‘(A) The term ‘qualified speech-language pathologist’ means
an individual with a master’s or doctoral degree in speech-
language pathology who—
‘‘(i) is licensed as a speech-language pathologist by
the State in which the individual furnishes such services,
or
‘‘(ii) in the case of an individual who furnishes services
in a State which does not license speech-language patholo-
gists, has successfully completed 350 clock hours of
supervised clinical practicum (or is in the process of
accumulating such supervised clinical experience), per-
formed not less than 9 months of supervised full-time
speech-language pathology services after obtaining a mas-
ter’s or doctoral degree in speech-language pathology or
a related field, and successfully completed a national
examination in speech-language pathology approved by the
Secretary.
‘‘(B) The term ‘qualified audiologist’ means an individual
with a master’s or doctoral degree in audiology who—
‘‘(i) is licensed as an audiologist by the State in which
the individual furnishes such services, or
‘‘(ii) in the case of an individual who furnishes services
in a State which does not license audiologists, has success-
fully completed 350 clock hours of supervised clinical
practicum (or is in the process of accumulating such super-
vised clinical experience), performed not less than 9 months
of supervised full-time audiology services after obtaining
a master’s or doctoral degree in audiology or a related
field, and successfully completed a national examination
in audiology approved by the Secretary.’’.
H. R. 5252—32
(b) CONFORMING AMENDMENTS RELATING TO MEDICARE TREAT-
MENT OF SPEECH AND LANGUAGE SERVICES.—
(1) EXTENDED
CARE
SERVICES.—Section 1861(h)(3) (42
U.S.C. 1395x(h)(3)) is amended by striking ‘‘, occupational, or
speech therapy’’ and inserting ‘‘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 inserting ‘‘or occupational therapy or speech-lan-
guage pathology services’’.
(3) OUTPATIENT PHYSICAL THERAPY SERVICES.—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 REHABILITATION 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 inserting ‘‘therapy, or speech-language
pathology services’’.
(c) EFFECTIVE DATE.—The amendments made by this section
shall take effect on January 1, 1995.
SEC. 147. 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 sec-
tion 1877(h)(5))’’.
(b) CONSULTATION
FOR
SOCIAL
WORKERS.—Effective 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 PAYMENT.—(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 appears and
inserting ‘‘system’’; and
(ii) by striking ‘‘paragraphs (1) and (6)’’ and inserting
‘‘paragraph (1)’’.
(d) RADIOLOGY AND DIAGNOSTIC SERVICES PROVIDED IN HOS-
PITAL OUTPATIENT DEPARTMENTS.—(1) 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—
(A) by inserting ‘‘and for services described in subsection
(a)(2)(E)(ii) furnished on or after January 1, 1992’’ after ‘‘1989’’;
and
H. R. 5252—33
(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 (SEC-
TION 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 inserting ‘‘sub-
section (aa)(5)’’; and
(B) by striking ‘‘subsection (aa)(4)’’ and inserting ‘‘sub-
section (aa)(6)’’.
(2) Section 1833(r)(1) (42 U.S.C. 1395l(r)(1)) is amended—
(A) by striking ‘‘ambulatory’’ each place it appears and
inserting ‘‘or ambulatory’’; and
(B) by striking ‘‘center,’’ and inserting ‘‘center’’.
(3) Section 1833(r)(2)(A) (42 U.S.C. 1395l(r)(2)(A)) is amended
by striking ‘‘subsection (a)(1)(M)’’ and inserting ‘‘subsection
(a)(1)(O)’’.
(4) Section 1861(b)(4) (42 U.S.C. 1395x(b)(4)) is amended by
striking ‘‘subsection (s)(2)(K)(i)’’ and inserting ‘‘clauses (i) or (iii)
of subsection (s)(2)(K)’’.
(5) Section 1861(aa)(5) (42 U.S.C. 1395x(aa)(5)) is amended
by striking ‘‘this Act’’ and inserting ‘‘this title’’.
(6) 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)’’.
(7) Section 1866(a)(1)(H) (42 U.S.C. 1395cc(a)(1)(H)) is amended
by striking ‘‘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 INDIVIDUALS COV-
ERED BY AN EMPLOYMENT-BASED PLAN.—(A) Subparagraphs (A)
and (B) of section 1837(i)(3) (42 U.S.C. 1395p(i)(3)) are each
amended—
(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 individual 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 individual 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 follows:
‘‘(1) in any month of the special enrollment period 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 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 individual,
on the first day of any of the following three months), or
‘‘(2) in any other month of the special enrollment period,
the coverage period shall begin on the first day of the month
following the month in which the individual so enrolls.’’.
H. R. 5252—34
(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 enactment of this Act.
(2) CLINICAL
DIAGNOSTIC
LABORATORY
TESTS.—Section
4154(e)(5) of OBRA–1990 is amended by striking ‘‘(1)(A)’’ and
inserting ‘‘(1)(A),’’.
(3) SEPARATE PAYMENT UNDER PART B FOR CERTAIN SERV-
ICES.—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
PRACTITIONERS.—Section’’.
(4) COMMUNITY HEALTH CENTERS AND RURAL HEALTH CLIN-
ICS.—(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 inserting ‘‘Secretary’s approval or
disapproval’’.
(B) Section 4161(a)(7)(B) of OBRA–1990 is amended by
inserting ‘‘and to the Committee on Finance of the Senate’’
after ‘‘Representatives’’.
(5) SCREENING
MAMMOGRAPHY.—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 performed on or after July
1, 1990.’’; and
(B) in subsection (e), by striking ‘‘The amendments’’
and inserting ‘‘Except as provided in subsection (d)(3), the
amendments’’.
(6) INJECTABLE DRUGS FOR TREATMENT OF OSTEOPOROSIS.—
(A) CLARIFICATION OF DRUGS COVERED.—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 strik-
ing ‘‘a bone fracture related to’’; and
(ii) in paragraph (1), by striking ‘‘patient’’ and
inserting ‘‘individual has suffered a bone fracture
related to post-menopausal osteoporosis and that the
individual’’.
(B) LIMITING COVERAGE TO DRUGS PROVIDED 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 excluding’’ 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
H. R. 5252—35
(II) by striking subparagraph (O) and redesignat-
ing subparagraph (P) as subparagraph (O).
(C) PAYMENT
BASED
ON
REASONABLE
COST.—Section
1833(a)(2) (42 U.S.C. 1395l(a)(2)) is amended—
(i) in subparagraph (A), by striking ‘‘health serv-
ices’’ and inserting ‘‘health services (other than a cov-
ered 
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 of
subparagraph (E) and inserting ‘‘; and’’; and
(iv) by adding at the end the following new
subparagraph:
‘‘(F) with respect to a covered osteoporosis drug (as
defined in section 1861(kk)) furnished by a home health
agency, 80 percent of the reasonable cost of such service,
as determined under section 1861(v);’’.
(D) APPLICATION
OF
PART
B
DEDUCTIBLE.—Section
1833(b)(2) (42 U.S.C. 1395l(b)(2)) is amended by striking
‘‘services’’ and inserting ‘‘services (other than a covered
osteoporosis drug (as defined in section 1861(kk)))’’.
(E) COVERED
OSTEOPOROSIS
DRUG
(SECTION
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–1990, by striking ‘‘(jj) The term’’ and inserting ‘‘(kk)
The term’’.
(7) OTHER MISCELLANEOUS AND TECHNICAL CORRECTIONS.—
(A) OWNERSHIP DISCLOSURE REQUIREMENTS.—(i) Sec-
tion 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 NUM-
BERS.—Section 4164(c) of OBRA–1990 is amended by strik-
ing ‘‘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.
Subtitle C—Provisions Relating to Parts A
and B
SEC. 151. MEDICARE SECONDARY PAYER REFORMS.
(a) IMPROVING IDENTIFICATION OF MEDICARE SECONDARY 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
H. R. 5252—36
nature of the coverage provided under the plan, including
the name, address, and identifying 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 60 days
after the date of the enactment of the Social Security
Act Amendments of 1994, to distribute the questionnaire
described in section 1862(b)(5)(D) of the Social Security
Act (as added by subparagraph (A)).
(C) NO MEDICARE SECONDARY PAYER DENIAL BASED ON
FAILURE TO COMPLETE QUESTIONNAIRE.—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 questionnaire 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
PROVIDERS
AND
SUPPLIERS.—
‘‘(A) IN GENERAL.—Notwithstanding any other provi-
sion of this title, no payment may be made for any item
or service furnished under part B unless the entity furnish-
ing such item or service completes (to the best of its knowl-
edge and on the basis of information obtained from the
individual to whom the item or service is furnished) the
portion of the claim form relating to the availability of
other health benefit plans.
‘‘(B) PENALTIES.—An entity that knowingly, 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 exceed $2,000 for each
such incident. The provisions of section 1128A (other than
subsections (a) and (b)) shall apply to a civil money penalty
under the previous sentence in the same manner 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 respect to items and
services furnished on or after the expiration of the 120-
day period beginning on the date of the enactment of this
Act.
(b) IMPROVEMENTS IN RECOVERY OF PAYMENTS FROM PRIMARY
PAYERS.—
(1) SUBMISSION OF REPORTS ON EFFORTS TO RECOVER ERRO-
NEOUS PAYMENTS.—
(A) FISCAL
INTERMEDIARIES
UNDER
PART
A.—Section
1816 (42 U.S.C. 1396h) is amended by adding at the end
the following new subsection:
H. R. 5252—37
‘‘(k) An agreement with an agency or organization under this
section shall require that such agency or organization submit an
annual report to the Secretary describing 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 amended—
(i) by striking ‘‘and’’ at the end of subparagraph
(G);
(ii) by striking ‘‘and’’ at the end of subparagraph
(H); and
(iii) by inserting after subparagraph (H) the follow-
ing 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 payment has been or could
be made under a primary plan (as defined in section
1862(b)(2)(A)); and’’.
(2) REQUIREMENTS UNDER CARRIER PERFORMANCE EVALUA-
TION PROGRAM.—
(A) FISCAL
INTERMEDIARIES
UNDER
PART
A.—Section
1816(f)(1)(A) (42 U.S.C. 1396h(f)(1)(A)) is amended by strik-
ing ‘‘processing’’ 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 subparagraph:
‘‘(D) In addition to any other standards and criteria established
by the Secretary for evaluating carrier performance under this
paragraph relating to avoiding erroneous payments, the carrier
shall be subject to 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 primary plan (as defined in section 1862(b)(2)(A)).’’.
(3) DEADLINE FOR REIMBURSEMENT BY PRIMARY PLANS.—
(A) IN GENERAL.—Section 1862(b)(2)(B)(i) (42 U.S.C.
1395y(b)(2)(B)(i)) 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 Secretary 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 applicable 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 REQUIRED.—’’.
(C) EFFECTIVE DATE.—The amendments made by this
paragraph shall apply to payments for items and services
H. R. 5252—38
furnished on or after the date of the enactment of this
Act.
(4) EFFECTIVE
DATE.—The amendments made by para-
graphs (1) and (2) shall apply to contracts with fiscal
intermediaries and carriers under title XVIII of the Social
Security Act for contract years beginning with 1995.
(c) MISCELLANEOUS AND TECHNICAL CORRECTIONS.—
(1) Effective as if included in the enactment of OBRA–
1993, section 1862(b)(1)(A) (42 U.S.C. 1395y(b)(1)(A)), as
amended by section 13561(e)(1) of OBRA–1993, is amended—
(A) in clause (i)(II), by striking ‘‘over (and the individ-
ual’s spouse age 65 or older) who is covered under the
plan by virtue of the individual’s current employment sta-
tus with an employer’’ and inserting ‘‘older (and the spouse
age 65 or older of any individual) who has current employ-
ment status with an employer’’; and
(B) in clause (ii), by striking ‘‘or employee organization
that has 20 or more individuals in current employment
status’’ and inserting ‘‘that has 20 or more employees’’.
(2) Effective as if included in the enactment of OBRA–
1993, section 1837(i) (42 U.S.C. 1395p(i)) is amended—
(A) by striking ‘‘as an active individual (as those terms
are defined in section 1862(b)(1)(B)(iv))’’ each place it
appears in the second sentence of paragraph (1), and the
second sentence of paragraph (2) and inserting ‘‘(as that
term is defined in section 1862(b)(1)(B)(iv)) by reason of
the individual’s current employment status (or the current
employment status of a family member of the individual)’’;
(B) in paragraph (3)(B), by striking ‘‘as an active
individual in a large group health plan (as such terms
are defined in section 1862(b)(1)(B)(iv))’’ and inserting ‘‘in
a large group health plan (as that term is defined in
section 1862(b)(1)(B)(iv)) by reason of the individual’s cur-
rent employment status (or the current employment status
of a family member of the individual)’’;
(C) in the second sentence of paragraph (2) (as amend-
ed by subparagraph (A)), by striking ‘‘as an active individ-
ual’’ and inserting ‘‘by reason of the individual’s current
employment status (or the current employment status of
a family member of the individual)’’; and
(D) by inserting ‘‘status’’ after ‘‘current employment’’
each place it appears in paragraphs (1)(A), (2)(B), (2)(C),
and (3)(A).
(3) Effective as if included in the enactment of OBRA–
1993, the second sentence of section 1839(b) (42 U.S.C. 1395r(b))
is amended—
(A) by inserting ‘‘status’’ after ‘‘current employment’’,
and
(B) by striking ‘‘as an active individual (as those terms
are defined in section 1862(b)(1)(B)(iv))’’ and inserting ‘‘(as
that term is defined in section 1862(b)(1)(B)(iv)) by reason
of the individual’s current employment status (or the cur-
rent employment status of a family member of the individ-
ual)’’.
(4) Effective as if included in the enactment of OBRA–
1990, the sentence in section 1862(b)(1)(C) added by section
H. R. 5252—39
4203(c)(1)(B) of OBRA–1990 is amended by striking ‘‘clauses
(i) and (ii)’’ and inserting ‘‘this subparagraph’’.
(5) Effective as if included in the enactment of OBRA–
1989, section 1862(b)(1)(C) is amended in the matter after
clause (ii), by striking ‘‘taking into account that’’ and inserting
‘‘paying benefits secondary to this title when’’.
(6) Effective as if included in the enactment of OBRA–
1989, section 1862(b)(5)(C)(i) (42 U.S.C. 1395y(b)(5)(C)(i)) is
amended 
by 
striking 
‘‘6103(l)(12)(D)(iii)’’ 
and 
inserting
‘‘6103(l)(12)(E)(iii)’’.
(7) Effective as if included in the enactment of OBRA–
1990, section 4203(c)(2) of such Act 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 regard to the number of
employees covered by such plans.’’.
(8) Effective as if included in the enactment of OBRA–
1990, section 4203(d) of OBRA–1990 is amended by striking
‘‘this subsection’’ and inserting ‘‘this section’’.
(9) Effective as if included in the enactment of OBRA–
1993, section 13561(e)(1)(D) of OBRA–1993 is amended—
(A) by inserting ‘‘effective as if included in the enact-
ment of OBRA–1989,’’ after ‘‘(D)’’, and
(B) by striking ‘‘of each subparagraph’’.
(10) The amendment made by section 13561(e)(1)(G) of
OBRA–1993, to the extent it relates to the definition of large
group health plan, shall be effective as if included in the enact-
ment of OBRA–1989.
SEC. 152. PHYSICIAN OWNERSHIP AND REFERRAL.
(a) IN
GENERAL.—Section 1877(f) (42 U.S.C. 1395nn) is
amended—
(1) in the matter before paragraph (1), by inserting ‘‘,
investment, and compensation’’ after ‘‘ownership’’;
(2) in paragraph (2), by inserting ‘‘, or with a compensation
arrangement (as described in subsection (a)(2)(B)),’’ after
‘‘investment interest (as described in subsection (a)(2)(A))’’;
(3) in paragraph (2), by inserting ‘‘interest or who have
such a compensation relationship with the entity’’ before the
period at the end;
(4) in the fourth sentence, by striking ‘‘covered items and’’
and inserting ‘‘designated health’’; and
(5) by striking the third and fifth sentences.
(b) RADIOLOGY
SERVICES.—Section 1877(h)(6) (42 U.S.C.
1395nn(h)(6)), as amended by section 13562(a)(2) of OBRA–1993,
is amended—
(1) in subparagraph (D), by striking ‘‘or other diagnostic
services’’ and inserting ‘‘services, including magnetic resonance
H. R. 5252—40
imaging, computerized axial tomography scans, and ultrasound
services’’; and
(2) in subparagraphs (E), (F), and (H), by inserting ‘‘and
supplies’’ before the period at the end.
(c) REVISION OF EFFECTIVE DATE EXCEPTION PROVISION.—Sec-
tion 13562(b)(2) of OBRA–1993 is amended by striking subpara-
graphs (A) and (B) and inserting the following:
‘‘(A) the second sentence of subsection (a)(2), and sub-
sections (b)(2)(B) and (d)(2), of section 1877 of the Social
Security Act (as in effect on the day before the date of
the enactment of this Act) shall apply instead of the cor-
responding provisions in section 1877 (as amended by this
Act);
‘‘(B) section 1877(b)(4) of the Social Security Act (as
in effect on the day before the date of the enactment
of this Act) shall apply;
‘‘(C) the requirements of section 1877(c)(2) of the Social
Security Act (as amended by this Act) shall not apply
to any securities of a corporation that meets the require-
ments of section 1877(c)(2) of the Social Security Act (as
in effect on the day before the date of the enactment
of this Act);
‘‘(D) section 1877(e)(3) of the Social Security Act (as
amended by this Act) shall apply, except that it shall
not apply to any arrangement that meets the requirements
of subsection (e)(2) or subsection (e)(3) of section 1877
of the Social Security Act (as in effect on the day before
the date of the enactment of this Act);
‘‘(E) the requirements of clauses (iv) and (v) of section
1877(h)(4)(A), and of clause (i) of section 1877(h)(4)(B),
of the Social Security Act (as amended by this Act) shall
not apply; and
‘‘(F) section 1877(h)(4)(B) of the Social Security Act
(as in effect on the day before the date of the enactment
of this Act) shall apply instead of section 1877(h)(4)(A)(ii)
of such Act (as amended by this Act).’’.
(d) EFFECTIVE DATES.—
(1) The amendments made by subsections (a) and (b) shall
apply to referrals made on or after January 1, 1995.
(2) The amendment made by subsection (c) shall apply
as if included in the enactment of OBRA–1993.
SEC. 153. DEFINITION OF FMGEMS EXAMINATION FOR PAYMENT OF
DIRECT GRADUATE MEDICAL EDUCATION.
(a) 
IN
GENERAL.—Section 
1886(h)(5)(E) 
(42 
U.S.C.
1395ww(h)(5)(E)) is amended by inserting ‘‘or any successor exam-
ination’’ after ‘‘Medical Sciences’’.
(b) EFFECTIVE DATE.—The amendment made by subsection (a)
shall apply as if included in the enactment of the Consolidated
Omnibus Budget Reconciliation Act of 1985 (Public Law 99–272).
SEC. 154. QUALIFIED MEDICARE BENEFICIARY OUTREACH.
Not later than 1 year after the date of the enactment of this
Act, the Secretary of Health and Human Services shall establish
and implement a method for obtaining information 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
H. R. 5252—41
medicare beneficiaries, and for transmitting such information to
the State in which such a beneficiary resides.
SEC. 155. HOSPITAL 
AGREEMENTS 
WITH 
ORGAN 
PROCUREMENT
ORGANIZATIONS.
(a) HOSPITAL AGREEMENTS.—
(1) IN GENERAL.—
(A) 
IDENTIFICATION
OF
ORGAN
DONORS.—Section
1138(a)(1)(A)(iii) 
(42 
U.S.C. 
1320b–8(a)(1)(A)(iii)) 
is
amended to read as follows:
‘‘(iii) require that such hospital’s designated organ
procurement agency (as defined in paragraph (3)(B)) is
notified of potential organ donors;’’.
(B) AGREEMENTS WITH DESIGNATED ORGAN PROCURE-
MENT
AGENCIES.—Section 1138(a)(1) (42 U.S.C. 1320b–
8(a)(1)) is amended—
(i) by striking the period at the end of subpara-
graph (B) and inserting ‘‘; and’’; and
(ii) by adding at the end the following new
subparagraph:
‘‘(C) the hospital or rural primary care hospital has an
agreement (as defined in paragraph (3)(A)) only with such
hospital’s designated organ procurement agency.’’.
(C) WAIVER
OF
REQUIREMENTS
RELATED
TO
AGREE-
MENTS.—Section 
1138(a) 
(42 
U.S.C. 
1320b–8(a)) 
is
amended—
(i) by redesignating paragraph (2) as paragraph
(3); and
(ii) by inserting after paragraph (1) the following
new paragraph:
‘‘(2)(A) The Secretary shall grant a waiver of the requirements
under subparagraphs (A)(iii) and (C) of paragraph (1) to a hospital
or rural primary care hospital desiring to enter into an agreement
with an organ procurement agency other than such hospital’s des-
ignated organ procurement agency if the Secretary determines
that—
‘‘(i) the waiver is expected to increase organ donation; and
‘‘(ii) the waiver will assure equitable treatment of patients
referred for transplants within the service area served by such
hospital’s designated organ procurement agency and within
the service area served by the organ procurement agency with
which the hospital seeks to enter into an agreement under
the waiver.
‘‘(B) In making a determination under subparagraph (A), the
Secretary may consider factors that would include, but not be
limited to—
‘‘(i) cost effectiveness;
‘‘(ii) improvements in quality;
‘‘(iii) whether there has been any change in a hospital’s
designated organ procurement agency due to a change made
on or after December 28, 1992, in the definitions for metropoli-
tan statistical areas (as established by the Office of Manage-
ment and Budget); and
‘‘(iv) the length and continuity of a hospital’s relationship
with an organ procurement agency other than the hospital’s
designated organ procurement agency;
H. R. 5252—42
except that nothing in this subparagraph shall be construed to
permit the Secretary to grant a waiver that does not meet the
requirements of subparagraph (A).
‘‘(C) Any hospital or rural primary care hospital seeking a
waiver under subparagraph (A) shall submit an application to the
Secretary containing such information as the Secretary determines
appropriate.
‘‘(D) The Secretary shall—
‘‘(i) publish a public notice of any waiver application
received from a hospital or rural primary care hospital under
this paragraph within 30 days of receiving such application;
and
‘‘(ii) prior to making a final determination on such applica-
tion under subparagraph (A), offer interested parties the oppor-
tunity to submit written comments to the Secretary during
the 60-day period beginning on the date such notice is
published.’’.
(D) DEFINITIONS.—Section 1138(a)(3) (42 U.S.C. 1320b–
8(a)(3)), as redesignated by subparagraph (C), is amended
to read as follows:
‘‘(3) For purposes of this subsection—
‘‘(A) the term ‘agreement’ means an agreement described
in section 371(b)(3)(A) of the Public Health Service Act;
‘‘(B) the term ‘designated organ procurement agency’
means, with respect to a hospital or rural primary care hospital,
the organ procurement agency designated pursuant to sub-
section (b) for the service area in which such hospital is located;
and
‘‘(C) the term ‘organ’ means a human kidney, liver, heart,
lung, pancreas, and any other human organ or tissue specified
by the Secretary for purposes of this subsection.’’.
(2) EXISTING AGREEMENTS.—Any hospital or rural primary
care hospital which has an agreement (as defined in section
1138(a)(3)(A) of the Social Security Act) with an organ procure-
ment agency other than such hospital’s designated organ
procurement agency (as defined in section 1138(a)(3)(B) of such
Act) on the date of the enactment of this section shall, if
such hospital desires to continue such agreement on and after
the effective date of the amendments made by paragraph (1),
submit an application to the Secretary for a waiver under
section 1138(a)(2) of such Act not later than January 1, 1996,
and such agreement may continue in effect pending the Sec-
retary’s determination with respect to such application.
(3) EFFECTIVE DATE.—The amendments made by paragraph
(1) shall apply to hospitals and rural primary care hospitals
participating in the programs under titles XVIII and XIX of
the Social Security Act beginning January 1, 1996.
(b) STUDY ON HOSPITAL AGREEMENTS WITH ORGAN PROCURE-
MENT AGENCIES.—
(1) IN
GENERAL.—The Office of Technology Assessment
(referred to in this section as the ‘‘OTA’’) shall, pursuant to
the approval of the Technology Assessment Board of the OTA,
conduct a study to determine the efficacy and fairness of requir-
ing a hospital to enter into an agreement under section
371(b)(3)(A) of the Public Health Service Act with the organ
procurement agency designated pursuant to section 1138(b)
of the Social Security Act for the service area in which such
H. R. 5252—43
hospital is located and the impact of such requirement on
the efficacy and fairness of organ procurement and distribution.
(2) REPORT.—Not later than 2 years after the date of the
enactment of this Act, the OTA shall complete the study
required under paragraph (1) and prepare and submit to the
Committee on Finance and the Committee on Labor and Human
Resources of the Senate and the Committee on Ways and
Means and the Committee on Energy and Commerce of the
House of Representatives a report containing the findings of
such study and the implications of such findings with respect
to policies affecting organ procurement and distribution.
SEC. 156. PEER REVIEW ORGANIZATIONS.
(a) REPEAL OF PRO PRECERTIFICATION REQUIREMENT FOR CER-
TAIN 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 paragraph (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—
(i) in subsection (a)(1)(D)(i), by striking ‘‘, or for
tests furnished in connection with obtaining a second
opinion required under section 1164(c)(2) (or a third
opinion, if the second opinion was in disagreement
with the first opinion)’’;
(ii) in subsection (a)(1), by striking subparagraph
(G);
(iii) in subsection (a)(2)(A), by striking ‘‘, to items
and services (other than clinical diagnostic laboratory
tests) furnished in connection with obtaining a second
opinion required under section 1164(c)(2) (or a third
opinion, if the second opinion was in disagreement
with the first opinion),’’;
(iv) in subsection (a)(2)(D)(i)—
(I) by striking ‘‘basis,’’ and inserting ‘‘basis
or’’, and
(II) by striking ‘‘, or for tests furnished in
connection with obtaining a second opinion
required under section 1164(c)(2) (or a third opin-
ion, if the second opinion was in disagreement
with the first opinion)’’;
(v) in subsection (a)(3), by striking ‘‘and for items
and services furnished in connection with obtaining
a second opinion required under section 1164(c)(2), or
a third opinion, if the second opinion was in disagree-
ment with the first opinion’’; and
(vi) in the first sentence of subsection (b), by strik-
ing ‘‘(4)’’ and all that follows through ‘‘and (5)’’ and
inserting ‘‘and (4)’’.
(C) Section 1834(g)(1)(B) (42 U.S.C. 1395m(g)(1)(B))
is amended by striking ‘‘and for items and services fur-
nished in connection with obtaining a second opinion
required under section 1164(c)(2), or a third opinion, if
H. R. 5252—44
the second opinion was in disagreement with the first
opinion’’.
(D) Section 1862(a) (42 U.S.C. 1395y(a)) is amended—
(i) by adding ‘‘or’’ at the end of paragraph (14),
(ii) by striking ‘‘; or’’ at the end of paragraph
(15) and inserting a period, and
(iii) by striking paragraph (16).
(E) The third sentence of section 1866(a)(2)(A) (42
U.S.C. 1395w(a)(2)(A)) is amended by striking ‘‘, with
respect to items and services furnished in connection with
obtaining a second opinion required under section
1164(c)(2) (or a third opinion, if the second opinion was
in disagreement with the first opinion),’’.
(3) EFFECTIVE DATE.—The amendments made by this sub-
section shall apply to services provided on or after the date
of the enactment of this Act.
(b) MISCELLANEOUS
AND TECHNICAL CORRECTIONS.—(1) The
third sentence of section 1156(b)(1) (42 U.S.C. 1320c–5(b)(1)) is
amended by striking ‘‘whehter’’ and inserting ‘‘whether’’.
(2)(A) Section 1154(a)(9)(B) (42 U.S.C. 1320c–3(a)(9)(B)) is
amended to read as follows:
‘‘(B) If the organization finds, after reasonable notice to
and opportunity for discussion with the physician or practi-
tioner concerned, that the physician or practitioner has
furnished services in violation of section 1156(a) and the
organization determines that the physician or practitioner
should enter into a corrective action plan under section
1156(b)(1), the organization shall notify the State board or
boards responsible for the licensing or disciplining of the physi-
cian or practitioner of its finding and of any action taken
as a result of the finding.’’.
(B) Subparagraph (D) of section 1160(b)(1) (42 U.S.C. 1320c–
9(b)(1)) is amended to read as follows:
‘‘(D) to provide notice in accordance with section
1154(a)(9)(B);’’.
(3) Section 4205(d)(2)(B) of OBRA–1990 is amended by striking
‘‘amendments’’ and inserting ‘‘amendment’’.
(4) Section 1160(d) (42 U.S.C. 1320c–9(d)) is amended by strik-
ing ‘‘subpena’’ and inserting ‘‘subpoena’’.
(5) Section 4205(e)(2) of OBRA–1990 is amended by striking
‘‘amendments’’ and inserting ‘‘amendment’’ and by striking ‘‘all’’.
(6)(A) Except as provided in subparagraph (B), the amendments
made by this subsection shall take effect as if included in the
enactment of OBRA–1990.
(B) The amendments made by paragraph (2) (relating to the
requirement on reporting of information to State boards) shall take
effect on the date of the enactment of this Act.
SEC. 157. HEALTH MAINTENANCE ORGANIZATIONS.
(a) REVISIONS IN THE PAYMENT METHODOLOGY FOR RISK CON-
TRACTORS.—Section 4204(b) of OBRA–1990 is amended to read as
follows:
‘‘(b) REVISIONS IN THE PAYMENT METHODOLOGY FOR RISK CON-
TRACTORS.—(1)(A) Not later than October 1, 1995, the Secretary
of Health and Human Services (in this subsection referred to as
the ‘Secretary’) shall submit a proposal to the Congress that pro-
vides for revisions to the payment method to be applied in years
H. R. 5252—45
beginning with 1997 for organizations with a risk-sharing contract
under section 1876(g) of the Social Security Act.
‘‘(B) In proposing the revisions required under subparagraph
(A), the Secretary shall consider—
‘‘(i) the difference in costs associated with medicare bene-
ficiaries 
with 
differing 
health 
status 
and 
demographic
characteristics; and
‘‘(ii) the effects of using alternative geographic classifica-
tions on the determinations of costs associated with bene-
ficiaries residing in different areas.
‘‘(2) Not later than 3 months after the date of submittal of
the proposal under paragraph (1), the Comptroller General shall
review the proposal and shall report to Congress on the appropriate-
ness of the proposed modifications.’’.
(b) MISCELLANEOUS AND TECHNICAL CORRECTIONS.—(1) Section
1876(a)(3) (42 U.S.C. 1395mm(a)(3)) is amended by striking ‘‘sub-
section (c)(7)’’ and inserting ‘‘subsections (c)(2)(B)(ii) and (c)(7)’’.
(2) Section 4204(c)(3) of OBRA–1990 is amended by striking
‘‘for 1991’’ and inserting ‘‘for years beginning with 1991’’.
(3) Section 4204(d)(2) of OBRA–1990 is amended by striking
‘‘amendment’’ and inserting ‘‘amendments’’.
(4) Section 1876(a)(1)(E)(ii)(I) (42 U.S.C. 1395mm(a)(1)(E)(ii)(I))
is amended by striking the comma after ‘‘contributed to’’.
(5) Section 4204(e)(2) of OBRA–1990 is amended by striking
‘‘(which has a risk-sharing contract under section 1876 of the Social
Security Act)’’.
(6) Section 4204(f)(4) of OBRA–1990 is amended by striking
‘‘final’’.
(7) 
Section 
1862(b)(3)(C) 
(42 
U.S.C. 
1395y(b)(3)(C)) 
is
amended—
(A) in the heading, by striking ‘‘PLAN’’ and inserting ‘‘PLAN
OR A LARGE GROUP HEALTH PLAN’’;
(B) by striking ‘‘group health plan’’ and inserting ‘‘group
health plan or a large group health plan’’;
(C) by striking ‘‘, unless such incentive is also offered
to all individuals who are eligible for coverage under the plan’’;
and
(D) by striking ‘‘the first sentence of subsection (a) and
other than subsection (b)’’ and inserting ‘‘subsections (a) and
(b)’’.
(8) The amendments made by this subsection shall take effect
as if included in the enactment of OBRA–1990.
SEC. 158. HOME HEALTH AGENCIES.
(a) USE
OF MOST CURRENT DATA
IN DETERMINING WAGE
INDEX.—
(1) IN
GENERAL.—Section 1861(v)(1)(L)(iii) (42 U.S.C.
1395x(v)(1)(L)(iii)) is amended by striking ‘‘as of such date
to’’ and inserting ‘‘and determined using the survey of the
most recent available wages and wage-related costs of’’.
(2) EFFECTIVE DATE.—The amendment made by paragraph
(1) shall apply with respect to cost reporting periods beginning
on or after July 1, 1996.
(b) CLARIFICATION OF EXTENSION OF WAIVER OF LIABILITY.—
(1) IN GENERAL.—The second sentence of section 9205 of
the Consolidated Omnibus Budget Reconciliation Act of 1985
H. R. 5252—46
is amended by striking ‘‘November 1, 1990’’ and inserting
‘‘December 31, 1995’’.
(2) EFFECTIVE DATE.—The amendment made by paragraph
(1) shall take effect as if included in the enactment of OBRA–
1990.
SEC. 159. PERMANENT EXTENSION OF AUTHORITY TO CONTRACT
WITH FISCAL INTERMEDIARIES AND CARRIERS ON OTHER
THAN A COST BASIS.
(a) IN GENERAL.—Section 2326(a) of the Deficit Reduction Act
of 1984, as amended by section 6215 of OBRA–1989, is amended
in the third sentence by striking ‘‘during such period’’ and inserting
‘‘beginning with fiscal year 1990 and any subsequent fiscal year’’.
(b) EFFECTIVE DATE.—The amendment made by subsection (a)
shall apply beginning with fiscal year 1994.
SEC. 160. MISCELLANEOUS AND TECHNICAL CORRECTIONS.
(a) SURVEY
AND CERTIFICATION REQUIREMENTS.—(1) Section
1864 (42 U.S.C. 1395aa) is amended—
(A) in subsection (e), by striking ‘‘title’’ and inserting ‘‘title
(other than any fee relating to section 353 of the Public Health
Service Act)’’; and
(B) in the first sentence of subsection (a), by striking
‘‘1861(s) or’’ and all that follows through ‘‘Service Act,’’ and
inserting ‘‘1861(s),’’.
(2) An agreement made by the Secretary of Health and Human
Services with a State under section 1864(a) of the Social Security
Act may include an agreement that the services of the State health
agency or other appropriate State agency (or the appropriate local
agencies) will be utilized by the Secretary for the purpose of deter-
mining whether a laboratory meets the requirements of section
353 of the Public Health Service Act.
(b) HOME
DIALYSIS
DEMONSTRATION
TECHNICAL
CORREC-
TIONS.—Section 4202 of OBRA–1990 is amended—
(1) in subsection (b)(1)(A), by striking ‘‘home hemodialysis
staff assistant’’ and inserting ‘‘qualified home hemodialysis staff
assistant (as described in subsection (d))’’;
(2) in subsection (b)(2)(B)(ii)(I), by striking ‘‘(as adjusted
to reflect differences in area wage levels)’’;
(3) in subsection (c)(1)(A), by striking ‘‘skilled’’; and
(4) in subsection (c)(1)(E), by striking ‘‘(b)(4)’’ and inserting
‘‘(b)(2)’’.
(c) TECHNICAL CORRECTION TO REVISIONS OF COVERAGE FOR
IMMUNOSUPPRESSIVE DRUG THERAPY.—The Secretary of Health and
Human Services may administer section 1861(s)(2)(J) of the Social
Security Act (42 U.S.C. 1395x(s)(2)(J)) in a manner such that the
months of coverage of drugs described in such section are provided
consecutively, so long as the total number of months of coverage
provided is the same as the number of months described in such
section.
(d) OTHER MISCELLANEOUS AND TECHNICAL PROVISIONS.—(1)
Section 1833 (42 U.S.C. 1395l) is amended by redesignating the
subsection (r) added by section 4206(b)(2) of OBRA–1990 as sub-
section (s).
(2) Section 1866(f)(1) (42 U.S.C. 1395cc(f)(1)) is amended by
striking ‘‘1833(r)’’ and inserting ‘‘1833(s)’’.
H. R. 5252—47
(3) Section 4201(d)(2) of OBRA–1990 is amended by striking
‘‘(B) by striking’’, ‘‘(C) by striking’’, and ‘‘(3) by adding’’ and inserting
‘‘(i) by striking’’, ‘‘(ii) by striking’’, and ‘‘(B) by adding’’, respectively.
(4) 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.
(5)(A) Section 4207(a)(1) of OBRA–1990 is amended by adding
closing quotation marks and a period after ‘‘such review.’’.
(B) Section 4207(a)(4) of OBRA–1990 is amended by striking
‘‘this subsection’’ and inserting ‘‘paragraphs (2) and (3)’’.
(C) Section 4207(b)(1) of OBRA–1990 is amended by striking
‘‘section 3(7)’’ and inserting ‘‘section 601(a)(1)’’.
(6) Section 2355(b)(1)(B) of the Deficit Reduction 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 
inserting
‘‘4207(b)(4)(B)(i)’’, and
(B) by striking ‘‘feasibilitly’’ and inserting ‘‘feasibility’’.
(7) Section 4207(b)(4)(B)(iii)(III) of OBRA–1990 is amended by
striking the period at the end and inserting a semicolon.
(8) 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)’’.
(9) 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’’.
(10) Section 4207(d) of OBRA–1990 is amended by redesignat-
ing the second paragraph (3) (relating to effective date) as para-
graph (4).
(11) Section 4207(i)(2) of OBRA–1990 is amended—
(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’’.
(12) Section 4207(j) of OBRA–1990 is amended by striking
‘‘title’’ each place it appears and inserting ‘‘subtitle’’.
Subtitle D—Provisions Relating to
Medicare Supplemental Insurance Policies
SEC. 171. STANDARDS FOR MEDICARE SUPPLEMENTAL INSURANCE
POLICIES.
(a) SIMPLIFICATION OF MEDICARE SUPPLEMENTAL POLICIES.—
(1) Section 4351 of OBRA–1990 is amended by striking
‘‘(a) IN GENERAL.—’’.
(2) Section 1882(p) (42 U.S.C. 1395ss(p)) is amended—
(A) in paragraph (1)(A)—
(i) 
by 
striking 
‘‘promulgates’’ 
and 
inserting
‘‘changes 
the 
revised 
NAIC 
Model 
Regulation
(described in subsection (m)) to incorporate’’,
(ii) by striking ‘‘(such limitations, language, defini-
tions, format, and standards referred to collectively
in this subsection as ‘NAIC standards’),’’, and
H. R. 5252—48
(iii) by striking ‘‘included a reference to the NAIC
standards’’ and inserting ‘‘were a reference to the
revised NAIC Model Regulation as changed under this
subparagraph (such changed regulation referred to in
this section as the ‘1991 NAIC Model Regulation’)’’;
(B) in paragraph (1)(B)—
(i) by striking ‘‘promulgate NAIC standards’’ and
inserting ‘‘make the changes in the revised NAIC Model
Regulation’’,
(ii) by striking ‘‘limitations, language, definitions,
format, and standards described in clauses (i) through
(iv) of such subparagraph (in this subsection referred
to collectively as ‘Federal standards’)’’ and inserting
‘‘a regulation’’, and
(iii) by striking ‘‘included a reference to the Federal
standards’’ and inserting ‘‘were a reference to the
revised NAIC Model Regulation as changed by the
Secretary under this subparagraph (such changed
regulation referred to in this section as the ‘1991 Fed-
eral Regulation’)’’;
(C) in paragraph (1)(C)(i), by striking ‘‘NAIC standards
or the Federal standards’’ and inserting ‘‘1991 NAIC Model
Regulation or 1991 Federal Regulation’’;
(D) in paragraphs (1)(C)(ii)(I), (1)(E), (2), and (9)(B),
by striking ‘‘NAIC or Federal standards’’ and inserting
‘‘1991 NAIC Model Regulation or 1991 Federal Regulation’’;
(E) in paragraph (2)(C), by striking ‘‘(5)(B)’’ and insert-
ing ‘‘(4)(B)’’;
(F) in paragraph (4)(A)(i), by inserting ‘‘or paragraph
(6)’’ after ‘‘(B)’’;
(G) in paragraph (4), by striking ‘‘applicable standards’’
each place it appears and inserting ‘‘applicable 1991 NAIC
Model Regulation or 1991 Federal Regulation’’;
(H) in paragraph (6), by striking ‘‘in regard to the
limitation of benefits described in paragraph (4)’’ and
inserting ‘‘described in clauses (i) through (iii) of paragraph
(1)(A)’’;
(I) in paragraph (7), by striking ‘‘policyholder’’ and
inserting ‘‘policyholders’’;
(J) in paragraph (8), by striking ‘‘after the effective
date of the NAIC or Federal standards with respect to
the policy, in violation of the previous requirements of
this subsection’’ and inserting ‘‘on and after the effective
date specified in paragraph (1)(C) (but subject to paragraph
(10)), in violation of the applicable 1991 NAIC Model Regu-
lation or 1991 Federal Regulation insofar as such regula-
tion relates to the requirements of subsection (o) or (q)
or clause (i), (ii), or (iii) of paragraph (1)(A)’’;
(K) in paragraph (9), by adding at the end the following
new subparagraph:
‘‘(D) Subject to paragraph (10), this paragraph shall apply
to sales of policies occurring on or after the effective date specified
in paragraph (1)(C).’’; and
(L) in paragraph (10), by striking ‘‘this subsection’’
and inserting ‘‘paragraph (1)(A)(i)’’.
(b) GUARANTEED RENEWABILITY.—Section 1882(q) (42 U.S.C.
1395ss(q)) is amended—
H. R. 5252—49
(1) in paragraph (2), by striking ‘‘paragraph (2)’’ and insert-
ing ‘‘paragraph (4)’’, and
(2) in paragraph (4), by striking ‘‘the succeeding issuer’’
and inserting ‘‘issuer of the replacement policy’’.
(c) ENFORCEMENT OF STANDARDS.—
(1) Section 1882(a)(2) (42 U.S.C. 1395ss(a)(2)) is amended—
(A) in subparagraph (A), by striking ‘‘NAIC standards
or the Federal standards’’ and inserting ‘‘1991 NAIC Model
Regulation or 1991 Federal Regulation’’, and
(B) by striking ‘‘after the effective date of the NAIC
or Federal standards with respect to the policy’’ and insert-
ing ‘‘on and after the effective date specified in subsection
(p)(1)(C)’’.
(2) The sentence in section 1882(b)(1) added by section
4353(c)(5) of OBRA–1990 is amended—
(A) by striking ‘‘The report’’ and inserting ‘‘Each
report’’,
(B) by inserting ‘‘and requirements’’ after ‘‘standards’’,
(C) by striking ‘‘and’’ after ‘‘compliance,’’, and
(D) by striking the comma after ‘‘Commissioners’’.
(3) Section 1882(g)(2)(B) (42 U.S.C. 1395ss(g)(2)(B)) is
amended by striking ‘‘Panel’’ and inserting ‘‘Secretary’’.
(4) Section 1882(b)(1) (42 U.S.C. 1395ss(b)(1)) is amended
by striking ‘‘the the Secretary’’ and inserting ‘‘the Secretary’’.
(d) PREVENTING DUPLICATION.—
(1) Section 1882(d)(3)(A) (42 U.S.C. 1395ss(d)(3)(A)) is
amended—
(A) by amending the first sentence to read as follows:
‘‘(i) It is unlawful for a person to sell or issue to an individual
entitled to benefits under part A or enrolled under part B of this
title—
‘‘(I) a health insurance policy with knowledge that the
policy duplicates health benefits to which the individual is
otherwise entitled under this title or title XIX,
‘‘(II) a medicare supplemental policy with knowledge that
the individual is entitled to benefits under another medicare
supplemental policy, or
‘‘(III) a health insurance policy (other than a medicare
supplemental policy) with knowledge that the policy duplicates
health benefits to which the individual is otherwise entitled,
other than benefits to which the individual is entitled under
a requirement of State or Federal law.’’;
(B) by designating the second sentence as clause (ii)
and, in such clause, by striking ‘‘the previous sentence’’
and inserting ‘‘clause (i)’’;
(C) by designating the third sentence as clause (iii)
and, in such clause—
(i) by striking ‘‘the previous sentence’’ and insert-
ing ‘‘clause (i) with respect to the sale of a medicare
supplemental policy’’, and
(ii) by striking ‘‘and the statement’’ and all that
follows up to the period at the end; and
(D) by striking the last sentence.
(2) Section 1882(d)(3)(B) (42 U.S.C. 1395ss(d)(3)(B)) is
amended—
(A) in clause (ii)(II), by striking ‘‘65 years of age or
older’’,
H. R. 5252—50
(B) in clause (iii)(I), by striking ‘‘another medicare’’
and inserting ‘‘a medicare’’,
(C) in clause (iii)(I), by striking ‘‘such a policy’’ and
inserting ‘‘a medicare supplemental policy’’,
(D) in clause (iii)(II), by striking ‘‘another policy’’ and
inserting ‘‘a medicare supplemental policy’’, and
(E) by amending subclause (III) of clause (iii) to read
as follows:
‘‘(III) If the statement required by clause (i) is obtained and
indicates that the individual is entitled to any medical assistance
under title XIX, the sale of the policy is not in violation of clause
(i) (insofar as such clause relates to such medical assistance), if
(aa) a State medicaid plan under such title pays the premiums
for the policy, (bb) in the case of a qualified medicare beneficiary
described in section 1905(p)(1), the policy provides for coverage
of outpatient prescription drugs, or (cc) the only medical assistance
to which the individual is entitled under the State plan is medicare
cost sharing described in section 1905(p)(3)(A)(ii).’’.
(3)(A) Section 1882(d)(3)(C) (42 U.S.C. 1395ss(d)(3)(C)) is
amended—
(i) by striking ‘‘the selling’’ and inserting ‘‘(i) the sale
or issuance’’, and
(ii) by inserting before the period at the end the follow-
ing: ‘‘, (ii) the sale or issuance of a policy or plan described
in subparagraph (A)(i)(I) (other than a medicare supple-
mental policy to an individual entitled to any medical
assistance under title XIX) under which all the benefits
are fully payable directly to or on behalf of the individual
without regard to other health benefit coverage of the
individual but only if (for policies sold or issued more
than 60 days after the date the statements are published
or promulgated under subparagraph (D)) there is disclosed
in a prominent manner as part of (or together with) the
application the applicable statement (specified under
subparagraph (D)) of the extent to which benefits payable
under the policy or plan duplicate benefits under this title,
or (iii) the sale or issuance of a policy or plan described
in subparagraph (A)(i)(III) under which all the benefits
are fully payable directly to or on behalf of the individual
without regard to other health benefit coverage of the
individual’’.
(B) Section 1882(d)(3) (42 U.S.C. 1395ss(d)(3)) is amended
by adding at the end the following:
‘‘(D)(i) If—
‘‘(I) within the 90-day period beginning on the date of
the enactment of this subparagraph, the National Association
of Insurance Commissioners develops (after consultation with
consumer and insurance industry representatives) and submits
to the Secretary a statement for each of the types of health
insurance policies (other than medicare supplemental policies
and including, but not limited to, as separate types of policies,
policies paying directly to the beneficiary fixed, cash benefits,
and policies that limit benefit payments to specific diseases)
which are sold or issued to persons entitled to health benefits
under this title, of the extent to which benefits payable under
the policy or plan duplicate benefits under this title, and
H. R. 5252—51
‘‘(II) the Secretary approves all the statements submitted
as meeting the requirements of subclause (I),
each such statement shall be (for purposes of subparagraph (C))
the statement specified under this subparagraph for the type of
policy involved. The Secretary shall review and approve (or dis-
approve) all the statements submitted under subclause (I) within
30 days after the date of their submittal. Upon approval of such
statements, the Secretary shall publish such statements.
‘‘(ii) If the Secretary does not approve the statements under
clause (i) or the statements are not submitted within the 90-day
period specified in such clause, the Secretary shall promulgate
(after consultation with consumer and insurance industry represent-
atives and not later than 90 days after the date of disapproval
or the end of such 90-day period (as the case may be)) a statement
for each of the types of health insurance policies (other than medi-
care supplemental policies and including, but not limited to, as
separate types of policies, policies paying directly to the beneficiary
fixed, cash benefits, and policies that limit benefit payments to
specific diseases) which are sold or issued to persons entitled to
health benefits under this title, of the extent to which benefits
payable under the policy or plan duplicate benefits under this
title, and each such statement shall be (for purposes of subpara-
graph (C)) the statement specified under this subparagraph for
the type of policy involved.’’.
(C) The requirement of a disclosure under section
1882(d)(3)(C)(ii) of the Social Security Act shall not apply to
an application made for a policy or plan before 60 days after
the date the Secretary of Health and Human Services publishes
or promulgates all the statements under section 1882(d)(3)(D)
of such Act.
(4) Subparagraphs (A) and (B) of section 1882(q)(5) are
amended by striking ‘‘of the Social Security Act’’.
(e) LOSS RATIOS AND REFUNDS OF PREMIUMS.—
(1) Section 1882(r) (42 U.S.C. 1395ss(r)) is amended—
(A) in paragraph (1), by striking ‘‘or sold’’ and inserting
‘‘or renewed (or otherwise provide coverage after the date
described in subsection (p)(1)(C))’’;
(B) in paragraph (1)(A), by inserting ‘‘for periods after
the effective date of these provisions’’ after ‘‘the policy
can be expected’’;
(C) in paragraph (1)(A), by striking ‘‘Commissioners,’’
and inserting ‘‘Commissioners)’’;
(D) in paragraph (1)(B), by inserting before the period
at the end the following: ‘‘, treating policies of the same
type as a single policy for each standard package’’;
(E) by adding at the end of paragraph (1) the following:
‘‘For the purpose of calculating the refund or credit required
under paragraph (1)(B) for a policy issued before the date
specified in subsection (p)(1)(C), the refund or credit cal-
culation shall be based on the aggregate benefits provided
and premiums collected under all such policies issued by
an insurer in a State (separated as to individual and group
policies) and shall be based only on aggregate benefits
provided and premiums collected under such policies after
the date specified in section 171(m)(4) of the Social Security
Act Amendments of 1994.’’;
H. R. 5252—52
(F) in the first sentence of paragraph (2)(A), by striking
‘‘by policy number’’ and inserting ‘‘by standard package’’;
(G) by striking the second sentence of paragraph (2)(A)
and inserting the following: ‘‘Paragraph (1)(B) shall not
apply to a policy until 12 months following issue.’’;
(H) in the last sentence of paragraph (2)(A), by striking
‘‘in order’’ and all that follows through ‘‘are effective’’;
(I) by adding at the end of paragraph (2)(A), the follow-
ing new sentence: ‘‘In the case of a policy issued before
the date specified in subsection (p)(1)(C), paragraph (1)(B)
shall not apply until 1 year after the date specified in
section 171(m)(4) of the Social Security Act Amendments
of 1994.’’;
(J) in paragraph (2), by striking ‘‘policy year’’ each
place it appears and inserting ‘‘calendar year’’;
(K) 
in 
paragraph 
(4), 
by 
striking 
‘‘February’’,
‘‘disllowance’’, ‘‘loss-ratios’’ each place it appears, and ‘‘loss-
ratio’’ and inserting ‘‘October’’, ‘‘disallowance’’, ‘‘loss ratios’’,
and ‘‘loss ratio’’, respectively;
(L) in paragraph (6)(A), by striking ‘‘issues a policy
in violation of the loss ratio requirements of this subsection’’
and ‘‘such violation’’ and inserting ‘‘fails to provide refunds
or credits as required in paragraph (1)(B)’’ and ‘‘policy
issued for which such failure occurred’’, respectively; and
(M) in paragraph (6)(B), by striking ‘‘to policyholders’’
and inserting ‘‘to the policyholder or, in the case of a
group policy, to the certificate holder’’.
(2) Section 1882(b)(1) (42 U.S.C. 1395ss(b)(1)) is amended,
in the matter after subparagraph (H), by striking ‘‘subsection
(F)’’ and inserting ‘‘subparagraph (F)’’.
(3) Section 4355(d) of OBRA–1990 is amended by striking
‘‘sold or issued’’ and all that follows and inserting ‘‘issued
or renewed (or otherwise providing coverage after the date
described in section 1882(p)(1)(C) of the Social Security Act)
on or after the date specified in section 1882(p)(1)(C) of the
Social Security Act.’’.
(f) TREATMENT OF HMO’S.—
(1) Section 1882(g)(1) (42 U.S.C. 1395ss(g)(1)) is amended
by striking ‘‘a health maintenance organization or other direct
service organization’’ and all that follows through ‘‘1833’’ and
inserting ‘‘an eligible organization (as defined in section 1876(b))
if the policy or plan provides benefits pursuant to a contract
under section 1876 or an approved demonstration project
described in section 603(c) of the Social Security Amendments
of 1983, section 2355 of the Deficit Reduction Act of 1984,
or section 9412(b) of the Omnibus Budget Reconciliation Act
of 1986, or, during the period beginning on the date specified
in subsection (p)(1)(C) and ending on December 31, 1995, a
policy or plan of an organization if the policy or plan provides
benefits pursuant to an agreement under section 1833(a)(1)(A)’’.
(2) Section 4356(b) of OBRA–1990 is amended by striking
‘‘on the date of the enactment of this Act’’ and inserting ‘‘on
the date specified in section 1882(p)(1)(C) of the Social Security
Act’’.
(g) PRE-EXISTING CONDITION LIMITATIONS.—Section 1882(s) (42
U.S.C. 1395ss(s)) is amended—
H. R. 5252—53
(1) in paragraph (2)(A), by striking ‘‘for which an applica-
tion is submitted’’ and inserting ‘‘in the case of an individual
for whom an application is submitted prior to or’’,
(2) in paragraph (2)(A), by striking ‘‘in which the individual
(who is 65 years of age or older) first is enrolled for benefits
under part B’’ and inserting ‘‘as of the first day on which
the individual is 65 years of age or older and is enrolled
for benefits under part B’’, and
(3) in paragraph (2)(B), by striking ‘‘before it’’ and inserting
‘‘before the policy’’.
(h) MEDICARE SELECT POLICIES.—
(1) Section 1882(t) (42 U.S.C. 1395ss(t)) is amended—
(A) in paragraph (1), by inserting ‘‘medicare supple-
mental’’ after ‘‘If a’’,
(B) in paragraph (1), by striking ‘‘NAIC Model Stand-
ards’’ and inserting ‘‘1991 NAIC Model Regulation or 1991
Federal Regulation’’,
(C) in paragraph (1)(A), by inserting ‘‘or agreements’’
after ‘‘contracts’’,
(D) in subparagraphs (E)(i) and (F) of paragraph (1),
by striking ‘‘NAIC standards’’ and inserting ‘‘standards in
the 1991 NAIC Model Regulation or 1991 Federal Regula-
tion’’, and
(E) in paragraph (2), by inserting ‘‘the issuer’’ before
‘‘is subject to a civil money penalty’’.
(2) Section 1154(a)(4)(B) (42 U.S.C. 1320c–3(a)(4)(B)) is
amended—
(A) by inserting ‘‘that is’’ after ‘‘(or’’, and
(B) by striking ‘‘1882(t)’’ and inserting ‘‘1882(t)(3)’’.
(i) HEALTH INSURANCE COUNSELING.—Section 4360 of OBRA–
1990 is amended—
(1) in subsection (b)(2)(A)(ii), by striking ‘‘Act’’ and inserting
‘‘Act)’’;
(2) in subsection (b)(2)(D), by striking ‘‘services’’ and insert-
ing ‘‘counseling’’;
(3) in subsection (b)(2)(I), by striking ‘‘assistance’’ and
inserting ‘‘referrals’’;
(4) in subsection (c)(1), by striking ‘‘and that such activities
will continue to be maintained at such level’’;
(5) in subsection (d)(3), by striking ‘‘to the rural areas’’
and inserting ‘‘eligible individuals residing in rural areas’’;
(6) in subsection (e)—
(A) by striking ‘‘subsection (c) or (d)’’ and inserting
‘‘this section’’,
(B) by striking ‘‘and annually thereafter, issue an
annual report’’ and inserting ‘‘and annually thereafter dur-
ing the period of the grant, issue a report’’, and
(C) in paragraph (1), by striking ‘‘State-wide’’;
(7) in subsection (f), by striking paragraph (2) and by
redesignating paragraphs (3) through (5) as paragraphs (2)
through (4), respectively; and
(8) in the second subsection (f) (relating to authorization
of appropriations for grants)—
(A) by striking ‘‘and 1993’’ and inserting ‘‘1993, 1994,
1995, and 1996’’; and
(B) by redesignating such subsection as subsection (g).
(j) TELEPHONE INFORMATION SYSTEM.—
H. R. 5252—54
(1) Section 1804 (42 U.S.C. 1395b–2) is amended—
(A) by adding at the end of the heading the following:
‘‘; MEDICARE AND MEDIGAP INFORMATION’’,
(B) by inserting ‘‘(a)’’ after ‘‘1804.’’, and
(C) by adding at the end the following new subsection:
‘‘(b) The Secretary shall provide information via a toll-free
telephone number on the programs under this title.’’.
(2) Section 1882(f) (42 U.S.C. 1395ss(f)) is amended by
adding at the end the following new paragraph:
‘‘(3) The Secretary shall provide information via a toll-free
telephone number on medicare supplemental policies (including the
relationship of State programs under title XIX to such policies).’’.
(3) Section 1889 is repealed.
(k) MAILING
OF
POLICIES.—Section 1882(d)(4) (42 U.S.C.
1395ss(d)(4)) is amended—
(1) in subparagraph (D), by striking ‘‘, if such policy’’ and
all that follows up to the period at the end, and
(2) by adding at the end the following new subparagraph:
‘‘(E) Subparagraph (A) shall not apply in the case of an issuer
who mails or causes to be mailed a policy, certificate, or other
matter solely to comply with the requirements of subsection (q).’’.
(l) EFFECTIVE DATE.—The amendments made by this section
shall be effective as if included in the enactment of OBRA–1990;
except that—
(1) the amendments made by subsection (d)(1) shall take
effect on the date of the enactment of this Act, but no penalty
shall be imposed under section 1882(d)(3)(A) of the Social Secu-
rity Act (for an action occurring after the effective date of
the amendments made by section 4354 of OBRA–1990 and
before the date of the enactment of this Act) with respect
to the sale or issuance of a policy which is not unlawful under
section 1882(d)(3)(A)(i)(II) of the Social Security Act (as
amended by this section);
(2) the amendments made by subsection (d)(2)(A) and by
subparagraphs (A), (B), and (E) of subsection (e)(1) shall be
effective on the date specified in subsection (m)(4); and
(3) the amendment made by subsection (g)(2) shall take
effect on January 1, 1995, and shall apply to individuals who
attain 65 years of age or older on or after the effective date
of section 1882(s)(2) of the Social Security Act (and, in the
case of individuals who attained 65 years of age after such
effective date and before January 1, 1995, and who were not
covered under such section before January 1, 1995, the 6-
month period specified in that section shall begin January
1, 1995).
(m) TRANSITION PROVISIONS.—
(1) IN GENERAL.—If the Secretary of Health and Human
Services identifies a State as requiring a change to its statutes
or regulations to conform its regulatory program to the changes
made by this section, the State regulatory program shall not
be considered to be out of compliance with the requirements
of section 1882 of the Social Security Act due solely to failure
to make such change until the date specified in paragraph
(4).
(2) NAIC STANDARDS.—If, within 6 months after the date
of the enactment of this Act, the National Association of Insur-
ance Commissioners (in this subsection referred to as the
H. R. 5252—55
‘‘NAIC’’) modifies its 1991 NAIC Model Regulation (adopted
in July 1991) to conform to the amendments made by this
section and to delete from section 15C the exception which
begins with ‘‘unless’’, such revised regulation incorporating the
modifications shall be considered to be the 1991 Regulation
for the purposes of section 1882 of the Social Security Act.
(3) SECRETARY STANDARDS.—If the NAIC does not make
the modifications described in paragraph (2) within the period
specified in such paragraph, the Secretary of Health and
Human Services shall make the modifications described in such
paragraph and such revised regulation incorporating the modi-
fications shall be considered to be the 1991 Regulation for
the purposes of section 1882 of the Social Security Act.
(4) DATE SPECIFIED.—
(A) IN GENERAL.—Subject to subparagraph (B), the date
specified in this paragraph for a State is the earlier of—
(i) the date the State changes its statutes or regu-
lations to conform its regulatory program to the
changes made by this section, or
(ii) 1 year after the date the NAIC or the Secretary
first makes the modifications under paragraph (2) or
(3), respectively.
(B) ADDITIONAL LEGISLATIVE ACTION REQUIRED.—In the
case of a State which the Secretary identifies as—
(i) requiring State legislation (other than legisla-
tion appropriating funds) to conform its regulatory pro-
gram to the changes made in this section, but
(ii) having a legislature which is not scheduled
to meet in 1996 in a legislative session in which such
legislation may be considered,
the date specified in this paragraph is the first day of
the first calendar quarter beginning after the close of the
first legislative session of the State legislature that begins
on or after January 1, 1996. For purposes of the previous
sentence, in the case of a State that has a 2-year legislative
session, each year of such session shall be deemed to be
a separate regular session of the State legislature.
SEC. 172. 6-MONTH EXTENSION OF PERIOD FOR ISSUANCE OF MEDI-
CARE SELECT POLICIES.
(a) IN GENERAL.—Section 4358(c) of the Omnibus Budget Rec-
onciliation Act of 1990 (42 U.S.C. 1320c–3 note) is amended by
striking ‘‘3-year’’ and inserting ‘‘31⁄2-year’’.
(b) EFFECTIVE DATE.—The amendment made by subsection (a)
shall take effect as if included in the enactment of the Omnibus
Budget Reconciliation Act of 1990.
H. R. 5252—56
TITLE 
II—MATERNAL 
AND 
CHILD
HEALTH 
SERVICES 
BLOCK 
GRANT
PROGRAM, 
INCOME 
SECURITY,
HUMAN RESOURCES, AND RELATED
PROGRAMS
SEC. 201. INCREASE IN AUTHORIZATION OF APPROPRIATIONS FOR
THE MATERNAL AND CHILD HEALTH SERVICES BLOCK
GRANT PROGRAM.
Section 501(a) (42 U.S.C. 701(a)) is amended by striking
‘‘$686,000,000 for fiscal year 1990’’ and inserting ‘‘$705,000,000
for fiscal year 1994’’.
Subtitle A—Child Welfare, Foster Care,
Adoption
SEC. 202. REQUIRED PROTECTIONS FOR FOSTER CHILDREN.
(a) IN
GENERAL.—Section 422(b) (42 U.S.C. 622(b)) is
amended—
(1) by striking ‘‘and’’ at the end of paragraph (7);
(2) by striking the period at the end of paragraph (8)
and inserting ‘‘; and’’; and
(3) by adding at the end the following:
‘‘(9) provide assurances that the State—
‘‘(A) since June 17, 1980, has completed an inventory
of all children who, before the inventory, had been in
foster care under the responsibility of the State for 6
months or more, which determined—
‘‘(i) the appropriateness of, and necessity for, the
foster care placement;
‘‘(ii) whether the child could or should be returned
to the parents of the child or should be freed for
adoption or other permanent placement; and
‘‘(iii) the services necessary to facilitate the return
of the child or the placement of the child for adoption
or legal guardianship;
‘‘(B) is operating, to the satisfaction of the Secretary—
‘‘(i) a statewide information system from which
can be readily determined the status, demographic
characteristics, location, and goals for the placement
of every child who is (or, within the immediately
preceding 12 months, has been) in foster care;
‘‘(ii) a case review system (as defined in section
475(5)) for each child receiving foster care under the
supervision of the State;
‘‘(iii) a service program designed to help children—
‘‘(I) where appropriate, return to families from
which they have been removed; or
‘‘(II) be placed for adoption, with a legal guard-
ian, or, if adoption or legal guardianship is deter-
mined not to be appropriate for a child, in some
other planned, permanent living arrangement; and
‘‘(iv) a preplacement preventive services program
designed to help children at risk of foster care place-
H. R. 5252—57
‘‘(C)(i) has reviewed (or within 12 months after the
date of the enactment of this paragraph will review) State
policies and administrative and judicial procedures in effect
for children abandoned at or shortly after birth (including
policies and procedures providing for legal representation
of such children); and
‘‘(ii) is implementing (or within 24 months after the
date of the enactment of this paragraph will implement)
such policies and procedures as the State determines, on
the basis of the review described in clause (i), to be nec-
essary to enable permanent decisions to be made expedi-
tiously with respect to the placement of such children.’’.
(b) RESTRICTION
ON REALLOTMENT.—Section 424 (42 U.S.C.
624) is amended—
(1) in the first sentence, by striking ‘‘The amount’’ and
inserting the following:
‘‘(a) IN GENERAL.—Subject to subsection (b), the amount’’; and
(2) by adding at the end the following:
‘‘(b) EXCEPTION RELATING TO FOSTER CHILD PROTECTIONS.—
The Secretary shall not reallot under subsection (a) of this section
any amount that is withheld or recovered from a State due to
the failure of the State to meet the requirements of section
422(b)(9).’’.
(c) REPEAL.—Section 427 (42 U.S.C. 627) is hereby repealed.
(d) CONFORMING AMENDMENTS.—
(1) Section 423(a) (42 U.S.C. 623(a)) is amended by striking
‘‘and in section 427’’.
(2) Section 425(a)(2) (42 U.S.C. 625(a)(2)) is amended by
striking ‘‘the statistical report required by section’’ and inserting
‘‘section 422(b)(9) or’’.
(3) Section 472(d) (42 U.S.C. 672(d)) is amended by striking
‘‘427(b)’’ and inserting ‘‘422(b)(9)’’.
(e) EFFECTIVE DATE.—The amendments and repeal made by
this section shall be effective with respect to fiscal years beginning
on or after April 1, 1996.
SEC. 203. CONFORMITY REVIEWS.
(a) IN GENERAL.—Part A of title XI (42 U.S.C. 1301–1320b–
13) is amended by inserting after section 1122 the following:
‘‘REVIEWS OF CHILD AND FAMILY SERVICES PROGRAMS, AND OF FOS-
TER CARE AND ADOPTION ASSISTANCE PROGRAMS, FOR CONFORMITY
WITH STATE PLAN REQUIREMENTS
‘‘SEC. 1123. (a) IN GENERAL.—The Secretary, in consultation
with the State agencies administering the State programs under
parts B and E of title IV, shall promulgate regulations for the
review of such programs to determine whether such programs are
in substantial conformity with—
‘‘(1) State plan requirements under such parts B and E,
‘‘(2) implementing regulations promulgated by the Sec-
retary, and
‘‘(3) the relevant approved State plans.
‘‘(b) ELEMENTS OF REVIEW SYSTEM.—The regulations referred
to in subsection (a) shall—
‘‘(1) specify the timetable for conformity reviews of State
programs, including—
‘‘(A) an initial review of each State program;
H. R. 5252—58
‘‘(B) a timely review of a State program following a
review in which such program was found not to be in
substantial conformity; and
‘‘(C) less frequent reviews of State programs which
have been found to be in substantial conformity, but such
regulations shall permit the Secretary to reinstate more
frequent reviews based on information which indicates that
a State program may not be in conformity;
‘‘(2) specify the requirements subject to review, and the
criteria to be used to measure conformity with such require-
ments and to determine whether there is a substantial failure
to so conform;
‘‘(3) specify the method to be used to determine the amount
of any Federal matching funds to be withheld (subject to para-
graph (4)) due to the State program’s failure to so conform,
which ensures that—
‘‘(A) such funds will not be withheld with respect to
a program, unless it is determined that the program fails
substantially to so conform;
‘‘(B) such funds will not be withheld for a failure to
so conform resulting from the State’s reliance upon and
correct use of formal written statements of Federal law
or policy provided to the State by the Secretary; and
‘‘(C) the amount of such funds withheld is related
to the extent of the failure to so conform; and
‘‘(4) require the Secretary, with respect to any State pro-
gram found to have failed substantially to so conform—
‘‘(A) to afford the State an opportunity to adopt and
implement a corrective action plan, approved by the Sec-
retary, designed to end the failure to so conform;
‘‘(B) to make technical assistance available to the State
to the extent feasible to enable the State to develop and
implement such a corrective action plan;
‘‘(C) to suspend the withholding of any Federal match-
ing funds under this section while such a corrective action
plan is in effect; and
‘‘(D) to rescind any such withholding if the failure
to so conform is ended by successful completion of such
a corrective action plan.
‘‘(c) PROVISIONS FOR ADMINISTRATIVE AND JUDICIAL REVIEW.—
The regulations referred to in subsection (a) shall—
‘‘(1) require the Secretary, not later than 10 days after
a final determination that a program of the State is not in
conformity, to notify the State of—
‘‘(A) the basis for the determination; and
‘‘(B) the amount of the Federal matching funds (if
any) to be withheld from the State;
‘‘(2) afford the State an opportunity to appeal the deter-
mination to the Departmental Appeals Board within 60 days
after receipt of the notice described in paragraph (1) (or, if
later, after failure to continue or to complete a corrective action
plan); and
‘‘(3) afford the State an opportunity to obtain judicial review
of an adverse decision of the Board, within 60 days after the
State receives notice of the decision of the Board, by appeal
to the district court of the United States for the judicial district
H. R. 5252—59
in which the principal or headquarters office of the agency
responsible for administering the program is located.’’.
(b) CONFORMING
AMENDMENT.—Section 471(b) (42 U.S.C.
671(b)) is amended by striking all that follows the first sentence.
(c) EFFECTIVE DATES.—
(1) IN GENERAL.—The amendment made by subsection (a)
shall take effect on the date of the enactment of this Act.
(2) CONFORMING AMENDMENT.—The amendment made by
subsection (b) shall take effect on October 1, 1995.
(3) REGULATIONS.—The Secretary shall promulgate the
regulations referred to in section 1123(a) of the Social Security
Act (as added by this section) not later than July 1, 1995,
to take effect on April 1, 1996.
SEC. 204. STATES REQUIRED TO REPORT ON MEASURES TAKEN TO
COMPLY WITH THE INDIAN CHILD WELFARE ACT.
(a) STATE PLAN REQUIREMENT.—Section 422(b) (42 U.S.C.
622(b)), as amended by section 202(a), is amended—
(1) by striking ‘‘and’’ at the end of paragraph (8);
(2) by striking the period at the end of paragraph (9)
and inserting ‘‘; and’’; and
(3) by adding at the end the following:
‘‘(10) contain a description, developed after consultation
with tribal organizations (as defined in section 4 of the Indian
Self-Determination and Education Assistance Act) in the State,
of the specific measures taken by the State to comply with
the Indian Child Welfare Act.’’.
(b) EFFECTIVE DATE.—The amendments made by subsection
(a) shall be effective with respect to fiscal years beginning on
or after October 1, 1995.
SEC. 205. CHILD WELFARE TRAINEESHIPS.
(a) IN GENERAL.—Subpart 1 of part B of title IV (42 U.S.C.
620–628) is amended by inserting after section 428 the following:
‘‘CHILD WELFARE TRAINEESHIPS
‘‘SEC. 429. The Secretary may approve an application for a
grant to a public or nonprofit institution for higher learning to
provide traineeships with stipends under section 426(a)(1)(C) only
if the application—
‘‘(1) provides assurances that each individual who receives
a stipend with such traineeship (in this section referred to
as a ‘recipient’) will enter into an agreement with the institution
under which the recipient agrees—
‘‘(A) to participate in training at a public or private
nonprofit child welfare agency on a regular basis (as deter-
mined by the Secretary) for the period of the traineeship;
‘‘(B) to be employed for a period of years equivalent
to the period of the traineeship, in a public or private
nonprofit child welfare agency in any State, within a period
of time (determined by the Secretary in accordance with
regulations) after completing the postsecondary education
for which the traineeship was awarded;
‘‘(C) to furnish to the institution and the Secretary
evidence of compliance with subparagraphs (A) and (B);
and
H. R. 5252—60
‘‘(D) if the recipient fails to comply with subparagraph
(A) or (B) and does not qualify for any exception to this
subparagraph which the Secretary may prescribe in regula-
tions, to repay to the Secretary all (or an appropriately
prorated part) of the amount of the stipend, plus interest,
and, if applicable, reasonable collection fees (in accordance
with regulations promulgated by the Secretary);
‘‘(2) provides assurances that the institution will—
‘‘(A) enter into agreements with child welfare agencies
for onsite training of recipients;
‘‘(B) permit an individual who is employed in the field
of child welfare services to apply for a traineeship with
a stipend if the traineeship furthers the progress of the
individual toward the completion of degree requirements;
and
‘‘(C) develop and implement a system that, for the
3-year period that begins on the date any recipient com-
pletes a child welfare services program of study, tracks
the employment record of the recipient, for the purpose
of determining the percentage of recipients who secure
employment in the field of child welfare services and
remain employed in the field.’’.
(b) CONFORMING AMENDMENT.—Section 426(a)(1)(C) (42 U.S.C.
626(a)(1)(C)) is amended by inserting ‘‘described in section 429’’
after ‘‘including traineeships’’.
(c) APPLICABILITY.—The amendments made by this section shall
apply to grants awarded on or after October 1, 1995.
SEC. 206. DISPOSITIONAL HEARING.
(a) MOST APPROPRIATE SETTING.—Section 475(5)(A) (42 U.S.C.
675(5)(A)) is amended by inserting ‘‘and most appropriate’’ after
‘‘(most family like)’’.
(b) TIMING
OF SUBSEQUENT REVIEW.—Section 475(5)(C) (42
U.S.C. 675(5)(C)) is amended by striking ‘‘periodically’’ and inserting
‘‘not less frequently than every 12 months’’.
(c) EFFECTIVE DATE.—The amendments made by this section
shall take effect on October 1, 1995.
SEC. 207. ELIMINATION OF FOSTER CARE CEILINGS AND OF AUTHOR-
ITY TO TRANSFER UNUSED FOSTER CARE FUNDS TO CHILD
WELFARE SERVICES PROGRAMS.
(a) REPEAL.—Subsections (b) and (c) of section 474 (42 U.S.C.
674 (b) and (c)) are hereby repealed.
(b) CONFORMING AMENDMENTS.—Section 474 (42 U.S.C. 674)
is amended—
(1) in subsection (d)(1)—
(A) by striking ‘‘subsections (a), (b), and (c)’’ and insert-
ing ‘‘subsection (a)’’; and
(B) by striking ‘‘the provisions of such subsections’’
and inserting ‘‘subsection (a)’’; and
(2) by redesignating subsections (d) and (e) as subsections
(b) and (c), respectively.
(c) EFFECTIVE DATE.—The amendments and repeals made by
this section shall apply to payments for calendar quarters beginning
on or after October 1, 1993.
SEC. 208. DEMONSTRATION PROJECTS.
Part A of title XI (42 U.S.C. 1301–1320b–13) is amended by
inserting after section 1129 the following:
H. R. 5252—61
‘‘DEMONSTRATION PROJECTS
‘‘SEC. 1130. (a) IN GENERAL.—The Secretary may authorize
not more than 10 States to conduct demonstration projects pursuant
to this section which the Secretary finds are likely to promote
the objectives of part B or E of title IV.
‘‘(b) WAIVER AUTHORITY.—The Secretary may waive compliance
with any requirement of part B or E of title IV which (if applied)
would prevent a State from carrying out a demonstration project
under this section or prevent the State from effectively achieving
the purpose of such a project, except that the Secretary may not
waive—
‘‘(1) any provision of section 427 (as in effect before April
1, 1996), section 422(b)(9) (as in effect after such date), or
section 479; or
‘‘(2) any provision of such part E, to the extent that the
waiver would impair the entitlement of any qualified child
or family to benefits under a State plan approved under such
part E.
‘‘(c) TREATMENT AS PROGRAM EXPENDITURES.—For purposes of
parts B and E of title IV, the Secretary shall consider the expendi-
tures of any State to conduct a demonstration project under this
section to be expenditures under subpart 1 or 2 of such part B,
or under such part E, as the State may elect.
‘‘(d) DURATION OF DEMONSTRATION.—A demonstration project
under this section may be conducted for not more than 5 years.
‘‘(e) APPLICATION.—Any State seeking to conduct a demonstra-
tion project under this section shall submit to the Secretary an
application, in such form as the Secretary may require, which
includes—
‘‘(1) a description of the proposed project, the geographic
area in which the proposed project would be conducted, the
children or families who would be served by the proposed
project, and the services which would be provided by the pro-
posed project (which shall provide, where appropriate, for ran-
dom assignment of children and families to groups served under
the project and to control groups);
‘‘(2) a statement of the period during which the proposed
project would be conducted;
‘‘(3) a discussion of the benefits that are expected from
the proposed project (compared to a continuation of activities
under the approved plan or plans of the State);
‘‘(4) an estimate of the costs or savings of the proposed
project;
‘‘(5) a statement of program requirements for which waivers
would be needed to permit the proposed project to be conducted;
‘‘(6) a description of the proposed evaluation design; and
‘‘(7) such additional information as the Secretary may
require.
‘‘(f) EVALUATIONS; REPORT.—Each State authorized to conduct
a demonstration project under this section shall—
‘‘(1) obtain an evaluation by an independent contractor
of the effectiveness of the project, using an evaluation design
approved by the Secretary which provides for—
‘‘(A) comparison of methods of service delivery under
the project, and such methods under a State plan or plans,
H. R. 5252—62
with respect to efficiency, economy, and any other appro-
priate measures of program management;
‘‘(B) comparison of outcomes for children and families
(and groups of children and families) under the project,
and such outcomes under a State plan or plans, for pur-
poses of assessing the effectiveness of the project in achiev-
ing program goals; and
‘‘(C) any other information that the Secretary may
require; and
‘‘(2) provide interim and final evaluation reports to the
Secretary, at such times and in such manner as the Secretary
may require.
‘‘(g) COST NEUTRALITY.—The Secretary may not authorize a
State to conduct a demonstration project under this section unless
the Secretary determines that the total amount of Federal funds
that will be expended under (or by reason of) the project over
its approved term (or such portion thereof or other period as the
Secretary may find appropriate) will not exceed the amount of
such funds that would be expended by the State under the State
plans approved under parts B and E of title IV if the project
were not conducted.’’.
SEC. 209. PLACEMENT ACCOUNTABILITY.
(a) CASE PLAN REQUIREMENTS.—Section 475(5)(A) (42 U.S.C.
675(5)(A)) is amended by adding at the end the following: ‘‘which—
‘‘(i) if the child has been placed in a foster family
home or child-care institution a substantial distance
from the home of the parents of the child, or in a
State different from the State in which such home
is located, sets forth the reasons why such placement
is in the best interests of the child, and
‘‘(ii) if the child has been placed in foster care
outside the State in which the home of the parents
of the child is located, requires that, periodically, but
not less frequently than every 12 months, a caseworker
on the staff of the State agency of the State in which
the home of the parents of the child is located, or
of the State in which the child has been placed, visit
such child in such home or institution and submit
a report on such visit to the State agency of the State
in which the home of the parents of the child is
located,’’.
(b) DISPOSITIONAL
HEARING.—Section 475(5)(C) (42 U.S.C.
675(5)(C)) is amended by inserting ‘‘and, in the case of a child
described in subparagraph (A)(ii), whether the out-of-State place-
ment continues to be appropriate and in the best interests of the
child,’’ after ‘‘long-term basis)’’.
(c) 
DATA
COLLECTION.—Section 
479(c)(3)(C) 
(42 
U.S.C.
679(c)(3)(C)) is amended—
(1) by striking ‘‘and’’ at the end of clause (i); and
(2) by adding at the end the following:
‘‘(iii) children placed in foster care outside the State
which has placement and care responsibility, and’’.
(d) EFFECTIVE DATE.—The amendments made by this section
shall be effective with respect to fiscal years beginning on or after
October 1, 1995.
H. R. 5252—63
SEC. 210. PAYMENTS OF STATE CLAIMS FOR FOSTER CARE AND ADOP-
TION ASSISTANCE.
(a) IN GENERAL.—Section 474(b) (42 U.S.C. 674(b)), as redesig-
nated by section 207(b)(2), is amended by adding at the end the
following:
‘‘(4)(A) Within 60 days after receipt of a State claim for expendi-
tures pursuant to subsection (a), the Secretary shall allow, disallow,
or defer such claim.
‘‘(B) Within 15 days after a decision to defer such a State
claim, the Secretary shall notify the State of the reasons for the
deferral and of the additional information necessary to determine
the allowability of the claim.
‘‘(C) Within 90 days after receiving such necessary information
(in readily reviewable form), the Secretary shall—
‘‘(i) disallow the claim, if able to complete the review and
determine that the claim is not allowable, or
‘‘(ii) in any other case, allow the claim, subject to disallow-
ance (as necessary)—
‘‘(I) upon completion of the review, if it is determined
that the claim is not allowable; or
‘‘(II) on the basis of findings of an audit or financial
management review.’’.
(b) EFFECTIVE DATE.—The amendment made by subsection (a)
shall be effective with respect to claims made on or after the
date of the enactment of this Act.
SEC. 211. EFFECT OF FAILURE TO CARRY OUT STATE PLAN.
(a) IN GENERAL.—Part A of title XI (42 U.S.C. 1301–1320b–
13), as amended by section 208, is amended by inserting after
section 1130 the following:
‘‘EFFECT OF FAILURE TO CARRY OUT STATE PLAN
‘‘SEC. 1130A. In an action brought to enforce a provision of
the Social Security Act, such provision is not to be deemed
unenforceable because of its inclusion in a section of the Act requir-
ing a State plan or specifying the required contents of a State
plan. This section is not intended to limit or expand the grounds
for determining the availability of private actions to enforce State
plan requirements other than by overturning any such grounds
applied in Suter v. Artist M., 112 S. Ct. 1360 (1992), but not
applied in prior Supreme Court decisions respecting such enforce-
ability: Provided, however, That this section is not intended to
alter the holding in Suter v. Artist M. that section 471(a)(15)
of the Act is not enforceable in a private right of action.’’.
(b) APPLICABILITY.—The amendment made by subsection (a)
shall apply to actions pending on the date of the enactment of
this Act and to actions brought on or after such date of enactment.
Subtitle B—Child Support Enforcement
SEC. 212. REPORTS TO CREDIT BUREAUS ON PERSONS DELINQUENT
IN CHILD SUPPORT PAYMENTS.
(a) IN GENERAL.—Section 466(a)(7) (42 U.S.C. 666(a)(7)) is
amended—
(1) by striking ‘‘Procedures’’ and all that follows through
‘‘request of such agency’’ and inserting ‘‘Procedures which
H. R. 5252—64
require the State to periodically report to consumer reporting
agencies (as defined in section 603(f) of the Fair Credit Report-
ing Act (15 U.S.C. 1681a(f))) the name of any parent who
owes overdue support and is at least 2 months delinquent
in the payment of such support and the amount of such delin-
quency’’; and
(2) by striking ‘‘(C) a fee’’ and all that follows through
‘‘by the State’’ and inserting ‘‘(C) such information shall not
be made available to (i) a consumer reporting agency which
the State determines does not have sufficient capability to
systematically and timely make accurate use of such informa-
tion, or (ii) an entity which has not furnished evidence satisfac-
tory to the State that the entity is a consumer reporting
agency’’.
(b) EFFECTIVE DATE.—The amendments made by subsection
(a) shall take effect on October 1, 1995.
SEC. 213. TECHNICAL AMENDMENTS TO PROVISION ON STATE PATER-
NITY ESTABLISHMENT PROGRAMS.
Section 452(g)(2)(A) (42 U.S.C. 652(g)(2)(A)), as amended by
section 13721(a) of OBRA–1993, is amended—
(1) in clause (i), by striking ‘‘during the fiscal year’’;
(2) in subclause (I) of clause (ii), by striking ‘‘as of the
end of the fiscal year’’ and inserting ‘‘in the fiscal year or,
at the option of the State, as of the end of such year’’;
(3) in subclause (II) of clause (ii), by striking ‘‘or E as
of the end of the fiscal year’’ and inserting ‘‘in the fiscal year
or, at the option of the State, as of the end of such year’’;
(4) in clause (iii), by striking ‘‘during the fiscal year’’; and
(5) in the matter following clause (iii)—
(A) by striking ‘‘who were born out of wedlock during
the immediately preceding fiscal year’’ and inserting ‘‘born
out of wedlock’’;
(B) by striking ‘‘such preceding fiscal year’’ both places
it appears and inserting ‘‘the preceding fiscal year’’; and
(C) by striking ‘‘or E’’ the second place it appears.
SEC. 214. AGREEMENT TO ASSIST IN LOCATING MISSING CHILDREN
UNDER THE PARENT LOCATOR SERVICE.
(a) IN GENERAL.—Section 463 (42 U.S.C. 663) is amended by
adding at the end the following new subsection:
‘‘(f) The Secretary shall enter into an agreement with the Attor-
ney General of the United States, under which the services of
the Parent Locator Service established under section 453 shall
be made available to the Office of Juvenile Justice and Delinquency
Prevention upon its request to locate any parent or child on behalf
of such Office for the purpose of—
‘‘(1) enforcing any State or Federal law with respect to
the unlawful taking or restraint of a child, or
‘‘(2) making or enforcing a child custody determination.
The Parent Locator Service shall charge no fees for services
requested pursuant to this subsection.’’.
(b) CONFORMING AMENDMENT.—Section 463(c) (42 U.S.C. 663(c))
is amended by striking ‘‘(a), (b), or (e)’’ and inserting ‘‘(a), (b),
(e), or (f)’’.
(c) EFFECTIVE DATE.—The amendments made by this section
shall take effect on October 1, 1995.
H. R. 5252—65
Subtitle C—Supplemental Security Income
SEC. 221. DEFINITION OF DISABILITY FOR CHILDREN UNDER AGE 18
APPLIED TO ALL INDIVIDUALS UNDER AGE 18.
(a) IN GENERAL.—Section 1614(a)(3) (42 U.S.C. 1382c(a)(3)) is
amended—
(1) in subparagraphs (A) and (H), by striking ‘‘a child’’
each place it appears and inserting ‘‘an individual’’; and
(2) in subparagraph (H), by striking ‘‘child’’ the second
and third place it appears and inserting ‘‘individual’’.
(b) EFFECTIVE DATE.—The amendments made by subsection
(a) shall apply to determinations made on or after the date of
the enactment of this Act.
Subtitle D—Aid to Families With
Dependent Children
SEC. 231. SIMPLIFICATION OF INCOME AND ELIGIBILITY VERIFICA-
TION SYSTEM.
Paragraph (1)(A) of section 1137(d) (42 U.S.C. 1320b–7(d)) is
amended to read as follows:
‘‘(1)(A) The State shall require, as a condition of an individ-
ual’s eligibility for benefits under a program listed in subsection
(b), a declaration in writing, under penalty of perjury—
‘‘(i) by the individual,
‘‘(ii) in the case in which eligibility for program benefits
is determined on a family or household basis, by any adult
member of such individual’s family or household (as
applicable), or
‘‘(iii) in the case of an individual born into a family
or household receiving benefits under such program, by
any adult member of such family or household no later
than the next redetermination of eligibility of such family
or household following the birth of such individual,
stating whether the individual is a citizen or national of the
United States, and, if that individual is not a citizen or national
of the United States, that the individual is in a satisfactory
immigration status.’’.
SEC. 232. MEASUREMENT AND REPORTING OF WELFARE RECEIPT.
(a) CONGRESSIONAL POLICY.—The Congress hereby declares
that—
(1) it is the policy and responsibility of the Federal Govern-
ment to reduce the rate at which and the degree to which
families depend on income from welfare programs and the
duration of welfare receipt, consistent with other essential
national goals;
(2) it is the policy of the United States to strengthen
families, to ensure that children grow up in families that are
economically self-sufficient and that the life prospects of chil-
dren are improved, and to underscore the responsibility of
parents to support their children;
(3) the Federal Government should help welfare recipients
as well as individuals at risk of welfare receipt to improve
their education and job skills, to obtain child care and other
H. R. 5252—66
necessary support services, and to take such other steps as
may be necessary to assist them to become financially independ-
ent; and
(4) it is the purpose of this section to provide the public
with generally accepted measures of welfare receipt so that
it can track such receipt over time and determine whether
progress is being made in reducing the rate at which and,
to the extent feasible, the degree to which, families depend
on income from welfare programs and the duration of welfare
receipt.
(b) DEVELOPMENT OF WELFARE INDICATORS AND PREDICTORS.—
The Secretary of Health and Human Services (in this section
referred to as the ‘‘Secretary’’) in consultation with the Secretary
of Agriculture shall—
(1) develop—
(A) indicators of the rate at which and, to the extent
feasible, the degree to which, families depend on income
from welfare programs and the duration of welfare receipt;
and
(B) predictors of welfare receipt;
(2) assess the data needed to report annually on the indica-
tors and predictors, including the ability of existing data collec-
tion efforts to provide such data and any additional data collec-
tion needs; and
(3) not later than 2 years after the date of the enactment
of this section, provide an interim report containing conclusions
resulting from the development and assessment described in
paragraphs (1) and (2), to—
(A) the Committee on Ways and Means of the House
of Representatives;
(B) the Committee on Education and Labor of the
House of Representatives;
(C) the Committee on Agriculture of the House of
Representatives;
(D) the Committee on Energy and Commerce of the
House of Representatives;
(E) the Committee on Finance of the Senate;
(F) the Committee on Labor and Human Resources
of the Senate; and
(G) the Committee on Agriculture, Nutrition, and For-
estry of the Senate.
(c) ADVISORY BOARD ON WELFARE INDICATORS.—
(1) ESTABLISHMENT.—There is established an Advisory
Board on Welfare Indicators (in this subsection referred to
as the ‘‘Board’’).
(2) COMPOSITION.—The Board shall be composed of 12 mem-
bers with equal numbers to be appointed by the House of
Representatives, the Senate, and the President. The Board
shall be composed of experts in the fields of welfare research
and welfare statistical methodology, representatives of State
and local welfare agencies, and organizations concerned with
welfare issues.
(3) VACANCIES.—Any vacancy occurring in the membership
of the Board shall be filled in the same manner as the original
appointment for the position being vacated. The vacancy shall
not affect the power of the remaining members to execute
the duties of the Board.
H. R. 5252—67
(4) DUTIES.—Duties of the Board shall include—
(A) providing advice and recommendations to the Sec-
retary on the development of indicators of the rate at
which and, to the extent feasible, the degree to which,
families depend on income from welfare programs and the
duration of welfare receipt; and
(B) providing advice on the development and presen-
tation of annual reports required under subsection (d).
(5) TRAVEL EXPENSES.—Members of the Board shall not
be compensated, but shall receive travel expenses, including
per diem in lieu of subsistence, at rates authorized for employ-
ees of agencies under subchapter I of chapter 57 of title 5,
United States Code, for each day the member is engaged in
the performance of duties away from the home or regular
place of business of the member.
(6) DETAIL OF FEDERAL EMPLOYEES.—The Secretary shall
detail, without reimbursement, any of the personnel of the
Department of Health and Human Services to the Board to
assist the Board in carrying out its duties. Any detail shall
not interrupt or otherwise affect the civil service status or
privileges of the Federal employee.
(7) VOLUNTARY SERVICE.—Notwithstanding section 1342 of
title 31, United States Code, the Board may accept the vol-
untary services provided by a member of the Board.
(8) TERMINATION OF BOARD.—The Board shall be termi-
nated at such time as the Secretary determines the duties
described in paragraph (4) have been completed, but in any
case prior to the submission of the first report required under
subsection (d).
(d) ANNUAL WELFARE INDICATORS REPORT.—
(1) PREPARATION.—The Secretary shall prepare annual
reports on welfare receipt in the United States.
(2) COVERAGE.—The report shall include analysis of fami-
lies and individuals receiving assistance under means-tested
benefit programs, including the program of aid to families with
dependent children under part A of title IV of the Social Secu-
rity Act (42 U.S.C. 601 et seq.), the food stamp program under
the Food Stamp Act of 1977 (7 U.S.C. 2011 et seq.), and the
Supplemental Security Income program under title XVI of the
Social Security Act (42 U.S.C. 1381 et seq.), or as general
assistance under programs administered by State and local
governments.
(3) CONTENTS.—Each report shall set forth for each of
the means-tested benefit programs described in paragraph (2)—
(A) indicators of—
(i) the rate at which and, to the extent feasible,
the degree to which, families depend on income from
welfare programs, and
(ii) the duration of welfare receipt;
(B) trends in indicators;
(C) predictors of welfare receipt;
(D) the causes of welfare receipt;
(E) patterns of multiple program receipt;
(F) such other information as the Secretary deems
relevant; and
(G) such recommendations for legislation, which shall
not include proposals to reduce eligibility levels or impose
H. R. 5252—68
barriers to program access, as the Secretary may determine
to be necessary or desirable to reduce—
(i) the rate at which and the degree to which
families depend on income from welfare programs, and
(ii) the duration of welfare receipt.
(4) SUBMISSION.—The Secretary shall submit such a report
not later than 3 years after the date of the enactment of
this section and annually thereafter, to the committees specified
in subsection (b)(3)(C). Each such report shall be transmitted
during the first 60 days of each regular session of Congress.
(e) SHORT TITLE.—This section may be cited as the ‘‘Welfare
Indicators Act of 1994’’.
SEC. 233. NEW HOPE DEMONSTRATION PROJECT.
(a) IN GENERAL.—The Secretary of Health and Human Services
(in this section referred to as the ‘‘Secretary’’) shall provide for
a demonstration project for a qualified program to be conducted
in Milwaukee, Wisconsin, in accordance with this section.
(b) PAYMENTS.—For each calendar quarter in which there is
a qualified program approved under this subsection, the Secretary
shall pay to the operator of the qualified program, for no more
than 20 calendar quarters, an amount equal to the aggregate
amount that would otherwise have been payable to the State with
respect to participants in the program for such calendar quarter,
in the absence of the program, for cash assistance and child care
under part A of title IV of the Social Security Act, for medical
assistance under title XIX of such Act, and for administrative
expenses related to such assistance. The amount payable to the
operator of the program under this section shall not include the
costs of evaluating the effects of the program.
(c) DEMONSTRATION PROJECT DESCRIBED.—For purposes of this
section, the term ‘‘qualified program’’ means a program operated—
(1) by The New Hope Project, Inc., a private, not-for-profit
corporation incorporated under the laws of the State of Wiscon-
sin (in this section referred to as the ‘‘operator’’), which offers
low-income residents of Milwaukee, Wisconsin, employment,
wage supplements, child care, health care, and counseling and
training for job retention or advancement; and
(2) in accordance with an application submitted by the
operator of the program and approved by the Secretary based
on the Secretary’s determination that the application satisfies
the requirements of subsection (d).
(d) CONTENTS OF APPLICATION.—The operator of the qualified
program shall provide, in its application to conduct a demonstration
project for the program, that the following terms and conditions
will be met:
(1) The operator will develop and implement an evaluation
plan designed to provide valid and reliable information on
the impact and implementation of the program. The evaluation
plan will include adequately sized groups of project participants
and control groups assigned at random.
(2) The operator will develop and implement a plan
addressing the services and assistance to be provided by the
program, the timing and determination of payments from the
Secretary to the operator of the program, and the roles and
responsibilities of the Secretary and the operator with respect
to meeting the requirements of this paragraph.
H. R. 5252—69
(3) The operator will specify a reliable methodology for
determining expenditures to be paid to the operator by the
Secretary, with assistance from the Secretary in calculating
the amount that would otherwise have been payable to the
State in the absence of the program, pursuant to subsection
(b).
(4) The operator will issue an interim and final report
on the results of the evaluation described in paragraph (1)
to the Secretary at such times as required by the Secretary.
(e) EFFECTIVE DATE.—This section shall take effect on the
first day of the first calendar quarter that begins after the date
of the enactment of this Act.
SEC. 234. DELAY IN REQUIREMENT THAT OUTLYING AREAS OPERATE
AN AFDC–UP PROGRAM.
(a) IN GENERAL.—Section 401(g)(2) of the Family Support Act
of 1988 (42 U.S.C. 602 note; 102 Stat. 2396) is amended by striking
‘‘October 1, 1992’’ and inserting ‘‘the date of the repeal of the
limitations contained in section 1108(a) of the Social Security Act
on payments to such jurisdictions for purposes of making mainte-
nance payments under parts A and E of title IV of such Act’’.
(b) EFFECTIVE DATE.—The amendment made by subsection (a)
shall take effect as if included in the provision of the Family
Support Act of 1988 to which the amendment relates at the time
such provision became law.
SEC. 235. STATE OPTION TO USE RETROSPECTIVE BUDGETING WITH-
OUT MONTHLY REPORTING.
(a) IN GENERAL.—Section 402(a)(13) (42 U.S.C. 602(a)(13)) is
amended—
(1) by striking all that precedes subparagraph (A) and
inserting the following:
‘‘(13) provide, at the option of the State and with respect
to such category or categories as the State may select and
identify in the State plan, that—’’; and
(2) in each of subparagraphs (A) and (B), by striking ‘‘,
in the case of families who are required to report monthly
to the State agency pursuant to paragraph (14)’’.
(b) EFFECTIVE DATE.—The amendment made by subsection (a)
shall take effect on October 1, 1994, and shall apply to payments
under part A of title IV of the Social Security Act for fiscal year
1994 and such payments for succeeding fiscal years.
Subtitle E—JOBS Program
SEC. 241. EXPANSION OF COVERAGE FOR INDIAN TRIBES.
(a) IN GENERAL.—Section 482(i)(2)(A) (42 U.S.C. 682(i)(2)(A))
is amended by striking ‘‘members of such Indian tribe receiving
aid to families with dependent children’’ and inserting ‘‘Indians
receiving aid to families with dependent children who reside on
the reservation or within the designated service area’’.
(b) EFFECTIVE DATE.—The amendment made by subsection (a)
shall take effect on October 1, 1995.
SEC. 242. REPORT TO THE CONGRESS WITH RESPECT TO PERFORM-
ANCE STANDARDS IN THE JOBS PROGRAM.
Section 487(a) (42 U.S.C. 687(a)) is amended—
H. R. 5252—70
(1) by striking ‘‘3’’ and inserting ‘‘4’’;
(2) in paragraph (1), by inserting ‘‘criteria for’’ after
‘‘develop’’;
(3) in paragraph (2), by striking ‘‘for’’ and inserting ‘‘with
respect to’’; and
(4) in the second sentence, by striking ‘‘under this sub-
section’’ and inserting ‘‘with respect to the program under this
part’’.
Subtitle F—Other Provisions
SEC. 261. EXTENSION 
OF 
DEMONSTRATION 
TO 
EXPAND 
JOB
OPPORTUNITIES.
(a) IN GENERAL.—Section 505 of the Family Support Act of
1988 (42 U.S.C. 1315 note; 102 Stat. 2404) is amended—
(1) in subsection (e), by striking ‘‘3-year period’’ and insert-
ing ‘‘6-year period’’,
(2) in subsection (f)(2), by striking ‘‘January 1, 1993’’ and
inserting ‘‘January 1, 1995’’, and
(3) in subsection (g), by striking ‘‘1991, and 1992’’ and
inserting ‘‘1991, 1992, 1993, 1994, 1995, and 1996’’.
(b) EFFECTIVE DATE.—The amendments made by subsection
(a) shall take effect on October 1, 1993.
SEC. 262. EARLY CHILDHOOD DEVELOPMENT PROJECTS.
Section 501(a) of the Family Support Act of 1988 (42 U.S.C.
1315 note; 102 Stat. 2400) is amended by adding at the end the
following:
‘‘(4) For grants to States to conduct demonstration projects
under this subsection, there are authorized to be appropriated not
to exceed $3,000,000 for each of the fiscal years 1995 through
1999.’’.
SEC. 263. REALLOCATION 
OF 
FUNDS 
UNDER 
TITLE 
XX 
FOR
EMPOWERMENT AND ENTERPRISE GRANTS.
Section 2007 (42 U.S.C. 1397f), as added by section 13761
of OBRA–1993, is amended—
(1) by redesignating subsection (e) as subsection (f); and
(2) by inserting after subsection (d) the following new
subsection:
‘‘(e) REALLOCATION OF REMAINING FUNDS.—
‘‘(1) REMITTED AMOUNTS.—The amount specified in section
2003(c) for any fiscal year is hereby increased by the total
of the amounts remitted during the fiscal year pursuant to
subsection (d) of this section.
‘‘(2) AMOUNTS NOT PAID TO THE STATES.—The amount speci-
fied in section 2003(c) for fiscal year 1998 is hereby increased
by the amount made available for grants under this section
that has not been paid to any State by the end of fiscal year
1997.’’.
SEC. 264. CORRECTIONS RELATED TO THE INCOME SECURITY AND
HUMAN RESOURCES PROVISIONS OF OBRA–1990.
(a) AMENDMENT
RELATED
TO
SECTION
5035(a)(2).—Section
5035(a)(2) of OBRA–1990 is amended by striking ‘‘a semicolon’’
and inserting ‘‘ ‘; and’ ’’.
H. R. 5252—71
(b) AMENDMENT RELATED TO SECTION 5040.—Section 1631(n)
(42 U.S.C. 1383(n)) is amended by striking ‘‘subsection’’ and insert-
ing ‘‘section’’.
(c) 
AMENDMENT
RELATED
TO
SECTION
5051(a).—Section
402(a)(14) (42 U.S.C. 602(a)(14)) is amended to read as follows:
‘‘(14) at the option of the State and with respect to such
category or categories as the State may select and identify
in the plan, provide that—
‘‘(A) the State agency will require each family to which
the State provides (or, but for paragraph (22) or (32),
would provide) aid to families with dependent children,
as a condition to the continued receipt of such aid (or
to continuing to be deemed to be a recipient of such aid),
to report to the State agency monthly (or less frequently
in the case of such categories of recipients as the State
may select) on—
‘‘(i) the income of the family, the composition of
the family, and other relevant circumstances during
the prior month; and
‘‘(ii) the income and resources the family expects
to receive, or any changes in circumstances affecting
continued eligibility for, or amount of benefits, the
family expects to occur, in that month or in future
months; and
‘‘(B) in addition to any action that may be appropriate
based on other reports or information received by the State
agency, the State agency will—
‘‘(i) take prompt action to adjust the amount of
assistance payable, as may be appropriate, on the basis
of the information contained in the report (or upon
the failure of the family to submit a timely report);
and
‘‘(ii) give the family an appropriate explanatory
notice concurrent with any action taken under clause
(i);’’.
(d) REPEAL OF PROVISION INADVERTENTLY INCLUDED.—Section
5057 of OBRA–1990, and the amendment made by such section,
are hereby repealed, and section 1139(d) of the Social Security
Act shall be applied and administered as if such section 5057
had never been enacted.
(e) AMENDMENT RELATED TO SECTION 5105(a)(1)(B).—The sec-
ond paragraph of section 1631(a) (42 U.S.C. 1383(a)) is amended
by striking ‘‘(A)(i) Payments’’ and inserting ‘‘(2)(A)(i) Payments’’.
(f) AMENDMENTS
RELATED
TO
SECTION
5105(b).—Section
1631(a)(2)(C) (42 U.S.C. 1383(a)(2)(C)) is amended—
(1) in clause (i), by striking ‘‘to representative’’ and insert-
ing ‘‘to a representative’’;
(2) by striking clause (ii);
(3) by redesignating clauses (iii), (iv), and (v) as clauses
(ii), (iii), and (iv), respectively; and
(4) in clause (iv) (as so redesignated), by striking ‘‘(iii),
and (iv)’’ and inserting ‘‘and (iii)’’.
(g) AMENDMENTS RELATED TO SECTION 5107(a)(2)(B).—Section
1631(c)(1)(B) (42 U.S.C. 1383(c)(1)(B)) is amended by striking ‘‘para-
graph (1)’’ each place such term appears and inserting ‘‘subpara-
graph (A)’’.