Sec. 201. Separate payment for interpretation of electrocardiograms.
Sec. 202. Payments for new physicians and practitioners.
Sec. 203. Basing payments for anesthesia services on actual time.
Sec. 204. Geographic adjustment factors for medicare physicians’ services.
Sec. 205. Extra-billing limits.
Sec. 206. Relative values for pediatric services.
Sec. 207. Antigens under physician fee schedule.
Sec. 208. Administration of claims relating to physicians’ services.
Sec. 209. Miscellaneous and technical corrections.
Subtitle B—Ambulatory Surgical Services
Sec. 211. Eye or eye and ear hospitals.
Sec. 212. Extension of cap on payments for intraocular lenses.
Sec. 213. Miscellaneous and technical corrections.
Subtitle C—Durable Medical Equipment
Sec. 221. Certification of suppliers.
Sec. 222. Prohibition against carrier forum shopping.
Sec. 223. Restrictions on certain marketing and sales activities.
Sec. 224. Kickback clarification.
Sec. 225. Beneficiary liability for noncovered services.
Sec. 226. Adjustments for inherent reasonableness.
Sec. 227. Payment for parenteral and enteral nutrients, supplies, and equip-
ment during 1993.
Sec. 228. Treatment of nebulizers and aspirators.
Sec. 229. Payment for ostomy supplies, tracheostomy supplies, urologicals, and
surgical dressings.
Sec. 230. Payments for TENS devices.
Sec. 231. Miscellaneous and technical corrections.
Subtitle D—Other Provisions
Sec. 241. Payment for medically directed certified registered nurse anesthetist
services.
Sec. 242. Extension of Alzheimer’s disease demonstration.
Sec. 243. Part B late enrollment penalty.
Sec. 244. Oral cancer drugs.
Sec. 245. Speech-language pathologists and audiologists.
Sec. 246. Extension of municipal health service demonstration projects.
Sec. 247. Treatment of certain Indian health programs and facilities as Feder-
ally-qualified health centers.
Sec. 248. Extension of influenza vaccination demonstration.
Sec. 249. Miscellaneous and technical corrections.
TITLE III—PROVISIONS RELATING TO PARTS A AND B
Sec. 301. Provisions relating to physician ownership and referral.
Sec. 302. Direct graduate medical education.
Sec. 303. End stage renal disease.
Sec. 304. Medicare secondary payer.
Sec. 305. Improved outreach for qualified medicare beneficiaries.
Sec. 306. Social health maintenance organizations.
Sec. 307. Peer review organizations.
Sec. 308. Hospice information to home health beneficiaries.
Sec. 309. Interest payments.
Sec. 310. Clarification of judicial review rights.
Sec. 311. Adjustments to discretionary spending limits.
Sec. 312. Health maintenance organizations.
Sec. 313. Treatment of certain State health care programs.
Sec. 314. Miscellaneous and technical corrections.
TITLE IV—PROVISIONS RELATING TO MEDICARE SUPPLEMENTAL
INSURANCE POLICIES
Sec. 401. Standards for medicare supplemental insurance policies.
TITLE I—PROVISIONS RELATING
TO PART A
SEC. 101. TRANSITION FOR HOSPITAL OUTLIER THRESH-
OLDS.
The Secretary of Health and Human Services, under
section 1886 of the Social Security Act, shall use the day
outlier methodology in effect for fiscal year 1992 for pay-
ment for discharges occurring on or after April 1, 1993,
and before September 30, 1993. For payment for dis-
charges occurring during fiscal year 1994, the Secretary
shall use the day outlier methodology in effect for the first
6 months of fiscal year 1993.
SEC. 
102. 
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 fol-
lows:
‘‘(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-
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
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
(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
(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—
‘‘(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—
(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
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.—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
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-
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 paragraph (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. 103. WAGE INDEX PROVISIONS.
(a) WAGE INDEX HOLD HARMLESS PROTECTION.—
(1) IN
GENERAL.—Section 1886(d)(8)(C)(iii)
(42 U.S.C. 1395ww(d)(8)(C)(iii)) is amended by
adding at the end the following new sentence: ‘‘In
the case of an urban area that has a wage index
below the wage index for rural areas in the State in
which it is located, or that is located in a State that
is composed of a single urban area, such an applica-
tion or decision may not result in a reduction of that
urban area’s wage index.’’.
(2) NO
STANDARDIZED
AMOUNT
ADJUST-
MENT.—The Secretary of Health and Human Serv-
ices shall not revise the fiscal year 1993 standard-
ized amounts pursuant to subsections (d)(3)(B) and
(d)(8)(D) of section 1886 of the Social Security Act
to account for the amendment made by paragraph
(1).
(3) EFFECTIVE DATE.—The amendment made
by paragraph (1) shall apply to discharges occurring
on or after the expiration of the 30-day period that
begins on the date of the enactment of this Act.
(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 the date of the enact-
ment of this Act shall continue to be so treated not-
withstanding 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
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. 
104. 
REAUTHORIZATION 
OF 
RURAL 
TRANSITION
GRANT PROGRAM.
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’’.
SEC. 105. REGIONAL REFERRAL CENTERS.
(a) EXTENSION THROUGH FISCAL YEAR 1994.—Sec-
tion 6003(d) of OBRA–1989 (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 1994, the Sec-
retary 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 fiscal year 1994 as if the
decision by the Review Board had not occurred.
SEC. 106. MEDICARE-DEPENDENT, SMALL RURAL HOS-
PITALS.
(a) IN GENERAL.—Section 1886(d)(5)(G) (42 U.S.C.
1395ww(d)(5)(G)) is amended—
(1) by amending clause (i) to read as follows:
‘‘(i) In the case of a subsection (d) hospital which
is a medicare-dependent, small rural hospital, payment
under paragraph (1)(A) for discharges occurring before
October 1, 1994, shall be equal to the sum of the amount
determined under clause (ii) and the amount determined
under paragraph (1)(A)(iii).’’;
(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
fiscal year 1994, the Secretary of Health and Human
Services shall—
(1) notify such hospital of such failure to qual-
ify,
(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 fiscal year 1994 as if the
decision by the Review Board had not occurred.
SEC. 107. HEMOPHILIA PASS-THROUGH.
(a) IN GENERAL.—Section 6011(d) of OBRA–1989
is amended by striking ‘‘2 years after the date of enact-
ment of this Act’’ and inserting ‘‘September 30, 1994’’.
(b) EFFECTIVE DATE.—The amendment made by
subsection (a) shall take effect as if included in the enact-
ment of OBRA–1989.
SEC. 108. STATE HOSPITAL PAYMENT PROGRAMS.
(a) RECOUPMENT FROM NEW JERSEY HOSPITALS.—
(1) MORATORIUM ON RECOUPMENT.—Prior to
April 1, 1993, the Secretary of Health and Human
Services (in this section referred to as the ‘‘Sec-
retary’’) may not recoup from or otherwise reduce
payments to hospitals in the State of New Jersey be-
cause of alleged overpayments to such hospitals
under title XVIII of the Social Security Act which
occurred during the period of the statewide hospital
reimbursement demonstration project conducted in
that State between January 1, 1985, and December
31, 1988, under a waiver granted under section
1886(c) of the Social Security Act.
(2) PROVISION OF PAYMENT DATA.—The Sec-
retary may not recoup from or otherwise reduce pay-
ments to hospitals in the State of New Jersey be-
cause of alleged overpayments described in para-
graph (1) until the Secretary provides the State and
hospitals located in the State with all relevant data
used by the Secretary to determine the amount of
such alleged overpayments, including (but not lim-
ited to) the cost reports submitted by the hospitals
to the Secretary during the period of the statewide
hospital reimbursement demonstration project de-
scribed in such paragraph and the methodology used
by the Secretary to determine payments to such hos-
pitals under title XVIII of the Social Security Act
during such period.
(b) CLARIFICATION OF PAYMENTS UNDER A MEDI-
CARE-APPROVED
STATE
HOSPITAL
REIMBURSEMENT
SYSTEM.—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 in title
XVIII of such Act, no provision of title XIX of such Act,
no provision of the Employee Retirement Income Security
Act of 1974, and no provision of chapter 81 or 89 of title
5, United States Code, shall be construed as preventing
the system from providing that payment for services cov-
ered under the system be made on the basis of rates pro-
vided for under the system.
SEC. 109. 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. 110. GRADUATE MEDICAL EDUCATION PROVIDED IN A
HOSPITAL-OWNED COMMUNITY HEALTH CEN-
TER.
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
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. 111. UNIFORMED SERVICES TREATMENT FACILITIES.
(a) COVERAGE OF SERVICES PROVIDED IN CERTAIN
UNIFORMED SERVICES TREATMENT FACILITIES.—
(1) IN GENERAL.—Subject to paragraph (2),
the Secretary of Health and Human Services may
not take any action to recover amounts that were
paid by the United States under title XVIII of the
Social Security Act to the facilities described in
paragraph (3) (or to other individuals or entities
with whom such facilities had entered into agree-
ments to provide services under such title) for serv-
ices provided during the period beginning October 1,
1986, and ending December 31, 1989.
(2) EXCEPTION.—The Secretary may take a
recoupment action for the sole purpose of securing
obligation of the funds provided to the Uniformed
Services Treatment Facilities program pursuant to
the Department of Defense Appropriations Act,
1993 to fulfill such an action.
(3) FACILITIES DESCRIBED.—The facilities re-
ferred to in paragraph (1) are the hospitals de-
scribed in section 248c of title 42, United States
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 Veterans
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 pro-
grams (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. 112. REQUIRING HOSPITALS AND NURSING FACILI-
TIES TO NOTIFY RESIDENTS OF AVAILABIL-
ITY OF HOSPICE BENEFIT.
(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).’’.
(c) EFFECTIVE DATE.—The amendments 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. 113. SKILLED NURSING FACILITY WAGE INDEX.
(a) IN GENERAL.—Within 2 years of the date of the
enactment of this Act, the Secretary of Health and
Human Services shall begin to collect data on employee
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 serv-
ice 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-
tine cost limits for skilled nursing facilities on a regional
basis.
SEC. 114. DRG PAYMENT WINDOW TECHNICAL CLARIFICA-
TION; 
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,’’.
(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’’.
SEC. 115. 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.’’.
TITLE II—PROVISIONS
RELATING TO PART B
Subtitle A—Physicians’ Services
SEC. 201. SEPARATE PAYMENT FOR INTERPRETATION OF
ELECTROCARDIOGRAMS.
(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-
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 201(a) of the
Miscellaneous 
and 
Technical 
Medicare
Amendments of 1993 would not result in
expenditures under this section that exceed
the amount 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
201(a) of the Miscellaneous and Technical
Medicare Amendments of 1993 would not
result in expenditures under this section in
1993 that exceed the amount of such ex-
penditures 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
(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
first day of the fourth month beginning after the date of
the enactment of this Act.
SEC. 202. 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:
(1) The relative values established under section
1848(c) of such Act for services (other than anesthe-
sia services) and, in the case of anesthesia services,
the conversion factor established under section 1848
of such Act for such services.
(2) The amounts determined under section
1848(a)(2)(B)(i)(I) of such Act.
(3) The prevailing charges or fee schedule
amounts to be applied under such part for services
of a health care practitioner (as defined in section
1842(b)(4)(F)(ii)(I) of such Act, as in effect before
the date of the enactment of this Act).
(c) CONFORMING AMENDMENTS.—Section 1848 (42
U.S.C. 1395w–4), as amended by section 201(c), is
amended—
(1) in subsection (a)(2)(B)(i)(I), by inserting
‘‘and section 202(b) of the Miscellaneous and Tech-
nical 
Medicare 
Amendments 
of 
1993’’ 
after
‘‘(c)(2)(E)(ii)’’ after ‘‘for 1993’’;
(2) in subsection (c)(2)(A)(i), by inserting ‘‘and
section 202(b) of the Miscellaneous and Technical
Medicare Amendments of 1993’’ after ‘‘under sub-
paragraph (E)(i)’’; and
(3) in subsection (i)(1)(B), by inserting ‘‘and
section 202(b) of the Miscellaneous and Technical
Medicare Amendments of 1993’’ after ‘‘under sub-
section (c)(2)(E)’’.
(d) EFFECTIVE DATE.—The amendments made by
subsection (a) shall apply to services furnished on or after
the first day of the fourth month beginning after the date
of the enactment of this Act.
SEC. 203. BASING PAYMENTS FOR ANESTHESIA SERVICES
ON ACTUAL TIME.
(a) PHYSICIANS’ SERVICES.—Section 1848(b)(2)(B)
(42 U.S.C. 1395w–4(b)(2)(B)) is amended by adding at
the end the following: ‘‘For anesthesia services furnished
on or after January 1, 1993, the Secretary may not mod-
ify the methodology in effect as of January 1, 1992, for
determining the amount of time that may be billed for
such services under this section.’’.
(b) SERVICES OF CERTIFIED REGISTERED NURSE
ANESTHETISTS.—Section 
1833(l)(1)(B) 
(42 
U.S.C.
1395l(l)(1)(B)) is amended by adding at the end the fol-
lowing: ‘‘For anesthesia services furnished on or after
January 1, 1993, the Secretary may not modify the meth-
odology in effect as of January 1, 1992, for determining
the amount of time that may be billed for such services
under this section.’’.
SEC. 204. GEOGRAPHIC ADJUSTMENT FACTORS FOR MEDI-
CARE PHYSICIANS’ SERVICES.
(a) REQUIRING CONSULTATION WITH REPRESENTA-
TIVES OF PHYSICIANS IN REVIEWING GEOGRAPHIC AD-
JUSTMENT FACTORS.—Section 1848(e)(1)(C) (42 U.S.C.
1395w–4(e)(1)(C)) is amended by striking ‘‘shall review’’
and inserting ‘‘shall, in consultation with appropriate rep-
resentatives of physicians, review’’.
(b) USE OF MOST RECENT DATA IN GEOGRAPHIC
ADJUSTMENT.—Section 1848(e)(1) (42 U.S.C. 1395w–
4(e)(1)) is amended by adding at the end the following
new subparagraph:
‘‘(D) USE OF RECENT DATA.—In estab-
lishing indices and index values under this
(C) the index values assigned to such com-
ponents;
(2) any limitations on the availability of data
necessary to review and revise such indices at least
every three years;
(3) ways of addressing such limitations, with
particular attention to the development of alternative
data sources for input components for which current
index values are based on data collected less fre-
quently than every three years; and
(4) the costs of developing more accurate and
timely data.
SEC. 205. EXTRA-BILLING LIMITS.
(a) ENFORCEMENT AND UNIFORM APPLICATION.—
(1) ENFORCEMENT.—Paragraph (1) of section
1848(g) (42 U.S.C. 1395w–4(g)) is amended 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 serv-
ice furnished with respect to an individual en-
rolled under this part, the following rules apply:
‘‘(i) 
APPLICATION
OF
LIMITING
CHARGE.—No person may bill or collect an
actual charge for the service in excess of
the limiting charge described in paragraph
(2) for such service.
‘‘(ii) NO
LIABILITY
FOR
EXCESS
CHARGES.—No person is liable for pay-
ment of any amounts billed for the service
in excess of such limiting charge.
‘‘(iii) 
CORRECTION
OF
EXCESS
CHARGES.—If such a physician, supplier,
or other person bills, but does not collect,
an actual charge for a service in violation
of clause (i), the physician, supplier, or
other person shall reduce on a timely basis
the actual charge billed for the service to
an amount not to exceed the limiting
charge for the service.
‘‘(iv) REFUND
OF
EXCESS
COLLEC-
TIONS.—If such a physician, supplier, or
other person collects an actual charge for
a service in violation of clause (i), the phy-
sician, supplier, or other person shall pro-
vide on a timely basis a refund to the indi-
vidual charged in the amount by which the
amount collected exceeded the limiting
charge for the service. The amount of such
a refund shall be reduced to the extent the
individual has an outstanding balance owed
by the individual to the physician.
‘‘(B) SANCTIONS.—If a physician, supplier,
or other person—
‘‘(i) knowingly and willfully bills or
collects for services in violation of subpara-
graph (A)(i) on a repeated basis,
‘‘(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 accord-
ance with paragraph (2) of section 1842(j). In
applying this subparagraph, paragraph (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 physi-
cian, supplier, or other person is notified by the
carrier under this part of such violation and of
the requirements of subparagraph (A).’’.
(2) UNIFORM APPLICATION OF EXTRA-BILLING
LIMITS TO PHYSICIANS’ SERVICES.—
(A) IN GENERAL.—Section 1848(g)(2)(C)
(42 U.S.C. 1395w–4(g)(2)(C)) is amended by
inserting ‘‘or for nonparticipating suppliers or
other persons’’ after ‘‘nonparticipating physi-
cians’’.
(B) CONFORMING
DEFINITION.—Section
1842(i)(2) (42 U.S.C. 1395u(i)(2)) is amend-
ed—
(i) by striking ‘‘, and the term’’ and
inserting ‘‘; the term’’, and
(ii) by inserting before the period at
the end the following: ‘‘; and the term
‘nonparticipating supplier or other person’
means a supplier or other person (exclud-
ing a provider of services) that is not a
participating physician or supplier (as de-
fined in subsection (h)(1))’’.
(3) ADDITIONAL CONFORMING AMENDMENTS.—
Section 1848 (42 U.S.C. 1395w–4) is amended—
(A) in subsection (a)(3), by inserting ‘‘AND
SUPPLIERS’’ after ‘‘PHYSICIANS’’, and by insert-
ing ‘‘or a nonparticipating supplier or other
person’’ after ‘‘nonparticipating physician’’ and
by adding at the end the following: ‘‘In the case
of physicians’ services (including services which
the Secretary excludes pursuant to subsection
(j)(3)) of a nonparticipating physician, supplier,
or other person for which payment is made
under this part on a basis other than the fee
schedule amount, the payment shall be based on
95 percent of the payment basis for such serv-
ices furnished by a participating physician, sup-
plier, or other person.’’;
(B) in subsection (g)(1)(A), as amended by
subsection (a), in the matter before clause (i),
by inserting ‘‘(including services which the Sec-
retary excludes pursuant to subsection (j)(3))’’
after ‘‘a physician’s service’’;
(C) in subsection (g)(2)(D), by inserting
‘‘(or, if payment under this part is made on a
basis other than the fee schedule under this sec-
tion, 95 percent of the other payment basis)’’
after ‘‘subsection (a)’’;
(D) in subsection (g)(3)(B)—
(i) by inserting after the first sentence
the following: ‘‘No person is liable for pay-
ment of any amounts billed for such a
service in violation of the previous sen-
tence.’’, and
(ii) in the last sentence, by striking
‘‘previous sentence’’ and inserting ‘‘first
sentence’’;
(E) in subsection (h)—
(i) by inserting ‘‘or nonparticipating
supplier or other person furnishing physi-
cians’ services (as defined in section
1848(j)(3))’’ after ‘‘physician’’ the first
place it appears,
(ii) by inserting ‘‘, supplier, or other
person’’ after ‘‘physician’’ the second place
it appears, and
(iii) by inserting ‘‘, suppliers, and
other persons’’ after ‘‘physicians’’ the sec-
ond place it appears; and
(F) in subsection (j)(3), by inserting ‘‘, ex-
cept for purposes of subsections (a)(3), (g), and
(h)’’ after ‘‘tests and’’.
(b) CLARIFICATION
OF MANDATORY ASSIGNMENT
RULES FOR CERTAIN PRACTITIONERS.—
(1) IN GENERAL.—Section 1842(b) (42 U.S.C.
1395u(b)) is amended by adding at the end the fol-
lowing new paragraph:
‘‘(19)(A) Payment for any service furnished by a
practitioner described in subparagraph (C) and for which
payment may be made under this part on a reasonable
charge or fee schedule basis may only be made under this
part on an assignment-related basis.
‘‘(B) A practitioner described in subparagraph (C) or
other person may not bill (or collect any amount from)
the individual or another person for any service described
in subparagraph (A), except for deductible and coinsur-
ance amounts applicable under this part. No person is lia-
ble for payment of any amounts billed for such a service
in violation of the previous sentence. If a practitioner or
other person knowingly and willfully bills (or collects an
amount) for such a service in violation of such sentence,
the Secretary may apply sanctions against the practitioner
or other person in the same manner as the Secretary may
apply sanctions against a physician in accordance with
section 1842(j)(2) in the same manner as such section ap-
plies with respect to a physician. Paragraph (4) of section
1842(j) shall apply in this subparagraph in the same man-
ner as such paragraph applies to such section.
‘‘(C) A practitioner described in this subparagraph
is any of the following:
‘‘(i) A physician assistant, nurse practitioner, or
clinical nurse specialist (as defined in section
1861(aa)(5)).
‘‘(ii) A certified registered nurse anesthetist (as
defined in section 1861(bb)(2)).
‘‘(iii) A certified nurse-midwife (as defined in
section 1861(gg)(2)).
‘‘(iv) A clinical social worker (as defined in sec-
tion 1861(hh)(1)).
‘‘(v) A clinical psychologist (as defined by the
Secretary for purposes of section 1861(ii)).
‘‘(D) For purposes of this paragraph, a service fur-
nished by a practitioner described in subparagraph (C) in-
cludes any services and supplies furnished as incident to
the service as would otherwise be covered under this part
if furnished by a physician or as incident to a physician’s
service.’’.
(2) CONFORMING AMENDMENTS.—
(A) Section 1833 (42 U.S.C. 1395l) is
amended—
(i) in subsection (l)(5), by striking
subparagraph (B) of subsection (l)(5) and
redesignating subparagraph (C) as sub-
paragraph (B);
(ii) by striking subsection (p); and
(iii) in subsection (r), by striking
paragraph (3) and redesignating para-
graph (4) as paragraph (3).
(B) 
Section 
1842(b)(12) 
(42 
U.S.C.
1395u(b)(12)) is amended by striking subpara-
graph (C).
(c) INFORMATION ON EXTRA-BILLING LIMITS.—
(1) PART OF EXPLANATION OF MEDICARE BEN-
EFITS.—Section 
1842(h)(7) 
(42 
U.S.C.
1395u(h)(7)) is amended—
(A) by striking ‘‘and’’ at the end of sub-
paragraph (B),
(B) in subparagraph (C), by striking ‘‘shall
include’’ and by striking the period at the end
and inserting ‘‘, and’’, and
(C) by adding at the end the following new
subparagraph:
‘‘(D) in the case of services for which the billed
amount exceeds the limiting charge imposed under
section 1848(g), information regarding such applica-
ble limiting charge (including information concern-
ing 
the 
right 
to 
a 
refund 
under 
section
1848(g)(1)(D)).’’.
(2) DETERMINATIONS BY CARRIERS.—Subpara-
graph (G) of section 1842(b)(3) (42 U.S.C.
1395u(b)(3)) is amended to read as follows:
‘‘(G) will, for a service that is furnished with
respect to an individual enrolled under this part,
that is not paid on an assignment-related basis, and
that is subject to a limiting charge under section
1848(g)—
‘‘(i) determine, prior to making payment,
whether the amount billed for such service ex-
ceeds the limiting charge applicable under sec-
tion 1848(g)(2);
‘‘(ii) notify the physician, supplier, or other
person periodically (but not less often than once
every 30 days) of determinations that amounts
billed exceeded such applicable limiting charges;
and
‘‘(iii) provide for prompt response to in-
quiries of physicians, suppliers, and other per-
sons concerning the accuracy of such limiting
charges for their services;’’.
(d) REPORT ON CHARGES IN EXCESS OF LIMITING
CHARGE.—Section 1848(g)(6)(B) (42 U.S.C. 1395w–
4(g)(6)(B)) is amended by inserting ‘‘the extent to which
actual charges exceed limiting charges, the number and
types of services involved, and the average amount of ex-
cess charges and’’ after ‘‘report to the Congress’’.
(e) MISCELLANEOUS
AND
TECHNICAL
AMEND-
MENTS.—Section 1833 (42 U.S.C. 1395l) is amended—
(1) in subsection (a)(1), as amended by section
249(e)(2)—
(A) by striking ‘‘and’’ before ‘‘(O)’’, and
(B) by inserting before the semicolon at
the end the following: ‘‘, and (P) with respect
to services described in clauses (i), (ii) and (iv)
of section 1861(s)(2)(K), the amounts paid are
subject 
to 
the 
provisions 
of 
section
1842(b)(12)’’; and
(2) in subsection (h)(5)(D)—
(A) by striking ‘‘paragraphs (2) and (3)’’
and by inserting ‘‘paragraph (2)’’, and
(B) 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
AND
UNIFORM
APPLICA-
TION; 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 the first day of the
fourth month beginning after the date of the enact-
ment of this Act.
(2) PRACTITIONERS.—The amendments made
by subsection (b) shall apply to services furnished on
or after the first day of the fourth month beginning
after the date of the enactment of this Act.
(3) EOMBS.—The amendments made by sub-
section (c)(1) shall apply to explanations of benefits
provided on or after the first day of the fourth
month beginning after the date of the enactment of
this Act.
(4) CARRIER
DETERMINATIONS.—The amend-
ments made by subsection (c)(2) shall apply to con-
tracts as of the first day of the fourth month begin-
ning after the date of the enactment of this Act.
(5) REPORT.—The amendment made by sub-
section (d) shall apply to reports for years beginning
with 1994.
SEC. 206. RELATIVE VALUES FOR PEDIATRIC SERVICES.
(a) IN GENERAL.—The Secretary of Health and
Human Services shall fully develop, by not later than July
1, 1994, relative values for the full range of pediatric phy-
sicians’ services which are consistent with the relative val-
ues developed for other physicians’ services under section
1848(c) of the Social Security Act. In developing such val-
ues, the Secretary shall conduct such refinements as may
be necessary to produce appropriate estimates for such rel-
ative 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 appropriate
organizations representing pediatricians and other
physicians.
(2) REPORT.—Not later than July 1, 1994, the
Secretary shall submit to Congress a report on the
study conducted under paragraph (1). Such report
shall include any appropriate recommendations re-
garding needed changes in coding or other payment
policies to ensure that payments for pediatric serv-
ices appropriately reflect the resources required to
provide these services.
SEC. 207. ANTIGENS UNDER PHYSICIAN FEE SCHEDULE.
(a) IN GENERAL.—Section 1848(j)(3) (42 U.S.C.
1395w–4(j)(3)) is amended by inserting ‘‘(2)(G),’’ after
‘‘(2)(D),’’.
(b) EFFECTIVE DATE.—The amendment made by
subsection (a) shall apply to services furnished on or after
January 1, 1994.
SEC. 208. ADMINISTRATION OF CLAIMS RELATING TO PHY-
SICIANS’ 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 physi-
cians’ services,
‘‘(B) for an error in filing a claim relating to
physicians’ services or for such a claim which is de-
nied,
‘‘(C) for any appeal under this title with respect
to physicians’ services,
‘‘(D) for applying for (or obtaining) a unique
identifier under subsection (r), or
‘‘(E) for responding to inquiries respecting phy-
sicians’ services or for providing information with re-
spect 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 fur-
nished incident to such services) furnished by a sec-
ond physician to patients of the first physician if (i)
the first physician is unavailable to provide the serv-
ices; (ii) the services are furnished pursuant to an
arrangement between the two physicians 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 phy-
sician over a continuous period of more than 60
days; and (iv) the claim form submitted to the car-
rier for such services includes the second physician’s
unique identifier (provided under the system estab-
lished under subsection (r)) and indicates that the
claim meets the requirements of this clause for pay-
ment 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. 209. MISCELLANEOUS AND TECHNICAL CORRECTIONS.
(a) OVERVALUED PROCEDURES (SECTION 4101 OF
OBRA–1990).—(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; chole-
cystectomy;’’,
(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 subcutane-
ous’’,
(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
(SECTION
4102 
OF
OBRA–1990).—(1) Section 1834(b)(4) (42 U.S.C.
1395m(b)(4)) is amended by redesignating subparagraphs
(E) and (F) as subparagraphs (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 ad-
justed conversion factor for the locality determined
as follows:’’,
(B) in clause (iv), by striking ‘‘LOCAL ADJUST-
MENT.—Subject to clause (vii), the conversion factor
to be applied to’’ and inserting ‘‘ADJUSTED CONVER-
SION FACTOR.—The adjusted conversion factor for’’,
(C) in clause (vii), by striking ‘‘under this sub-
paragraph’’, and
(D) in clause (vii), by inserting ‘‘reduced under
this subparagraph by’’ after ‘‘shall not be’’.
(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 subpara-
graph’’.
(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 sec-
tion’’ and inserting ‘‘provided under section 6105(b) of the
Omnibus Budget Reconciliation Act of 1989’’.
(c) ANESTHESIA
SERVICES
(SECTION
4103 OF
OBRA–1990).—(1) Section 4103(a) of OBRA–1990 is
amended by striking ‘‘REDUCTION IN FEE SCHEDULE’’
and inserting ‘‘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 ad-
justed prevailing charge conversion factor for the lo-
cality determined as follows:’’, and
(B) in clause (iii), by striking ‘‘Subject to
clause (iv), the prevailing charge conversion factor to
be applied in’’ and inserting ‘‘The adjusted prevail-
ing charge conversion factor for’’.
(d) ASSISTANTS AT SURGERY (SECTION 4107 OF
OBRA–1990).—(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 recog-
nized 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 SERV-
ICES (SECTION 4108 OF OBRA–1990).—Section 1842(b)
(42 U.S.C. 1395u(b)) is amended by redesignating para-
graph (18), as added by section 4108(a) of OBRA–1990,
as paragraph (17) and, in such paragraph, by inserting
‘‘, tests specified in paragraph (14)(C)(i),’’ after ‘‘diag-
nostic laboratory tests’’.
(f) STATEWIDE FEE SCHEDULES (SECTION 4117 OF
OBRA–1990).—Section 4117 of OBRA–1990 is amend-
ed—
(1) in subsection (a)—
(A) by striking ‘‘IN GENERAL.—’’, and
(B) by striking ‘‘, if the’’ and all that fol-
lows through ‘‘1991, ’’; and
(2) by striking subsections (b), (c), and (d).
(g) STUDY OF AGGREGATION RULE FOR CLAIMS OF
SIMILAR
PHYSICIAN
SERVICES
(SECTION
4113 
OF
OBRA–1990).—Section 4113 of OBRA–1990 is amend-
ed—
(1) by inserting ‘‘of the Social Security Act’’
after ‘‘1869(b)(2)’’; and
(2) by striking ‘‘December 31, 1992’’ and in-
serting ‘‘December 31, 1993’’.
(h) 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 inserting ‘‘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)’’.
(C) Section 4105(d) of OBRA–1990 is amended by
inserting ‘‘PUBLICATION OF PERFORMANCE STANDARD
RATES.—’’ after ‘‘(d)’’.
(3) 
Section 
1842(b)(4)(F) 
(42 
U.S.C.
1395u(b)(4)(F)) is amended—
(A) in clause (i), by striking ‘‘prevailing
charge’’ the first place it appears and inserting
‘‘customary charge’’; and
(B) in clause (ii)(III), by striking ‘‘second,
third, and fourth’’ and inserting ‘‘first, second, and
third’’.
(4) 
Section 
1842(b)(4)(F)(ii)(I) 
(42 
U.S.C.
1395u(b)(4)(F)(ii)(I)) is amended by striking ‘‘respiratory
therapist,’’.
(5) Section 4106(c) of OBRA–1990 is amended by
inserting 
‘‘of 
the 
Social 
Security 
Act’’ 
after
‘‘1848(d)(1)(B)’’.
(6) Section 4114 of OBRA–1990 is amended by
striking ‘‘patients’’ the second place it appears.
(7) Section 1848(e)(1)(C) (42 U.S.C. 1395w–
4(e)(1)(C)) is amended by inserting ‘‘date of the’’ after
‘‘since the’’.
(8) Section 4118(f)(1)(D) of OBRA–1990 is amend-
ed by striking ‘‘is amended’’.
(9) Section 4118(f)(1)(N)(ii) of OBRA–1990 is
amended by striking ‘‘subsection (f)(5)(A)’’ and inserting
‘‘subsection (f)(5)(A))’’.
(10) 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 paragraphs (2), (3), and (4).
(11) Section 4118(j)(2) of OBRA–1990 is amended
by striking ‘‘In section’’ and inserting ‘‘Section’’.
(12)(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 by striking ‘‘as such provi-
sions apply to physicians’ services and physicians and a
reasonable charge under section 1842(b)’’.
(i) EFFECTIVE DATE.—The amendments made by
this section and the provisions of this section shall take
effect as if included in the enactment of OBRA–1990.
Subtitle B—Ambulatory Surgical
Services
SEC. 211. EYE OR EYE AND EAR HOSPITALS.
(a) IN
GENERAL.—Section 1833(i) (42 U.S.C.
1395l(i)) is amended—
(1) in subparagraph (B)(ii)—
(A) by striking ‘‘the last sentence of this
clause’’ and inserting ‘‘paragraph (4)’’, and
(B) by striking the last sentence; and
(2) by inserting after paragraph (3) the follow-
ing new paragraph:
‘‘(4)(A) In the case of a hospital that—
‘‘(i) makes application to the Secretary and
demonstrates that it specializes in eye services or eye
and ear services (as determined by the Secretary),
‘‘(ii) receives more than 30 percent of its total
revenues from outpatient services, and
‘‘(iii) on October 1, 1987—
‘‘(I) was an eye specialty hospital or an eye
and ear specialty hospital, or
‘‘(II) was operated as an eye or eye and
ear unit (as defined in subparagraph (B)) of a
general acute care hospital which, on the date
of the application described in clause (i), oper-
ates less than 20 percent of the beds that the
hospital operated on October 1, 1987, and has
sold or otherwise disposed of a substantial por-
tion of the hospital’s other acute care oper-
ations,
the cost proportion and ASC proportion in effect under
subclauses (I) and (II) of paragraph (2)(B)(ii) for cost
reporting periods beginning in fiscal year 1988 shall re-
main in effect for cost reporting periods beginning on or
after October 1, 1988, and before January 1, 1995.
‘‘(B) For purposes of this subparagraph (A)(iii)(II),
the term ‘eye or eye and ear unit’ means a physically sepa-
rate or distinct unit containing separate surgical suites de-
voted solely to eye or eye and ear services.’’.
(b) EFFECTIVE DATE.—The amendments made by
subsection (a) shall apply to portions of cost reporting pe-
riods beginning on or after January 1, 1994.
SEC. 212. EXTENSION OF CAP ON PAYMENTS FOR INTRA-
OCULAR LENSES.
(a) IN GENERAL.—Section 4151(c)(3) of OBRA–
1990 is amended by striking ‘‘December 31, 1992’’ and
inserting ‘‘December 31, 1994’’.
(b) EFFECTIVE DATE.—The amendment made by
subsection (a) shall be effective as if included in the enact-
ment of OBRA–1990.
SEC. 213. MISCELLANEOUS AND TECHNICAL CORRECTIONS.
(a) PAYMENT AMOUNTS FOR SERVICES FURNISHED
IN AMBULATORY SURGICAL CENTERS.—(1)(A) Section
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 follow-
ing: ‘‘, as determined in accordance with a survey (based
upon a representative sample of procedures and facilities)
taken not later than January 1, 1994, and every 5 years
thereafter, of the actual audited costs incurred by such
centers in providing such services,’’.
(B) Section 1833(i)(2) (42 U.S.C. 1395l(i)(2)) is
amended—
(i) 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
(ii) by adding at the end the following new sub-
paragraph:
‘‘(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.’’.
(C) 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.’’.
(2) Section 4151(c)(3) of OBRA–1990 is amended
by striking ‘‘for the insertion of an intraocular lens’’ and
inserting ‘‘for an intraocular lens inserted’’.
(b) ADJUSTMENTS TO PAYMENT AMOUNTS FOR NEW
TECHNOLOGY
INTRAOCULAR
LENSES.—(1) Not later
than 1 year after the date of the enactment of this Act,
the Secretary of Health and Human Services (in this sub-
section 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 technology intraocular lenses. For pur-
poses of the preceding sentence, an intraocular lens may
not be treated as a new technology lens unless it has been
approved by the Food and Drug Administration.
(2) In determining whether to provide an adjustment
of payment with respect to a particular lens under para-
graph (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,
accelerated postoperative recovery, reduced induced astig-
matism, improved postoperative visual acuity, more stable
postoperative vision, or other comparable clinical advan-
tages.
(3) 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 Sec-
retary shall publish a notice of his determinations with
respect to intraocular lenses listed in the notice within 90
days after the close of the comment period.
(4) Any adjustment of a payment amount (or pay-
ment limit) made under this subsection shall become effec-
tive not later than 30 days after the date on which the
notice with respect to the adjustment is published under
paragraph (3).
(c) 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 insert-
ing ‘‘for portions of cost reporting’’; and
(B) by striking ‘‘and on or before’’ and in-
serting ‘‘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.
Subtitle C—Durable Medical
Equipment
SEC. 221. CERTIFICATION OF SUPPLIERS.
(a) REQUIREMENTS.—
(1) IN
GENERAL.—Section 1834 (42 U.S.C.
1395m) is amended by adding at the end the follow-
ing new subsection:
‘‘(i) 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 October 1, 1993, 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 SUP-
PLIER NUMBER.—A supplier may not obtain a
supplier number unless—
‘‘(i) for medical equipment and sup-
plies furnished on or after October 1,
1993, and on or before December 31,
1994, the supplier meets standards pre-
scribed by the Secretary; and
‘‘(ii) for medical equipment and sup-
plies furnished on or after January 1,
1995, the supplier meets revised standards
prescribed by the Secretary (in consulta-
tion with representatives of suppliers of
medical equipment and supplies, carriers,
and consumers) that shall include require-
ments that the supplier—
‘‘(I) comply with all applicable
State and Federal licensure and regu-
latory requirements;
‘‘(II) maintain a physical facility
on an appropriate site;
‘‘(III) have proof of appropriate
liability insurance; and
‘‘(IV) meet such other require-
ments as the Secretary 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 as
an incident to a physician’s service.
‘‘(D) PROHIBITION
AGAINST
MULTIPLE
SUPPLIER NUMBERS.—The Secretary may not
issue more than one supplier number to any
supplier of medical equipment and supplies un-
less the issuance of more than one number is
appropriate to identify subsidiary or regional
entities under the supplier’s ownership or con-
trol.
‘‘(E) PROHIBITION AGAINST DELEGATION
OF
SUPPLIER
DETERMINATIONS.—The Sec-
retary may not delegate (other than by contract
under section 1842) the responsibility to deter-
mine whether suppliers meet the standards nec-
essary to obtain a supplier number.
‘‘(2) CERTIFICATES OF MEDICAL NECESSITY.—
‘‘(A) STANDARDIZED CERTIFICATES.—Not
later than October 1, 1993, the Secretary shall,
in consultation with carriers under this part,
develop one or more standardized certificates of
medical necessity (as defined in subparagraph
(C)) for medical equipment and supplies for
which the Secretary determines that such a cer-
tificate is necessary.
‘‘(B) PROHIBITION AGAINST DISTRIBUTION
BY SUPPLIERS OF CERTIFICATES OF MEDICAL
NECESSITY.—
‘‘(i) IN
GENERAL.—Except as pro-
vided in clause (ii), a supplier of medical
equipment and supplies may not distribute
to physicians or to individuals entitled to
benefits under this part for commercial
purposes any completed or partially com-
pleted certificates of medical necessity on
or after October 1, 1993.
‘‘(ii) EXCEPTION FOR CERTAIN BILL-
ING
INFORMATION.—Clause (i) shall not
apply with respect to a certificate of medi-
cal necessity for any item that is not con-
tained on the list of potentially overused
items developed by the Secretary under
subsection (a)(15)(A) to the extent that
such certificate contains only information
completed by the supplier of medical equip-
ment and supplies identifying such supplier
and the beneficiary to whom such medical
equipment and supplies are furnished, a
description of such medical equipment and
supplies, any product code identifying such
medical equipment and supplies, and any
other administrative information (other
than information relating to the bene-
ficiary’s medical condition) identified by
the Secretary. In the event a supplier pro-
vides a certificate of medical necessity con-
taining information permitted under this
clause, such certificate shall also contain
the fee schedule amount and the supplier’s
charge for the medical equipment or sup-
plies being furnished prior to distribution
of such certificate to the physician.
‘‘(iii) PENALTY.—Any supplier of
medical equipment and supplies who know-
ingly and willfully distributes a certificate
of medical necessity in violation of clause
(i) is subject to a civil money penalty in an
amount not to exceed $1,000 for each such
certificate of medical necessity so distrib-
uted. The provisions of section 1128A
(other than subsections (a) and (b)) shall
apply to civil money penalties under this
subparagraph in the same manner as they
apply to a penalty or proceeding under sec-
tion 1128A(a).
‘‘(C) DEFINITION.—For purposes of this
paragraph, the term ‘certificate of medical ne-
cessity’ means a form or other document con-
taining information required by the Secretary to
be submitted to show that a covered 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.—
‘‘(A) DEVELOPMENT
AND
ESTABLISH-
MENT.—Not later than January 1, 1995, the
Secretary, in consultation with representatives
of suppliers of medical equipment and supplies,
individuals enrolled under this part, and appro-
priate medical specialty societies, shall develop
and establish uniform national coverage and
utilization review criteria for 200 items of medi-
cal equipment and supplies selected in accord-
ance with the standards described in subpara-
graph (B). The Secretary shall publish the cri-
teria as part of the instructions provided to fis-
cal intermediaries and carriers under this part
and no further publication, including publica-
tion in the Federal Register, shall be required.
‘‘(B) STANDARDS FOR SELECTING ITEMS
SUBJECT TO CRITERIA.—The Secretary may se-
lect an item for coverage under the criteria de-
veloped and established under subparagraph
(A) if the Secretary finds that—
‘‘(i) the item is frequently purchased
or rented by beneficiaries;
‘‘(ii) the item is frequently subject to
a determination that such item is not
medically necessary; or
‘‘(iii) the coverage or utilization cri-
teria applied to the item (as of the date of
the enactment of this subsection) is not
consistent among carriers.
‘‘(C) ANNUAL REVIEW AND EXPANSION OF
ITEMS SUBJECT TO CRITERIA.—The Secretary
shall annually review the coverage and utiliza-
tion of items of medical equipment and supplies
to determine whether items not included among
the items selected under subparagraph (A)
should be made subject to uniform national cov-
erage and utilization review criteria, and, if ap-
propriate, shall develop and apply such criteria
to such additional items.
‘‘(4) DEFINITION.—The term ‘medical equip-
ment and supplies’’ means—
‘‘(A) durable medical equipment (as de-
fined in section 1861(n));
‘‘(B) prosthetic devices (as described in
section 1861(s)(8));
‘‘(C) orthotics and prosthetics (as de-
scribed 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 equip-
ment 
(as 
described 
in 
section
1861(s)(2)(F)), and
‘‘(ii) immunosuppressive drugs (as de-
scribed in section 1861(s)(2)(J)).’’.
(2) CONFORMING AMENDMENT.—Effective October
1, 1993, paragraph (16) of section 1834(a) (42 U.S.C.
1395m(a)) is repealed.
(b) REPORT ON EFFECT OF UNIFORM CRITERIA ON
UTILIZATION OF ITEMS.—Not later than July 1, 1995, the
Secretary shall submit a report 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 analyzing the impact of the uniform
criteria established under section 1834(i)(3)(A) of the So-
cial Security Act (as added by subsection (a)) on the utili-
zation of items of medical equipment and supplies by indi-
viduals enrolled under part B of the medicare program.
(c) USE OF COVERED ITEMS BY DISABLED BENE-
FICIARIES.—
(1) IN GENERAL.—The Secretary of Health and
Human Services, in consultation with representa-
tives of suppliers of durable medical equipment
under part B of the medicare program and individ-
uals entitled to benefits under such program on the
basis of disability, shall conduct a study of the ef-
fects 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 May 1, 1994, the
Secretary shall submit a report to Congress on the
study conducted under paragraph (1), and shall in-
clude in the report such recommendations as the
Secretary considers appropriate to assure that dis-
abled medicare beneficiaries have access to items of
durable medical equipment.
(d) CRITERIA FOR TREATMENT OF ITEMS AS PROS-
THETICS DEVICES OR ORTHOTICS AND PROSTHETICS.—
Not later than July 1, 1994, 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 pro-
gram that do not require individualized or custom fitting
and adjustment to be used by a patient. Such report shall
include recommendations for an appropriate methodology
for determining the amount of payment for such items
under such program.
SEC. 222. PROHIBITION AGAINST CARRIER FORUM SHOP-
PING.
(a) IN GENERAL.—Section 1834(a)(12) (42 U.S.C.
1395m(a)(12)) is amended to read as follows:
‘‘(12) 
USE
OF
CARRIERS
TO
PROCESS
CLAIMS.—
‘‘(A) DESIGNATION
OF
REGIONAL
CAR-
RIERS.—The Secretary may designate, by regu-
lation under section 1842, one carrier for one
or more entire regions to process all claims
within the region for covered items under this
section.
‘‘(B) 
PROHIBITION
AGAINST
CARRIER
SHOPPING.—(i) No supplier of a covered item
may present or cause to be presented a claim
for payment under this part unless such claim
is presented to the appropriate regional carrier
(as designated by the Secretary).
‘‘(ii) For purposes of clause (i), the term
‘appropriate regional carrier’ means the carrier
having jurisdiction over the geographic area
that includes the permanent residence of the
patient to whom the item is furnished.’’.
(b) EFFECTIVE DATE.—The amendment made by
subsection (a) shall apply to items furnished on or after
October 1, 1993.
(c) CLARIFICATION OF AUTHORITY TO DESIGNATE
CARRIERS FOR OTHER ITEMS AND SERVICES.—Nothing
in this subsection or the amendment made by this sub-
section may be construed to restrict the authority of the
Secretary of Health and Human Services to designate re-
gional carriers or modify claims jurisdiction rules with re-
spect to items or services under part B of the medicare
program that are not covered items under section 1834(a)
of the Social Security Act or prosthetic devices or orthotics
and prosthetics under section 1834(h) of such Act.
SEC. 223. RESTRICTIONS ON CERTAIN MARKETING AND
SALES ACTIVITIES.
(a) PROHIBITING UNSOLICITED TELEPHONE CON-
TACTS FROM SUPPLIERS OF DURABLE MEDICAL EQUIP-
MENT TO MEDICARE BENEFICIARIES.—
(1) IN GENERAL.—Section 1834(a) (42 U.S.C.
1395m(a)) is amended by adding at the end the fol-
lowing new paragraph:
‘‘(17) PROHIBITION
AGAINST
UNSOLICITED
TELEPHONE CONTACTS BY SUPPLIERS.—
‘‘(A) IN GENERAL.—A supplier of a cov-
ered item under this subsection may not contact