Table Of Contenti
103d CONGRESS H.R.2138
1st Session
To provide for budget reconciliation with respect to part B of the medicare
program, the medicaid program, and other health programs within the
jurisdictionoftheCommitteeon Energyand Commerce.
IN THE HOUSE OP REPRESENTATIVES
May 17, 1993
Mr.Waxmanintroduced thefollowingbill;whichwasreferredjointlyto the
CommitteesonEnergyand Commerce andWaysandMeans
A
BILL
To provide for budget reconciliation with respect to part
B of the medicare program, the medicaid program, and
other health programs within thejurisdiction ofthe Com-
mittee on Energy and Commerce.
1 Be it enacted by the Senate and House ofRepresenta-
2 tives ofthe United States ofAmerica in Congress assembled,
TITLE I—SHORT TITLE
3
4 SEC. 101. SHORTTITLE.
5 ThisAct maybe cited as the "Medicare and Medicaid
6 BudgetReconciliationAct of1993".
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2
TITLE II—TABLE OF CONTENTS
1
2 SEC.201.TABLEOFCONTENTS.
3 The table ofcontents ofthisAct is as follows:
TITLE I—SHORT TITLE
Sec. 101. Shorttitle.
TITLE II—TABLE OP CONTENTS
Sec. 201. Tableofcontents.
TITLE III—REFERENCES TO OMNIBUS BUDGET RECONCILIATION
ACT OF 1993
Sec. 302. ReferencestoOmnibusBudgetReconciliationActof1993.
TITLE IV—OTHER REFERENCES IN ACT
Sec. 401. Otherreferencesinact.
TITLE V—RECONCILIATION PROVISIONS RELATING TO
MEDICARE, MEDICAID, AND OTHER HEALTH PROGRAMS
Chapter 1 Provisions Relating to Part B
SUBCHAPTERA—PHYSICIANS' SERVICES
Sec. 5001. Reductionindefaultupdateforconversionfactorfor 1994.
Sec. 5002. Reduction in performance standard rate ofincrease andincrease in
maximumreductionpermittedindefaultupdate.
Sec. 5003. Classification of primary care services as a separate category of
services.
Sec. 5004. Phased-in reduction in practice expense relativevalueunits forcer-
tainservices.
Sec. 5005. Limitationonpaymentfortheanesthesiacareteam.
Sec. 5006. Basingpaymentsforanesthesiaservicesonactualtime.
Sec. 5007. Separatepaymentforinterpretationofelectrocardiograms.
Sec. 5008. Paymentsfornewphysiciansandpractitioners.
Sec. 5009. Geographicadjustmentfactorsformedicarephysicians'services.
Sec. 5010. Extra-billinglimits.
Sec. 5011. Relativevaluesforpediatricservices.
Sec. 5012. Antigensunderphysicianfeeschedule.
Sec. 5013. Administrationofclaimsrelatingtophysicians'services.
Sec. 5014. Miscellaneousandtechnicalcorrections.
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SUBCHAPTER B OUTPATIENT HOSPITAL SERVICES AND AMBULATORY
SURGICAL SERVICES
Sec. 5021. Extension of 10 percent reduction in payments for capital-related
costsofoutpatienthospitalservices.
Sec. 5022. Extension ofcurrent reduction in payments for other costs ofout-
patienthospitalservices.
Sec. 5023. 1-yearfreezeinambulatorysurgeryrates.
Sec. 5024. Eyeoreyeandearhospitals.
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Sec. 5025. Extensionofcaponpaymentsforintraocularlenses.
Sec. 5026. Miscellaneousandtechnicalcorrections.
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SUBCHAPTER C DURABLE MEDICAL EQUIPMENT
Sec. 5031. Revisionstopaymentrulesfordurablemedicalequipment.
Sec. 5032. Payment for parenteral and enteral nutrients, supplies, and equip-
mentduring1994.
Sec. 5033. Treatmentofnebulizersandaspirators.
Sec. 5034. Certificationofsuppliers.
Sec. 5035. Prohibitionagainstcarrierforumshopping.
Sec. 5036. Restrictionsoncertainmarketingandsalesactivities.
Sec. 5037. Kickbackclarification.
Sec. 5038. Beneficiaryliabilityfornoncoveredservices.
Sec. 5039. Adjustmentsforinherentreasonableness.
Sec. 5040. Paymentforsurgicaldressings.
Sec. 5041. Paymentsfortensdevices.
Sec. 5042. Miscellaneousandtechnicalcorrections.
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SUBCHAPTER D PART B PREMIUM
Sec. 5051. PartBpremium.
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SUBCHAPTER E OTHER PROVISIONS
Sec. 5061. Paymentsforclinicaldiagnosticlaboratorytests.
Sec. 5062. Treatmentofinpatients and provision ofdiagnostic and therapeutic
X-ray services by rural health clinics and Federally qualified
healthcenters.
Sec. 5063. Applicationofmammographycertificationrequirements.
Sec. 5064. ExtensionofAlzheimer'sdiseasedemonstration.
Sec. 5065. Oralcancerdrugs.
Sec. 5066. Extensionofmunicipalhealthservicedemonstrationprojects.
Sec. 5067. Treatment ofcertain Indian health programs and facilities as Fed-
erally-qualifiedhealthcenters.
Sec. 5068. Interestpayments.
Sec. 5069. Clarification of coverage of certified nurse-midwife services per-
formedoutsidethematernitycycle.
Sec. 5069A. Increasein, and studyof, annual capon amountofmedicarepay-
ment foroutpatientphysical therapyand occupational therapy
services.
Sec. 5070. Miscellaneousandtechnicalcorrections.
Chapter 2 Provisions Relating to Parts A and B
Sec. 5071. Elimination of add-on for overhead of hospital-based home health
agencies.
Sec. 5072. StudyandreportonmedicareGMEpayments.
Sec. 5073. Medicareassecondarypayer.
Sec. 5074. Extensionofself-referralbantoadditionalspecifiedservices.
Sec. 5075. Reductioninpaymentforerythropoietin.
Sec. 5076. Medicare hospital agreements with organ procurement organiza-
tions.
Sec. 5077. ExtensionofwaiverforWattsHealthFoundation.
Sec. 5078. Improvedoutreachforqualifiedmedicarebeneficiaries.
Sec. 5079. Socialhealthmaintenanceorganizations.
Sec. 5080. Peerrevieworganizations.
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Sec. 5081. Hospiceinformationtohomehealthbeneficiaries.
Sec. 5082. Healthmaintenanceorganizations.
Sec. 5083. Miscellaneousandtechnicalcorrections.
Chapter 3 Provisions Relating to Medicare Supplemental
Insurance Policies
Sec. 5091. Standardsformedicaresupplementalinsurancepolicies.
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Subtitle B Medicaid Program and Other Health Care Provisions
Chapter 1 Medicaid Program
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subchapter a program savings provisions
Part I Repeal of Mandate
Sec. 5101. Personal care services furnished outside the home asoptionalbene-
fit.
Part II Outpatdsnt Prescription Drugs
Sec. 5106. PermittingprescriptiondrugformulariesunderStateplans.
Sec. 5107. Elimination of special exemption from prior authorization for new
drugs.
Sec. 5108. Technicalcorrectionsrelatingtosection4401 ofOBRA-1990.
Part III Restrictions on Divestiture of Assets and Estate
Recovery
Sec. 5111. Transferofassets.
Sec. 5112. Medicaidestaterecoveries.
Sec. 5113. Closingloopholepermittingwealthyindividualstoqualifyformedic-
aid.
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Part TV Improvement in Identification and Collection of Third
Party Payments
Sec. 5116. Liabilityofthirdpartiestopayforcareandservices.
Sec. 5117. HealthCoverageClearinghouse.
"TITLE XXI—HEALTH COVERAGE CLEARINGHOUSE
"Sec. 2101. Establishmentofclearinghouse.
"Sec. 2102. Provisionofinformation.
"Sec. 2103. Requirementthatemployersfurnishinformation.
"Sec. 2104. Databank.
Sec. 5118. Medicalchildsupport.
Part V Assuring Proper Payments to Disproportionate Share
Hospitals
Sec. 5121. Assuringproperpaymentstodisproportionatesharehospitals.
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subchapter b miscellaneous provisions
Part I—Anti-fraud and Abuse Provisions
Sec. 5131. Applicationofmedicareruleslimitingcertainphysicianreferrals.
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Sec. 5132. Intermediatesanctionsforkickbackviolations.
Sec. 5133. Requiring maintenance of effort for State medicaid fraud control
units.
Part II Managed Care Provisions
Sec. 5135. Medicaidmanagedcareanti-fraudprovisions.
Sec. 5136. ClarificationoftreatmentofHMOenrolleesincomputingthemedic-
aid inpatient utilization rate in qualifying hospitals as dis-
proportionatesharehospitals.
Sec. 5137. Extension of period of applicability of enrollment mix requirement
to certain health maintenance organizations providing services
underDaytonAreaHealthPlan.
Sec. 5138. ExtensionofmedicaidwaiverforTennessee PrimaryCare Network.
Sec. 5139. Waiver of application of medicaid enrollment mix requirement to
DistrictofColumbiaCharteredHealthPlan,Inc.
Sec. 5140. ExtensionofMinnesotaPrepaidMedicaidDemonstrationProject.
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Part ITL Emergency Services to Undocumented Aliens
Sec. 5141. IncreaseinFederalfinancialparticipationforemergencymedicalas-
sistancetoundocumentedaliens.
Sec. 5142. Limiting Federal medicaid matching payment to bona fide emer-
gencyservicesforundocumentedaliens.
Part P7 Miscellaneous Provisions
Sec. 5144. Increase inlimitonFederal medicaid matchingpayments toPuerto
Ricoandotherterritories.
Sec. 5145. Criteria for making determinations of denial of Federal medicaid
matchingpaymentstoStates.
Sec. 5146. Renewalofunfundeddemonstrationprojectforlow-incomepregnant
womenandchildren.
Sec. 5147. Optional medicaid coverage of TB-related services for certain TB-
infectedindividuals.
Sec. 5148. Application of mammography certification requirements under the
medicaidprogram.
Sec. 5149. Removalofsunsetonextensionofeligibilityforworkingfamilies.
Sec. 5150. Extension ofmoratorium on treatment ofcertain facilities as insti-
tutionsformentaldiseases.
Sec. 5150A. Treatmentofcertainclinicsasfederally-qualifiedhealthcenters.
Sec. 5150B. Nursinghomereform.
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SUBCHAPTER C MISCELLANEOUS AND TECHNICAL CORRECTIONS RELATING
TO OBRA-1990
Sec. 5151. Effectivedate.
Sec. 5152. Correctionsrelatingto section 4402 (enrollmentundergrouphealth
plans).
Sec. 5153. Corrections relating to section 4501 (low-income medicare bene-
ficiaries).
Sec. 5154. Correctionsrelatingtosection4601 (childhealth).
Sec. 5155. Correctionsrelatingtosection4602 (outreachlocations).
Sec. 5156. Corrections relating to section 4604 (payment for hospital services
forchildrenunder6yearsofage).
Sec. 5157. Corrections relating to section 4703 (payment adjustments for dis-
proportionatesharehospitals).
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Sec. 5158. Corrections relatingto section 4704 (Federally-qualified healthcen-
ters).
Sec. 5159. Correctionsrelatingtosection4708 (substitutephysicians).
Sec. 5160. Corrections relatingto section 4711 (home and communitycare for
frailelderly).
Sec. 5161. Correctionsrelatingtosection4712 (communitysupportedlivingar-
rangementsservices).
Sec. 5162. Correctionrelatingtosection4713 (COBRAcontinuationcoverage).
Sec. 5163. Correction relating to section 4716 (medicaid transition for family
assistance).
Sec. 5164. Corrections relating to section 4723 (medicaid spenddown option).
Sec. 5165. Corrections relatingto section 4724 (optional Statedisabilitydeter-
minations).
Sec. 5166. Correction relatingto section 4732 (special rules forhealthmainte-
nanceorganizations).
Sec. 5167. Corrections relating to section 4741 (home and community-based
waivers).
Sec. 5168. Correctionsrelatingtosection4744(frailelderlywaivers).
Sec. 5169. Corrections relatingto section 4747 (coverage ofHIV-positive indi-
viduals).
Sec. 5170. Correctionrelatingtosection4751 (advancedirectives).
Sec. 5171. Correctionsrelatingtosection4752 (physicians'services).
Sec. 5172. Correctionsrelatingtosection4801 (nursinghomereform).
Sec. 5173. Othertechnicalcorrections.
Sec. 5174. Correctionstodesignationsofnewprovisions.
Chapter 2 Universal Access to Childhood Immunizations
Sec. 5181. Establishmentofentitlement andmonitoringprogramswithrespect
tochildhoodimmunizations.
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"Subtitle 3 Entitlement and Monitoring ProgramsWith Respect to
Childhood Immunizations
"Part A Entitlement Program
"Sec. 2151. DeliverytoStatesofsufficientquantitiesofpediatricvaccines.
"Sec. 2152. Entitlements.
"Sec. 2153. Voluntaryparticipationofhealthcareproviders.
"Sec. 2154. Intrastatedistributionofpediatricvaccines.
"Sec. 2155. Generalprovisions.
"Sec. 2156. State option regarding immunization of additional categories
ofchildren.
"Sec. 2157. Stateapplicationforvaccines.
"Sec. 2158. Contractswithmanufacturersofpediatricvaccines.
"Sec. 2159. Certainadministrativevariations.
"Sec. 2160. Listofpediatricvaccines;scheduleforadministration.
"Sec. 2161. ChildhoodImmunizationTrustFund.
"Sec. 2162. Definitions.
"Sec. 2163. Terminationofprogram.
"Part B—National System for Monitoring Immunization Status of
Children
"Sec. 2171. Formula grants for State registries with respect to monitor-
ing.
"Sec. 2172. Registrydata.
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"Sec. 2173. Generalprovisions.
"Sec. 2174. Applicationforgrant.
"Sec. 2175. Determinationofamountofallotment.
"Sec. 2176. Definitions.
"Sec. 2177. Authorizationofappropriations.
"Part 0—Funding for Other Purposes Regarding Childhood
Immunizations
"Sec. 2181. GrantsregardingYear2000healthobjectives.
Sec. 5182. NationalVaccineInjuryCompensationProgramamendments.
Sec. 5183. Medicaidimmunizationprovisions.
Sec. 5184. Availabilityofmedicaidpayments forchildhoodvaccine replacement
programs.
Sec. 5185. Healthystartforinfants.
Sec. 5186. Increase in authorization of appropriations for the Maternal and
ChildHealthServicesBlockGrantProgram.
Sec. 5187. MiscellaneoustechnicalcorrectionstoPublicHealthServiceActpro-
visions.
TITLE III—REFERENCES TO OM-
1
NIBUS BUDGET RECONCILI-
2
ATION ACT OF 1993
3
4 SEC. 302. REFERENCES TO OMNIBUS BUDGET RECONCILI-
5 ATIONACTOF 1993.
6 Anyreference in thisAct (orin anyamendment made
7 by this Act) to the Omnibus Budget Reconciliation Act
8 of 1993 shall be deemed to be a reference to this Act.
TITLE IV—OTHER REFERENCES
9
IN ACT
10
11 SEC.401.OTHERREFERENCESINACT.
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12 (a) Amendments to Social Security Act. Ex-
13 cept as otherwise specifically provided, whenever in this
14 Act an amendment is expressed in terms ofan amendment
15 to or repeal of a section or other provision, the reference
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1 shall be considered to be made to that section or other
2 provision ofthe Social SecurityAct.
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3 (b) References to OBRA. In this Act, the terms
4 "OBRA-1986", "OBRA-1987", "OBRA-1989", and
5 "OBRA-1990" refer to the Omnibus Budget Reconcili-
6 ation Act of 1986 (Public Law 99-509), the Omnibus
7 Budget ReconciliationAct of 1987 (Public Law 100-203),
8 the Omnibus Budget Reconciliation Act of 1989 (Public
9 Law 101-239), and the Omnibus Budget Reconciliation
10 Actof 1990 (Public Law 101-508), respectively.
TITLE V—RECONCILIATION PRO-
11
VISIONS RELATING TO MEDI-
12
CARE, MEDICAID, AND OTHER
13
HEALTH PROGRAMS
14
Subtitle A—Medicare Program
15
CHAPTER 1—PROVISIONS RELATING TO
16
PART B
17
18 Subchapter A—Physicians' Services
19 SEC. 5001. REDUCTION IN DEFAULT UPDATE FOR CONVER-
20 SIONFACTORFOR 1994.
21 Section 1848(d)(3)(A) (42 U.S.C. 1395w-
22 4(d)(3)(A)) is amended—
23 (1) in clause (i), by striking "clause (iii)" and
24 inserting "clauses (iii) and (iv)", and
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1 (2) by adding at the end the following new
2 clause:
3 "(iv) Adjustment in percentage
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4 INCREASE FOR 1994. In applying clause
5 (i) for services (other than primary care
6 services) furnished in 1994, the percentage
7 increase in the appropriate update index
8 shall be reduced by
9 "(I) 3 percentage points for sur-
10 gical services (as defined for purposes
11 of subsection (j)(l)), and
12 "(II) 2 percentage points for
13 other services.".
14 SEC. 5002. REDUCTION E*PERFORMANCE STANDARD RATE
15 OF INCREASE AND INCREASE IN MAXIMUM
16 REDUCTION PERMITTED IN DEFAULT UP-
17 DATE.
18 (a) Reduction in Performance Standard Fac-
19 TOR.—Section 1848(f)(2)(B) (42 U.S.C. 1395w-
20 4(f)(2)(B)) is amended—
21 (1) by striking "and" at the end of clause (ii),
22 and
23 (2) by striking clause (iii) and inserting the fol-
24 lowing:
25 "(iii) for 1993 is 2 percentage points,
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1 "(iv) for 1994 is SV2 percentage
2 points, and
3 "(v) for each succeedingyear is 4 per-
4 centage points.".
5 (b) Increase in Maximum Reduction Permitted
6 in Default Update.—Section 1848(d)(3)(B)(ii) (42
7 U.S.C. 1395w-4(d)(3)(B)(ii)) is amended—
8 (1) in subclause (II), by striking "or 1995",
9 and
10 (2) in subclause (III), by striking "3" and hi-
ll serting"5".
12 SEC. 5003. CLASSIFICATION OF PRIMARY CARE SERVICES
13 ASASEPARATECATEGORYOFSERVICES.
14 (a) In General.—Section 1848(j)(l) (42 U.S.C.
15 1395w-4(j)(l)) is amended by inserting ", primary care
16 services (as defined in section 1842(i)(4))," after "Sec-
17 retary)".
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18 (b) Effective Date. The amendment made by
19 subsection (a) shall apply
20 (1) to volume performance standard rates ofin-
21 crease established under section 1848(f) of the So-
22 cial Security Act for fiscal years beginning with fis-
23 cal year 1994, and
24 (2) to updates in the conversion factors for phy-
25 sicians* services established under section 1848(d) of
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