858
CHAPTER 5—UNEMPLOYMENT
INSURANCE
SEC. 13271. TREATMENT OF SHORT-TIME COMPENSATION
PROGRAMS.
(a) GENERAL RULE.—Section 3306 of the Internal
Revenue Code of 1986 is amended by adding at the end
thereof the following new subsection:
‘‘(t) SHORT-TIME COMPENSATION PROGRAM.—For
purposes of this chapter, the term ‘short-time compensa-
tion program’ means a program under which—
‘‘(1) individuals whose workweeks have been re-
duced by at least 10 percent are eligible for unem-
ployment compensation;
‘‘(2) the amount of unemployment compensa-
tion payable to any such individual is a pro rata por-
tion of the unemployment compensation which would
be payable to the individual if the individual were
totally unemployed;
‘‘(3) eligible employees are not required to meet
the availability for work or work search test require-
ments while collecting short-time compensation bene-
fits, but are required to be available for their normal
workweek;
‘‘(4) eligible employees may participate in an
employer-sponsored training program to enhance
859
jobs skills if such program has been approved by the
State agency;
‘‘(5) there is a reduction in the number of
hours worked by employees in lieu of temporary
layoffs;
‘‘(6) there is a plan of an employer (or an em-
ployers association which is party to a collective bar-
gaining agreement) approved by the State agency
consisting of factors in this subsection or other fac-
tors as the Secretary of Labor may find relevant;
and
‘‘(7) the employer continues to provide health
benefits and pension benefits under a pension plan
(as defined in section 3(35) of the Employee Retire-
ment Income Security Act of 1974) to any employee
whose workweek is reduced under such plan.
A short-time compensation program may also contain such
other factors as the Secretary of Labor finds relevant.’’.
(b) CONFORMING AMENDMENTS.—
(1) Subparagraph (E) of section 3304(a)(4) of
such Code is amended to read as follows:
‘‘(E) amounts may be withdrawn for the
payment of short-time compensation under a
short-time compensation program approved by
the Secretary of Labor:’’.
861
‘‘(A) the transfers to such account pursuant to
section 901(b)(2) during such month, exceed
‘‘(B) the payments during such month from the
employment security administration account pursu-
ant to section 901(b)(3) and (d).
If for any month the payments referred to in subpara-
graph (B) exceed the transfers referred to in subpara-
graph (A), proper adjustments shall be made in the
amounts subsequently transferred.’’.
SEC. 13273. EXTENSION OF REPORTING DATE FOR ADVI-
SORY COUNCIL.
In the case of the first Advisory Council on Unem-
ployment Compensation established under section 908 of
the Social Security Act, subsection (f) of such section 908
shall be applied—
(1) by substituting ‘‘3rd year’’ for ‘‘2d year’’ in
paragraph (1), and
(2) by substituting ‘‘February 1, 1995’’ for
‘‘February 1, 1994’’ in paragraph (2).
SEC. 13274. CLARIFICATION OF EMERGENCY UNEMPLOY-
MENT BENEFITS PROVISIONS.
(a) IN GENERAL.—Subclauses (II) and (III) of sec-
tion 102(b)(2)(A)(v) of the Emergency Unemployment
Compensation Act of 1991 are amended to read as follows:
862
‘‘(II) The requirements of this
subclause are met for any week if the
national rate of total unemployment
(seasonally adjusted) for each of the 2
most recent calendar months (not
averaged) for which data are pub-
lished before the close of such week is
less than 7 percent, and if the re-
quirements of subclause (III) are not
met for such week.
‘‘(III) The requirements of this
subclause are met for any week if the
national rate of total unemployment
(seasonally adjusted) for each of the 2
most recent calendar months (not
averaged) for which data are pub-
lished before the close of such week is
less than 6.8 percent.’’.
(b) EFFECTIVE DATE.—The amendment made by
subsection (a) shall apply as if included in the amend-
ments made by section 101(b) of the Unemployment Com-
pensation Amendments of 1992.
863
SEC. 13275. MODIFICATIONS TO EXTENDED UNEMPLOY-
MENT PROGRAM.
(a) INCREASE
IN REIMBURSEMENT RATE.—Sub-
section (a) of section 204 of the Federal-State Extended
Unemployment Compensation Act of 1970 is amended by
striking ‘‘one-half’’ and inserting ‘‘75 percent’’.
(b) REPEAL
OF SPECIAL ELIGIBILITY REQUIRE-
MENTS.—Subsection (a) of section 202 of such Act is
amended—
(1) by striking paragraphs (3), (4), and (7),
(2) by redesignating paragraphs (5) and (6) as
paragraphs (3) and (4), respectively, and
(3) by striking ‘‘paragraphs (3), (4), and (5)’’
in paragraph (4) (as redesignated by paragraph (1)
of this subsection) and inserting ‘‘paragraph (3)’’.
(c) EFFECTIVE DATE.—
(1) IN GENERAL.—The amendments made by
this section shall apply to weeks beginning after Oc-
tober 2, 1993.
(2) SPECIAL RULE.—In the case of any State
the legislature of which has not been in session for
at least 30 calendar days (whether or not successive)
between the date of the enactment of this Act and
October 1, 1993, the amendment made by sub-
section (b) shall not be a requirement of the State
law of such State before the date 30 calendar days
864
after the 1st day on which such legislature is in ses-
sion on or after October 1, 1993.
SEC. 13276. EXTENSION OF CURRENT FEDERAL UNEM-
PLOYMENT RATE.
Section 3301 of the Internal Revenue Code of 1986
is amended—
(1) by striking ‘‘1996’’ in paragraph (1) and in-
serting ‘‘1998’’, and
(2) by striking ‘‘1997’’ in paragraph (2) and in-
serting ‘‘1999’’.
SEC. 13277. DISCLOSURE OF INFORMATION TO RAILROAD
RETIREMENT BOARD.
Section 6103(l)(1)(C) of the Internal Revenue Code
of 1986 is amended to read as follows:
‘‘(C) taxes imposed by chapters 22 and
23A, to the Railroad Retirement Board for pur-
poses of its administration of the Railroad Re-
tirement and Railroad Unemployment Insur-
ance Acts.’’.
865
CHAPTER 6—TECHNICAL PROVISIONS
SEC. 13281. CORRECTIONS RELATED TO THE INCOME SE-
CURITY AND HUMAN RESOURCES PROVI-
SIONS OF THE OMNIBUS BUDGET RECONCILI-
ATION ACT OF 1990.
(a) 
AMENDMENT
RELATED
TO
SECTION
5035(a)(2).—Section 5035(a)(2) of the Omnibus Budget
Reconciliation Act of 1990 (Public Law 101–508) is
amended by striking ‘‘a semicolon’’ and inserting
‘‘ ‘; and’ ’’.
(b) REPEAL
OF PROVISION INADVERTENTLY IN-
CLUDED.—Section 5057 of the Omnibus Budget Rec-
onciliation Act of 1990 (Public Law 101–508), 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.
(c) 
AMENDMENT
RELATED
TO
SECTION
5105(d)(1)(B).—Section 5105(d)(1)(B) of the Omnibus
Budget Reconciliation Act of 1990 (Public Law 101–508;
104 Stat. 1388–266) is amended to read as follows:
‘‘(B) TITLE
XVI.—Section 1631(a)(2)(F)
(42 U.S.C. 1383(a)(2)(F)), as so redesignated
by subsection (c)(2) of this section, is amended
to read as follows:
866
‘‘ ‘(F) The Secretary shall include as a part of the
annual report required under section 704 information with
respect to the implementation of the preceding provisions
of this paragraph, including—
‘‘ ‘(i) the number of cases in which the rep-
resentative payee was changed;
‘‘ ‘(ii) the number of cases discovered where
there has been a misuse of funds;
‘‘ ‘(iii) how any such cases were dealt with by
the Secretary;
‘‘ ‘(iv) the final disposition of such cases (in-
cluding any criminal penalties imposed); and
‘‘ ‘(v) such other information as the Secretary
determines to be appropriate.’.’’.
(d) 
AMENDMENT
RELATED
TO
SECTION
5105(a)(1)(B).—The 2nd paragraph of section 1631(a)
(42 U.S.C. 1383(a)) is amended by striking ‘‘(A)(i) Pay-
ments’’ and inserting ‘‘(2)(A)(i) Payments’’.
(e) AMENDMENTS RELATED TO SECTION 5105(b).—
Section 1631(a)(2)(C) (42 U.S.C. 1383(a)(2)(C)) is
amended—
(1) by striking clause (ii);
(2) by redesignating clauses (iii), (iv), and (v)
as clauses (ii), (iii), and (iv), respectively; and
867
(3) in clause (iv) (as so redesignated), by strik-
ing ‘‘(iii), and (iv)’’ and inserting ‘‘and (iii)’’.
(f) 
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 ‘‘paragraph (1)’’
each place such term appears and inserting ‘‘subpara-
graph (A)’’.
(g) 
AMENDMENT
RELATED
TO
SECTION
5109(a)(2).—Section 1631 (42 U.S.C. 1383) is amended
by redesignating the subsection (n) added by section
5109(a)(2) of the Omnibus Budget Reconciliation Act of
1990, as subsection (o).
(h) 
AMENDMENTS
RELATED
TO
SECTION
11115(b)(2).—Section 11115(b)(2) of the Omnibus Budg-
et Reconciliation Act of 1990 (Public Law 101–508) is
amended—
(1) in subparagraph (A), by striking ‘‘para-
graph (8)’’ and inserting ‘‘paragraph (9)’’;
(2) in subparagraph (B), by striking ‘‘para-
graph (9)’’ and inserting ‘‘paragraph (10)’’; and
(3) in subparagraph (C), by redesignating the
new paragraph added thereby as paragraph (11).
(i) 
AMENDMENT
RELATED
TO
SECTION
13101(d)(2).—Section 256(k)(2)(A) of the Balanced
868
Budget and Emergency Deficit Control Act of 1985 is
amended—
(1) by striking ‘‘—’’ the 2nd place it appears
and all that follows through ‘‘(I)’’; and
(2) by striking ‘‘; or’’ and all that follows
through ‘‘(II)’’ and inserting ‘‘, except that a State
may not be allotted an amount under this subpara-
graph that exceeds’’.
(j) EFFECTIVE DATE.—Each amendment made by
this section shall take effect as if included in the provision
of the Omnibus Budget Reconciliation Act of 1990 to
which the amendment relates at the time such provision
became law.
SEC. 13282. TECHNICAL CORRECTIONS RELATED TO THE
HUMAN RESOURCE AND INCOME SECURITY
PROVISIONS OF THE OMNIBUS BUDGET REC-
ONCILIATION ACT OF 1989.
(a) AMENDMENT RELATING TO SECTION 8004(a).—
Section 408(m)(2)(A) (42 U.S.C. 608(m)(2)(A)) is
amended by striking ‘‘a fiscal’’ and inserting ‘‘the fiscal’’.
(b) AMENDMENT RELATING TO SECTION 8006(a).—
Section 473(a)(6)(B) (42 U.S.C. 673(a)(6)(B)) is amend-
ed 
by 
striking 
‘‘474(a)(3)(B)’’ 
and 
inserting
‘‘474(a)(3)(C)’’.
869
(c) 
AMENDMENT
RELATING
TO
SECTION
8007(b)(3).—Subparagraph (D) of section 475(5) (42
U.S.C. 675(5)(D)) is amended by moving such subpara-
graph 2 ems to the right so that the left margin of such
subparagraph is aligned with the left margin of subpara-
graph (C) of such section.
(d) EFFECTIVE DATE.—Each amendment made by
this section shall take effect as if the amendment had been
included in the provision of the Omnibus Budget Rec-
onciliation Act of 1989 to which the amendment relates,
at the time the provision became law.
SEC. 13283. ELIMINATION OF OBSOLETE PROVISIONS RE-
LATING TO TREATMENT OF THE EARNED IN-
COME TAX CREDIT.
(a) TREATMENT OF EITC AS EARNED INCOME.—
Section 1612(a)(1) (42 U.S.C. 1382a(a)(1)) is amended
by striking subparagraph (C) and by redesignating sub-
paragraphs (D) and (E) as subparagraphs (C) and (D),
respectively.
(b) ADJUSTMENT OF BENEFITS DUE TO TREAT-
MENT OF EITC AS EARNED INCOME.—Section 1631(b)
(42 U.S.C. 1383(b)) is amended by striking paragraph (3)
and by redesignating paragraphs (4) and (5) as para-
graphs (3) and (4), respectively.
870
SEC. 13284. REDESIGNATION OF CERTAIN PROVISIONS.
Section 1631(e)(6) (42 U.S.C. 1383(e)(6)) is amend-
ed by redesignating subparagraphs (1) and (2) as sub-
paragraphs (A) and (B), respectively.
Subtitle C—Medicare Program
SEC. 13400. REFERENCES IN SUBTITLE; TABLE OF CON-
TENTS OF SUBTITLE.
(a) AMENDMENTS TO SOCIAL SECURITY ACT.—Ex-
cept as otherwise specifically provided, whenever in this
subtitle an amendment is expressed in terms of an amend-
ment to or repeal of a section or other provision, the ref-
erence shall be considered to be made to that section or
other provision of the Social Security Act.
(b) REFERENCES TO OBRA.—In this subtitle, the
terms ‘‘OBRA–1986’’, ‘‘OBRA–1987’’, ‘‘OBRA–1989’’,
and ‘‘OBRA–1990’’ refer to the Omnibus Budget Rec-
onciliation Act of 1986 (Public Law 99–509), the Omni-
bus Budget Reconciliation Act of 1987 (Public Law 100–
203), the Omnibus Budget Reconciliation Act of 1989
(Public Law 101–239), and the Omnibus Budget Rec-
onciliation Act of 1990 (Public Law 101–508), respec-
tively.
(c) TABLE OF CONTENTS OF SUBTITLE.—The table
of contents of this subtitle is as follows:
Sec. 13400. References in subtitle; table of contents of subtitle.
CHAPTER 1—PROVISIONS RELATING TO PART A
871
SUBCHAPTER A—ELIMINATION OF INFLATION UPDATE FOR SERVICES
PROVIDED UNDER PART A
Sec. 13401. Inpatient hospital services and hospice care.
Sec. 13402. Limits on per diem routine service costs for extended care services.
SUBCHAPTER B—OTHER PROVISIONS RELATING TO PART A
Sec. 13411. Wage index provisions.
Sec. 13412. Transition for hospital outlier thresholds.
Sec. 13413. Essential access community hospital (EACH) amendments.
Sec. 13414. Rural health transition grant program extension.
Sec. 13415. Regional referral center extension.
Sec. 13416. Medicare-dependent, small rural hospital payment extension.
Sec. 13417. Extension of regional floor.
Sec. 13418. Extension of rural hospital demonstration.
Sec. 13419. Hemophilia pass-through extension.
Sec. 13420. State hospital payment programs.
Sec. 13421. Psychology services in hospitals.
Sec. 13422. Graduate medical education payments in hospital-owned commu-
nity health centers.
Sec. 13423. Treatment of certain military facilities.
Sec. 13424. Epilepsy DRG.
Sec. 13425. Skilled nursing facility wage index.
Sec. 13426. Hospice notification to beneficiaries.
Sec. 13427. Reduction in part A premium for certain individuals with 30 or
more quarters of Social Security coverage.
Sec. 13428. Periodic updates to salary equivalency guidelines for physical ther-
apy and respiratory therapy services.
Sec. 13429. Extension of deadline for application for geographic classification
for certain reclassified hospitals.
Sec. 13430. Clarification of DRG payment window expansion; miscellaneous
and technical corrections.
CHAPTER 2—PROVISIONS RELATING TO PART B
SUBCHAPTER A—ELIMINATION OF INFLATION UPDATE
Sec. 13431. Elimination of inflation update for physician and related profes-
sional services.
Sec. 13432. Elimination of cost-of-living adjustments for certain items and
services.
Sec. 13433. Ambulatory surgical center services.
Sec. 13434. Other items and services under part B.
SUBCHAPTER B—PHYSICIANS’ SERVICES
Sec. 13441. Reinstating separate payment for the interpretation of electro-
cardiograms (EKGs).
Sec. 13442. Payments for new physicians and practitioners.
Sec. 13443. Retaining payment for actual anesthesia time.
Sec. 13444. Geographic cost of practice index refinements.
Sec. 13445. Extra-billing.
Sec. 13446. Relative values for pediatric services.
Sec. 13447. Antigens under physician fee schedule.
Sec. 13448. Administration of claims relating to physicians’ services.
Sec. 13449. Miscellaneous and technical corrections.
872
SUBCHAPTER C—AMBULATORY SURGICAL CENTER SERVICES
Sec. 13451. Designation of certain hospitals as eye or eye and ear hospitals.
Sec. 13452. Treatment of intraocular lenses.
Sec. 13453. Technical amendments.
SUBCHAPTER D—DURABLE MEDICAL EQUIPMENT
Sec. 13461. Certification of suppliers.
Sec. 13462. Prohibition against carrier forum shopping.
Sec. 13463. Restrictions on certain marketing and sales activities.
Sec. 13464. Anti-kickback clarification.
Sec. 13465. Limitations on beneficiary liability for noncovered services.
Sec. 13466. Adjustments for inherent reasonableness.
Sec. 13467. Treatment of nebulizers and aspirators.
Sec. 13468. Payment for ostomy supplies and other supplies.
Sec. 13469. Miscellaneous and technical corrections.
SUBCHAPTER E—OTHER PROVISIONS
Sec. 13471. Clarifying payments for medically directed certified registered
nurse anesthetist services.
Sec. 13472. Extension of Alzheimer’s disease demonstration projects.
Sec. 13473. Oral cancer drugs.
Sec. 13474. Part B premium for late enrollment.
Sec. 13475. Coverage 
of 
services 
of 
speech-language 
pathologists 
and
audiologists.
Sec. 13476. Extension of municipal health service demonstration projects.
Sec. 13477. Treatment of certain Indian health programs and facilities as Fed-
erally-qualified health centers.
Sec. 13478. Miscellaneous and technical corrections.
SUBCHAPTER F—PART B PREMIUM
Sec. 13481. Part B premium.
CHAPTER 3—PROVISIONS RELATING TO PARTS A AND B
SUBCHAPTER A—ELIMINATION OF UPDATES
Sec. 13501. Elimination of cost-of-living update in per resident amounts for di-
rect medical education.
Sec. 13502. Elimination of inflation update in cost limits for home health serv-
ices.
SUBCHAPTER B—MEDICARE SECONDARY PAYER PROVISIONS
Sec. 13511. Extension of transfer of data.
Sec. 13512. 3-year extension of medicare secondary payer to disabled bene-
ficiaries.
Sec. 13513. 3-year extension of 18-month rule for ESRD beneficiaries.
Sec. 13514. Medicare secondary payer reforms.
SUBCHAPTER C—PHYSICIAN OWNERSHIP AND REFERRAL
Sec. 13521. Application of medicare ban on self-referrals to all payers.
Sec. 13522. Extension of self-referral ban to additional specified services.
Sec. 13523. Exceptions for both ownership and compensation arrangements.
Sec. 13524. Exceptions related only to ownership or investment.
873
Sec. 13525. Exceptions related only to compensation arrangements.
Sec. 13526. Clarification concerning civil money penalty sanctions.
Sec. 13527. Requirements for group practice.
Sec. 13538. No Federal preemption of more restrictive State laws.
Sec. 13529. Miscellaneous provisions.
Sec. 13530. Effective dates.
SUBCHAPTER D—OTHER PROVISIONS
Sec. 13551. Direct graduate medical education.
Sec. 13552. Immunosuppressive drug therapy.
Sec. 13553. Reduction in payments for erythropoientin.
Sec. 13554. Qualified medicare beneficiary outreach.
Sec. 13555. Extension of social health maintenance organization demonstra-
tions.
Sec. 13556. Hospice notification to home health beneficiaries.
Sec. 13557. Interest payments.
Sec. 13558. Peer review organizations.
Sec. 13559. Health maintenance organizations.
Sec. 13560. Medicare administration budget process.
Sec. 13561. Other provisions.
CHAPTER 4—MEDICARE SUPPLEMENTAL INSURANCE POLICIES
Sec. 13571. Standards for medicare supplemental insurance policies.
CHAPTER 5—TREATMENT OF CERTAIN STATE HEALTH CARE PROGRAMS
Sec. 13581. Treatment of certain State health care programs.
CHAPTER 1—PROVISIONS RELATING TO
PART A
Subchapter A—Elimination of Inflation
Update for Services Provided Under Part A
SEC. 13401. INPATIENT HOSPITAL SERVICES AND HOSPICE
CARE.
Section 
1886(b)(3)(B)(iii) 
(42 
U.S.C.
1395ww(b)(3)(B)(iii)) is amended—
(1) by striking ‘‘(iii) For purposes of this sub-
paragraph’’ and inserting ‘‘(iii)(I) Except as pro-
vided in subclause (II), for purposes of this subpara-
graph’’, and
874
(2) by adding at the end the following new
subclause:
‘‘(II) For purposes of this subparagraph and section
1814(i)(1)(C)(ii), the ‘market basket percentage increase’,
with respect to cost reporting periods and discharges oc-
curring in fiscal year 1994 or 1995, is 0 percent.’’.
SEC. 13402. LIMITS ON PER DIEM ROUTINE SERVICE COSTS
FOR EXTENDED CARE SERVICES.
The Secretary of Health and Human Services shall
not provide for any increase, on the basis of inflation or
changes in the cost of goods and services, in the limits
on per diem routine service costs for extended care services
under section 1888 of the Social Security Act for cost re-
porting periods beginning during fiscal year 1994 or fiscal
year 1995.
Subchapter B—Other Provisions Relating to
Part A
SEC. 13411. WAGE INDEX PROVISIONS.
(a) WAGE INDEX HOLD HARMLESS PROTECTION.—
(1) IN GENERAL.—Section 1886(d)(8)(C) (42
U.S.C. 1395ww(d)(8)(C)) is amended by adding at
the end the following new clause:
‘‘(iv) The application of subparagraph (B) or a deci-
sion of the Medicare Geographic Classification Review
875
Board or the Secretary under paragraph (1) may not re-
sult in a reduction in an urban area’s wage index if—
‘‘(I) the urban area has a wage index below the
wage index for rural areas in the State in which it
is located; or
‘‘(II) the urban area is located in a State that
is composed of a single urban area.’’.
(2) NO
STANDARDIZED
AMOUNT
ADJUST-
MENT.—The Secretary of Health and Human Serv-
ices shall not revise the fiscal year 1992 or fiscal
year 1993 standardized amounts pursuant to sub-
sections (d)(3)(B) and (d)(8)(D) of section 1886 of
the Social Security Act to account for the amend-
ment made by paragraph (1).
(3) EFFECTIVE DATE.—The amendment made
by paragraph (1) shall apply to discharges occur-
ring—
(A) on or after October 1, 1991, in the
case of hospitals located in an urban area de-
scribed in section 1886(d)(8)(C)(iv)(I) of the
Social Security Act (as added by paragraph
(1)); and
(B) on or after the date of the enactment
of this Act, in the case of hospitals located in
an 
urban 
area 
described 
in 
section
876
1886(d)(8)(C)(iv)(II) of the Social Security Act
(as added by paragraph (1)).
(b) UPDATING STANDARDS FOR TREATING RURAL
COUNTIES AS URBAN COUNTIES BASED ON RATES OF
COMMUTATION.—
(1) IN GENERAL.—Section 1886(d)(8)(B) (42
U.S.C. 1395ww(d)(8)(B)) is amended—
(A) by striking ‘‘standards’’ each place it
appears and inserting ‘‘standards most recently
used’’, and
(B) by striking ‘‘published in the Federal
Register on January 3, 1980’’.
(2) HOLD
HARMLESS
FOR
COUNTIES
CUR-
RENTLY TREATED AS URBAN.—Any hospital that is
treated as being located in an urban metropolitan
statistical area pursuant to section 1886(d)(8)(B) of
the Social Security Act as of September 30, 1992,
shall continue to be so treated notwithstanding the
amendments made by paragraph (1).
(3) EFFECTIVE DATE.—The amendments made
by paragraph (1) shall be effective on October 1,
1993.
(c) USE OF OCCUPATIONAL MIX IN GUIDELINES.—
(1) IN GENERAL.—Section 1886(d)(10)(D)(i)(I)
(42 U.S.C. 1395ww(d)(10)(D)(i)(I)) is amended by
877
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.
SEC. 13412. TRANSITION FOR HOSPITAL OUTLIER THRESH-
OLDS.
Section 1886(d)(5)(A) (42 U.S.C. 1395ww(d)(5)(A))
is amended—
(1) in clause (i), by striking ‘‘The Secretary’’
and inserting ‘‘For discharges occurring during fis-
cal years ending on or before September 30, 1997,
the Secretary’’; and
(2) by adding at the end the following new
clauses:
‘‘(v) The Secretary shall provide that—
‘‘(I) the day outlier percentage for fiscal year
1995 shall be 75 percent of the day outlier percent-
age for fiscal year 1994;
‘‘(II) the day outlier percentage for fiscal year
1996 shall be 50 percent of the day outlier percent-
age for fiscal year 1994; and
‘‘(III) the day outlier percentage for fiscal year
1997 shall be 25 percent of the day outlier percent-
age for fiscal year 1994.
878
‘‘(vi) For purposes of this subparagraph, the term
‘day outlier percentage’ means, for a fiscal year, the per-
centage of the total additional payments made by the Sec-
retary under this subparagraph for discharges in that fis-
cal year which are additional payments under clause (i).’’.
SEC. 13413. ESSENTIAL ACCESS COMMUNITY HOSPITAL
(EACH) AMENDMENTS.
(a) 
INCREASING
NUMBER
OF
PARTICIPATING
STATES.—Section 1820(a)(1) (42 U.S.C. 1395i–4(a)(1))
is amended by striking ‘‘7’’ and inserting ‘‘9’’.
(b) 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 con-
ditions as the Secretary may establish) for pro-
viding inpatient care to patients requiring sta-
bilization before discharge or transfer to a hos-
pital, 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 dis-
879
charged 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 physi-
cian 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 IN-
PATIENT 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
the previous year in which the designation was in ef-
fect exceeded 72 hours. In determining the compli-
ance of a facility with the requirement of the pre-
vious sentence, there shall not be taken into account
880
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 inclem-
ent 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 in-
serting ‘‘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 Con-
gress on—
(A) the application of the requirements
under section 1820(f) of the Social Security Act
(as amended by this subsection) that rural pri-
mary 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
881
(B) the extent to which such requirements
have resulted in such hospitals providing inpa-
tient care beyond their capabilities or have lim-
ited the ability of such hospitals to provide
needed services.
(c) 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 sub-
section (e) and redesignating paragraphs
(2) through (6) as paragraphs (1) through
(5); and
(ii) in subsection (e)(1)(A) (as redes-
ignated by subparagraph (A))—
(I) by striking ‘‘is located’’ and
inserting ‘‘except in the case of a hos-
pital located in an urban area, is lo-
cated’’,
(II) by striking ‘‘, (ii)’’ and in-
serting ‘‘or (ii)’’,
(III) by striking ‘‘or (iii)’’ and all
that follows through ‘‘section,’’, and
882
(IV) in subsection (i)(1)(B), by
striking ‘‘paragraph (3)’’ and insert-
ing ‘‘paragraph (2)’’.
(B) NO CHANGE IN MEDICARE PROSPEC-
TIVE
PAYMENT.—Section 1886(d)(5)(D) (42
U.S.C. 1395ww(d)(5)(D)) is amended—
(i) in clause (iii)(III), by inserting ‘‘lo-
cated 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 AD-
JOINING STATES TO PARTICIPATE IN STATE PRO-
GRAM.—
(A) IN
GENERAL.—Section 1820 (42
U.S.C. 1395i–4) is amended—
(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—
883
‘‘(1) for purposes of including a hospital or fa-
cility as a member institution of a rural health net-
work, 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 hospital;
‘‘(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 subsection shall be eligible to receive a grant
under subsection (a)(2).’’.
(B) CONFORMING AMENDMENTS.—(i) Sec-
tion 1820(c)(1) (42 U.S.C. 1395i–4(c)(1)) is
amended by striking ‘‘paragraph (3)’’ and in-
serting ‘‘paragraph (3) or subsection (k)’’.
(ii) Paragraphs (1)(A) and (2)(A) of sec-
tion 1820(i) (42 U.S.C. 1395i–4(i)) are each
amended—
884
(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 ‘‘sub-
paragraph (B)’’ and inserting ‘‘subpara-
graph (B) or subsection (k)’’.
(d) SKILLED NURSING SERVICES IN RURAL PRIMARY
CARE HOSPITALS.—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 serv-
ices, except that the number of beds used for the furnish-
ing 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 inpa-
tient 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
885
nursing facility at the time the facility applies to the State
for designation as a rural primary care hospital.’’.
(e) PAYMENT
FOR OUTPATIENT RURAL PRIMARY
CARE HOSPITAL SERVICES.—
(1) IMPLEMENTATION
OF
PROSPECTIVE
PAY-
MENT
SYSTEM.—Section 
1834(g) 
(42 
U.S.C.
1395m(g)) is amended—
(A) in paragraph (1), by striking ‘‘during
a year before 1993’’ and inserting ‘‘during a
year before the prospective payment system de-
scribed 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 DETER-
MINING PAYMENT.—Section 1834(g)(1) (42 U.S.C.
1395m(g)(1)) is amended by adding at the end the
following:
‘‘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 RE-
QUIREMENT 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 follow-
ing: ‘‘, except that in determining whether a facility meets
886
the requirements of this subparagraph, subparagraphs (E)
and (F) of that paragraph shall be applied as if any ref-
erence to a ‘physician’ is a reference to a physician as de-
fined in section 1861(r)(1).’’.
(g) TECHNICAL AMENDMENTS RELATING TO PART
A DEDUCTIBLE, COINSURANCE, AND SPELL
OF ILL-
NESS.—(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 hos-
pital services or inpatient rural primary care hos-
pital services’’;
(B) by striking ‘‘inpatient hospital services’’ the
second place it appears and inserting ‘‘such serv-
ices’’; 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 in-
serting ‘‘inpatient hospital services or inpatient rural pri-
mary care hospital services’’.
(3) 
Section 
1813(b)(3)(B) 
(42 
U.S.C.
1395e(b)(3)(B)) is amended by striking ‘‘inpatient hos-
887
pital services’’ and inserting ‘‘inpatient hospital services,
inpatient rural primary care hospital services’’.
(4) Section 1861(a) (42 U.S.C. 1395x(a)) is amend-
ed—
(A) in paragraphs (1), by striking ‘‘inpatient
hospital services’’ and inserting ‘‘inpatient hospital
services, inpatient rural primary care hospital serv-
ices’’; and
(B) in paragraph (2), by striking ‘‘hospital’’
and inserting ‘‘hospital or rural primary care hos-
pital’’.
(h) AUTHORIZATION OF APPROPRIATIONS.—Section
1820(k) (42 U.S.C. 1395i–4(k)) is amended by striking
‘‘1990, 1991, and 1992’’ and inserting ‘‘1990 through
1995’’.
(i) EFFECTIVE DATE.—The amendments made by
this section shall take effect on the date of the enactment
of this Act.
SEC. 13414. RURAL HEALTH TRANSITION GRANT PROGRAM
EXTENSION.
Section 4005(e)(9) of OBRA–1987 is amended—
(1) by striking ‘‘1989 and’’ and inserting
‘‘1989,’’; and
888
(2) by striking ‘‘1992’’ and inserting ‘‘1992
and $30,000,000 for each of fiscal years 1993
through 1997’’.
SEC. 13415. REGIONAL REFERRAL CENTER EXTENSION.
(a) EXTENSION OF CLASSIFICATION THROUGH FIS-
CAL YEAR 1994.—Effective on the date of the enactment
of this Act, section 6003(d) of such Act (42 U.S.C.
1395ww note) is amended by striking ‘‘October 1, 1992’’
and inserting ‘‘October 1, 1994’’.
(b) PERMITTING HOSPITALS TO DECLINE RECLASSI-
FICATION.—If any hospital fails to qualify as a rural refer-
ral center under section 1886(d)(5)(C) of the Social Secu-
rity Act as a result of a decision by the Medicare Geo-
graphic Classification Review Board under section
1886(d)(10) of such Act to reclassify the hospital as being
located in an urban area for fiscal year 1993 or fiscal year
1994, the Secretary of Health and Human Services
shall—
(1) notify such hospital of such failure to
qualify,
(2) provide an opportunity for such hospital to
decline such reclassification, and
(3) if the hospital declines such reclassification,
administer the Social Security Act (other than sec-
889
tion 1886(d)(8)(D)) for such fiscal year as if the de-
cision by the Review Board had not occurred.
(c) REQUIRING LUMP-SUM RETROACTIVE PAYMENT
FOR HOSPITALS LOSING CLASSIFICATION.—
(1) IN GENERAL.—In the case of an affected
regional referral center (as described in paragraph
(2)), the Secretary of Health and Human Services
shall make a lump sum payment to the center equal
to the difference between the aggregate payment
made to the center under section 1886 of such Act
(excluding 
outlier 
payments 
under 
subsection
(d)(5)(A) of such section) during the period of appli-
cability described in paragraph (3) and the aggre-
gate payment that would have been made to the cen-
ter under such section if, during the period of appli-
cability, the center was classified a regional referral
center under section 1886(d)(5)(C) of such Act.
(2) AFFECTED CENTERS DESCRIBED.—In para-
graph (1), an ‘‘affected regional referral center’’ is
a hospital classified as regional referral center under
section 1886(d)(5)(C) of the Social Security Act as
of September 30, 1992, that was not classified as
such a center after such date but would have been
so classified if the reference in section 6003(d) of
890
OBRA–1989 to ‘‘October 1, 1992,’’ had been
deemed a reference to ‘‘October 1, 1994,’’.
(3) PERIOD OF APPLICABILITY.—In paragraph
(1), the ‘‘period of applicability’’ is the period that
begins on October 1, 1992, and ends on the date of
the enactment of this Act.
SEC. 13416. MEDICARE-DEPENDENT, SMALL RURAL HOS-
PITAL PAYMENT EXTENSION.
(a) EXTENSION OF ADDITIONAL PAYMENTS.—Effec-
tive on the date of the enactment of this Act, section
1886(d)(5)(G) (42 U.S.C. 1395ww(d)(5)(G)) is amend-
ed—
(1) in clause (i) in the matter preceding
subclause (I)—
(A) by inserting ‘‘(or portion thereof)’’
after ‘‘cost reporting period’’, and
(B) by striking ‘‘March 31, 1993,’’ and all
that follows and inserting the following: ‘‘Sep-
tember 30, 1994, in the case of a subsection (d)
hospital which is a medicare-dependent, small
rural hospital, payment under paragraph (1)(A)
shall be equal to the sum of the amount deter-
mined under clause (ii) and the amount deter-
mined under paragraph (1)(A)(iii).’’;
891
(2) by redesignating clauses (ii) and (iii) as
clauses (iii) and (iv); and
(3) by inserting after clause (i) the following
new clause:
‘‘(ii) The amount determined under this clause is—
‘‘(I) for discharges occurring during the first 3
12-month cost reporting periods that begin on or
after April 1, 1990, the amount by which the hos-
pital’s target amount for the cost reporting period
(as defined in subsection (b)(3)(D)) exceeds the
amount determined under paragraph (1)(A)(iii); and
‘‘(II) for discharges occurring during any subse-
quent cost reporting period (or portion thereof), 50
percent of the amount by which the hospital’s target
amount for the cost reporting period (as defined in
subsection (b)(3)(D)) exceeds the amount deter-
mined under paragraph (1)(A)(iii).’’.
(b) PERMITTING HOSPITALS TO DECLINE RECLASSI-
FICATION.—If any hospital fails to qualify as a medicare-
dependent, 
small 
rural 
hospital 
under 
section
1886(d)(5)(G)(i) of the Social Security Act as a result of
a decision by the Medicare Geographic Classification Re-
view Board under section 1886(d)(10) of such Act to re-
classify the hospital as being located in an urban area for
892
fiscal year 1993 or fiscal year 1994, the Secretary of
Health and Human Services shall—
(1) notify such hospital of such failure to
qualify,
(2) provide an opportunity for such hospital to
decline such reclassification, and
(3) if the hospital declines such reclassification,
administer the Social Security Act (other than sec-
tion 1886(d)(8)(D)) for such fiscal year as if the de-
cision by the Review Board had not occurred.
(c) REQUIRING
LUMP-SUM
RETROACTIVE
PAY-
MENT.—
(1) IN GENERAL.—In the case of a hospital
treated as a medicare dependent, small rural hos-
pital under section 1886(d)(5)(G) of the Social Se-
curity Act, the Secretary of Health and Human
Services shall make a lump sum payment to the hos-
pital equal to the difference between the aggregate
payment made to the hospital under section 1886 of
such Act (excluding outlier payments under sub-
section (d)(5)(A) of such section) during the period
of applicability described in paragraph (2) and the
aggregate payment that would have been made to
the hospital under such section if, during the period
893
of applicability, section 1886(d)(5)(G) of such Act
had been applied as if—
(A) the reference in clause (i) to ‘‘March
31, 1993,’’ had been deemed a reference to
‘‘September 30, 1994,’’; and
(B) the amendments made by subsection
(a) had been in effect.
(2) PERIOD OF APPLICABILITY.—In paragraph
(1), the ‘‘period of applicability’’ is, with respect to
a hospital, the period that begins on the first day of
the hospital’s first 12-month cost reporting period
that begins after April 1, 1992, and ends on the
date of the enactment of this Act.
SEC. 13417. EXTENSION OF REGIONAL FLOOR.
Section 
1886(d)(1)(A)(iii) 
(42 
U.S.C.
1395ww(d)(1)(A)(iii)) is amended by striking ‘‘September
30, 1993’’ and inserting ‘‘September 30, 1996’’.
SEC. 13418. EXTENSION OF RURAL HOSPITAL DEMONSTRA-
TION.
Section 4008(i)(1) of OBRA–1990 is amended by
adding at the end the following new sentence: ‘‘The Sec-
retary shall continue any such demonstration project until
at least December 31, 1995.’’.
894
SEC. 13419. HEMOPHILIA PASS-THROUGH EXTENSION.
Effective as if included in the enactment of OBRA–
1989, section 6011(d) of such Act is amended by striking
‘‘2 years after the date of enactment of this Act’’ and
inserting ‘‘September 30, 1994’’.
SEC. 13420. STATE HOSPITAL PAYMENT PROGRAMS.
In the case of a State hospital reimbursement system
that meets the requirements of section 1814(b)(3) of the
Social Security Act, no other provision of law shall be con-
strued as preventing the system from providing that pay-
ment for services covered under the system be made on
the basis of rates provided for under the system.
SEC. 13421. PSYCHOLOGY SERVICES IN HOSPITALS.
Section 1861(e)(4) (42 U.S.C. 1395x(e)(4)) is
amended by striking ‘‘physician;’’ and inserting ‘‘physi-
cian, 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. 13422. GRADUATE MEDICAL EDUCATION PAYMENTS IN
HOSPITAL-OWNED COMMUNITY HEALTH CEN-
TERS.
Section 
1886(d)(5)(B)(iv) 
(42 
U.S.C.
1395ww(d)(5)(B)(iv)) is amended by inserting after ‘‘the
hospital’’ the following: ‘‘or providing services at any en-
tity receiving a grant under section 330 of the Public
895
Health Service Act that is under the ownership or control
of the hospital (if the hospital incurs all, or substantially
all, of the costs of the services furnished to the hospital
by such interns and residents)’’.
SEC. 13423. TREATMENT OF CERTAIN MILITARY FACILI-
TIES.
(a) COVERAGE OF SERVICES PROVIDED IN CERTAIN
UNIFORMED SERVICES TREATMENT FACILITIES.—
(1) IN GENERAL.—The Secretary of Health and
Human Services may not take any recoupment ac-
tion to recover amounts that were paid by the Unit-
ed States under title XVIII of the Social Security
Act to the facilities described in paragraph (2) (or
to other individuals or entities with whom such fa-
cilities had entered into agreements to provide serv-
ices under such title) for services provided during
the period beginning October 1, 1986, and ending
December 31, 1989, except to the extent that funds
were obligated to the Uniformed Services Treatment
Facilities program to fulfill such an action pursuant
to title VI of the Department of Defense Appropria-
tions Act, 1993.
(2) FACILITIES DESCRIBED.—The facilities re-
ferred to in paragraph (1) are the hospitals de-
scribed in section 248c of title 42, United States
896
Code, that are located in Boston, Massachusetts;
Baltimore, Maryland; and Seattle, Washington.
(b) STUDY OF JOINT MEDICAL FACILITIES.—
(1) STUDY.—The Secretary of Health and
Human Services, in consultation with the Secretary
of Defense and the Secretary of Veterans Affairs,
shall conduct a study of the feasibility and desirabil-
ity of establishing joint medical facilities among the
Department of Defense, the Department of Veter-
ans’ Affairs, and other public and private entities,
and shall include in such study an analysis of the
need to make changes in the medicare and medicaid
programs (including facility certification standards
under such programs) in order to facilitate the es-
tablishment of such joint medical facilities.
(2) REPORT.—Not later than October 1, 1993,
the Secretary of Health and Human Services shall
submit a report to Congress on the study conducted
under paragraph (1).
SEC. 13424. EPILEPSY DRG.
(a) IN GENERAL.—The Secretary of Health and
Human Services shall review the diagnosis-related groups
established pursuant to section 1886(d)(4) of the Social
Security Act that are assigned to discharges of patients
with intractable epilepsy, including patients whose admis-
897
sions involve intensive neurodiagnostic monitoring, and
shall revise, for discharges occurring on or after October
1, 1994, the assignment of discharges to such groups as
the Secretary considers appropriate to account for the re-
source requirements of such patients.
(b) CONSULTATION REQUIREMENTS.—In carrying
out subsection (a), the Secretary shall consult with the
Prospective Payment Assessment Commission and na-
tional organizations representing individuals with epilepsy
or individuals and entities providing specialized medical
services to such individuals related to the treatment of
epilepsy.
SEC. 13425. SKILLED NURSING FACILITY WAGE INDEX.
(a) IN GENERAL.—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 em-
ployee compensation 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) PROPAC REPORT.—The Prospective Payment
Assessment Commission shall, by March 1, 1994, study
and report to the Congress on the impact of applying rou-
898
tine per diem cost limits for skilled nursing facilities on
a regional basis.
SEC. 13426. HOSPICE NOTIFICATION TO BENEFICIARIES.
(a) HOSPITALS.—Section 1861(ee)(2)(D) (42 U.S.C.
1395x(ee)(2)(D)) is amended by inserting ‘‘, including
hospice services,’’ after ‘‘post-hospital services’’.
(b) NURSING FACILITIES.—Section 1819(c)(1)(B)
(42 U.S.C. 1395i–3(c)(1)(B)) is amended—
(1) by striking ‘‘and’’ at the end of clause (ii);
(2) by striking the period at the end of clause
(iii) and inserting ‘‘; and’’; and
(3) by inserting after clause (iii) the following
new clause:
‘‘(iv) inform each resident who is enti-
tled to benefits under this title, orally and
in writing at the time of admission to the
facility, of the entitlement of individuals to
hospice care under section 1812(a)(4) (un-
less there is no hospice program providing
hospice care for which payment may be
made under this title within the geographic
area of the facility and it is not the com-
mon practice of the facility to refer pa-
tients to hospice programs located outside
such geographic area).’’.
899
(c) EFFECTIVE DATE.—The amendments made by
this section 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. 13427. REDUCTION IN PART A PREMIUM FOR CERTAIN
INDIVIDUALS WITH 30 OR MORE QUARTERS
OF SOCIAL SECURITY COVERAGE.
(a) IN
GENERAL.—Section 1818(d) (42 U.S.C.
1395i–2(d)) is amended—
(1) in the second sentence of paragraph (2), by
striking ‘‘Such amount’’ and inserting ‘‘Subject to
paragraph (4), the amount of an individual’s month-
ly premium under this section’’; and
(2) by adding at the end the following new
paragraph:
‘‘(4)(A) In the case of an individual described in sub-
paragraph (B), the monthly premium for a month shall
be reduced by the applicable reduction percent specified
in the following table:
The applicable reduction
‘‘For a month in:
percent is:
1994 .........................................................................................
25 percent
1995 .........................................................................................
30 percent
1996 .........................................................................................
35 percent
1997 .........................................................................................
40 percent
1998 or subsequent year ..........................................................
45 percent.
‘‘(B) An individual described in this subparagraph
with respect to a month is an individual who establishes
900
to the satisfaction of the Secretary that, as of the last
day of the previous month, the individual—
‘‘(i) had at least 30 quarters of coverage under
title II;
‘‘(ii) was married (and had been married for
the previous 1 year period) to an individual who had
at least 30 quarters of coverage under such title;
‘‘(iii) had been married to an individual for a
period of at least 1 year (at the time of the individ-
ual’s death) if at such time the individual had at
least 30 quarters of coverage under such title; and
‘‘(iv) is divorced from an individual and had
been married to the individual for a period of at
least 10 years (at the time of the divorce) if at such
time the individual had at least 30 quarters of cov-
erage under such title.’’.
(b) EFFECTIVE DATE.—The amendments made by
this section shall apply to monthly premiums under section
1818 of the Social Security Act for months beginning with
January 1, 1994.
901
SEC. 13428. PERIODIC UPDATES TO SALARY EQUIVALENCY
GUIDELINES FOR PHYSICAL THERAPY AND
RESPIRATORY THERAPY SERVICES.
(a) IN GENERAL.—Section 1861(v)(5) (42 U.S.C.
1395x(v)(5)) is amended by adding at the end the follow-
ing new subparagraph:
‘‘(C) Using the most recent available data, the Sec-
retary shall update, not less often than every 3 years, the
salary equivalency guidelines used under subparagraph
(A) with respect to physical therapy and respiratory
therapy services.’’.
(b) EFFECTIVE DATE.—The Secretary of Health and
Human Services shall first update the salary equivalency
guidelines, under the amendment made by subsection (a),
by not later than December 31, 1993. Such updated
guidelines shall apply to cost reporting periods beginning
on or after July 1, 1993.
SEC. 13429. EXTENSION OF DEADLINE FOR APPLICATION
FOR GEOGRAPHIC CLASSIFICATION FOR CER-
TAIN RECLASSIFIED HOSPITALS.
Notwithstanding section 1886(d)(10)(C)(ii) of the
Social Security Act, a hospital may submit an application
to the Medicare Geographic Classification Review Board
requesting a change in geographic classification for fiscal
year 1994 after the first day of fiscal year 1993 if—
902
(1) the hospital’s geographic classification for
fiscal year 1994 was changed from urban to rural as
a result of the issuance of the Revised Statistical
Definitions for Metropolitan Areas established by
the Office of Management and Budget on December
28, 1992 (pursuant to OMB Bulletin No. 93-05);
and
(2) the hospital submits the application not
later than 60 days after the date of the enactment
of this Act.
SEC. 13430. CLARIFICATION OF DRG PAYMENT WINDOW EX-
PANSION; MISCELLANEOUS AND TECHNICAL
CORRECTIONS.
(a) CLARIFICATION OF DRG PAYMENT WINDOW EX-
PANSION.—The first sentence of section 1886(a)(4) (42
U.S.C. 1395ww(a)(4)) is further amended by striking
‘‘and includes’’ and inserting ‘‘and (in the case of a sub-
section (d) hospital) includes’’.
(b) TECHNICAL CORRECTION RELATING TO RESI-
DENT
ASSESSMENT
IN
NURSING
HOMES.—Section
1819(b)(3)(C)(i)(I) (42 U.S.C. 1395i–3(b)(3)(C)(i)(I)) is
amended by striking ‘‘not later than’’ before ‘‘14 days’’.
(c) 
CLERICAL
CORRECTIONS.—(1) 
Section
1814(i)(1)(C)(i) (42 U.S.C. 1395f(i)(1)(C)(i)) is amended
by striking ‘‘1990,,’’ and inserting ‘‘1990,’’.
903
(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’’.
(3) 
Section 
1886(d)(1)(A)(iii) 
(42 
U.S.C.
1395ww(d)(1)(A)(iii)) is amended by striking ‘‘, the sum
of’’ and inserting ‘‘is equal to the sum of’’.
CHAPTER 2—PROVISIONS RELATING TO
PART B
Subchapter A—Elimination of Inflation
Update
SEC. 13431. ELIMINATION OF INFLATION UPDATE FOR PHY-
SICIAN AND RELATED PROFESSIONAL SERV-
ICES.
(a) NO INCREASE IN INDEX.—Section 1848(d)(3)(A)
(42 U.S.C. 1395w–4(d)(3)(A)) is amended—
(1) in clause (i), by striking ‘‘clause (iii)’’ and
inserting ‘‘clauses (iii) and (iv)’’, and
(2) by adding at the end the following new
clause:
‘‘(iv) NO
INCREASE
IN
INDEX
FOR
1994 OR 1995.—In applying clause (i) for
services furnished on or after January 1,
1994, the percentage increase in the ap-
propriate update index for each of 1994
and 1995 shall be 0 percent.’’.
904
(b) NO INCREASE IN MEI FOR 1994 AND 1995.—Sec-
tion 1842(b)(4)(E) (42 U.S.C. 1395u(b)(4)(E)) is amend-
ed by adding at the end the following new clause:
‘‘(vi) For purposes of this part for items and services
furnished in 1994 or 1995, the percentage increase in the
MEI is 0 percent.’’.
SEC. 13432. ELIMINATION OF COST-OF-LIVING ADJUST-
MENTS FOR CERTAIN ITEMS AND SERVICES.
(a) CLINICAL
LABORATORY
SERVICES.—Section
1833(h)(2)(A)(ii) 
(42 
U.S.C. 
1395l(h)(2)(A)(ii)) 
is
amended—
(1) by striking ‘‘and’’ at the end of subclause
(II),
(2) by striking the period at the end of
subclause (III) and inserting ‘‘, and’’, and
(3) by adding at the end the following new
subclause:
‘‘(IV) the annual adjustment in the fee sched-
ules determined under clause (i) for each of the
years 1994 and 1995 shall be 0 percent.’’.
(b) 
DURABLE
MEDICAL
EQUIPMENT.—Section
1834(a)(14) (42 U.S.C. 1395m(a)(14)) is amended—
(1) in subparagraph (A), as amended by
13469(a), by striking ‘‘and’’ at the end;
(2) in subparagraph (B)—
905
(A) by striking ‘‘a subsequent year’’ and
inserting ‘‘1993’’, and
(B) by striking ‘‘June of the previous
year.’’ and inserting ‘‘June 1992,’’; and
(3) by adding at the end the following new sub-
paragraphs:
‘‘(C) for 1994 and 1995, no percentage
change, and
‘‘(D) for a subsequent year, 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.’’.
(c) 
ORTHOTICS
AND
PROSTHETICS.—Section
1834(h)(4)(A) (42 U.S.C. 1395m(h)(4)(A)) is amended—
(1) in clause (i), by striking ‘‘and’’;
(2) in clause (ii), by striking ‘‘a subsequent
year’’ and inserting ‘‘1992 and 1993’’; and
(3) by adding at the end the following new
clauses:
‘‘(iii) for 1994 and 1995, 0 percent,
and
‘‘(iv) for a subsequent year, the per-
centage increase in the consumer price
index for all urban consumers (United
906
States city average) for the 12-month pe-
riod ending with June of the previous
year;’’.
(d) REASONABLE CHARGE LIMITS
FOR ENTERAL
AND PARENTERAL NUTRIENTS, SUPPLIES AND EQUIP-
MENT.—In determining the amount of payment under
part B of title XVIII of the Social Security Act during
1994 and 1995, the charges determined to be reasonable
with respect to parenteral and enteral nutrients, supplies,
and equipment may not exceed the charges determined to
be reasonable with respect to such nutrients, supplies, and
equipment during 1993.
SEC. 13433. AMBULATORY SURGICAL CENTER SERVICES.
(a) ELIMINATION OF INFLATION UPDATE.—The Sec-
retary of Health and Human Services shall not provide
for any inflation update in the payment amounts under
subparagraphs (A) and (B) of section 1833(i)(2) of the
Social Security Act for fiscal year 1994 or for fiscal year
1995.
(b) 
CONFORMING
AMENDMENT.—Section
1833(i)(2)(C) (42 U.S.C. 1395l(i)(2)(C)), as added by
section 13453(a)(2)(B), is amended by striking ‘‘fiscal
year 1995’’ and inserting ‘‘fiscal year 1996’’.
907
SEC. 13434. OTHER ITEMS AND SERVICES UNDER PART B.
(a) RURAL HEALTH CLINIC SERVICES; FEDERALLY-
QUALIFIED HEALTH CENTER SERVICES; COMPREHEN-
SIVE OUTPATIENT REHABILITATION FACILITY SERV-
ICES.—In determining the amount of payment made for
rural health clinic services, Federally qualified health cen-
ter services, or comprehensive outpatient rehabilitation fa-
cility services furnished under part B of title XVIII of the
Social Security Act for services furnished on or after Jan-
uary 1, 1994, the Secretary of Health and Human Serv-
ices shall provide that any inflation update, in the applica-
ble limits used to determine the costs which are reasonable
and related to the cost of furnishing such services under
section 1833(a)(3) of such Act, that would otherwise have
applied for 1994 or for 1995 shall be deemed to be 0
percent.
(b) DIALYSIS SERVICES.—In determining the amount
of payment made for dialysis services furnished under part
B of title XVIII of the Social Security Act on or after
January 1, 1994, the Secretary of Health and Human
Services shall provide that any inflation update, in the
payment 
amounts 
determined 
under 
section
1881(b)(2)(B) of such Act or the rates determined under
section 1881(b)(7) of such Act, that would otherwise have
applied for 1994 or for 1995 shall be deemed to be 0
percent.
908
(c) OTHER PART B ITEMS AND SERVICES.—In deter-
mining the amount of payment made for an item or service
furnished under part B of title XVIII of the Social Secu-
rity Act on or after January 1, 1994, other than an item
or service to which a preceding provision of (or amend-
ment made by) this subchapter applies, the Secretary of
Health and Human Services shall provide that any infla-
tion update in the fee schedule amount for the item or
service established under such part B of such title, or (if
applicable) any applicable limit used to determine the ac-
tual charge, reasonable charge, or reasonable cost for the
item or service under such part, that would otherwise have
applied for 1994 or for 1995 shall be deemed to be 0
percent.
Subchapter B—Physicians’ Services
SEC. 13441. REINSTATING SEPARATE PAYMENT FOR THE
INTERPRETATION 
OF 
ELECTROCARDIO-
GRAMS (EKGS).
(a) IN GENERAL.—Paragraph (3) of section 1848(b)
(42 U.S.C. 1395w–4(b)) is amended to read as follows:
‘‘(3) TREATMENT
OF
INTERPRETATION
OF
ELECTROCARDIOGRAMS.—The Secretary—
‘‘(A) shall make separate payment under
this section for the interpretation of electro-
cardiograms performed or ordered to be per-
909
formed as part of or in conjunction with a visit
to or a consultation with a physician, and
‘‘(B) shall adjust the relative values estab-
lished for visits and consultations under sub-
section (c) so as not to include relative value
units for interpretations of electrocardiograms
in the relative value for visits and consulta-
tions.’’.
(b) 
ASSURING
BUDGET
NEUTRALITY.—Section
1848(c)(2) (42 U.S.C. 1395w–4(c)(2)) is amended by add-
ing at the end the following new subparagraph:
‘‘(E) 
BUDGET
NEUTRALITY
ADJUST-
MENTS.—The Secretary—
‘‘(i) shall reduce the relative values
for all services (other than anesthesia serv-
ices) established under this paragraph
(and, in the case of anesthesia services, the
conversion factor established by the Sec-
retary for such services) by such percent-
age as the Secretary determines to be nec-
essary so that, beginning in 1996, the
amendment made by section 13441(a) of
the Omnibus Budget Reconciliation Act of
1993 would not result in expenditures
under this section that exceed the amount
910
of such expenditures that would have been
made if such amendment had not been
made, and
‘‘(ii) shall reduce the amounts deter-
mined under subsection (a)(2)(B)(i)(I) by
such percentage as the Secretary deter-
mines to be required to assure that, taking
into account the reductions made under
clause (i), the amendment made by section
13441(a) of the Omnibus Budget Rec-
onciliation Act of 1993 would not result in
expenditures under this section in 1993
that exceed the amount of such expendi-
tures that would have been made if such
amendment had not been made.’’.
(c) CONFORMING AMENDMENTS.—Section 1848 (42
U.S.C. 1395w–4) is amended—
(1) in subsection (a)(2)(B)(i)(I), by inserting
‘‘and as adjusted under subsection (c)(2)(E)(ii)’’
after ‘‘for 1993’’;
(2) in subsection (c)(2)(A)(i), by adding at the
end the following: ‘‘Such relative values are subject
to adjustment under subparagraph (E)(i).’’; and
911
(3) in subsection (i)(1)(B), by adding at the
end 
‘‘including 
adjustments 
under 
subsection
(c)(2)(E),’’.
(d) EFFECTIVE DATE.—The amendments made by
this section shall apply to services furnished on or after
January 1, 1994.
SEC. 13442. PAYMENTS FOR NEW PHYSICIANS AND PRACTI-
TIONERS.
(a) EQUAL TREATMENT OF NEW PHYSICIANS AND
PRACTITIONERS.—(1) 
Section 
1848(a) 
(42 
U.S.C.
1395w–4(a)) is amended by striking paragraph (4).
(2) Section 1842(b)(4) (42 U.S.C. 1395u(b)(4)) is
amended by striking subparagraph (F).
(b) BUDGET NEUTRALITY ADJUSTMENT.—Notwith-
standing any other provision of law, the Secretary of
Health and Human Services shall reduce the following val-
ues and amounts for 1993 (to be applied for that year
and subsequent years) by such uniform percentage as the
Secretary determines to be required to assure that the
amendments made by subsection (a) will not result in ex-
penditures under part B of title XVIII of the Social Secu-
rity Act in 1993 that exceed the amount of such expendi-
tures that would have been made if such amendments had
not been made:
942
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 subpara-
graph (A) and the second sentence of subpara-
graph (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 sub-
paragraph (A) or the second sentence of subparagraph
(B), if the Secretary has not updated amounts established
under such subparagraphs with respect to facility services
furnished during a fiscal year (beginning with fiscal year
1995), such amounts shall be increased by the percentage
increase in the consumer price index for all urban consum-
ers (U.S. city average) for the 12-month period ending
with March of the preceding fiscal year.’’.
(3) CONSULTATION
REQUIREMENT.—The sec-
ond 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 ap-
propriate trade and professional organizations.’’.