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under that part, to report claims for payment for such services under such part using a HCFA Common Procedure Coding System, 42 USC-1395/ note.

Contracts.

(h) EFFECTIVE DATES.—

(1) The amendments made by subsection (a)(1) shall apply to cost reporting periods beginning on or after October 1, 1987 (2) The amendments made by subsections (b)(1) and (d) shall apply to services furnished after June 30, 1987. (3) The Secretary of Health and Human Services shall first provide, under the amendment made by subsection (b)(2), for the review and update of procedure lists within 6 months after the date of the enactment of this Act. (4) The amendments made by subsection (c) shall apply to contracts entered into or renewed after January 1, 1987. SEC. 9344. TECHNICAL AMENDMENTS AND MISCELLANEOUS PROVISIONS RELATING TO PART B. (a) ADDITIONAL MEMBERS FOR PHYSICIAN PAYMENT REVIEW COMMISSION.— (1) 2 ADDITIONAL MEMBERS.—Section 1845(a)(2) of the Social

Security Act (42 U.S.C. 1395w-l(a)(2)) is amended by striking "11 individuals" and inserting "13 individuals". 42 USC 1395W-1 note.

(2) APPOINTMENT OF ADDITIONAL MEMBERS.—The Director of

the Congressional Office of Technology Assessment shall appoint the two additional members of the Physician Payment Review Commission, as required by the amendment made by paragraph (1), no later than 60 days after the date of the enactment of this Act, for terms of 3 years, except that the Director may provide initially for such terms as will insure that (on a continuing basis) the terms of no more than five members expire in any one year. (b) EFFECTIVE MEDICARE.—

42 USC 1395q.

42 USC 1395q note.

DATE

OF VOLUNTARY

DISENROLLMENT

FROM

(1) IN GENERAL.—The second and sixth sentences of section 1838(b) of the Social Security Act (42 U.S.C. 1395p(b)) are each amended by striking "calendar quarter following the calendar quarter" and inserting "month following the month". (2) EFFECTIVE DATE.—The amendments made by paragraph (1) shall apply to notices filed on or after July 1, 1987. (c) STUDY ON PROSPECTIVE PAYMENT OF RADIOLOGY, ANESTHESIA, AND PATHOLOGY SERVICES TO HOSPITAL INPATIENTS.—The Secretary

42 USC 1395J.

42 USC 1395b-l note. Ante, p. 194. Rural areas.

of Health and Human Services shall study and report to Congress by July 1, 1987, concerning the design and implementation of a prospective payment system for payment, under part B of title XVIII of the Social Security, for radiology, anesthesia, and pathology services furnished to hospital inpatients. Such report shall include data, from a representative sample, showing, for discharges classified within each diagnosis-related group, the distribution of total reasonable charges and costs for each inpatient discharge for such services. (d) PREVENTIVE HEALTH SERVICES DEMONSTRATION PROGRAM.—

Effective as if included in section 9314 of the Consolidated Omnibus Budget Reconciliation Act of 1985 when such section was enacted, such section is amended— (1) in subsection (c)(2), by inserting "(at least one of which shall serve a rural area)" after "five sites", and (2) by striking the last sentence of subsection (f) and inserting . the following: "Funding for the administrative costs of the

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demonstration program shall not exceed $5,900,000 over the duration of the program.".

PART 4—IMPROVED REVIEW OF QUALITY BY PEER REVIEW ORGANIZATIONS SEC. 9351. PRO REVIEW OF HOSPITAL DENIAL NOTICES.

(a) IN GENERAL.—Section 1154 of the Social Security Act (42 U.S.C. 1320c-3), as amended by section 9343(d)(2) of this subtitle, is amended by adding at the end the following new subsection: "(e)(1) I f "(A) a hospital has determined that a patient no longer requires inpatient hospital care, and "(B) the attending physician has agreed with the hospital's determination, the hospital may provide the patient (or the patient's representative) with a notice (meeting conditions prescribed by the Secretary under section 1879) of the determination. "(2)If— "(A) a hospital has determined that a patient no longer requires inpatient hospital care, but "(B) the attending physician has not agreed with the hospital's determination, the hospital may request the appropriate peer review organization to review under subsection (a) the validity of the hospital's determination. "(3)(A) If a patient (or a patient's representative)— "(i) has received a notice under paragraph (1), and "(ii) requests the appropriate peer review organization to review the determination, then, the organization shall conduct a review under subsection (a) of the validity of the hospital's determination and shall provide notice (by telephone and in writing) to the patient or representative and the hospital and attending physician involved of the results of the review. Such review shall be conducted regardless of whether or not the hospital will charge for continued hospital care or whether or not the patient will be liable for payment for such continued care. "(B) If a patient (or a patient's representative) requests a review under subparagraph (A) while the patient is still an inpatient in the hospital and not later than noon of the first working day after the date the patient receives the notice under paragraph (1), then— "(i) the hospital shall provide to the appropriate peer review organization the records required to review the determination by the close of business of such first working day, and "(ii) the peer review organization must provide the notice under subparagraph (A) by not later than one full working day after the date the organization has received the request and such records. "(4) If— "(A) a request is made under paragraph (3)(A) not later than < noon of the first working day after the date the patient (or patient's representative) receives the notice under paragraph (1), and "(B) the conditions described in section 1879(a)(2) with respect to the patient or representative are met.

Health care facilities.

Ante, p. 1991.

.ete-fc-;

 * Aa.k

Records.

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PUBLIC LAW 99-509—OCT. 21, 1986

the hospital may not charge the patient for inpatient hospital services furnished before noon of the day after the date the patient or representative receives notice of the peer review organization's decision. "(5) In any review conducted under paragraph (2) or (3), the organization shall solicit the views of the patient involved (or the patient's representative).". (b) EFFECTIVE DATE.—(1) Except as provided in paragraph (2), the amendment made by subsection (a) shall apply to denial notices furnished by hospitals to individuals on or after the first day of the first month that begins more than 30 days after the date of the enactment of this Act. (2) Section 1154(e)(4) of the Social Security Act (as added by the amendment made by subsection (a)) shall take effect on the date of the enactment of this Act. SEC. 9352. PRO REVIEW OF INPATIENT HOSPITAL SERVICES AND EARLY READMISSION CASES.

42 USC 1320C-3.

Contracts. 42 USC 1320c.

(a) TIMELY PROVISION OF HOSPITAL INFORMATION.—(1) Section 1153 of the Social Security Act (42 U.S.C. 1320c-2) is amended by adding at the end the following new subsection: "(g) The Secretary shall provide that fiscal intermediaries furnish to peer review organizations, each month on a timely basis, data necessary to initiate the review process under section 1154(a) on a timely basis. If the Secretary determines that a fiscal intermediary is unable to furnish such data on a timely basis, the Secretary shall require the hospital to do so.". (2) Section 1816(a) of such Act (42 U.S.C. 1395h(a)) is amended by adding at the end the following: "As used in this title and part B of title XI, the term 'fiscal intermediary' means an agency or organization with a contract under this section.". (b) REQUIRING REVIEW OF EARLY READMISSION CASES.—Section

Ante, p. 196.

42 USC 1320C-2 note. Contracts. 42 USC 1320C-3 note.

1154(a) of such Act (42 U.S.C. 1320c-3(a)), as amended by section 9401(a) of the Consolidated Omnibus Budget Reconciliation Act of 1985, is amended by adding at the end the following new paragraph: "(13) Notwithstanding paragraph (4), the organization shall early readmission cases to determine if the previous inpatient hospital services and the post-hospital services met professionally recognized standards of health care. Such reviews may be performed on a sample basis if the organization and the Secretary determine it to be appropriate. In this paragraph, an 'early readmission case' is a case in which an individual, after discharge from a hospital, is readmitted to a hospital less than 31 days after the date of the most recent previous discharge.". (c) EFFECTIVE DATES.—(1) The Secretary of Health and Human Services shall implement the amendment made by subsection (a) not later than 6 months after the date of the enactment of this Act. (2) The amendment made by subsection (b) shall apply to contracts entered into or renewed on or after January 1, 1987, except that in applying such amendment before January 1, 1989, the term "posthospital services" does not include physicians' services, other than physicians' services furnished in a hospital, other inpatient facility, ambulatory surgical center, or rural health clinic. SEC. 9353. PRO REVIEW OF QUALITY OF CARE. (a) REQUIRING PRO REVIEW OF QUALITY OF CARE.—
 * perform the review described in paragraph (1) with respect to

^.

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100 STAT. 2045

(1) ALLOCATION OF FUNDS FOR QUALITY CARE REVIEW.—Section

1154(a)(4) of the Social Security Act (42 U.S.C. 1320c-3(a)(4)) is amended by adding at the end the following: "Each peer review organization shall provide that a reasonable proportion of its activities are involved with reviewing, under paragraph (1)(B), the quality of services and that a reasonable allocation of such activities is made among the different cases and settings (including post-acute-care settings, ambulatory settings, and health maintenance organizations). In establishing such allocation, the organization shall consider (i) whether there is reason to believe that there is a particular need for reviews of particular cases or settings because of previous problems regarding quality of care, (ii) the cost of such reviews and the likely yield of such reviews in terms of number and seriousness of quality of care problems likely to be discovered as a result of such reviews, and (iii) the availability and adequacy of alternative quality review and assurance mechanisms.".

•J ' !

(2) REQUIRING REVIEW OF HEALTH MAINTENANCE ORGANIZA-

TIONS AND COMPETITIVE MEDICAL PLANS.—Such section is further amended— (A) by inserting "(A)" after "(4)"; (B) by adding at the end the following new subparagraph: "(B) The contract of each organization shall provide for the review of services (including both inpatient and outpatient services) provided by eligible organizations pursuant to a contract under section 1876 for the purpose of determining whether the quality of such services meets professionally recognized standards of health care, including whether appropriate health care services have not been provided or have been provided in inappropriate settings. The previous sentence shall not apply with respect to a contract year if another entity has been awarded a contract under subparagraph (C)."; (C) by adding at the end of such subparagraph the following: "Under the contract the level of effort expended by the Oi u v organization on reviews under this subparagraph shall be equivalent, on a per enrollee basis, to the level of effort expended by the organization on utilization and quality reviews performed with respect to individuals not enrolled with an eligible organization."; and (D) by adding at the end the following additional new subparagraph: "(C) The Secretary may provide, by contract under competitive procurement procedures on a State-by-State basis in up to 25 States, for the review described in subparagraph (B) by an appropriate entity (which may be a peer review organization described in that subparagraph). In selecting among States in which to conduct such competitive procurement procedures, the Secretary may not select States which, as a group, have more than 50 percent of the total number of individuals enrolled with eligible organizations under section 1876. Under a contract with an entity under this subparagraph— "(i) the entity must be, or must meet all the requirements under section 1152 to be, a utilization and quality control peer review organization, "(ii) the contract must meet the requirement of section 1153(b)(3), and

Contracts.

42 USC 1395inm.

Contracts, , >

Contracts. State and local governments.

42 USC 1320c-l. 42 USC l320c-2.

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PUBLIC LAW 99-509—OCT. 21, 1986

""''

"(iii) the level of effort expended under the contract shall be, to the extent practicable, not less than the level of effort that would otherwise be required under the third sentence of subparagraph (B) if this subparagraph did not gpply.". (3) IDENTIFICATION OF METHODS FOR IDENTIFYING CASES OF SUBSTANDARD CARE.—Section 1154 of such Act (42 U.S.C.

42 USC 1320C-3 note. 42 USC 1320c.

42 USC 1395. 42 USC 1320C-3 ^° ' contracts. 42 USC 1320C-3 note.

contracts.

sii

1320C-3), as amended by sections 9343(d)(2) and 9351(a), is amended by adding at the end the following new subsection: "(f) The Secretary, in consultation with appropriate experts, shall identify methods that would be available to assist peer review organizations (under subsection (a)(4)) in identifying those cases which are more likely than others to be associated with a quality of services which does not meet professionally recognized standards of health care.". (4) SMALL-AREA ANALYSIS.—The Secretary of Health and Human Services shall provide, to at least 12 utilization and quality control peer review organizations with contracts under " part B of title XI of the Social Security Act, data and data processing assistance to allow each of these organizations to review and analyze small-area variations, in the service area of the organization, in the utilization of hospital and other health care services for which payment is made under title XVIII of such Act. (5) CONFORMING AMENDMENT.—Section 9405 of the Consolidated Omnibus Budget Reconciliation Act of 1986 is amended by striking "January" and inserting "April", (6) EFFECTIVE DATES.—(A)(i) Except as provided in clause (ii), the amendments made by paragraphs (1) and (2)(D) shall apply to contracts as of January 1, 1987. (ii) The amendment made by paragraph (1) shall not be construed as requiring, before January 1, 1989, the review of physicians' services, other than physicians' services furnished in a hospital, other inpatient facility, ambulatory surgical center, or rural health clinic, (B) The amendment made by paragraph (2)(B) shall apply to contracts as of April 1, 1987. (C) The amendment made by paragraph (2)(C) shall apply to review activities conducted by organizations on or after January 1, 1988. w if (D) The amendment made by paragraph (3) becomes effective on the date of the enactment of this Act. (b) REQUIRING BOARDS.—

REPRESENTATIVE

ON PEER

REVIEW

(1) IN GENERAL.—Section 1152 of such Act (42 U.S.C. 1320c-l) is amended— (A) by striking "and" at the end of paragraph (1), (B) by striking the period at the end of paragraph (2) and inserting "; and", and (C) by adding at the end the following new paragraph: "(3) has at least one individual who is a representative of consumers on its governing body.". (2) EFFECTIVE DATE.—The amendment made by paragraph (1) shall apply to contracts entered into or renewed on or after January 1, 1987.

contracts. 42 USC 1320C-1 note(c)

s.^'M',i:)80 5it

CONSUMER

IMPROVING PEER REVIEW RESPONSIVENESS TO BENEFICIARY

COMPLAINTS.—

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100 STAT. 2047

(1) APPROPRIATE REVIEW OF COMPLAINTS REQUIRED.—Section

1154(a) of such Act (42 U.S.C. 1320c-3(a)), as amended by section 9352(b), is further amended by adding at the end the following new paragraph: "(14) The organization shall conduct an appropriate review of all written complaints about the quality of services (for which payment may otherwise be made under title XVIII) not meeting 42 USC 1395. professionally recognized standards of health care, if the complaint is filed with the organization by an individual entitled to benefits for such services under such title (or a person acting on the individual's behalf). The organization shall inform the individual (or representative) of the organization's final disposition of the complaint. Before the organization concludes that the quality of services does not meet professionally recognized standards of health care, the organization must provide the practitioner or person concerned with reasonable notice and opportunity for discussion.". (2) EFFECTIVE DATE.—The amendment made by paragraph (1) 42 USC 1320C-3 shall apply to complaints received on or after the first day of the note. first month that begins more than 9 months after the date of the enactment of this Act. (d) SHARING OF INFORMATION BY PEER REVIEW ORGANIZATIONS.—

(1) IN GENERAL.—Subparagraph (C) of section 1160(b)(1) of such Act (42 U.S.C. 1320c-9(b)(l)) is amended to read as follows: "(C) to assist appropriate State agencies recognized by the State and local Secretary as having responsibility for licensing or certifi- governments. '" cation of providers or practitioners or to assist national accreditation bodies acting pursuant to section 1865 in 42 USC 1395bb. accrediting providers for purposes of meeting the conditions described in title XVIII, which data and information shall be provided by the peer review organization to any such agency or body at the request of such agency or body relating to a specific case or to a possible pattern of substandard care, but only to the extent that such data and information are required by the agency or body to carry out its respective function which is within the jurisdiction of the agency or body under State law or under section 1865;". (2) EFFECTIVE DATE.—The amendments made by paragraph (1) 42 USC 1320C-9 shall apply to requests for data and information made on and note. after the end of the 6-month period beginning on the date of the enactment of this Act. (e) FUNDING OF ADDITIONAL PRO ACTIVITIES.— (1) THROUGH AGREEMENTS WITH HOSPITALS, SKILLED NURSING FACILITIES, A N D HOME HEALTH A G E N C I E S. — S e c t i o n 1 8 6 6 (a) o f SUCh

rf Act (42 U.S.C. 1395cc(a)) is amended— (A) in paragraph (1)(F)— (i) by redesignating clauses (i), (ii), and (iii), as subclauses (I), (II), and (III), respectively, (ii) by inserting "(i)" after "(F)", and (iii) by adding at the end the following new clause: "(ii) in the case of hospitals, skilled nursing facilities, and Contracts. home health agencies, to maintain an agreement with a utilization and quality control peer review organization (which has a contract with the Secretary under part B of title XI for the area 42 USC 1320c. in which the hospital, facility, or agency is located) to perform the functions described in paragraph (4)(A);"; and (B) by adding at the end the following new paragraph:

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42 USC 1320C-3. ^IT,

42 USC 1320c.

PUBLIC LAW 99-509—OCT. 21, 1986

"(4)(A) Under the agreement required under paragraph (l)(F)(ii), the peer review organization must perform functions (other than those covered under an agreement under paragraph (l)(F)(i)) under the third sentence of section 1154(a)(4)(A) and under section 1154(a)(14) with respect to services, furnished by the hospital, facility, or agency involved, for which payment may be made under this title. "(B) For purposes of payment under this title, the cost of such an agreement to the hospital, facility, or agency shall be considered a cost incurred by such hospital, facility, or agency in providing covered services under this title and shall be paid directly by the Secretary to the peer review organization on behalf of such hospital, facility, or agency in accordance with a schedule established by the Secretary. "(C) Such payments— "(i) shall be transferred in appropriate proportions from the Federal Hospital Insurance Trust Fund and from the Federal Supplementary Medical Insurance Trust Fund, without regard to amounts appropriated in advance in appropriation Acts, in the same manner as transfers are made for payment for services provided directly to beneficiaries, and "(ii) shall not be less in the aggregate for hospitals, facilities, and agencies for a fiscal year than the amounts the Secretary determines to be sufficient to cover the costs of such organizations' conducting the activities described in subparagraph (A) with respect to such hospitals, facilities, or agencies under part B of title XL". (2) THROUGH AGREEMENTS WITH HEALTH MAINTENANCE ORGANIZATIONS AND COMPETITIVE MEDICAL PLANS.—Section

42 USC 1395CC.

1876(i) of such Act (42 U.S.C. 1395mm(i)), as amended by section 9312(f) of this subtitle, is amended by adding at the end the following new paragraph: "(7)(A) Except as provided under section 1154(a)(4)(C), each risksharing contract with an eligible organization under this section shall provide that the organization will maintain an agreement with a utilization and quality control peer review organization (which has a contract with the Secretary under part B of title XI for the area in which the eligible organization is located) under which the peer review organization will perform functions under section 1154(a)(4)(B) and section 1154(a)(14) (other than those performed under contracts described in section 1866(a)(1)(F)) with respect to services, furnished by the eligible organization, for which payment may be made under this title. "(B) For purposes of payment under this title, the cost of such agreement to the eligible organization shall be considered a cost incurred by a provider of services in providing covered services under this title and shall be paid directly by the Secretary to the peer review organization on behalf of such eligible organization in accordance with a schedule established by the Secretary. "(C) Such payments— "(i) shall be transferred in appropriate proportions from the Federal Hospital Insurance Trust Fund and from the Supplementary Medical Insurance Trust Fund, without regard to amounts appropriated in advance in appropriation Acts, in the same manner as transfers are made for payment for services provided directly to beneficiaries, and

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100 STAT. 2049

"(ii) shall not be less in the aggregate for such organizations for a fiscal year than the amounts the Secretary determines to be sufficient to cover the costs of such organizations' conducting activities described in subparagraph (A) with respect to such eligible organizations under part B of title XL". 42 USC 1320c. (3) EFFECTIVE DATE.— (A) HOSPITALS, SKILLED NURSING FACILITIES, AND HOME

,, ,

HEALTH AGENCIES.—The amendments made by paragraph (1) shall apply to provider agreements as of October 1, 1987. (B) HMOs AND CMPS.—The amendment made by paragraph (2) shall apply to risk-sharing contracts with eligible organizations, under section 1876 of the Social Security Act, as of April 1, 1987.

Subtitle E—Medicaid and Maternal and Child Health TABLE OF CONTENTS OF SUBTITLE PART 1—COVERAGE OF INDIVIDUALS

Sec. 9401. Optional coverage for poor pregnant women, infants, and children. Sec. 9402. Optional coverage of elderly and disabled poor for all medicaid benefits. Sec. 9403. Optional coverage of poor medicare beneficiaries for medicare cost-sharing expenses. Sec. 9404. Medicaid eligibility for qualified severely impaired individuals. Sec. 9405. Clarification of eligibility of homeless individuals. Sec. 9406. Payment for aliens under medicaid. Sec. 9407. Optional presumptive eligibility period for pregnant women. Sec. 9408. Respiratory care services for ventilator-dependent individuals. PART 2—PROVISION OF SERVICES UNDER WAIVER AUTHORITY

Sec. 9411. Permitting States to offer home and community-based services to certain low-income individuals. Sec. 9412. Waiver authority for chronically mentally ill and frail elderly. Sec. 9413. Continuation of "Case-Managed Medical Care for Nursing Home Patients" demonstration project. Sec. 9414. New Jersey respite care pilot project. Sec. 9415. Inapplicability of Paperwork Reduction Act. PART 3—PAYMENTS

Sec. 9421. Holding States harmless in fiscal year 1987 against a decrease in the Federal medical assistance percentage. Sec. 9422. Waiver of certain requirements. PART 4—OTHER QUAUTY AND EFFICIENCY MEASURES

Sec. 9431. Independent quality review of HMO services. Sec. 9432. State utilization review systems. Sec. 9433. Clarification of flexibility for State medicaid payment systems for inpatient services. Sec. 9434. Financial disclosure requirements for HMOs; civil money penalties. Sec. 9435. COBRA technical corrections and clarifications relating to the medicaid program. Sec. 9436. Payment for certain long-term care patients in hospitals. -

PART 5—MATERNAL AND CHILD HEALTH

Sec. 9441. Authorization and allotment of additional funds. Sec. 9442. Maternal and child health and adoption clearinghouse. Sec. 9443. Collection of data relating to adoption and foster care.

42 USC 1395CC note. Contracts. 42 USC 1395mm note. 42 USC 1395mm.

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PUBLIC LAW 99-509—OCT. 21, 1986

=.r,

PART 1—COVERAGE OF INDIVIDUALS

SEC. 9401. OPTIONAL COVERAGE OF POOR PREGNANT WOMEN, INFANTS, AND CHILDREN. '

'

'^

(a) CREATION OF NEW OPTIONAL CATEGORICALLY NEEDY GROUP.—

Section 1902(a)(10)(A)(ii) of the Social Security Act (42 U.S.C. • \rt 1396a(a)(10)(A)(ii)) is amended— (1) by striking ", or" at the end of subclause (VII) and inserting a semicolon, " ^ ' (2) by inserting "or" at the end of subclause (VIII), and (3) by adding at the end the following new subclause: ' ' '" "(IX) subject to subsection (1)(4), who are described in subsection (1)(1);". (b) DESCRIPTION OF GROUP.—Section 1902 of such Act is amended by inserting after subsection (k) the following new subsection: -> "(1)(1) Individuals described in this paragraph are— "(A) women during pregnancy (and during the 60-day period beginning on the last day of the pregnancy), "(B) infants under one year of age, "(C) children who have attained one year of age but have not attained two years of age, "(D) children who have attained two years of age but have not attained three years of age, "(E) children who have attained three years of age but have not attained four years of age, and State and local "(F) children who have attained four years of age but have not governments. ygt attained five years of age, who are not described in subsection (a)(10)(A)(i), whose family income does not exceed the income level established by the State under paragraph (2) for a family size equal to the size of the family, including the woman, infant, or child. "(2) For purposes of paragraph (1), the State shall establish an income level which is a percentage (not more than 100 percent) of the nonfarm income official poverty line (as defined by the Office of Management and Budget, and revised annually in accordance with 42 USC 9902. section 673(2) of the Omnibus Budget Reconciliation Act of 1981) applicable to a family of the size involved. "(3) Notwithstanding subsection (a)(17), for individuals who are eligible for medical assistance because of subsection (a)(lOXAXiiXIX)"(A) application of a resource standard shall be at the option of the State; "(B) any resource standard or methodology that is applied with respect to an individual described in subparagraph (A) of paragraph (1) may not be more restrictive than the resource 42 USC 1381. sq, standard or methodology that is applied under title XVI; "(C) any resource standard or methodology that is applied with respect to an individual described in subparagraph (B), (C), '*'-' (D), (E), or (F) of paragraph (1) may not be more restrictive than the corresponding methodology that is applied under the State 42 USC 601. plan under part A of title IV; "(D) the income standard to be applied is the income standard established under paragraph (2); and "(E) family income shall be determined in accordance with the methodology employed under the State plan under part A

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100 STAT. 2051

or E of title IV, and costs incurred for medical care or for any 42 USC 670. other type of remedial care shall not be taken into account. Any different treatment provided under this paragraph for such individuals shall not, because of subsection (a)(17), require or permit such treatment for other individuals. "(4)(A) A State plan may not elect the option of furnishing medical State and local assistance to individuals described in subsection (a)(10)(A)(ii)(IX) governments. unless the State has in effect, under its plan established under part A of title IV, payment levels that are not less than the payment levels in effect under its plan on April 17, 1986. "(B)(i) A State may not elect, under subsection (a)(10)(A)(ii)(IX), to cover only individuals described in paragraph (1)(A) or to cover only individuals described in paragraph (1)(B). "(ii) A State may not elect, under subsection (a)(10)(A)(ii)(IX), to cover individuals described in subparagraph (C), (D), (E), or (F) of paragraph (1) unless the State has elected, under such subsection, to cover individuals described in the preceding subparagraphs of such paragraph.". (c) LIMITED BENEFITS FOR NEWLY ELIGIBLE PREGNANT WOMEN.—

Section 1902(a)(10) of such Act (42 U.S.C. 1396a(a)(10)) is amended, in the matter after subparagraph (D)— (1) by striking "and" before "(VI)", and (2) by inserting before the semicolon at the end the following: ", and (VII) the medical assistance made available to an individual described in subsection (1)(1)(A) who is eligible for medical assistance only because of subparagraph (A)(ii)(IX) shall be limited to medical assistance for services related to pregnancy (including prenatal, delivery, and postpartum services) and to other conditions which may complicate pregnancy". (d) CONTINUATION OF MEDICAL ASSISTANCE FOR CERTAIN PREGNANT WOMEN DURING PREGNANCY AND FOR CERTAIN INFANTS AND CHILDREN RECEIVING INPATIENT SERVICES.—Section 1902(e) of such Act

(42 U.S.C. 1396a(e)) is amended by adding at the end the following new paragraphs: "(6) At the option of a State, if a State plan provides medical State and local assistance for individuals under subsection (a)(10)(A)(ii)(IX), the plan governments. may provide that any woman described in such subsection and subsection (1)(1)(A) shall continue to be treated as an individual described in subsection (a)(10)(A)(ii)(IX) without regard to any change in income of the family of which she is a member until the end of the 60-day period beginning on the last day of her pregnancy. "(7) If a State plan provides medical assistance for individuals under subsection (a)(10)(A)(ii)(IX), in the case of an infant or child described in subparagraph (B), (C), (D), (E), or (F) of subsection (1)(1)"(A) who is receiving inpatient services for which medical assistance is provided on the date the infant or child attains the maximum age with respect to which coverage is provided under the State plan for such individuals, and "(B) who, but for attaining such age, would remain eligible for medical assistance under such subsection, the infant or child shall continue to be treated as an individual described in subsection (a)(10)(A)(ii)(IX) and subsection (IXD until the end of the stay for which the inpatient services are furnished.". (e) CONFORMING AMENDMENTS.—

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»":i

42 USC 1396a

"°^-

PUBLIC LAW 99-509—OCT. 21, 1986

" -

(1) Section 1902(a)(17) of such Act (42 U.S.C. 1396(a)(17)) is amended by inserting "except as provided in subsection (1)(3)," after "(17)". (2) Section 1903(f)(4) of such Act (42 U.S.C. 1396b(f)(4)) is amended by inserting "for any individual described in section 1902(a)(10)(A)(iiXIX) or" after "as medical assistance".

(f) EFFECTIVE DATES.—

(1) Except as provided in paragraph (2), the amendments made by this section shall apply to medical assistance furnished in calendar quarters beginning on or after April 1, 1987. (2)(A) Subparagraph (C) of section 1902(1)(1) of the Social Security Act, as added by subsection (b) of this section, shall apply to medical assistance furnished in calendar quarters beginning on or after October 1, 1987. (B) Subparagraph (D) of section 1902(1)(1) of the Social Security Act, as added by subsection (b) of this section, shall apply to • medical assistance furnished in calendar quarters beginning on or after October 1, 1988. (C) Subparagraph (E) of section 1902(1)(1) of the Social Security Act, as added by subsection (b) of this section, shall apply to medical assistance furnished in calendar quarters beginning on or after October 1, 1989. (D) Subparagraph (F) of section 1902(1)(1) of the Social Security Act, as added by subsection (b) of this section, shall apply to medical assistance furnished in calendar quarters beginning on or after October 1, 1990. (3) An amendment made by this section shall become effective c as provided in paragraph (1) or (2) without regard to whether or not final regulations to carry out such amendment have been promulgated by the applicable date. SEC. 9402. OPTIONAI. COVERAGE OF ELDERLY AND DISABLED POOR FOR ALL MEDICAID BENEFITS. (a) CREATION OF N E W OPTIONAL CATEGORICALLY NEEDY GROUPS.—

>.

'_ • •"' '

42 USC 1382c. State and local governments. 42 USC 1382a. 42 USC 1382b.

(1) IN GENERAL.—Subsection (a)(lOXAXii) of section 1902 of the Social Security Act (42 U.S.C. 1396a), as amended by section 9401(a) of this subtitle, is amended— (A) by striking "or" at the end of subclause (VIII), (B) by striking the semicolon at the end of subclause (IX) and inserting ", or", and (C) by adding at the end the following new subclause: "(X) subject to subsection (m)(3), who are described in subsection (m)(l);". (2) DESCRIPTION OF INDIVIDUALS.—Section 1902 of such Act is further amended by adding after subsection (1), as added by section 9401(b) of this subtitle, the following new subsection: "(m)(l) Individuals described in this paragraph are individuals— "(A) who are 65 years of age or older or are disabled individuals (as determined under section 1614(a)(3)), "(B) whose income (as determined under section 1612 for purposes of the supplemental security income program) does not exceed an income level established by the State consistent with paragraph (2)(A), and "(C) whose resources (as determined under section 1613 for purposes of the supplemental security income program) do not exceed (except as provided in paragraph (2)(B)) the maximum

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100 STAT. 2053

amount of resources that an individual may have and obtain benefits under that program. "(2)(A) The income level established under paragraph (1)(B) may not exceed a percentage (not more than 100 percent) of the nonfarm official poverty line (as defined by the Office of Management and Budget, and revised annually in accordance with section 673(2) of the Omnibus Budget Reconciliation Act of 1981) applicable to a 42 USC 9902. family of the size involved. "(B) In the case of a State that provides medical assistance to State and local individuals not described in subsection (a)(10)(A) and at the State's governments, option, the State may use under paragraph (1)(C) such resource level (which is higher than the level described in that paragraph) as may be applicable with respect to individuals described in paragraph dXA) who are not described in subsection (a)(10)(A).". (b) REQUIREMENT OF COVERAGE OF CERTAIN PREGNANT WOMEN AND CHILDREN AND OTHER SPECIAL RULES.—Section 1902(m) of such

Act, as added by subsection (a)(2), is further amended by adding at the end the following new paragraphs: "(3) A State plan may not provide coverage for individuals under subsection (a)(10)(A)(ii)(X), unless the plan provides coverage of some or all of the individuals described in subsection (1)(1). "(4) Notwithstanding subsection (a)(17), for individuals described in paragraph (1) who are covered under the State plan by virtue of subsection (a)(10)(A)(ii)(X)— "(A) the income standard to be applied is the income standard described in paragraph (1)(B), and "(B) except as provided in section 1612(b)(4)(B)(ii), costs incurred for medical care or for any other type of remedial care shall not be taken into account in determining income. Any different treatment provided under this paragraph for such individuals shall not, because of subsection (a)(17), require or permit such treatment for other individuals.". (c) EFFECTIVE DATE.—The amendments made by this section shall apply to payments to States for calendar quarters beginning on or after July 1, 1987, without regard to whether or not final regulations to carry out such amendments have been promulgated by such date.

42 USC 1396a. state and local governments.

42 USC 1382a.

State and local governments. 42 USC 1396a note.

SEC. 9403. OPTIONAL COVERAGE OF POOR MEDICARE BENEFICIARIES FOR MEDICARE COST-SHARING EXPENSES. (a)

ELIGIBILITY OF QUALIFIED MEDICARE BENEFICIARY.—Section

1902(a)(10) of the Social Security Act (42 U.S.C. 139a(a)(10)) is 42 USC 1396a. amended— (1) by striking "and" at the end of subparagraph (C), i t. (2) by inserting "and" at the end of subparagraph (D), and (3) by inserting after subparagraph (D) the following new subparagraph: "(E) at the option of a State, but subject to subsection State and local £ J = (m)(3), for making medical assistance available for medicare governments. cost-sharing (as defined in section 1905(p)(3)) for qualified 42 USC I396d. medicare beneficiaries described in section 1905(p)(l);" (b) QUALIFIED MEDICARE BENEFICIARY DEFINED.—Section 1905

of

such Act (42 U.S.C. 1396d) is amended by adding at the end the following new subsection: "(p)(l) The term 'qualified medicare beneficiary' means an individual—

• J-i

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42 USC 1395c. 42 USC 1395i-2.

State and local governments. 42 USC 1382a. 42 USC 1382b.

42 USC 9902. State and local governments.

42 USC 1396a.

42 USC 1396d.

42 USC 13960.

42 USC 13951-2. 42 USC 1395e. 42 USC 1395Z. State and local governments.

42 USC 1395mm.

PUBLIC LAW 99-509—OCT. 21, 1986

"(A) who is entitled to hospital insurance benefits under part A of title XVIII (including an individual entitled to such benefits pursuant to an enrollment under section 1818), "(B) who, but for section 1902(a)(10)(E) and the election of the State, is not eligible for medical assistance under the plan, "(C) whose income (as determined under section 1612 for purposes of the supplemental security income program) does not exceed an income level established by the State consistent with paragraph (2)(A), and "(D) whose resources (as determined under section 1613 for purposes of the supplemental security income program) do not exceed (except as provided in paragraph (2)(B)) the maximum amount of resources that an individual may have and obtain benefits under that program. "(2)(A) The income level established under paragraph (1)(C) may not exceed a percentage (not more than 100 percent) of the nonfarm official poverty line (as defined by the Office of Management and Budget, and revised annually in accordance with section 673(2) of the Omnibus Budget Reconciliation Act of 1981) applicable to a family of the size involved. "(B) In the case of a State that provides medical assistance to individuals not described in section 1902(a)(10)(A) and at the State's option, the State may use under paragraph (1)(D) such resource level (which is higher than the level described in that paragraph) as may be applicable with respect to individuals described in paragraph (1)(A) who are not described in section 1902(a)(10)(A).". (c) LIMITED, MEDICARE GAP-FILUNG BENEFITS.—Section 1902(a)(10) of such Act (42 U.S.C. 1395a(a)(10)), as amended by section 9401(c) of this subtitle and by subsection (a) of this section, is amended, in the matter after subparagraph (E)— (1) by striking "and" before "(VII)", and (2) by inserting before the semicolon at the end the following: ", and (VIII) the medical assistance made available to a quali' •'• fied medicare beneficiary described in section 1905(p)(l) shall be limited to medical assistance for medicare cost-sharing (described in section 1905(p)(3)), subject to the provisions of subsection (n) and section 1916(b)". (d) MEDICARE COST-SHARING DEFINED.—Section 1905(p) of such Act, as added by subsection (b), is amended by adding at the end the following: "(3) The term 'medicare cost-sharing' means the following costs incurred with respect to a qualified medicare beneficiary: "(A) Premiums under part B and (if applicable) under section 1818. "(B) Deductibles and coinsurance described in section 1813. "(C) The annual deductible described in section 1833(b). "(D) The difference between the amount that is paid under section 1833(a) and the amount that would be paid under such section if any reference to '80 percent' therein were deemed a reference to '100 percent'. Such term also may include, at the option of a State, premiums for enrollment of a qualified medicare beneficiary with an eligible organization under section 1876.". (e) PAYMENT AMOUNTS.—Section 1902 of such Act, as amended by sections 9401(b) and 9402(a)(2) of this subtitle, is further amended by adding at the end the following new subsection:

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100 STAT. 2055

"(n) In the case of medical assistance furnished under this title for medicare cost-sharing respecting the furnishing of a service or item to a qualified medicare beneficiary, the State plan may provide payment in an amount with respect to the service or item that results in the sum of such payment amount and any amount of payment made under title XVIII with respect to the service or item exceeding the amount that is otherwise payable under the State plan for the item or service for eligible individuals who are not qualified medicare beneficiaries.". (f) REQUIREMENT OF COVERAGE OF CERTAIN PREGNANT WOMEN AND CHILDREN AND OTHER SPECIAL RULES.— (1) REQUIRING COVERAGE OF CERTAIN PREGNANT WOMEN AND CHILDREN AND INCOME STANDARD TO BE USED.—Section 1902(m)

State and local governments.

42 USC 1395.

42 USC 1396a.

of such Act, as added by section 9402(a)(2) of this subtitle, and as amended by section 9402(b) of this subtitle, is amended— (A) in paragraph (3), by inserting "or coverage under subsection (a)(10)(E)" after "subsection (a)(10)(A)(ii)(IX)", and (B) by adding at the end the following new paragraph: "(5^ Notwithstanding subsection (a)(17), for qualified medicare beneficiaries described in section 1905(p)(l)— 42 USC 1396d. "(A) the income standard to be applied is the income standard described in section 1905(p)(l)(C), and "(B) except as provided in section 16120!))(4)(B)(ii), costs in- 42 USC 1382a. curred for medical care or for any other type of remedial care shall not be taken into account in determining income. Any different treatment provided under this paragraph for such individuals shall not, because of subsection (a)(l'7), require or permit such treatment for other individuals.". (2) EFFECTIVE DATE OF BENEFITS.—Section 1902(e) of such Act, as amended by section 9401(d) of this subtitle, is amended by adding at the end the following new paragraph: "(8^ If an individual is determined to be a qualified medicare State and local beneficiary (as defined in section 1905(p)(l)), such determination governments. shall apply to services furnished after the end of the month in which the determination first occurs. For purposes of payment to a State under section 1903(a), such determination shall be considered to be 42 USC 1396b. valid for an individual for a period of 12 months, except that a State may provide for such determinations more frequently, but not more frequently than once every 6 months for an individual.". (g) CONFORMING AMENDMENTS.— (1) TREATMENT OF BENEFITS.—Section 1902(a)(10)(C) of such

Act (42 U.S.C. 1396a(a)(10)(C)) is amended, in the matter before clause (i), by inserting "or (E)" after "subparagraph (A)". (2) PAYMENT OF MEDICARE PREMIUMS AND PART A DEDUCT-

1

IBLE.—Section 1903(a)(1) of such Act (42 U.S.C. 1396b(a)(l)) is amended— (A) by inserting "deductible amounts under part A and" after "(including expenditures for", (B) by inserting "(and, in the case of qualified medicare beneficiaries described in section 1905(p)(l), part A)" after "premiums under part B", and (C) by striking "or (B)" and inserting "(B) are qualified medicare beneficiaries described in section 1905(p)(l), or (C)".

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100 STAT. 2056

(3) TIMING OF BENEFITS.—Section 1905(a) of such Act (42 U.S.C. 1396d(a)) is amended, in the matter before subdivision (i), by inserting "or, in the case of a qualified medicare beneficiary described in subsection (p)(l), if provided after the month in which the individual becomes such a beneficiary" after "makes application for assistance". (4) COPAYMENTS.—

42 USC 1396a note. 42 USC 1396.

(A) Section 1902(a)(15) of such Act (42 U.S.C. 1396a(a)(15)) is amended by inserting "are not qualified medicare bene:niA ficiaries (as defined in section 1905(p)(l)) but" after "older who". (fv A (B) Subsections (a) and (b) of section 1916 of such Act (42 U.S.C. 1396o) are each amended by striking "section 1902(a)(10)(A)" and inserting "subparagraph (A) or (E) of section 1902(a)(10)". (h) EFFECTIVE DATE.—The amendments made by this section apply to payments under title XIX of the Social Security Act for calendar quarters beginning on or after July 1, 1987, without regard to whether or not final regulations to carry out such amendments have been promulgated by such date. SEC. 9404. MEDICAID ELIGIBILITY FOR QUALIFIED SEVERELY IMPAIRED INDIVIDUALS. (a) As CATEGORICALLY NEEDY.—Section 1902(a)(10)(A)(i)(II) of the

Social Security Act (42 U.S.C. 1396a(a)(10)(A)(i)(II)) is amended by inserting "or who are qualified severely impaired individuals (as defined in section 1905(q))" after "title XVI". (b) DESCRIPTION OF QUALIFIED SEVERELY IMPAIRED INDIVIDUALS.—

42 USC 1382. 42 USC 1382e. 42 USC 1382 note. 42 USC 1382h. State and local governments.

42 USC 1381.

Section 1905 of such Act (42 U.S.C. 1396d), as amended by section 9403(b) of this subtitle, is amended by adding at the end the following new subsection: "(q) The term 'qualified severely impaired individual' means an individual under age 65— "(1) who for the month preceding the first month to which this subsection applies to such individual— "(A) received (i) a payment of supplemental security income benefits under section 1611(b) on the basis of blindness or disability, (ii) a supplementary payment under section 1616 of this Act or under section 212 of Public Law 93-66 on such basis, (iii) a payment of monthly benefits under section 1619(a), or (iv) a supplementary payment under section 1616(c)(3), and "(B) was eligible for medical assistance under the State plan approved under this title; and "(2) with respect to whom the Secretary determines that— "(A) the individual continues to be blind or continues to '£^1^ have the disabling physical or mental impairment on the basis of which he was found to be under a disability and, except for his earnings, continues to meet all non-disabilityA related requirements for eligibility for benefits under title XVI, "(B) the income of such individual would not, except for his earnings, be equal to or in excess of the amount which would cause him to be ineligible for payments under section 16110?) (if he were otherwise eligible for such payments),

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100 STAT. 2057

"(C) the lack of eligibility for benefits under this title would seriously inhibit his ability to continue or obtain employment, and "(D) the individual's earnings are not sufficient to allow him to provide for himself a reasonable equivalent of the benefits under title XVI (including any federally administered State supplementary payments), this title, and publicly funded attendant care services (including personal care assistance) that would be available to him in the absence of such earnings. In the case of an individual who is eligible for medical assistance pursuant to section 1619(b) in June, 1987, the individual shall be a qualified severely impaired individual for so long as such individual meets the requirements of paragraph (2).". (c) EFFECTIVE DATE.—(1) The amendments made by this section apply (except as provided under paragraph (2)) to payments under title XIX of the Social Security Act for calendar quarters beginning on or after July 1, 1987, without regard to whether regulations to implement such amendments are promulgated by such date. (2) In the case of a State plan for medical assistance under title XIX of the Social Security Act which the Secretary of Health and Human Services determines requires State legislation (other than legislation appropriating funds) in order for the plan to meet the additional requirements imposed by the amendments made by this section, the State plan shall not be regarded as failing to comply with the requirements of such title solely on the basis of its failure to meet these additional requirements before the first day of the first calendar quarter beginning after the close of the first regular session of the State legislature that begins after the date of the enactment of this Act.

State and local governments. 42 USC 1381.

42 USC 1382h. 42 USC 1396a note. 42 USC 1396. -^' State and local governments.

•JcU ^ •

SEC. 9405. CLARIFICATION OF ELIGIBILITY OF HOMELESS INDIVIDUALS.

Section 1902(b)(2) of the Social Security Act (42 U.S.C. 1396a(b)(2)) is amended by inserting before the semicolon the following: ", regardless of whether or not the residence is maintained permanently or at a fixed address". SEC. 9406. PAYMENT FOR ALIENS UNDER MEDICAID.

(a) IN GENERAL.—Section 1903 of the Social Security Act (42 U.S.C. 1396b) is amended by adding at the end thereof the following new subsection: "(v)(1) Notwithstanding the preceding provisions of this section, except as provided in paragraph (2), no payment may be made to a State under this section for medical assistance furnished to an alien who is not lawfully admitted for permanent residence or otherwise permanently residing in the United States under color of law. "(2) Payment shall be made under this section for care and services that are furnished to an alien described in paragraph (1) only if— "(A) such care and services are necessary for the treatment of an emergency medical condition of the alien, and "(B) such alien otherwise meets the eligibility requirements for medical assistance under the State plan approved under this title (other than the requirement of the receipt of aid or assistance under title IV, supplemental security income benefits under title XVI, or a State supplementary payment).

State and local governments.

42 USC 601. 42 USC 1381.

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 100 STAT. 2058

i State and local governments. ,r' .T.p 42 USC 1396a note.

ii- b. ^''

PUBLIC LAW 99-509—OCT. 21, 1986

"(3) For purposes of this subsection, the term 'emergency medical condition' means a medical condition (including emergency labor and delivery) manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in— "(A) placing the patient's health in serious jeopardy, "(B) serious impairment to bodily functions, or "(C) serious dysfunction of any bodily organ or part.". (b) CONFORMING AMENDMENT.—Section 1902(a) of such Act (42 U.S.C. 1396a(a)) is amended by adding at the end thereof the following new sentence: "Notwithstanding paragraph (10)(B) or any other provision of this subsection, a State plan shall provide medical assistance with respect to an alien who is not lawfully admitted for permanent residence or otherwise permanently residing in the United States under color of law only in accordance with section 1903(v).". (c) EFFECTIVE DATE.—

42 USC 1396.

(1) Except as provided in paragraph (2), the amendments made by this section shall apply to medical assistance furnished to aliens on or after January 1, 1987, without regard to whether or not final regulations to carry out such amendments have been promulgated by such date. (2) In the case of a State plan for medical assistance under title XIX of the Social Security Act which the Secretary of Health and Human Services determines requires State legislation (other than legislation appropriating funds) in order for the plan to meet the additional requirement imposed by the amendment made in subsection (b), the State plan shall not be regarded as failing to comply with the requirements of such title solely on the basis of its failure to meet such additional requirement before the first day of the first calendar quarter beginning after the close of the first regular session of the State legislature that begins after the date of the enactment of this Act. SEC. 9407. OPTIONAL PRESUMPTIVE ELIGIBILITY PERIOD FOR PREGNANT WOMEN. (a) STATE OPTION.—Section 1902(a) of such Act (42 U.S.C. 1396a(a))

.,. < ^
 * /i c - /

is amended— (1) by striking "and" at the end of paragraph (45), (2) by striking the period at the end of paragraph (46) and inserting in lieu thereof "; and", and (3) by adding at the end the following: "(47) at the option of the State, provide for making ambulatory prenatal care available to pregnant women during a presumptive eligibility period in accordance with section 1920.". (b) PRESUMPTIVE ELIGIBILITY.—Title XIX of the Social Security Act

42 USC 1396s.

is amended by redesignating section 1920 as section 1921 and inserting after section 1919 the following new section: i^, ^, ^.

42 USC 1396r-l.

PRESUMPTIVE ELIGIBILITY FOR P R E G N A N T WOMEN

"SEC. 1920. (a) A State plan approved under section 1902 may provide for making ambulatory prenatal care available to a pregnant woman during a presumptive eligibility period. "(b) For purposes of this section— "(1) the term 'presumptive eligibility period' means, with respect to a pregnant woman, the period that—

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100 STAT. 2059

"(A) begins with the date on which a qualified provider determines, on the basis of preliminary information, that the family income of the woman does not exceed the applicable income level of eligibility under the State plan, and "(B) ends with (and includes) the earlier of— aty "(i) the day on which a determination is made with respect to the eligibility of the woman for medical Wi I1&: assistance under the State plan, "(ii) the day that is 45 days after the date on which the provider makes the determination referred to in subparagraph (A), or "(iii) in the case of a woman who does not file an application for medical assistance within 14 calendar days after the date on which the provider makes the determination referred to in subparagraph (A), the fourteenth calendar day after such determination is t made; and "(2) the term 'qualified provider' means any provider that— "(A) is eligible for payments under a State plan approved under this title, «' "(B) provides services of the type described in subparagraph (A) or (B) of section 1905(a)(2) or in section 1905(a)(9), "(C) is determined by the State agency to be capable of making determinations of the type described in paragraph (1)(A), and "(D)(i) receives funds under— zs 3l "(I) section 329 or section 330 of the Public Health Service Act, or "(II) title V of this Act; tiO' "(ii) participates in a program established under— "(I) section 17 of the Child Nutrition Act of 1966, or f "(II) section 4(a) of the Agriculture and Consumer 2 Protection Act of 1973; or "(iii) participates in a State perinatal program. "(c)(1) The State agency shall provide qualified providers with— "(A) such forms as are necessary for a pregnant woman to I make application for medical assistance under the State plan, I and "(B) information on how to assist such women in completing n and filing such forms. "(2) A qualified provider that determines under subsection (b)(1)(A) that a pregnant woman is presumptively eligible for medical assistance under a State plan shall— "(A) notify the State agency of the determination within 5 working days after the date on which determination is made, and "(B) inform the woman at the time the determination is made that she is required to make application for medical assistance under the State plan within 14 calendar days after the date on which the determination is made. "(3) A pregnant woman who is determined by a qualified provider to be presumptively eligible for medical assistance under a State plan shall make application for medical assistance under such plan within 14 calendar days after the date on which the determination is made.
 * r!'

42 USC 1396d.

42 USC 254b, 254c. 42 USC 701. 42 USC 1786. 42 USC 1446a.

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 100 STAT. 2060

42 USC 1396b.

Ante, p. 2058. 42 USC 1396a note.

PUBLIC LAW 99-509—OCT. 21, 1986

"(d) Notwithstanding any other provision of this title, ambulatory prenatal care that— "(1) is furnished to a pregnant woman— "(A) during a presumptive eligibility period, "(B) by a qualified provider; and "(2) is included in the care and services covered by a State plan; shall be treated as medical assistance provided by such plan for purposes of section 1903.". (c) CONFORMING CHANGE.—Section 1903(u)(l)(D) of such Act (42 U.S.C. 1396b(u)(l)(D)) is amended by adding at the end the following: "(v) In determining the amount of erroneous excess payments, there shall not be included any erroneous payments made for ambulatory prenatal care provided during a presumptive eligibility period (as defined in section 1920(b)(1)).". (d) EFFECTIVE DATE.—The amendments made by this section shall apply to ambulatory prenatal care furnished in calendar quarters beginning on or after April 1, 1987, without regard to whether or not final regulations to carry out such amendments have been promulgated by such date. SEC. 9408. RESPIRATORY CARE SERVICES FOR VENTILATOR-DEPENDENT INDIVIDUALS.

42 USC 1396a. State and local governments.

Health care facilities.

(a) REQUIRED SERVICES.—Section 1902(e) of the Social Security Act (42 U.S.C. 1396b(e)), as amended by sections 9401(d) and 9403(f) of this subtitle, is further amended by adding at the end the following new paragraph: "(9)(A) At the option of the State, the plan may include as medical assistance respiratory care services for any individual who— "(i) is medically dependent on a ventilator for life support ^' at least six hours per day; iax<., "(ii) has been so dependent for at least 30 consecutive days (or the maximum number of days authorized under the State plan, whichever is less) as an inpatient; — f< "(iii) but for the availability of respiratory care services, would require respiratory care as an inpatient in a hospital, skilled nursing facility, or intermediate care facility, and would be eligible to have payment made for such inpatient care under the State plan; "(iv) has adequate social support services to be cared for >- • ' ' ' at home; and "(v) wishes to be cared for at home. "(B) The requirements of subparagraph (A)(ii) may be satisfied by a continuous stay in one or more hospitals, skilled ,- nursing facilities, or intermediate care facilities. "(C) For purposes of this paragraph, respiratory care services means services provided on a part-time basis in the home of the individual by a respiratory therapist or other health care professional trained in respiratory therapy (as determined by the State), payment for which is not otherwise included within other items and services furnished to such individual as medical assistance under the plan.". (b) WAIVER OF COMPARABILITY.—Section 1902(a)(10) of such Act (42 U.S.C. 1396a(a)(10)), as amended by sections 9401(c), 9403(a), and
 * u^'

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100 STAT. 2061

9403(c) of this subtitle, is further amended, in the matter following subparagraph (E)— (1) by striking "and" before "(VIII)"; and (2) by inserting before the semicolon at the end thereof the following: ", and (IX) the making available of respiratory care services in accordance with subsection (e)(9) shall not, by reason of this paragraph (10), require the making available of such services, or the making available of such services of the same amount, duration, and scope, to any individuals not included under subsection (e)(9)(A), provided such services are made available (in the same amount, duration, and scope) to all individuals described in such subsection". (c) CONFORMING CHANGES.—

(1) Section 1905(a) of the Social Security Act (42 U.S.C. 1395d(a)), as amended by section 1895(c)(3) of the Tax Reform Act of 1986, is further amended— Ante, p. 2931. (A) by striking "and" at the end of paragraph (19), (B) by redesignating paragraph (20) as paragraph (21), and ' ' (C) by inserting after paragraph (19) the following new paragraph: "(20) respiratory care services (as defined in section 1902(e)(9)(C)); and". Ante, p. 2060. (2) Section 19020") of the Social Security Act (42 U.S.C. 1396a(j)), as amended by section 1895(c)(3) of the Tax Reform Act of 1986, is amended by striking "(20)" and inserting in lieu thereof "(21)". (3) Section 1902(a)(10XCXiv) of the Social Security Act (42 U.S.C. 1396a(a)(10XCXiv)), as amended by section 1895(c)(3) of the Tax Reform Act of 1986, is amended by striking "through (19)" and inserting in lieu thereof "through (20)". (d) EFFECTIVE DATE.—The amendments made by this section shall 42 USC 1396a apply to services furnished on or after the date of the enactment of note. this Act.

PART 2—PROVISION OF SERVICES UNDER WAIVER AUTHORITY SEC. 9411. PERMITTING STATES TO OFFER HOME AND COMMUNITYBASED SERVICES TO CERTAIN LOW-INCOME INDIVIDUALS. (a) WAIVER AUTHORITY.—

(1) Section 1915(c)(l) of the Social Security Act (42 U.S.C. 1396n(c)(l)) is amended— (A) by inserting "a hospital or" after "level of care provided in", and (B) by striking out all beginning with "or but for" through "State plan" the third place it appears. (2) Section 1915(c)(2)(B) of such Act is amended— (A) in clause (i) by striking "skilled nursing facility or" and inserting in lieu thereof "inpatient hospital, skilled nursing facility, or", and (B) in the matter following clause (iii) by inserting 1 "inpatient hospital," after "need for". • (3) Section 1915(c)(7) of such Act is amended to read as follows: "(7) In making estimates under paragraph (2)(D) in the case of a waiver that applies only to individuals with a particular illness or

Health care facilities.

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 100 STAT. 2062

PUBLIC LAW 99-509—OCT. 21, 1986

condition who are inpatients in hospitals or in skilled nursing or intermediate care facilities, the State may determine the average per capita expenditure that would have been made in a fiscal year for those individuals under the State plan separately from the expenditures for other individuals who are inpatients of those respective facilities.". State and local governments. AIDS. 42 USC 1396n.

Ante, pp. 203, 204. 42 USC 1396a.

(b) PROVIDING CASE MANAGEMENT SERVICES TO PATIENTS WITH CERTAIN CONDITIONS.—Section 1915(g)(1) of such Act is amended by

adding at the end the following: "A State may limit the provision of case management services under this subsection to individuals with acquired immune deficiency syndrome (AIDS), or with AIDS-related conditions, or with either, and a State may limit the provision of case management services under this subsection to individuals with chronic mental illness.". (c) WAIVER OF COMPARABILITY REQUIREMENT.—The first sentence of section 1915(c)(3) of such Act is amended by striking all that follows "statewideness)" and inserting "and section 1902(a)(10)(B) (relating to comparability).". (d) PROVIDING CERTAIN OTHER SERVICES TO PATIENTS WITH CHRONIC MENTAL ILLNESS.—Section 1915(c)(4)(B) of such Act is

Aj'.; / i;

42 USC 1396n note.

amended by inserting before the period at the end the following: "and for day treatment or other partial hospitalization services, psychosocial rehabilitation services, and clinic services (whether or not furnished in a facility) for individuals with chronic mental illness". (e) EFFECTIVE DATE.—The amendments made by this section shall apply to applications for waivers (or renewals thereof) approved on or after the date of the enactment of this Act. SEC. 9412. WAIVER AUTHORITY FOR CHRONICALLY MENTALLY ILL AND FRAIL ELDERLY. (a) CHRONICALLY MENTALLY III DEMONSTRATION PROGRAM.—

State and local governments. 42 USC 1396.

Grants.

(1) The Secretary of Health and Human Services may, in accordance with this subsection, waive certain provisions of title XIX of the Social Security Act in order to allow States to implement demonstration programs to improve the continuity, quality, and cost-effectiveness of mental health services available to chronically mentally ill medicaid beneficiaries. (2) A waiver shall be granted under this subsection with ' respect to a demonstration program only if— (A) the demonstration program has been awarded a grant r K ^: from the Robert Wood Johnson Foundation and the Department of Housing and Urban Development under their <Kff; "Program for the Chronically Mentally 111", (B) the State provides assurances satisfactory to the Secretary that under such waiver— (i) the average per capita expenditure estimated by the State in any fiscal year for medical assistance for mental health services provided with respect to individuals covered under the program does not exceed 100 percent of the average per capita expenditure that the "UfMt^'^^c: State reasonably estimates would have been made in that fiscal year for expenditures under the State plan for such services for such individuals if the waiver had not been granted, and

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Page:United States Statutes at Large Volume 100 Part 3.djvu/255

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100 STAT. 2063

^'

(ii) there will be no reduction or limitation in benefits to a medicaid beneficiary under the program. (3) The authority under this subsection extends only to the following, as they relate to the provision of mental health services: (A) A waiver of the requirements of sections 1902(a)(l), 1902(a)(10)(B), 1902(a)(23), and 1902(a)(30) and clauses (i) and 42 USC 1396a, (ii) of section 1903(m)(2) of the Social Security Act. (B) Including as "medical assistance" under the State 1396b. plan case management services with respect to mentally ill patients, habilitation services (as defined in section 1915(c)(5) of such Act), day treatment or other partial hos- 42 USC 1396n. -af,; pitalization services, residential services (other than room and board), psychosocial rehabilitation services, clinic services (whether or not furnished in a facility), and such other services as the State may request and the Secretary may approve for individuals covered under the demonstration project. (4)(A) A waiver under this subsection shall be for an initial term of three years which may be extended for an additional two-year term. The request of a State for extension of such a waiver shall be deemed granted unless the Secretary denies such request in writing within 90 days after the date of its submission to the Secretary. (B) The authority to approve a waiver under this subsection extends only during the five-year period beginning on October 1, 1986. (5) Subsections (c)(6) and (e)(1) of section 1915 of the Social Security Act shall apply to a waiver under this subsection in the same manner as they apply to a waiver under that section. (6) The Secretary shall report, not later than January 1, 1993, Reports. to Congress on the cost, accessibility, utilization, and quality of services provided under waivers granted under this subsection, (b) FRAIL ELDERLY DEMONSTRATION PROJECT WAIVERS.—

"

t'

(1) The Secretary of Health and Human Services shall grant waivers of certain requirements of titles XVIII and XIX of the Social Security Act to not more than 10 public or nonprofit private community-based organizations to enable such organizations to provide comprehensive health care services on a capitated basis to frail elderly patients at risk of institutionalization. (2)(A) Except as provided in subparagraph (B), the terms and conditions of a waiver granted pursuant to this subsection shall be substantially the same as the terms and conditions of the On Lok waiver (referred to in section 603(c) of the Social Security Amendments of 1983 and extended by section 9220 of the Consolidated Omnibus Budget Reconciliation Act of 1985). (B) In order to receive a waiver under this subsection, an organization must be awarded a grant from the Robert Wood Johnson Foundation. (C) Subject to subparagraph (B), any waiver granted pursuant to this subsection shall be for an initial period of 3 years. The Secretary may extend such waiver beyond such initial period for so long as the Secretary finds that the organization complies with the terms and conditions described in subparagraphs (A) and (B).

42 USC 1395, 1396.

42 USC 1395b-l notes. Ante, p. 183. Grants.

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Page:United States Statutes at Large Volume 100 Part 3.djvu/256

 100 STAT. 2064

PUBLIC LAW 99-509—OCT. 21, 1986

SEC. 9413. CONTINUATION OF "CASE-MANAGED MEDICAL CARE FOR NURSING HOME PATIENTS" DEMONSTRATION PROJECT. Massachusetts. 42 USC 1395, 1396.

42 USC 1315.

(a) APPROVAL OF APPLICATION.—The Secretary of Health and Human Services shall approve any application for a waiver of any requirement of title XVIII or XIX of the Social Security Act necessary to provide for continuation, from July 1, 1987, through June 30, 1989, of the "Case-Managed Medical Care for Nursing Home Patients" demonstration project (#95-P-98346/l-01) carried out pursuant to section 222 of the Social Security Amendments of 1972, section 402 of the Social Security Amendments of 1967, and section 1115 of the Social Security Act by the Department of Public Welfare, Commonwealth of Massachusetts. (b) TERMS AND CONDITIONS.—The Secretary's approval of an ap-

plication (or renewal of an application) under subsection (a) shall be on the same terms and conditions as applied to the demonstration project on July 1, 1986. SEC. 9414. NEW JERSEY RESPITE CARE PILOT PROJECT. Handicapped persons. Aged persons.

contracts. State and local governments.

42 USC 1396.

42 USC 13960.

(a) ESTABLISHMENT.—The Secretary of Health and Human Services (in this section referred to as the "Secretary") shall enter into an agreement with the State of New Jersey (in this section referred to as the "State") for the purpose of conducting a pilot project (in this section referred to as the "project") under title XIX of the Social Security Act for providing respite care services for elderly and disabled individuals in order to determine the extent to which— (1) the provision of necessary respite care services to individuals at risk of institutionalization will delay or avert the need for institutional care, and (2) respite care services enhance and sustain the role of the family in providing long-term care services for elderly and disabled individuals at risk of institutionalization. (b) CONDITIONS.—The agreement with the Secretary under this section shall— (1) provide that the project shall be administered by a State health services agency designated for such purpose by the Governor (which may be the State agency administering or responsible for the administration of the State plan for medical assistance under title XIX of the Social Security Act), (2) provide that if the project imposes any cost sharing f requirements on participants who are eligible for benefits under title XIX of the Social Security Act, such requirements shall be imposed only in accordance with the provisions of section 1916 of such Act, (3) provide for a system of review to assure that respite care services are provided only to individuals reasonably determined to be in need of such services, and (4) meet such other requirements as the Secretary may establish for the proper and efficient implementation of the project. (c) DEFINITION.—For purposes of this section, the term "respite care services" shall include— (1) short-term and intermittent— (A) companion or sitter services (paid as well as volunteer), (B) homemaker and personal-care services, (C) adult day care, and (D) inpatient care in a hospital, a skilled nursing facility, or an intermediate care facility (not to exceed a total of 14 days for any individual); and

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 PUBLIC LAW 99-509—OCT. 21, 1986

100 STAT. 2065

(2) peer support and training for family caregivers (using informal support groups and organized counseling). (d) PAYMENTS.—The agreement under this section shall be Contracts. entered into between the Secretary and the State agency designated State and local by the Governor. Under such agreement the Secretary shall pay to governments. Aged persons. the State, as in additional payment under section 1903 of the Social Handicapped Security Act for each quarter, an amount equal to 50 percent of the persons. reasonable costs incurred by such State during such quarter in 42 USC 1396b. providing respite care services under the project for elderly and disabled individuals who are eligible for medical assistance under the State plan approved under title XIX of such Act (or who would 42 USC 1396. be eligible if coverage under such plan was as broad as allowed under Federal law). The Federal payment shall not exceed $1,000,000 for fiscal year 1987, and $2,000,000 for each of the fiscal years 1988, 1989, and 1990. No payments shall be made pursuant to this section for any fiscal year beginning after September 30, 1990. (e) DURATION.—The project under this section shall be of a maxi- Reports. mum duration of four years, plus an additional time period of up to six months for final evaluation and reporting. (f) REPORTS.—The State shall arrange for an independent evaluation of the project and shall transmit the evaluation to the Secretary not more than six months after the conclusion of project. (g) PROVISIONS SUBJECT TO WAIVER.—At the request of the State, the Secretary shall waive the following provisions of title XIX of the Social Security Act as they relate to the pilot project: section 1902(a)(1), section 1902(a)(10)(B), section 1902(a)(13), and section 1902(a)(30). The Secretary may not waive any other provision of such 42 USC 1396a. title with respect to the pilot project. SEC. 9415. INAPPLICABILITY OF PAPERWORK REDUCTION ACT.

Notwithstanding any other provision of law, chapter 35 of title 44, United States Code, shall not apply to information required to carry out any provision of this part or the amendments made by this part.

44 USC 3501 et seq.

PART 3—PAYMENTS SEC. 9421. HOLDING STATES HARMLESS IN FISCAL YEAR 1987 AGAINST A DECREASE IN THE FEDERAL MEDICAL ASSISTANCE PERCENTAGE.

(a) IN GENERAL.—Section 9528 of the Consolidated Omnibus Budget Reconciliation Act of 1985 is amended by adding at the end the following new subsection: "(c) HOLD HARMLESS PROVISION.—Notwithstanding subsection (b), for calendar quarters occurring during fiscal year 1987 and only for purposes of making payment to a State under section 1903 of the Social Security Act, the amendments made by subsection (a) shall not apply to a State if the effect of the applying the amendments would be to reduce the amount of payment made to the State under that section.". (b) EFFECTIVE DATE.—The amendment made by subsection (a) shall be effective as though it had been included in the Consolidated Omnibus Budget Reconciliation Act of 1985 at the time of its enactment.

42 USC 1301 note. Ante, p. 1972.

42 USC 1396b.

42 USC 1301 note. Ante, p. 82.

SEC. 9422. WAIVER OF CERTAIN REQUIREMENTS.

Notwithstanding the three-month limitation set forth in sections 1902(a)(34) and 1905(a) of the Social Security Act, payment may be

South Carolina. 42 USC 1396a, 1396d.

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Page:United States Statutes at Large Volume 100 Part 3.djvu/258

 100 STAT. 2066 42 USC 1396.

42 USC 1396a. Women. State and local governments.

^

•

^

PUBLIC LAW 99-509—OCT. 21, 1986

made under title XIX of such Act with respect to care and services provided by the Medical University of South Carolina, after September 30, 1984, and before July 1, 1985, to individuals— (1) who are not described in section 1902(a)(10)(A) of such Act, (2) who, upon application, would have been eligible as individuals under the age of 18 or pregnant women, for medical assistance under the State plan approved under such title at the time such care and services were provided, and (3) who, not later than six months after the date of the enactment of this Act, are determined by the State agency administering or supervising the administration of such plan to have been so eligible. PART 4—OTHER QUALITY AND EFFICIENCY MEASURES

SjXoq^H

contracts. State and local governments. 42 USC 1320c. 42 USC 1396b.

42 USC 1396a note.

SEC. 9431. INDEPENDENT QUALITY REVIEW OF HMO SERVICES.

(a) IN GENERAL.—Section 1902(a)(30) of the Social Security Act (42 U.S.C. 1396a(a)(30)) is amended— (1) by inserting "and" at the end of subparagraph (B), and (2) by adding at the end the following new subparagraph: "(C) provide a utilization and quality control peer review organization (under part B of title XI) or a private accreditation body to conduct (on an annual basis) an independent, external review of the quality of services furnished under each contract under section 1903(m), with the results of such review made available to the State and, upon request, to the Secretary, the Inspector General in the Department of Health and Human Services, and the Comptroller General;". (b) CONFORMING AMENDMENTS.—(1) Section 1902(d) of such Act (42 U.S.C. 1396a(d)) is amended by inserting "(including quality review functions described in subsection (a)(30)(C))" after "medical or utilization review functions". (2) Section 1903(a)(3)(C) of such Act (42 U.S.C. 1396b(a)(3)(C)) is amended by inserting "or quality review" after "medical and utilization review". (c) EFFECTIVE DATE.—The amendments made by this section apply to payments under title XIX of the Social Security Act for calendar quarters beginning on or after July 1, 1987, without regard to whether or not final regulations to carry out such amendments have been promulgated by such date. SEC. 9432. STATE UTILIZATION REVIEW SYSTEMS.

Health care facilities. 42 USC 1396a note.

42 USC 1396.

(a) IN GENERAL.—The Secretary of Health and Human Services (in this section referred to as the "Secretary") may not, during the period beginning with the date of the enactment of this Act and ending with the date that is 180 days after the day on which the report required by subsection (b) is submitted to the Congress, publish final or interim final regulations requiring a State plan approved under title XIX of the Social Security Act to include a program requiring second surgical opinions or a program of inpatient hospital preadmission review. (b) REPORT.—

(1) The Secretary shall report to Congress, by not later than October 1, 1988, for each State in a representative sample of States—

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 PUBLIC LAW 99-509—OCT. 21, 1986

100 STAT. 2067

(A) the identity of those procedures which are high volume or high cost procedures among patients who are covered under the State medicaid plan, (B) the payment rates under those plans for such procedures, and the aggregate annual payment amounts made under such plans for such procedures (including the Federal share of such payment amounts), (C) the rate at which each such procedure is performed on medicaid patients and (to the extent that data are available) comparisons to the rate at which such procedure is performed on patients of comparable age who are not medicaid patients, (D) with respect to each such procedure— (i) the number of board certified or board eligible " physicians in the State who provide care and services to medicaid patients and who perform the procedure, and -¥#i*l (ii) in the case of a State with a mandatory second surgical opinion program in operation, the number of physicians described in clause (i) who provide second opinions (of the type described in section 1164 of the Social Security Act) for the procedure at prevailing payment rates under the State medicaid plan, and (E) in the case of a State with a mandatory second ' surgical opinion program or a program of inpatient hospital preadmission review in operation, a description of— (i) the extent to which such program impedes access to necessary care and services, and (ii) the measures that the State has taken to address such impediments, particularly in rural areas. (2) Such report shall also include a list of those surgical procedures which the Secretary believes meet the following criteria and for which a mandatory second opinion program under medicaid plans may be appropriate: (A) The procedure is one which generally can be postponed without undue risk to the patient. (B) The procedure is a high volume procedure among patients who are covered under State medicaid plans or is a high cost procedure. (C) The procedure has a comparatively high rate of cri,£ • nonconfirmation upon examination by another qualified physician, there is substantial geographic variation in the rates of performance of the procedure, or there are other ws,o reasons why requiring second opinions for 100 percent of such procedures would be cost effective. (3) The representative sample of States required to be included in the report shall include States with mandatory second surgical opinion programs in operation, States with programs of inpatient hospital preadmission review in operation, and States with neither such program in operation. (4) In this subsection, the term "medicaid plan ' means a State plan approved under title XIX of the Social Security Act. (c) STUDY.—

(1) The Secretary shall conduct a study of the utilization of selected medical treatments and surgical procedures by medicaid beneficiaries in order to assess the appropriateness, necessity, and effectiveness of such treatments and procedures. (2) The study shall analyze the extent to which there is significant variation in the rate of utilization by medicaid bene-

Health care professionals.

Ante, p. 196. Health care facilities.

Rural areas.

 * ic; c&

Health care professionals.

Health care facilities.

42 USC 1396.

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Page:A Collection of Several Philosophical Writings of Dr. Henry More.djvu/51

Rh

1. That the Pronenesse of these Ages of the World to winde themselves from under the awe of Superstition makes the attempt seasonable of endeavouring to steer them off from Atheisme. 2. That they that adhere to Religion in a mere superstitious and accustomary way, if that tye once fail, easily turn Atheists. 3. The usefulness of this present Treatise even to them that are seriously Religious.

grand Truth which we are now to be imployed about and to prove, is, That there is a God: And I made choice of this Subject as very seasonable for the Times we are in, and are coming on, wherein Divine Providence more universally loosening the minds of men from the awe and tyranny of mere accustomary Superstition, and permitting a freer perusal of matters of Religion then in former Ages, the Tempter would take advantage, where he may, to carry men captive out of one dark prison into another, out of Superstition into Atheism it self.

2. Which is a thing feasible enough for him to bring about in such men as have adhered to Religion in a mere externall way, either for fashion sake, or in a blinde obedience to the Authority of a Church. For when this externall frame of Godliness shall break about their ears, they being really at the bottome devoid of the true fear and love of God, and destitute of a more free and unprejudic'd use of their Faculties, by reason of the sinfulness and corruption of their natures, it will be an easy thing to allure them to an assent to that which seems so much for their present Interest; and so being imboldened by the tottering and falling of what they took for the chief Structure of Religion before, they will gladly in their conceit cast down also the very Object of that Religious Worship after it, and conclude that there is as well no God as no Religion; that is; they have a mind there should be none, that they may be free from all  Rh


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Page:United States Statutes at Large Volume 100 Part 3.djvu/260

 100 STAT. 2068

Research and development. Ante, p. 2006.

PUBLIC LAW 99-509—OCT. 21, 1986

ficiaries of selected treatments and procedures for different geographic areas within States and among States. (3) The study shall also identify underutilized, medically necessary treatments and procedures for which— (A) a failure to furnish could have an adverse effect on •u Ihealth status, and (B) the rate of utilization by medicaid beneficiaries is significantly less than the rate for comparable, age-adjusted populations. (4) The study shall be coordinated, to the extent practicable, with the research program established pursuant to section 1875(c) of the Social Security Act, with particular regard to the relationship of the variations described in paragraph (2) to patient outcomes. (5) The Secretary shall report the results of the study to the Congress not later than January 1, 1990. SEC. 9433. CLARIFICATION OF FLEXIBILITY FOR STATE MEDICAID PAYMENT SYSTEMS FOR INPATIENT SERVICES.

42 USC 1396a. 42 USC 1396a. Health care facilities. Disadvantaged persons. 42 USC 1396a note. 95 Stat. 357.

(a) IN GENERAL.—Section 2173 of the Omnibus Budget Reconciliation Act of 1981 (Public Law 97-35, 95 Stat. 809) is amended by adding at the end the following new subsection: "(d) Section 1902 of such Act is further amended by inserting before subsection (i) the following new subsection: " '(h) Nothing in this title (including subsections (a)(13) and (a)(30) of this section) shall be construed as authorizing the Secretary to limit the amount of payment adjustments that may be made under a plan under this title with respect to hospitals that serve a disproportionate number of low-income patients with special needs.' ". (b) EFFECTIVE DATE.—The amendment made by subsection (a) shall apply as though it was included in the enactment of the Omnibus Budget Reconciliation Act of 1981 (Public Law 97-35). SEC. 9434. FINANCIAL DISCLOSURE REQUIREMENTS FOR HMOS; CIVIL MONEY PENALTIES. (a) DISCLOSURE OF INTERLOCKING RELATIONSHIPS.—

contracts. 42 USC 1320a-3.

Reports. 42 USC 300e-9.

42 USC 300e-17.

(1) Section 1903(m) of the Social Security Act (42 U.S.C. ^.. 1396b(m)) is amended— (A) in paragraph (2)(A)— (i) by striking "and" at the end of clause (vi), (ii) by striking the period at the end of clause (vii) and inserting ", and", and (iii) by adding after clause (vii) the following new i''^ clause: "(viii) such contract provides for disclosure of information in accordance with section 1124 and paragraph (4) of this subsection."; and (B) by adding at the end the following new paragraph: "(4)(A) Each health maintenance organization which is not a qualified health maintenance organization (as defined in section 1310(d) of the Public Health Service Act) must report to the State and, upon request, to the Secretary, the Inspector General of the Department of Health and Human Services, and the Comptroller General a description of transactions between the organization and a party in interest (as defined in section 1318(b) of such Act), including the following transactions: ••.18

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100 STAT. 2069

"(i) Any sale or exchange, or leasing of any property between the organization and such a party. "(ii) Any furnishing for consideration of goods, services (including management services), or facilities between the organization and such a party, but not including salaries paid to employees for services provided in the normal course of their employment. "(iii) Any lending of money or other extension of credit between the organization and such a party. The State or Secretary may require that information reported respecting an organization which controls, or is controlled by, or is under common control with, another entity be in the form of a consolidated financial statement for the organization and such entity. "(B) Each organization shall make the information reported pursuant to subparagraph (A) available to its enrollees upon reasonable request.". (2) Section 1903(m)(2)(A)(iii) of the Social Security Act (42 U.S.C. 1396b(m)(2)(A)(iii)) is amended by inserting before the semicolon the following: "and under which the Secretary must provide prior approval for contracts providing for expenditures in excess of $100,000". (3)(A) The amendments made by paragraph (1) shall take effect 6 months after the date of the enactment of this Act. (B) The amendment made by paragraph (2) shall take effect on the date of the enactment of this Act and shall apply to contracts entered into, renewed, or extended after the end of the 30-day period beginning on the date of the enactment of this Act.

Gifts and property.

State and local governments.

Contracts.

Effective date. Contracts. 42 USC 1396b note.

O> CIVIL MONEY PENALTIES.—Section 1903(m) of the Social Secut)

rity Act, as amended by subsection (a), is further amended by adding at the end the following new paragraph: "(5)(A) Any entity with a contract under this subsection that fails Contracts. substantially to provide medically necessary items and services that are required (under law or such contract) to be provided to individuals covered under such contract, if the failure has adversely affected (or has a substantial likelihood of adversely affecting) these individuals, is subject to a civil money penalty of not more than $10,000 for each such failure. "(B) The provisions of section 1128A (other than subsection (a)) Ante, pp. 2003, shall apply to a civil money penalty under subparagraph (A) in the 2008. same manner as they apply to a civil money penalty under that section.". SEC. 9435. COBRA TECHNICAL CORRECTIONS AND CLARIFICATIONS RELATING TO THE MEDICAID PROGRAM.

(a) MAINTENANCE INCOME STANDARDS.—Section 9502(j)(4) of the 42 USC 1396n Consolidated Omnibus Budget Reconciliation Act of 1985 is amended note. by striking out "on or after" and inserting in lieu thereof "before, Ante, p. 202. on, or after". ^ (b) HOSPICE CARE FOR DUAL ELIGIBLES.—

^

(1) Section 1902(a)(13XD) of the Social Security Act, as amended by sections 9505(c)(l) and 9509(a)(4) of the Consolidated Omnibus Budget Reconciliation Act of 1985, is amended by inserting before the first semicolon the following: "and for pa3niient of amounts under section 1905(o)(3)".

42 USC 1396a. Ante, pp. 208, 211. 42 USC 1396d.

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Page:United States Statutes at Large Volume 100 Part 3.djvu/262

 100 STAT. 2070

PUBLIC LAW 99-509—OCT. 21, 1986

,^,

Ante, p. 208. State and local governments.

42 USC 1395c. 42 USC 1395d.

42 USC 1396a. 42 USC 1395e.

42 USC 1396a note. Ante, p. 210. Handicapped persons.

Ante, pp. 208, 210.

Ante, p. 212.

42 USC 1396b note. Ante, p. 2931.

(2) Section 1905(o) of the Social Security Act, as amended by section 9505(a)(2) of the Consolidated Omnibus Budget Reconciliation Act of 1985, is amended by adding at the end the following new paragraph: "(3) In the case of a State which elects not to provide medical ^ assistance for hospice care, but provides medical assistance for skilled nursing or intermediate care facility services with rej spect to an individual— "(A) who is residing in a skilled nursing or intermediate care facility and is receiving medical assistance for services in such facility under the plan, "(B) who is entitled to benefits under part A of title XVIII and has elected, under section 1812(d), to receive hospice care under such part, and "(C) with respect to whom the hospice program under such title and the skilled nursing or intermediate care facility have entered into a written agreement under which y the program takes full responsibility for the professional management of the individual's hospice care and the facility agrees to provide room and board to the individual, ^, instead of any payment otherwise made under the plan with respect to the facility'services, the State shall provide for payment to the hospice program of an amount equal to the amounts allocated under the plan for room and board in the facility, in accordance with the rates established under section 1902(a)(13), and, if the individual is an individual described in section 1902(a)(10)(A), shall provide for payment of any coinsurance amounts imposed under section 1813(a)(4). For purposes of this paragraph and section 1902(a)(13)(D), the term 'room and board' includes performance of personal care services, including assistance in activities of daily living, in socializing activities, administration of medication, maintaining the cleanliness of a resident's room, and supervising and assisting in the use of durable medical equipment and prescribed therapies.". (c) MEDICAID QUALIFYING TRUSTS.—Section 9506 of the Consolidated Omnibus Budget Reconciliation Act of 1985 is amended by adding at the end the following new subsection: "(c) EXCEPTION.—The amendment made by subsection (a) shall not apply to any trust or initial trust decree established prior to April 7, 1986, solely for the benefit of a mentally retarded individual who resides in an intermediate care facility for the mentally retarded.". (1) Sections 9505(e) and 9508(b) of the Consolidated Omnibus Budget Reconciliation Act of 1985 are each amended by insert• ing before the period at the end the following: ", without regard to whether or not regulations to carry out the amendments have been promulgated by that date". (2) Sections 9510(b) and 9511(b) of the Consolidated Omnibus Budget Reconciliation Act of 1985 are each amended by inserting before the period at the end the following: ", without regard to whether or not regulations to carry out the amendment have been promulgated by that date". (e) HEALTH INSURING ORGANIZATIONS.—Section 9517(c)(2) of the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended by section 1895(c)(4) of the Tax Reform Act of 1986, is amended by adding at the end the following new subparagraph:

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