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 PUBLIC LAW 97-248—SEPT. 3, 1982 zation shall be entitled to receive payments from the Secretary under this title for services furnished to the individual. "(b) For purposes of this section, the term 'eligible organization' means a public or private entity (which may be a health maintenance organization or a competitive medical plan), organized under the laws of any State, which— "(1) is a qualified health maintenance organization (as defined in section 1310(d) of the Public Health Service Act), or "(2) meets the following requirements: "(A) The entity provides to enrolled members at least the following health care services: "(i) Physicians' services performed by physicians (as defined in section 1861(r)(l)). "(ii) Inpatient hospital services, "(iii) Laboratory, X-ray, emergency, and preventive services. "(iv) Out-of-area coverage. "(B) The entity is compensated (except for deductibles, coinsurance, and copayments) for the provision of health care services to enrolled members by a payment which is paid on a periodic basis without regard to the date the health care services are provided and which is fixed without regard to the frequency, extent, or kind of health care service actually provided to a member. "(C) The entity provides physicians' services primarily (i) directly through physicians who are either employees or partners of such organization, or (ii) through contracts with individual physicians or one or more groups of physicians (organized on a group practice or individual practice basis). "(D) The entity assumes full financial risk on a prospective basis for the provision of the health care services listed in paragraph (1), except that such entity may— "(i) obtain insurance or make other arrangements for the cost of providing to any enrolled member health care services listed in subparagraph (A) the aggregate value of which exceeds $5,000 in any year, "(ii) obtain insurance or make other arrangements for the cost of health care service listed in subparagraph (A) provided to its enrolled members other than through the entity because medical necessity required their provision before they could be secured through the entity, "(iii) obtain insurance or make other arrangements for not more than 90 percent of the amount by which its costs for any of its fiscal years exceed 115 percent of its income for such fiscal year, and "(iv) make arrangements with physicians or other health professionals, health care institutions, or any combination of such individuals or institutions to assume all or part of the financial risk on a prospective basis for the provision of basic health services by the physicians or other health professionals or through the institutions. "(E) The entity has made adequate provision against the risk of insolvency, which provision is satisfactory to the Secretary.

<)7-5'nn O—R4—nt 1

l.S: OL3

96 STAT. 343

"Eligible organization."

42 USC 300e-9.

42 USC 1395x.

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 96 STAT. 344

42 USC 1396.

42 USC 1301. 42 USC 1395c, ^^^^J-

PUBLIC LAW 97-248—SEPT. 3, 1982 Paragraph (2)(A)(ii) shall not apply to an entity which had contracted with a single State agency administering a State plan approved under title XIX for the provision of services (other than inpatient hospital services) to individuals eligible for such services under such State plan on a prepaid risk basis prior to 1970. "(c)(1) The Secretary may not enter into a contract under this section with an eligible organization unless it meets the requirements of this subsection and subsection (e) with respect to members enrolled under this section. "(2) The organization must provide to members enrolled under this section, through providers and other persons that meet the applicable requirements of this title and part A of title XI— "(A) only those services covered under parts A and B of this title, for those members entitled to benefits under part A and enrolled under part B, or "(B) only those services covered under part B, for those members enrolled only under such part, which are available to individuals residing in the geographic area served by the organization, except that (i) the organization may provide such members with such additional health care services as the members may elect, at their option, to have covered, and (ii) in the case of an organization with a risk-sharing contract, the organization may provide such members with such additional health care services as the Secretary may approve. The Secretary shall approve any such additional health care services which the organization proposes to offer to such members, unless the Secretary determines that including such additional services will substantially discourage enrollment by covered individuals with the organization. "(3)(A) Each eligible organization must have an open enrollment period, for the enrollment of individuals under this section, of at least 30 days duration every year, and must provide that at any time during which enrollments are accepted, the organization will accept up to the limits of its capacity (as determined by the Secretary) and without restrictions, except as may be authorized in regulations, individuals who are eligible to enroll under subsection (d) in the order in which they apply for enrollment, unless to do so would result in failure to meet the requirements of subsection (f) or would result in the enrollment of enrollees substantially nonrepresentative, as determined in accordance with regulations of the Secretary, of the population in the geographic area served by the organization. "(B) An individual may enroll under this section with an eligible organization in such manner as may be prescribed in regulations and may terminate his enrollment with the eligible organization as of the beginning of the first calendar month following a full calendar month after the request is made for such termination (or, in the case of financial insolvency of the organization, as may be prescribed by regulations) or, in the case of such an organization with a reasonable cost reimbursement contract, as may be prescribed by regulations. "(C) The Secretary may prescribe the procedures and conditions under which an eligible organization that has entered into a contract with the Secretary under this subsection may inform individuals eligible to enroll under this section with the organization about the organization, or may enroll such individuals with the organization. "(D) The organization must provide assurances to the Secretary that it will not expel or refuse to re-enroll any such individual

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Page:United States Statutes at Large Volume 96 Part 1.djvu/387

 PUBLIC LAW 97-248-SEPT. 3, 1982

96 STAT. 345

because of the individual's health status or requirements for health care services, and that it will notify each such individual of such fact at the time of the individual's enrollment. "(4) The organization must— "(A) make the services described in paragraph (2) (and such other health care services as such individuals have contracted for)(i) available and accessible to each such individual, within the area served by the organization, promptly as appropriate and in a manner which assures continuity, and (ii) when medically necessary, available and accessible twenty-four hours a day and seven days a week, and (B) provide for reimbursement with respect to services which are described in subparagraph (A) and which are provided to such an individual other than through the organization, if (i) the services were medically necessary and immediately required because of an unforeseen illness, injury, or condition and (ii) it was not reasonable given the circumstances to obtain the services through the organization. "(5)(A) The organization must provide meaningful procedures for hearing and resolving grievances between the organization (including any entity or individual through which the organization provides health care services) and members enrolled with the organization under this section. "(B) A member enrolled with an eligible organization under this section who is dissatisfied by reason of his failure to receive any health service to which he believes he is entitled and at no greater charge than he believes he is required to pay is entitled, if the amount in controversy is $100 or more, to a hearing before the Secretary to the same extent as is provided in section 205(b), and in 42 USC 405. any such hearing the Secretary shall make the eligible organization a party. If the amount in controversy is $1,000 or more, the individual or eligible organization shall, upon notifying the other party, be entitled to judicial review of the Secretary s final decision as provided in section 205(g), and both the individual and the eligible organization shall be entitled to be parties to that judicial review. "(6) The organization must have arrangements, established in accordance with regulations of the Secretary, for an ongoing quality assurance program for health care services it provides to such individuals, which program (A) stresses health outcomes and (B) provides review by physicians and other health care professionals of the process followed in the provision of such health care services. "(d) Subject to the provisions of subsection (c)(3), every individual entitled to benefits under part A and enrolled under part B or 42 USC 1395c, enrolled under part B only (other than an individual medically 1395j. determined to have end-stage renal disease) shall be eligible to enroll under this section with any eligible organization with which the Secretary has entered into a contract under this section and which serves the geographic area in which the individual resides. "(e)(1) In no case may— "(A) the portion of an eligible organization's premium rate and the actuarial value of its deductibles, coinsurance, and copayments charged (with respect to services covered under parts A and B) to individuals who are enrolled under this section with the organization and who are entitled to benefits under part A and enrolled under part B, or "(B) the portion of its premium rate and the actuarial value of its deductibles, coinsurance, and copayments charged (with

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Page:United States Statutes at Large Volume 96 Part 1.djvu/388

 96 STAT. 346

42 USC 1395c, 1395J.

"Adjusted community rate." "Community rating system.'

95 Stat. 575. 42 USC 300e-l.

PUBLIC LAW 97-248—SEPT. 3, 1982 respect to services covered under part B) to individuals who are enrolled under this section with the organization and enrolled under part B only exceed the actuarial value of the coinsurance and deductibles that would be applicable on the average to individuals enrolled under this section with the organization (or, if the Secretary finds that adequate data are not available to determine that actuarial value, the actuarial value of the coinsurance and deductibles applicable on the average to individuals in the area, in the State, or in the United States, eligible to enroll under this section with the organization, or other appropriate data) and entitled to benefits under part A and enrolled under part B, or enrolled under part B only, respectively, if they were not members of an eligible organization. "(2) If the eligible organization provides to its members enrolled under this section services in addition to services covered under parts A and B of this title, election of coverage for such additional services (unless such services have been approved by the Secretary under subsection (c)(2)) shall be optional for such members and such organization shall furnish such members with information on the portion of its premium rate or other charges applicable to such additional services. In no case may the sum of— "(A) the portion of such organization's premium rate charged, with respect to such additional services, to members enrolled under this section, and "(B) the actuarial value of its deductibles, coinsurance, and copayments charged, with respect to such services to such members exceed the adjusted community rate for such services. "(3) For purposes of this section, the term 'adjusted community rate' for a service or services means, at the election of an eligible organization, either— "(A) the rate of payment for that service or services which the Secretary annually determines would apply to a member enrolled under this section with an eligible organization if the rate of payment were determined under a 'community rating system' (as defined in section 1302(8) of the Public Health Service Act, other than subparagraph (O), or "(B) such portion of the weighted aggregate premium, which the Secretary annually estimates would apply to a member enrolled under this section with the eligible organization, as the Secretary annually estimates is attributable to that service or services, but adjusted for differences between the utilization characteristics of the members enrolled with the eligible organization under this section and the utilization characteristics of the other members of the organization (or, if the Secretary finds that adequate data are not available to adjust for those differences, the differences between the utilization characteristics of members in other eligible organizations, or individuals in the area, in the State, or in the United States, eligible to enroll under this section with an eligible organization and the utilization characteristics of the rest of the population in the area, in the State, or in the United States, respectively). "(4) Notwithstanding any other provision of law, the eligible organization may (in the case of the provision of services to a member enrolled under this section for an illness or injury for which the member is entitled to benefits under a workmen's compensation law or plan of the United States or a State, under an automobile or

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Page:United States Statutes at Large Volume 96 Part 1.djvu/389

 PUBLIC LAW 97-248—SEPT. 3, 1982 liability insurance policy or plan, including a self-insured plan, or under no fault insurance) charge or authorize the provider of such services to charge, in accordance with the charges allowed under such law or policy— "(A) the insurance carrier, employer, or other entity which under such law, plan, or policy is to pay for the provision of such services, or "(B) such member to the extent that the member has been paid under such law, plan, or policy for such services. "(f)(1) Each eligible organization with which the Secretary enters into a contract under this section shall have, for the duration of such contract, an enrolled membership at least one-half of which consists of individuals who are not entitled to benefits under this title or under a State plan approved under title XIX. "(2) The Secretary may modify or waive the requirement imposed by paragraph (1) only if the Secretary determines that— "(A) special circumstances warrant such modification or waiver, and "(B) the eligible organization has taken and is making reasonable efforts to enroll individuals who are not entitled to benefits under this title or under a State plan approved under title XIX. "(g)(1) The Secretary may enter a risk-sharing contract with any eligible organization, as defined in subsection (b)(1), which has at least 5,000 members, except that the Secretary may enter into such a contract with an eligible organization that has fewer members if the organization primarily serves members residing outside of urbanized areas. "(2) Each risk-sharing contract shall provide that— "(A) if the adjusted community rate, as defined in subsection (e)(3), for services under parts A and B (as reduced for the actuarial value of the coinsurance and deductibles under those parts) for members enrolled under this section with the organization and entitled to benefits under part A and enrolled in part B,or "(B) if the adjusted community rate for services under part B (as reduced for the actuarial value of the coinsurance and deductibles under that part) for members enrolled under this section with the organization and entitled to benefits under part B only is less than the average of the per capita rates of payment to be made under subsection (a)(1) at the beginning of an annual contract period for members enrolled under this section with the organization and entitled to benefits under part A and enrolled in part B, or enrolled in part B only, respectively, the eligible organization shall provide to members enrolled under a risk-sharing contract under this section with the organization and entitled to benefits under part A and enrolled in part B, or enrolled in part B only, respectively, the additional benefits described in paragraph (3) which are selected by the eligible organization and which the Secretary finds are at least equal in value to the difference between that average per capita payment and the adjusted community rate (as so reduced); except that this paragraph shall not apply with respect to any organization which elects to receive a lesser payment to the extent that there is no longer a difference between the average per capita payment and adjusted community rate (as so reduced). If the Secretary finds that there is insufficient enrollment experience to determine an average of the per capita rates of payment to be made under subsection (a)(D

96 STAT. 347

42 USC 1396. Waiver.

Risk-sharing contract.

Provisions. 42 USC 1395c, 1395J.

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Page:United States Statutes at Large Volume 96 Part 1.djvu/390

 96 STAT. 348

42 USC 1395x.

Ante, p. 331.

PUBLIC LAW 97-248—SEPT. 3, 1982 at the beginning of a contract period, the Secretary may determine such an average based on the enrollment experience of other contracts entered into under this section. "(3) The additional benefits referred to in paragraph (2) are— "(A) the reduction of the premium rate or other charges made with respect to services furnished by the organization to members enrolled under this section, or "(B) the provision of additional health benefits, or both. "(h)(1) I f "(A) the Secretary is not satisfied that an eligible organization has the capacity to bear the risk of potential losses under a risksharing contract under this section, or "(B) the eligible organization so elects or has an insufficient number of members to be eligible to enter into a risk-sharing contract under subsection (g)(1), the Secretary may, if he is otherwise satisfied that the eligible organization is able to perform its contractual obligations effectively and efficiently, enter into a contract with such organization pursuant to which such organization is reimbursed on the basis of its reasonable cost (as defined in section 1861(v)) in the manner prescribed in paragraph (3). "(2) A reasonable cost reimbursement contract under this subsection may, at the option of such organization, provide that the Secretary— "(A) will reimburse hospitals and skilled nursing facilities either for the reasonable cost (as determined under section 1861(v)) or for payment amounts determined in accordance with section 1886, as applicable, of services furnished to individuals enrolled with such organization pursuant to subsection (d), and "(B) will deduct the amount of such reimbursement from payment which would otherwise be made to such organization. If such an eligible organization pays a hospital or skilled nursing facility directly, the amount paid shall not exceed the reasonable cost of the services (as determined under section 1861(v)) or the amount determined under section 1886, as applicable, unless such organization demonstrates to the satisfaction of the Secretary that such excess payments are justified on the basis of advantages gained by the organization. "(3) Payments made to an organization with a reasonable cost reimbursement contract shall be subject to appropriate retroactive corrective adjustment at the end of each contract year so as to assure that such organization is paid for the reasonable cost actually incurred (excluding any part of incurred cost found to be unnecessary in the efficient delivery of health services) or the amounts otherwise determined under section 1886 for the types of expenses otherwise reimbursable under this title for providing services covered under this title to individuals described in subsection (a)(1). "(4) Any reasonable cost reimbursement contract with an eligible organization under this subsection shall provide that the Secretary shall require, at such time following the expiration of each accounting period of the eligible organization (and in such form and in such detail) as he may prescribe— "(A) that the organization report to him in an independently certified financial statement its per capita incurred cost based on the types of components of expenses otherwise reimbursable under this title for providing services described in subsection

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Page:United States Statutes at Large Volume 96 Part 1.djvu/391

 PUBLIC LAW 97-248—SEPT. 3, 1982 (a)(1), including therein, in accordance with accounting procedures prescribed by the Secretary, its methods of allocating costs between individuals enrolled under this section and other individuals enrolled with such organization; "(B) that failure to report such information as may be required may be deemed to constitute evidence of likely overpayment on the basis of which appropriate collection action may be taken; "(C) that in any case in which an eligible organization is related to another organization by common ownership or control, a consolidated financial statement shall be filed and that the allowable costs for such organization may not include costs for the types of expense otherwise reimbursable under this title, in excess of those which would be determined to be reasonable in accordance with regulations (providing for limiting reimbursement to costs rather than charges to the eligible organization by related organizations and owners) issued by the Secretary; and "(D) that in any case in which compensation is paid by an eligible organization substantially in excess of what is normally paid for similar services by similar practitioners (regardless of method of compensation), such compensation may as appropriate be considered to constitute a distribution of profits. "(i)(l) Each contract under this section shall be for a term of at least one year, as determined by the Secretary, and may be made automatically renewable from term to term in the absence of notice by either party of intention to terminate at the end of the current term; except that the Secretary may terminate any such contract at any time (after such reasonable notice and opportunity for hearing to the eligible organization involved as he may provide in regulations), if he finds that the organization— "(A) has failed substantially to carry out the contract, "(B) is carrying out the contract in a manner inconsistent with the efficient and effective administration of this section, or "(C) no longer substantially meets the applicable conditions of subsections (b), (c), and (e). "(2) The effective date of any contract executed pursuant to this section shall be specified in the contract. "(3) Each contract under this section— "(A) shall provide that the Secretary, or any person or organization designated by him— "(i) shall have the right to inspect or otherwise evaluate (I) the quality, appropriateness, and timeliness of services performed under the contract and (II) the facilities of the organization when there is reasonable evidence of some need for such inspection, and "(ii) shall have the right to audit and inspect any books and records of the eligible organization that pertain (I) to the ability of the organization to bear the risk of potential financial losses, or (II) to services performed or determinations of amounts payable under the contract; "(B) shall require the organization with a risk-sharing contract to provide (and pay for) written notice in advance of the contract's termination, as well as a description of alternatives for obtaining benefits under this title, to each individual enrolled under this section with the organization; and

96 STAT. 349

Filing of a consolidated financial statement.

Distribution of profits.

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Page:United States Statutes at Large Volume 96 Part 1.djvu/392

 96 STAT. 350 42 USC 300e-17. 42 USC 300e.

42 USC 1395x.

Ante, p. 341.

42 USC 1395mm note.

42 USC 1395c, 1395J.

PUBLIC LAW 97-248—SEPT. 3, 1982 "(C) shall require the organization to comply with subsections (a) and (c) of section 1318 of the Public Health Service Act (relating to disclosure of certain financial information) and with the requirement of section 1301(c)(8) of such Act (relating to liability arrangements to protect members); and "(D) shall contain such other terms and conditions not inconsistent with this section (including requiring the organization to provide the Secretary with such information) as the Secretary may find necessary and appropriate. "(4) The Secretary may not enter into a risk-sharing contract with an eligible organization if a previous risk-sharing contract with that organization under this section was terminated at the request of the organization within the preceding five-year period, except in circumstances which warrant special consideration, as determined by the Secretary. "(5) The authority vested in the Secretary by this section may be performed without regard to such provisions of law or regulations relating to the making, performance, amendment, or modification of contracts of the United States as the Secretary may determine to be inconsistent with the furtherance of the purpose of this title.". (b) Section 1861(s)(2) of the Social Security Act is amended— (1) by striking out "and" at the end of subparagraph (F); (2) by inserting "and" after the semicolon in subparagraph (G); and (3) by adding after subparagraph (G) the following new subparagraph: "(H) services furnished pursuant to a contract under section 1876 to a member of an eligible organization by a physician assistant or by a nurse practitioner (as defined in subsection (aa)(3)) and such services and supplies furnished as an incident to his service to such a member as would otherwise be covered under this part if furnished by a physician or as an incident to a physician's service;". (c)(1) Subject to paragraph (2), the amendment made by subsection (a) shall apply with respect to services furnished on or after the initial effective date (as defined in paragraph (4)), except that such amendment shall not apply— (A) with respect to services furnished by an eligible organization to any individual who is enrolled with that organization under an existing cost contract (as defined in paragraph (3)(A)) and entitled to benefits under part A, or enrolled in part B, of title XVIII of the Social Security Act at the time the organization first enters into a new risk-sharing contract (as defined in paragraph (3)(D)) unless— (i) the individual requests at any time that the amendment apply, or (ii) the Secretary determines at any time that the amendment should apply to all members of the organization because of administrative costs or other administrative burdens involved and so informs in advance each affected member of the eligible organization; (B) with respect to services furnished by an eligible organization during the five-year period beginning on the initial effective date, if— (i) the organization has an existing risk-sharing contract (as defined in paragraph (3)(B)) on the initial effective date, or

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 PUBLIC LAW 97-248—SEPT. 3, 1982 (ii) on the date of the enactment of this Act the organization was furnishing services pursuant to an existing demonstration project (as defined in paragraph (3)(C)), such demonstration project is concluded before the initial effective date, and before such initial effective date the organization enters into an existing risk-sharing contract, unless the organization requests that the amendment apply earlier; or (C) with respect to services furnished by an eligible organization during the period of an existing demonstration project if on the initial effective date the organization was furnishing services pursuant to the project and if the project concludes after such date. (2)(A) In the case of an eligible organization which has in effect an existing cost contract (as defined in paragraph (3)(A)) on the initial effective date, the organization may receive payment under a new risk-sharing contract with respect to a current, nonrisk medicare enrollee (as defined in subparagraph (O) only to the extent that the organization enrolls, for each such enrollee, two new medicare enrollees (as defined in subparagraph (D)). The selection of those current nonrisk medicare enrollees with respect to whom payment may be so received under a new risk-sharing contract shall be made in a nonbiased manner. (B) Subparagraph (A) shall not be construed to prevent an eligible organization from providing for enrollment, on a basis described in subsection (a)(6) of section 1876 of the Social Security Act (as amended by this Act, other than under a reasonable cost reimbursement contract), of current, nonrisk medicare enrollees and from providing such enrollees with some or all of the additional benefits described in section 1876(g)(2) of the Social Security Act (as amended by this Act), but (except as provided in subparagraph (A))— (i) payment to the organization with respect to such enrollees shall only be made in accordance with the terms of a reasonable cost reimbursement contract, and (ii) no payment may be made under section 1876 of such Act with respect to such enrollees for any such additional benefits. Individuals enrolled with the organization under this subparagraph shall be considered to be individuals enrolled with the organization for the purpose of meeting the requirement of section 1876(g)(2) of the Social Security Act (as amended by this Act). (C) For purposes of this paragraph, the term "current, nonrisk medicare enrollee" means, with respect to an organization, an individual who on the initial effective date— (i) is enrolled with that organization under an existing cost contract, and (ii) is entitled to benefits under part A, or enrolled in part B, of title XVIII of the Social Security Act. (D) For purposes of this paragraph, the term "new medicare enrollee" means, with respect to an organization, an individual who— (i) is enrolled with the organization after the date the organization first enters into a new risk-sharing contract, (ii) at the time of such enrollment is entitled to benefits under part A, or enrolled in part B, of title XVIII of the Social Security Act, and

96 STAT. 351

Ante, p. 341.

"Current, nonrisk medicare enrollee."

42 USC 1395c, 1395J.

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Page:United States Statutes at Large Volume 96 Part 1.djvu/394

 96 STAT. 352

Definitions. Ante, p. 341. 42 USC 1395/.

81 Stat. 930. 86 Stat. 1390. 42 USC 1395.

Study. 42 USC 1395mm note. Report to Congress.

Study. 42 USC 1395mm note.

95 Stat. 813. 42 USC 1396a note.

PUBLIC LAW 97-248—SEPT. 3, 1982 (iii) was not enrolled with the organization at the time the individual became entitled to benefits under part A, or to enroll in part B, of such title. (3) For purposes of this subsection: (A) The term "existing cost contract" means a contract which is entered into under section 1876 of the Social Security Act, as in effect before the initial effective date, or reimbursement on a reasonable cost basis under section 1833(a)(1)(A) of such Act, and which is not an existing risk-sharing contract or an existing demonstration project. (B) The term "existing risk-sharing contract" means a contract entered into under section 1876(i)(2)(A) of the Social Security Act, as in effect before the initial effective date. (C) The term "existing demonstration project" means a demonstration project under section 402(a) of the Social Security Amendments of 1967 or under section 222(a) of the Social Security Amendments of 1972, relating to the provision of services for which payment may be made under title XVIII of the Social Security Act. (D) The term "new risk-sharing contract" means a contract entered into under section 1876(g) of the Social Security Act, as amended by this Act. (E) The term "reasonable cost reimbursement contract" means a contract entered into under section 1833(a)(1) of the Social Security Act or under section 1876(h) of such Act, as amended by this Act. (4) As used in this section, the term "initial effective date" means— (A) the first day of the thirteenth month which begins after the date of the enactment of this Act, or (B) the first day of the first month after the month in which the Secretary of Health and Human Services notifies the Committee on Finance of the Senate and the Committees on Ways and Means and on Energy and Commerce of the House of Representatives that he is reasonably certain that the methodology to make appropriate adjustments (referred to in section 1876(a)(4) of the Social Security Act, as amended by this Act) has been developed and can be implemented to assure actuarial equivalence in the estimation of adjusted average per capita costs under that section, whichever is later. (d) The Secretary of Health and Human Services shall conduct a study of the additional benefits selected by eligible organizations pursuant to section 1876(g)(2) of the Social Security Act, as amended by subsection (a) of this section. The Secretary shall report to the Congress within 24 months of the initial effective date (as defined in subsection (c)(4)) with respect to the findings and conclusions made as a result of such study. (e) The Secretary of Health and Human Services shall conduct a study evaluating the extent of, and reasons for, the termination by medicare beneficiaries of their memberships in organizations with contracts under section 1876 of the Social Security Act. Such study may be coordinated with the study provided for under section 2178(d) of the Omnibus Budget Reconciliation Act of 1981. In conducting such study, the Secretary shall place special emphasis on the quantity and quality of medical care provided in such organizations and the quality of such care when provided on a fee-for-service

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 PUBLIC LAW 97-248—SEPT. 3, 1982

96 STAT. 353

basis. The Secretary shall submit an interim report to the Congress, Report to within two years after the initial effective date (as defined in Congress. subsection (c)(4)), and a final report within five years after such date containing the respective interim and final findings and conclusions made as a result of such study. PROHIBITION OF PAYMENT FOR INEFFECTIVE DRUGS

SEC. 115. (a) Effective September 30, 1982, section 131 of Public Law 97-92 is repealed, and the provisions of such section, and of section 210 of the Departments of Labor, Health and Human Services, and Education and Related Agencies Appropriation Act, 1982 (H.R. 4560), as passed by the House of Representatives on October 6, 1981, and of section 209 of such Act as reported by the Senate Committee on Appropriations on November 9, 1981, shall not apply to any sums appropriated for fiscal year 1983 or any succeeding fiscal year. (b) No provision of law limiting the use of funds for purposes of enforcing or implementing section 1862(c) or section 1903(i)(5) of the Social Security Act, section 2103 of the Omnibus Budget Reconciliation Act of 1981, or any rule or regulation issued pursuant to any such section (including any provision contained in, or incorporated by reference into, any appropriation Act or resolution making continuing appropriations) shall apply to any period after September 30, 1982, unless such provision of law is enacted after the date of the enactment of this Act and specifically states that such provision is to supersede this section.

Repeal. 95 Stat. 1199.

42 USC 1395y note. 42 USC 1395y, 1396b. 95 Stat. 787.

Subpart C—Other Payment Provisions MEDICARE PAYMENTS SECONDARY FOR OLDER WORKERS COVERED UNDER GROUP HEALTH PLANS

SEC. 116. (a) Section 4 of the Age Discrimination in Employment Act of 1967 is amended by adding at the end thereof the following 29 USC 623. new subsection: "(g)(1) For purposes of this section, any employer must provide that any employee aged 65 through 69 shall be entitled to coverage under any group health plan offered to such employees under the same conditions as any employee under age 65. "(2) For purposes of paragraph (1), the term 'group health plan' "Group health has the meaning given to such term in section 162(i)(2) of the plan." Internal Revenue Code of 1954.". 26 USC 162. (b) Section 1862(b) of the Social Security Act is amended by adding 42 USC 13953^ at the end thereof the following new paragraph: "(3)(A)(i) Payment under this title may not be made, except as provided in clause (ii), with respect to any item or service furnished during the period described in clause (iii) to an individual who is over 64 but under 70 years of age (or to the spouse of such individual, if the spouse is over 64 but under 70 years of age) who is employed at the time such item or service is furnished to the extent that payment with respect to expenses for such item or service has been made, or can reasonably be expected to be made, under a group health plan (as defined in clause (iv)) under which such individual is covered by reason of such employment. "(ii) Any payment under this title with respect to any item or service during the period described in clause (iii) shall be condi-

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 96 STAT. 354

"Waiver."

42 USC 426. 42 USC 426-1. "Group health plan." 26 USC 162.

Ante, p. 331.

Effective date. 29 USC 623 note.

PUBLIC LAW 97-248—SEPT. 3, 1982 tioned on reimbursement to the appropriate Trust Fund established by this title when notice or other information is received that payment for such item or service has been made under a group health plan. The Secretary may waive the provisions of this clause in the case of an individual claim if he determines that the probability of recovery or amount involved in such claim does not warrant the pursuing of the claim. "(iii) The provisions of clauses (i) and (ii) shall apply to an individual only for the period beginning with the month in which such individual becomes entitled to benefits under this title under section 226(a) and ending with the month in which such individual attains the age of 70 and shall not include any month for which the individual would, upon application, be entitled to benefits under section 226A. "(iv) For purposes of this paragraph, the term 'group health plan' has the meaning given to such term in section 162(i)(2) of the Internal Revenue Code of 1954. "(B) Where payment for an item or service under a group health plan is less than the amount of the charge for such item or service, payment may be made under this title (without regard to deductibles and coinsurance under this title) for the remainder of such charge, but— "(i) such payment under this title may not exceed an amount which would be payable under this title for such item or service in the absence of such group health plan; and "(ii) such payment under this title, when combined with the amount payable under such plan, may not exceed— "(I) in the case of an item or service payment for which is determined under this title on the basis of reasonable cost (or other cost-related basis) or under section 1886, the amount which would be payable under this title on such basis; and "(II) in the case of an item or service for which payment is authorized under this title on another basis, the greater of— "(a) the amount which would be payable under the group health plan (without regard to deductibles and coinsurance under such plan), or "(b) the reasonable charge or other amount which would be payable under this title (without regard to deductibles and coinsurance under this title).". (c) The amendment made by subsection (a) shall become effective on January 1, 1983, and the amendment made by subsection (b) shall apply with respect to items and services furnished on or after such date. INTEREST CHARGES ON OVERPAYMENTS A N D UNDERPAYMENTS

42 USC I395g.

SEC. 117. (a)(1) Section 1815 of the Social Security Act is amended by adding at the end the following new subsection: "(d) Whenever a final determination is made that the amount of payment made under this part to a provider of services was in excess of or less than the amount of payment that is due, and payment of such excess or deficit is not made (or effected by offset) within 30 days of the date of the determination, interest shall accrue on the balance of such excess or deficit not paid or offset (to the extent that the balance is owed by or owing to the provider) at a rate deter-

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 PUBLIC LAW 97-248—SEPT. 3, 1982

96 STAT. 355

mined in accordance with the regulations of the Secretary of the Treasury applicable to charges for late payments.". (2) Section 1833 of such Act is amended by adding at the end the 42 USC 1395/. following new subsection: "(j) Whenever a final determination is made that the amount of payment made under this part either to a provider of services or to another person pursuant to an assignment under section 1842(b)(3)(B)(ii) was in excess of or less than the amount of payment 42 USC 1395u. that is due, and payment of such excess or deficit is not made (or effected by offset) within 30 days of the date of the determination, interest shall accrue on the balance of such excess or deficit not paid or offset (to the extent that the balance is owed by or owing to the provider) at a rate determined in accordance with the regulations of the Secretary of the Treasury applicable to charges for late payments.". (b) The amendments made by subsection (a) apply to final determi- 42 USC 1395g nations made on or after the date of the enactment of this Act. note. AUDIT AND MEDICAL CLAIMS REVIEW

SEC. 118. In addition to any funds otherwise provided for fiscal years 1983, 1984, and 1985 for payments to intermediaries and carriers under agreements entered into under sections 1816 and 1842 of the Social Security Act, there are transferred from the Federal Hospital Insurance Trust Fund and the Federal Supplementary Medical Insurance Fund in such proportions as the Secretary of Health and Human Services determines to be appropriate, an additional $45,000,000 for each of such fiscal years for payments to such intermediaries and carriers under such agreements to be used exclusively for the purpose of carrying out provider cost audits and reviews of medical necessity, consistent with the provisions of sections 1816 and 1842 of the Social Security Act.

42 USC 1395h note. 42 USC 1395h, 1395u.

PRIVATE SECTOR REVIEW INITIATIVE

SEC. 119. (a) The Secretary of Health and Human Services shall 42 USC 1395CC undertake an initiative to improve medical review by intermediaries note. and carriers under title XVIII of the Social Security Act and to 42 USC 1395 encourage similar review efforts by private insurers and other private entities. The initiative shall include the development of specific standards for measuring the performance of such intermediaries and carriers with respect to the identification and reduction of unnecessary utilization of health services. (b) Where such review activity results in the denial of payment to providers of services under title XVIII of the Social Security Act, such providers shall be prohibited, in accordance with sections 1866 and 1879 of such title, from collecting any payments from beneficiaries unless otherwise provided under such title. TEMPORARY DELAY IN PERIODIC INTERIM PAYMENTS

SEC. 120. Notwithstanding section 1815(a) of the Social Security Act, in the case of a hospital which is paid periodic interim payments under such section, the Secretary of Health and Human Services shall provide that—

42 USC 1395g note. 42 USC 1395g.

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 96 STAT. 356

PUBLIC LAW 97-248—SEPT. 3, 1982 (1) with respect to the last 21 days for which such would otherwise be made during fiscal year 1983, ments shall be deferred until fiscal year 1984; and (2) with respect to the last 21 days for which such would otherwise be made during fiscal year 1984, ments shall be deferred until fiscal year 1985.

payments such paypayments such pay-

PART II—CHANGES IN BENEFITS, PREMIUMS, AND ENROLLMENT MEDICARE COVERAGE OF FEDERAL EMPLOYEES

Post, p. 559.

SEC. 121. For provisions providing certain employees of the United States and instrumentalities thereof with entitlement to hospital insurance benefits under part A of title XVIII of the Social Security Act, see section 278 of this Act. HOSPICE CARE

42 USC 1395c. 45 USC 23if. 42 USC I395d.

SEC. 122. (a)(1) Section 1811 of the Social Security Act is amended by striking out "and home health services" and inserting in lieu thereof "home health services, and hospice care". (2) Section 7(d)(l) of the Railroad Retirement Act of 1974 is amended by inserting "hospice care," after "home health services,", (b)(1) Section 1812(a) of the Social Security Act is amended by striking out "and" at the end of paragraph (2), by striking out the period at the end of paragraph (3) and inserting in lieu thereof "; and", and by adding after paragraph (3) the following new paragraph: "(4) in lieu of certain other benefits, hospice care with respect to the individual during up to two periods of 90 days each and one subsequent period of 30 days with respect to which the individual makes an election under subsection (d)(1).". (2) Section 1812 of such Act is further amended by inserting after subsection (c) the following new subsection: "(d)(1) Payment under this part may be made for hospice care provided with respect to an individual only during two periods of 90 days each and one subsequent period of 30 days during the individual's lifetime and only, with respect to each such period, if the individual makes an election under this paragraph to receive hospice care under this part provided by, or under arrangements made by, a particular hospice program instead of certain other benefits under this title. "(2)(A) Except as provided in subparagraphs (B) and (C) and except in such exceptional and unusual circumstances as the Secretary may provide, if an individual makes such an election for a period with respect to a particular hospice program, the individual shall be deemed to have waived all rights to have payment made under this title with respect to— "(i) hospice care provided by another hospice program (other than under arrangements made by the particular hospice program) during the period, and "(ii) services furnished during the period that are determined (in accordance with guidelines of the Secretary) to be— "(I) related to the treatment of the individual's condition with respect to which a diagnosis of terminal illness has been made or

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 PUBLIC LAW 97-248—SEPT. 3, 1982

96 STAT. 357

"(II) equivalent to (or duplicative of) hospice care; except that clause (ii) shall not apply to physicians' services furnished by the individual's attending physician (if not an employee of the hospice program) or to other than services provided by (or under arrangements made by) the hospice program. "(B) After an individual makes such an election with respect to a 90- or 30-day period, the individual may revoke the election during the period, in which case— "(i) the revocation shall act as a waiver of the right to have payment made under this part for any hospice care benefits for the remaining time in such period and (for purposes of subsection (a)(4) and subparagraph (A)) the individual shall be deemed to have been provided such benefits during such entire period, and "(ii) the individual may at any time after the revocation execute a new election for a subsequent period, if the individual otherwise is entitled to hospice care benefits with respect to such a period. "(C) An individual may, once in each such period, change the hospice program with respect to which the election is made and such change shall not be considered a revocation of an election under subparagraph (B). "(D) For purposes of this title, an individual's election with respect to a hospice program shall no longer be considered to be in effect with respect to that hospice program after the date the individual's revocation or change of election with respect to that election takes effect.". (c)(i) Section 1814(a) of the Social Security Act is amended by 42 USC 1395f. striking out "and" at the end of paragraph (6), by striking out the period at the end of paragraph (7) and inserting in lieu thereof "; and", and by inserting after paragraph (7) the following new paragraph: "(8) in the case of hospice care provided an individual— "(A)(i) in the first 90-day period— "(I) the individual's attending physician (as defined in section 1861(dd)(3)(B)), and Post, p. 359. "(II) the medical director (or physician member of the interdisciplinary group described in section 1861(dd)(2)(B)) of the hospice program providing (or arranging for) the care, each certify, not later than two days after hospice care is initiated, that the individual is terminally ill (as defined in section 1861(dd)(3)(A)), and "(ii) in a subsequent 90- or 30-day period, the medical director or physician described in clause (i)(II) recertifies at the beginning of the period that the individual is terminally ill; "(B) a written plan for providing hospice care with respect to such individual has been established (before such care is provided by, or under arrangements made by, that hospice program) and is periodically reviewed by the individual's attending physician and by the medical director (and the interdisciplinary group described in section 1861(dd)(2)(B)) of the hospice program; and "(C) such care is being or was provided pursuant to such plan of care.".

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 96 STAT. 358 42 USC 1395f.

PUBLIC LAW 97-248—SEPT. 3, 1982 (2)(A) Section 1814(b) of such Act is amended by inserting "(other than a hospice program providing hospice care)" after "The amount paid to any provider of services". (B) Section 1814 of such Act is further amended by adding at the end the following new subsection: PAYMENT FOR HOSPICE CARE

Post, p. 361.

"Cap amount."

"Cap amount."

"(i)(l) Subject to the limitation under paragraph (2) and the provisions of section 1813(a)(4), the amount paid to a hospice program with respect to hospice care for which payment may be made under this part shall be an amount equal to the costs which are reasonable and related to the cost of providing hospice care or which are based on such other tests of reasonableness as the Secretary may prescribe in regulations (including those authorized under section 1861(v)(l)(A)), except that no payment may be for bereavement counseling and no reimbursement may be made for other counseling services (including nutritional and dietary counseling) as separate services. "(2)(A) The amount of payment made under this part for hospice care provided by (or under arrangements made by) a hospice program located in a region (as defined by the Secretary) for an accounting year may not exceed the 'cap amount' for the region for the year (computed under subparagraph (B)) multiplied by the number of medicare beneficiaries in the hospice program in that year (determined under subparagraph (O). "(B) For purposes of subparagraph (A), the 'cap amount' for a region for a year is computed as follows: "(i) The Secretary, using records of the program under this title, shall identify individuals (or a representative sample of such individuals)— "(I) who died during the base period (as defined in clause (v)), "(II) with respect to whom the primary cause of death was cancer, and "(III) who, during the six-month period preceding death, were provided benefits under this title, "(ii) The Secretary shall determine a national average medicare per capita expenditure amount by (I) determining (or estimating) the amount of payments made under this title with respect to services provided to individuals identified in clause (i) during the six months before death, and (II) dividing such amount of payments by the number of such individuals. "(iii) The Secretary, using the best available data, shall then compute a regional average medicare per capita expenditure amount for each region, by adjusting the national average medicare per capita expenditure amount (computed under clause (ii)) to reflect the relative difference between that region's average cost of delivering health care and the national average cost of delivering health care. "(iv) The 'cap amount' for a region for an accounting year is 40 percent of the regional average determined under clause (iii) for that region, increased or decreased by the same percentage as the percentage increase or decrease, respectively, in the medical care expenditure category of the consumer price index for all urban consumers (U.S. city average), published by the

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Page:United States Statutes at Large Volume 96 Part 1.djvu/401

 PUBLIC LAW 97-248—SEPT. 3, 1982 Bureau of Labor Statistics, from the fourth month of the base period to the fifth month of the accounting year. "(v) For purposes of this subparagraph, the term 'base period' means the most recent period of 12 months (ending before the date proposed regulations are first issued to carry out this paragraph) for which the Secretary determines he has sufficient data to make the determinations required under clauses (i) through (iii). "(C) For purposes of subparagraph (A), the 'number of medicare beneficiaries' in a hospice program in an accounting year is equal to the number of individuals who have made an election under subsection (d) with respect to the hospice program and have been provided hospice care by (or under arrangements made by) the hospice program under this part in the accounting year, such number reduced to reflect the proportion of hospice care that each such individual was provided in a previous or subsequent accounting year or under a plan of care established by another hospice program.". (3) Section 1816(e) of such Act is amended by adding at the end thereof the following new paragraph: "(5) Notwithstanding any other provision of this title, the Secretary shall designate the agency or organization which has entered into an agreement under this section to perform functions under such an agreement with respect to each hospice program, except that with respect to a hospice program which is a subdivision of a provider of services (and such hospice program and provider of services are under common control) due regard shall be given to the agency or organization which performs the functions under this section for the provider of services.". (d)(1) Section 1861(u) of the Social Security Act is amended by inserting "hospice program," after "home health agency,". (2) Section 1861(w)(l) of such Act is amended by striking out "or home health agency" and by inserting in lieu thereof "home health agency, or hospice program". (3) Section 1861 of such Act is further amended by adding at the end the following new subsection:

96 STAT. 359

"Base period."

"Number of medicare beneficiaries.'

42 USC I395h.

42 USC I395x.

HOSPICE CARE; HOSPICE PROGRAM

"(dd)(l) The term 'hospice care' means the following items and services provided to a terminally ill individual by, or by others under arrangements made by, a hospice program under a written plan (for providing such care to such individual) established and periodically reviewed by the individual's attending physician and by the medical director (and by the interdisciplinary group described in paragraph (2)(B)) of the program— "(A) nursing care provided by or under the supervision of a registered professional nurse, "(B) physical or occupational therapy or speech-language pathology, "(C) medical social services under the direction of a physician, "(D)(i) services of a home health aide who has successfully completed a training program approved by the Secretary and (ii) homemaker services, "(E) medical supplies (including drugs and biologicals) and the use of medical appliances, while under such a plan, "(F) physicians' services,

"Hospice care.

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Page:United States Statutes at Large Volume 96 Part 1.djvu/402

 96 STAT. 360

"Hospice program."

42 USC I395d.

PUBLIC LAW 97-248—SEPT. 3, 1982 "(G) short-term inpatient care (including both respite care and procedures necessary for pain control and acute and chronic symptom management) in an inpatient facility meeting such conditions as the Secretary determines to be appropriate to provide such care, but such respite care may be provided only on an intermittent, nonroutine, and occasional basis and may not be provided consecutively over longer than five days, and "(H) counseling (including dietary counseling) with respect to care of the terminally ill individual and adjustment to his death. The care and services described in subparagraphs (A) and (D) may be provided on a 24-hour, continuous basis only during periods of crisis (meeting criteria established by the Secretary) and only as necessary to maintain the terminally ill individual at home. "(2) The term 'hospice program' means a public agency or private organization (or a subdivision thereof) which— "(A)(i) is primarily engaged in providing the care and services described in paragraph (1) and makes such services available (as needed) on a 24-hour basis and which also provides bereavement counseling for the immediate family of terminally ill individuals, "(ii) provides for such care and services in individuals' homes, on an outpatient basis, and on a short-term inpatient basis, directly or under arrangements made by the agency or organization, except that— "(I) the agency or organization must routinely provide directly substantially all of each of the services described in subparagraphs (A), (C), (F), and (H) of paragraph (1), and "(II) in the case of other services described in paragraph (1) which are not provided directly by the agency or organization, the agency or organization must maintain professional management responsibility for all such services furnished to an individual, regardless of the location or facility in which such services are furnished; and "(iii) provides assurances satisfactory to the Secretary that the aggregate number of days of inpatient care described in paragraph (1)(G) provided in any 12-month period to individuals who have an election in effect under section 1812(d) with respect to that agency or organization does not exceed 20 percent of the aggregate number of days during that period on which such elections for such individuals are in effect; "(B) has an interdisciplinary group of personnel which— "(i) includes at least— "(I) one physician (as defined in subsection (r)(l)), "(II) one registered professional nurse, and "(III) one social worker, employed by the agency or organization, and also includes at least one pastoral or other counselor, "(ii) provides (or supervises the provision of) the care and services described in paragraph (1), and "(iii) establishes the policies governing the provision of such care and services; "(C) maintains central clinical records on all patients; "(D) does not discontinue the hospice care it provides with respect to a patient because of the inability of the patient to pay for such care;

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Page:United States Statutes at Large Volume 96 Part 1.djvu/403

 PUBLIC LAW 97-248—SEPT. 3, 1982 "(E)(i) utilizes volunteers in its provision of care and services in accordance with standards set by the Secretary, which standards shall ensure a continuing level of effort to utilize such volunteers, and (ii) maintains records on the use of these volunteers and the cost savings and expansion of care and services achieved through the use of these volunteers; "(F) in the case of an agency or organization in any State in which State or applicable local law provides for the licensing of agencies or organizations of this nature, is licensed pursuant to such law; and "(G) meets such other requirements as the Secretary may find necessary in the interest of the health and safety of the individuals who are provided care and services by such agency or organization. "(3)(A) An individual is considered to be 'terminally ill' if the individual has a medical prognosis that the individual's life expectancy is 6 months or less. "(B) The term 'attending physician' means, with respect to an individual, the physician (as defined in subsection (r)(l)), who may be employed by a hospice program, whom the individual identifies as having the most significant role in the determination and delivery of medical care to the individual at the time the individual makes an election to receive hospice care. "(4)(A) An entity which is certified as a provider of services other than a hospice program shall be considered, for purposes of certification as a hospice program, to have met any requirements under paragraph (2) which are also the same requirements for certification as such other type of provider. The Secretary shall coordinate surveys for determining certification under this title so as to provide, to the extent feasible, for simultaneous surveys of an entity which seeks to be certified as a hospice program and as a provider of services of another type. "(B) Any entity which is certified as a hospice program and as a provider of another type shall have separate provider agreements under section 1866 and shall file separate cost reports with respect to costs incurred in providing hospice care and in providing other services and items under this title.'. (e) Section 1813(a) of such Act is amended by adding at the end the following new paragraph: "(4)(A) The amount payable for hospice care shall be reduced— "(i) in the case of drugs and biologicals provided on an outpatient basis by (or under arrangements made by) the hospice program, by a coinsurance amount equal to an amount (not to exceed $5 per prescription) determined in accordance with a drug copayment schedule (established by the hospice program) which is related to, and approximates 5 percent of, the cost of the drug or biological to the program, and "(ii) in the case of respite care provided by (or under arrangements made by) the hospice program, by a coinsurance amount equal to 5 percent of the amount estimated by the hospice program (in accordance with regulations of the Secretary) to be equal to the amount of payment under section 1814(i) to that program for respite care; except that the total of the coinsurance required under clause (ii) for an individual may not exceed for a hospice coinsurance period the inpatient hospital deductible applicable for the year in which the period began. For purposes of this subparagraph, the term 'hospice

96 STAT. 361

"Terminally ill." "Attending physician.'

42 USC 1395cc. 42 USC 1395e.

Ante, p. 358.

"Hospice coinsurance period."

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Page:United States Statutes at Large Volume 96 Part 1.djvu/404

 96 STAT. 362

Ante, p. 356.

42 USC 1395y.

42 USC 1395x.

42 USC 1395y. 42 USC 1395z. 42 USC 1395aa.

42 USC 1395bb. 42 USC 1395CC.

42 USC 1395c note.

PUBLIC LAW 97-248—SEPT. 3, 1982 coinsurance period' means, for an individual, a period of consecutive days beginning with the first day for which an election under section 1812(d) is in effect for the individual and ending with the close of the first period of 14 consecutive days on each of which such an election is not in effect for the individual. "(B) During the period of an election by an individual under section 1812(d)(1), no copayments or deductibles other than those under subparagraph (A) shall apply with respect to services furnished to such individual which constitute hospice care, regardless of the setting in which such services are furnished.". (f) Section 1862(a) of the Social Security Act is amended— (1) by amending paragraph (1) to read as follows: "(1)(A) which, except for items and services described in subparagraph (B) or (C), are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, "(B) in the case of items and services described in section 1861(s)(10), which are not reasonable and necessary for the prevention of illness, and "(C) in the case of hospice care, which are not reasonable and necessary for the palliation or management of terminal illness;"; (2) by inserting "(except, in the case of hospice care, as is otherwise permitted under paragraph (1)(C))" in paragraph (6) after "comfort items"; (8) by striking out "paragraph (1)" in paragraph (7) and inserting in lieu thereof "paragraph (1)(B)"; and (4) by inserting "(except, in the case of hospice care, as is otherwise permitted under paragraph (1)(C))" in paragraph (9) after "custodial care". (g)(1) Section 1862(f) of the Social Security Act is amended by striking out "paragraph (1)" and inserting in lieu thereof "paragraph (1)(A)". (2) Section 1863 of the Social Security Act is amended by striking out "and (cc)(2)(I)" and inserting in lieu thereof "(cc)(2)(I), and (dd)(2)". (3) Section 1864(a) of such Act is amended— (A) by inserting "or whether an agency is a hospice program" in the first sentence after "home health agency,"; and (B) by striking out "or home health agency" in the second sentence and inserting in lieu thereof "home health agency, or hospice program". (4) Section 1865(a) of such Act is amended by striking out "or (o)" in the last sentence and inserting in lieu thereof "(o), or (dd)". (5) Section 1866(b)(2)(A) of such Act is amended by striking out "or (a)(3)" and inserting in lieu thereof "(a)(3), or (a)(4)". (6) Section 1866(b)(4)(A) of such Act is amended by inserting "or hospice care" after "home health services". (h)(1)(A) Subject to subparagraph (B), the amendments made by this section apply to hospice care provided on or after November 1, 1983, and before October 1, 1986. (B) An individual who on October 1, 1986, has an election under section 1812(d)(1) of the Social Security Act in effect for a period, is entitled to hospice care benefits after that date during the remainder of that period and any consecutive period to which the individual would have been entitled before such date.

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96 STAT. 363

(2) In order to provide for the timely implementation of the amendments made by this Act, the Secretary of Health and Human Services shall, not later than September 1, 1983, promulgate such final regulations as may be necessary to set forth— (A) a description of the care included in "hospice care" and the standards for qualification of a "hospice program", under section 1861(dd) of the Social Security Act, and (B) the standards for payment for hospice care under part A of title XVIII of such Act, pursuant to section 1814(i) of such Act. (h)(1) Notwithstanding any provision of law which has the effect of restricting the time period of a hospice demonstration project in effect on July 15, 1982, pursuant to section 402(a) of the Social Security Amendments of 1967, the Secretary of Health and Human Services, upon request of the hospice involved, shall permit continuation of the project until November 1, 1983, or, if later, the date on which payments can first be made to any hospice program under the amendments made by this section. (2) Prior to September 30, 1983, the Secretary shall submit to Congress a report on the effectiveness of demonstration projects referred to in paragraph (1), including an evaluation of the costeffectiveness of hospice care, the reasonableness of the 40-percent cap amount for hospice care as provided in section 1814(i) of the Social Security Act (as added by this section), proposed methodology for determining such cap amount, proposed standards for requiring and measuring the maintenance of effort for utilizing volunteers as required under section 1861(dd) of such Act, an evaluation of physician reimbursement for services furnished as a part of hospice care and for services furnished to individuals receiving hospice care but which are not reimbursed as a part of the hospice care, and any proposed legislative changes in the hospice care provisions of title XVIII of such Act. (i)(l) The Secretary of Health and Human Services shall conduct a study and, prior to January 1, 1986, report to the Congress on whether or not the reimbursement method and benefit structure (including copayments) for hospice care under title XVIII of the Social Security Act are fair and equitable and promote the most efficient provision of hospice care. Such report shall include the feasibility and advisability of providing for prospective reimbursement for hospice care, an evaluation of the inclusion of payment for outpatient drugs, an evaluation of the need to alter the method of reimbursement for nutritional, dietary, and bereavement counseling as hospice care, and any recommendations for legislative changes in the hospice care reimbursement or benefit structure. (2) The Comptroller General shall monitor and evaluate the study and the preparation of the report under paragraph (1). Q) The Secretary of Health and Human Services shall grant waivers of the limitations imposed by section 1814(i)(2) of the Social Security Act (relating to the cap amount), section 1861(dd)(l)(G) of such Act (relating to the limitations on the frequency and number of respite care days), and section 1861(dd)(2)(A)(iv) of such Act (relating to the aggregate limit on the number of days of inpatient care), as may be necessary to allow any institution which commenced operations as a hospice prior to January 1, 1975, to participate until October 1, 1986, in a viable manner as a hospice program under title XVIII of the Social Security Act.

42 USC 1395f note.

Ante, p. 359. 42 USC 1395; Ante, p. 358. 42 USC 1395b-l note. 81 Stat. 930.

Report to Congress.

42 USC 1395. Study; report to Congress. 42 USC 1395f note.

Waivers. 42 USC 1395f note.

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 96 STAT. 364

PUBLIC LAW 97-248—SEPT. 3, 1982 COVERAGE OF EXTENDED CARE SERVICES WITHOUT REGARD TO THREEDAY PRIOR HOSPITALIZATION REQUIREMENT

42 USC 1395d.

42 USC 1395f, 1395x; Ante, p. 331.

SEC. 123. (a) Section 1812(a)(2) of the Social Security Act is amended by inserting "(A)" after "(2)" and' by inserting before the semicolon at the end the following: ", and (B) to the extent provided in subsection (f), extended care services that are not post-hospital extended care services". (b) Section 1812 of such Act is further amended by redesignating subsection (f) as subsection (g) and by inserting after subsection (e) the following new subsection: "(f)(1) The Secretary shall provide for coverage, under clause (B) of subsection (a)(2), of extended care services which are not posthospital extended care services at such time and for so long as the Secretary determines, and under such terms and conditions (described in paragraph (2)) as the Secretary finds appropriate, that the inclusion of such services will not result in any increase in the total of payments made under this title and will not alter the acute care nature of the benefit described in subsection (a)(2). "(2) The Secretary may provide— "(A) for such limitations on the scope and extent of services described in subsection (a)(2)(B) and on the categories of individuals who may be eligible to receive such services, and "(B) notwithstanding sections 1814, 1861(v), and 1886, for such restrictions and alternatives on the amounts and methods of payment for services described in such subsection, as may be necessary to carry out paragraph (1).". PROVISION TEMPORARILY HOLDING PART B PREMIUM AT CONSTANT PERCENTAGE OF COST

42 USC I395r.

42 USC I395w. Supra.

SEC. 124. (a)(1) Section 1839(c)(2) of the Social Security Act is amended by striking out "except as provided in subsection (d)" and inserting in lieu thereof "except as provided in subsections (d) and (g)". (2) Section 1839(c)(3) of such Act is amended by inserting "(except as otherwise provided in subsection (g))" after "The monthly premium shall". (b) Section 1839 of such Act is amended by adding at the end thereof the following new subsection: "(g)(1) Notwithstanding the provisions of subsection (c), the monthly premium for each individual enrolled under this part for each month after June 1983 and prior to July 1985 shall be an amount equal to 50 percent of the monthly actuarial rate for enrollees age 65 and over, as determined under subsection (c)(1) and applicable to such month. "(2) Any increases in premium amounts taking effect prior to July 1985 by reason of paragraph (1) shall be taken into account for purposes of determining increases thereafter under subsection (c)(3).". (c) Section 1844(a)(1) of such Act is amended by striking out "section 1839(c)(3)" each place it appears in subparagraphs (A)(i) and (B)(i) and inserting in lieu thereof in each instance "section 1839(c)(3) or 1839(g), as the case may be".

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 PUBLIC LAW 97-248—SEPT. 3, 1982

96 STAT. 365

SPECIAL ENROLLMENT PROVISIONS FOR MERCHANT SEAMEN

SEC. 125. (a) Any individual who— (1) was entitled to medical, surgical, and dental treatment and hospitalization under section 322(a) of the Public Health Service Act (as in effect on September 30, 1981), including such entitlement on the basis of continuing medical care under 42 C.F.R. § 32.17, at any time during the period beginning on March 10, 1981, and ending on October 1, 1981, and (2) as of September 30, 1981, was eligible under section 1818(a) or section 1836 of the Social Security Act to enroll in the insurance program established by part A or part B, respectively, of title XVIII of that Act (hereinafter in this section referred to as the "respective program"), may enroll (if not otherwise enrolled) in the respective program during the period beginning on the first day of the first month beginning at least 20 days after the date of the enactment of this Act and ending on December 31, 1982. (b)(1) The coverage period under the respective program of an individual who enrolls under subsection (a) shall begin— (A) on the first day of the month following the month in which the individual enrolls, or (B) on October 1, 1981, if the individual files a request for this subparagraph to apply and pays the monthly premiums for the months so covered. (2) The coverage period under the respective program of an individual described in subsection (a) who enrolled in the respective program before the enrollment period described in that subsection shall be retroactively extended to October 1, 1981, if the individual files a request before January 1, 1983, for such retroactive extension and pays the monthly premiums for the months so covered. (c)(1) For purposes of section 1839(d) of the Social Security Act with respect to the monthly premium for months after September 1981, if an individual described in subsection (a) has enrolled in the insurance program under part B of title XVIII of the Social Security Act at any time before the end of the enrollment period described in subsection (a), any month (before the end of that enrollment period) in which he was not enrolled in that program shall not be treated as a month in which he could have been enrolled in the program. (2) Paragraph (1) shall not apply to an individual— (A) if the individual has enrolled in the insurance program before March 10, 1981, unless the enrollment was terminated solely because the individual lost eligibility to be so enrolled, or (B) unless the individual applies for the benefit of such paragraph before January 1, 1983. (d)(1) The Secretary of Health and Human Services, beginning as soon as possible but not later than 30 days after the date of the enactment of this Act, shall provide for the dissemination of information— (A) to unions and other associations representing or assisting seamen, (B) to offices enrolling individuals under the respective programs, and (C) to such other entities and in such a manner as will effectively inform individuals eligible for benefits under this section, concerning the special benefits provided under this section.

42 USC 1395i-2 note. 95 Stat. 603. 42 USC 249.

42 USC 1395i-2, 1395o. 42 USC 1395c, 1395J.

42 USC 1395r.

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The New International Encyclopædia/Lichtenstein, Martin Heinrich Karl

LICHTENSTEIN, lĭ K 'ten-stīn, (1780-1857). A German traveler and zoölogist, born at Hamburg, and educated at Jena and Hehnstedt. He went as physician and tutor with the Dutch General Janssens to South Africa (1801), and served as surgeon to an infantry battalion of Hottentots and as governmental commissioner to the Bechuanas. In 1806, on the occupation of the colony by the English, he returned to Germany, devoting himself to the study and classification of the zoölogical and especially ornithological material he had collected in Africa. In 1811 he was made professor of zoölogy at Berlin, and two years afterwards was appointed to succeed Illiger as director of the Zoölogical Museum. His more important publications were Reisen im südlichen Afrika (1810-11) and Darstellungen neuer oder wenig bekannter Säugetiere (1827-34).


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Page:United States Statutes at Large Volume 96 Part 1.djvu/408

 96 STAT. 366

95 Stat. 603. 42 USC 249.

PUBLIC LAW 97-248—SEPT. 3, 1982 (2) An individual may establish that the individual was entitled at a date to medical, surgical, and dental treatment and hospitalization under section 322(a) of the Public Health Service Act (as in effect before October 1, 1981) by providing— (A) documentation relating to the status under which the individual was provided care in (or under arrangements with) a Public Health Service facility on that date, (B) the individual's seamen's papers covering that date, or (C) such other reasonable documentation as the Secretary may require. PART III—MISCELLANEOUS PROVISIONS EXTENDING MEDICARE PROFICIENCY EXAMINATION AUTHORITY

42 USC l320a-2.

SEC. 126. Section 1123(a) of the Social Security Act is amended by striking out "December 31, 1981" and inserting in lieu thereof "September 30, 1983". REGULATIONS REGARDING ACCESS TO BOOKS AND RECORDS

42 USC 1395x note. 94 Stat. 2646. 42 USC 1395x.

SEC. 127. Section 952 of the Omnibus Reconciliation Act of 1980 (94 Stat. 2646) is amended— (1) by inserting "(a)" after "SEC. 952.", and (2) by adding at the end the following new subsection: "(b) Unless the Secretary of Health and Human Services first publishes final regulations prescribing the criteria and procedures described in the last sentence of section 1861(v)(l)(I) of the Social Security Act by January 1, 1983, after providing a period of not less than 60 days for public comment on proposed regulations, the amendment made by subsection (a) shall only apply to books, documents, and records relating to services furnished (pursuant to contract or subcontract) on or after the date on which final regulations of the Secretary are first published.". TECHNICAL CORRECTIONS TO OMNIBUS BUDGET RECONCILIATION ACT OF 1981

42 USC I395x. 42USei395y. 95 Stat. 800. 42 USC 1395y. 42 USC 1395CC. 95 Stat. 785. 42 USC I395uu. 26 USC 162. 95 Stat. 202.

SEC. 128. (a)(1) Section 1861(cc)(l) of the Social Security Act is amended, in the matter following subparagraph (H), by striking out "outpatient" and inserting in lieu thereof "inpatient". (2) The second sentence of section 1862(b)(1) of such Act is amended by striking out "or plan". (3) Section 1862(b)(2)(A) of such Act is amended by striking out "section 162(h)(2)" and inserting in lieu thereof "section 162(i)(2)". (4) The first sentence of section 1862(b)(2)(B) of such Act is amended by inserting "furnished" before "to an individual". (5) Section 1866(b) of such Act is amended by striking out "(and in the case of a skilled nursing facility, prior to the end of the term specified in subsection (a)(1))" in the matter preceding paragraph (1). (6) The second subsection (c) of section 1884 of such Act is redesignated as subsection (d). (b) Section 162 of the Internal Revenue Code of 1954 is amended— (1) by redesignating the subsection (i) (relating to cross reference), as redesignated by the Economic Recovery Tax Act of 1981 (Public Law 95-34), as subsection (j), and

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Page:United States Statutes at Large Volume 96 Part 1.djvu/409

 PUBLIC LAW 97-248—SEPT. 3, 1982 (2) by redesignating the subsection (h) (relating to group health plans), as added by section 2146(b) of the Omnibus Budget Reconciliation Act of 1981, as subsection (i). (c)(1) Section 2143(b)(1) of the Omnibus Budget Reconciliation Act of 1981 is amended by striking out "costs" and inserting in lieu thereof "cost". (2) Section 2203(f)(3) of such Act is amended by striking out "August 1982" and inserting in lieu thereof "August 1981". (d)(1) Sections 1842(b)(3)(B)(ii)(II) and 1870(c) of the Social Security Act are each amended by striking out "1862" and inserting in lieu thereof "1862(a)". (2) The final subparagraph (C) of section 1861(e) of such Act is amended by striking out "may (i)," and inserting in lieu thereof "(i) may". (3) Section 1865(b) of such Act is amended by striking out "an institution" and "such institution" and inserting in lieu thereof "a hospital" and "the hospital", respectively. (4) Section 1866(a)(1)(B) of such Act is amended by inserting "of section 1862(a)" after "(1) or (9)". (e)(1) Any amendment to the Omnibus Budget Reconciliaton Act of 1981 made by this section shall be effective as if it had been originally included in the provision of the Omnibus Budget Reconciliation Act of 1981 to which such amendment relates. (2) Except as otherwise provided in this section, any amendment to the Social Security Act or the Internal Revenue Code of 1954 made by this section (other than subsection (d)) shall be effective as if it had been originally included as a part of that provision of the Social Security Act or Internal Revenue Code of 1954 to which it relates, as such provision of such Act or Code was amended by the Omnibus Budget Reconciliaton Act of 1981. (3) The amendments made by subsection (d) shall take effect upon enactment.

96 STAT. 367

95 Stat. 800. 95 Stat. 798. 42 USC 1395x note. 95 Stat. 835. 42 USC 1395u, 1395gg. 42 USC 1395x. 42 USC 1395bb. 42 USC 1395CC. Effective date. 42 USC 1395x note. 95 Stat. 357. 42 USC 1305; 26

usei.

Effective date.

Subtitle B—Medicaid COPAYMENTS BY MEDICAID RECIPIENTS

SEC. 131. (a) Section 1902(a)(14) of the Social Security Act is amended to read as follows: "(14) provide that enrollment fees, premiums, or similar charges, and deductions, cost sharing, or similar charges, may be imposed only as provided in section 1916;". (b) Title XIX of the Social Security Act is amended by adding at the end thereof the following new section:

42 USC I396a.

42 USC 1396.

USE OF ENROLLMENT FEES, PREMIUMS, DEDUCTIONS, COST SHARING, AND SIMILAR CHARGES

"SEC. 1916. (a) The State plan shall provide that in the case of 42 USC 13960. individuals described in section 1902(a)(10)(A) who are eligible under 95 Stat. 807. the plan— "(1) no enrollment fee, premium, or similar charge will be imposed under the plan; "(2) no deduction, cost sharing or similar charge will be imposed under the plan with respect to—

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Page:United States Statutes at Large Volume 96 Part 1.djvu/410

 96 STAT. 368

42 USC I396d. 42 USC 1396b.

95 Stat. 807. 42 USC 1396a.

PUBLIC LAW 97-248—SEPT. 3, 1982 "(A) services furnished to individuals under 18 years of age (and, at the option of the State, individuals under 21, 20, or 19 years of age, or any reasonable category of individuals 18 years of age or over), "(B) services furnished to pregnant women, if such services relate to the pregnancy or to any other medical condition which may complicate the pregnancy (or, at the option of the State, any services furnished to pregnant women), "(C) services furnished to any individual who is an inpatient in a hospital, skilled nursing facility, intermediate care facility, or other medical institution, if such individual is required, as a condition of receiving services in such institution under the State plan, to spend for costs of medical care all but a minimal amount of his income required for personal needs, or "(D) emergency services (as defined by the Secretary), family planning services and supplies described in section 1905(a)(4)(C), or services furnished to such an individual by a health maintenance organization (as defined in section 1903(m)) in which he is enrolled; and "(3) any deduction, cost sharing, or similar charge imposed under the plan with respect to other such individuals or other care and services will be nominal in amount (as determined by the Secretary in regulations which shall, if the definition of 'nominal' under the regulations in effect on July 1, 1982 is changed, take into account the level of cash assistance provided in such State and such other criteria as the Secretary determines to be appropriate); except that a deduction, cost-sharing, or similar charge of up to twice the nominal amount established for outpatient services may be imposed by a State under a waiver granted by the Secretary for services received at a hospital emergency room if the services are not emergency services (referred to in paragraph (2)(D)) and the State has established to the satisfaction of the Secretary that individuals eligible for services under the plan have actually available and accessible to them alternative sources of nonemergency, outpatient services. "(b) The State plan shall provide that in the case of individuals other than those described in section 1902(a)(10)(A) who are eligible under the plan— "(1) there may be imposed an enrollment fee, premium, or similar charge, which (as determined in accordance with standards prescribed by the Secretary) is related to the individual's income, "(2) no deduction, cost sharing, or similar charge will be imposed under the plan with respect to— "(A) services furnished to individuals under 18 years of age (and, at the option of the State, individuals under 21, 20, or 19 years of age, or any reasonable category of individuals 18 years of age or over), "(B) services furnished to pregnant women, if such services relate to the pregnancy or to any other medical condition which may complicate the pregnancy (or, at the option of the State, any services furnished to pregnant women), "(C) services furnished to any individual who is an inpatient in a hospital, skilled nursing facility, intermediate care facility, or other medical institution, if such individual

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 PUBLIC LAW 97-248—SEPT. 3, 1982

96 STAT. 369

is required, as a condition of receiving services in such institution under the State plan, to spend for costs of medical care all but a minimal amount of his income required for personal needs, or "(D) emergency services (as defined by the Secretary), family planning services and supplies described in section 1905(a)(4)(C), or (at the option of the State) services fur- 42 USC 1396cl. nished to such an individual by a health maintenance organization (as defined in section 1903(m)) in which he is 42 USC 1396b. enrolled; and "(3) any deduction, cost sharing, or similar charge imposed under the plan with respect to other such individuals or other care and services will be nominal in amount (as determined by the Secretary in regulations which shall, if the definition of 'nominal' under the regulations in effect on July 1, 1982 is changed, take into account the level of cash assistance provided in such State and such other criteria as the Secretary determines to be appropriate); except that a deduction, cost-sharing, or similar charge of up to twice the nominal amount established for outpatient services may be imposed by a State under a waiver granted by the Secretary for services received at a hospital emergency room if the services are not emergency services (referred to in paragraph (2)(D)) and the State has established to the satisfaction of the Secretary that individuals eligible for services under the plan have actually available and accessible to them alternative sources of nonemergency, outpatient services. "(c) The State plan shall require that no provider participating under the State plan may deny care or services to an individual eligible for such care or services under the plan on account of such individual's inability to pay a deduction, cost sharing, or similar charge. The requirements of this subparagraph shall not extinguish the liability of the individual to whom the care or services were furnished for payment of the deduction, cost sharing, or similar charge. "(d) No deduction, cost sharing, or similar charge may be imposed under any waiver authority of the Secretary unless authorized under this section, unless such waiver is for a demonstration project which the Secretary finds after public notice and opportunity for comment— "(1) will test a unique and previously untested use of copayments, "(2) is limited to a period of not more than two years, "(3) will provide benefits to recipients of medical assistance which can reasonably be expected to be equivalent to the risks to the recipients, "(4) is based on a reasonable hypothesis which the demonstration is designed to test in a methodologically sound manner, including the use of control groups of similar recipients of medical assistance in the area, and "(5) in which participation is voluntary, or in which provision is made for assumption of liability for preventable damage to the health of recipients of medical assistance resulting from involuntary participation.". (b) Section 1902(a)(10) of such Act is amended in the matter 42 USC 1396a. following subparagraph (D)— (1) by striking out "and" before "(III)"; and

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Page:United States Statutes at Large Volume 96 Part 1.djvu/412

 96 STAT. 370

Ante, p. 367.

Effective date. 42 USC 13960 note. 42 USC 1396.

PUBLIC LAW 97-248—SEPT. 3, 1982 (2) by inserting before the semicolon at the end thereof the following: "and (IV) the imposition of a deductible, cost sharing, or similar charge for any item or service furnished to an individual not eligible for the exemption under section 1916(a)(2) or (b)(2) shall not require the imposition of a deductible, cost sharing, or similar charge for the same item or service furnished to an individual who is eligible for such exemption". (c)(1) Except as provided in paragraph (2), the amendments made by this section shall become effective on October 1, 1982. (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 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. MODIFICATIONS IN LIEN PROVISIONS

42 USC 1396a. Infra.

SEC. 132. (a) Section 1902(a)(18) of the Social Security Act is amended to read as follows: "(18) comply with the provisions of section 1917 with respect to liens, adjustments and recoveries of medical assistance correctly paid, and transfers of assets;", (b) Title XIX of such Act is amended by adding after section 1916 (added by section 131 of this Act) the following new section: LIENS, ADJUSTMENTS AND RECOVERIES, AND TRANSFERS OF ASSETS

42 USC 1396p.

42 USC 1381.

"SEC. 1917. (a)(1) No lien may be imposed against the property of any individual prior to his death on account of medical assistance paid or to be paid on his behalf under the State plan, except— "(A) pursuant to the judgment of a court on account of benefits incorrectly paid on behalf of such individual, or "(B) in the case of the real property of an individual— "(i) who is an inpatient in a skilled nursing facility, intermediate care facility, or other medical institution, if such individual is required, as a condition of receiving services in such institution under the State plan, to spend for costs of medical care all but a minimal amount of his income required for personal needs, and "(ii) with respect to whom the State determines, after notice and opportunity for a hearing (in accordance with procedures established by the State), that he cannot reasonably be expected to be discharged from the medical institution and to return home, except as provided in paragraph (2). "(2) No lien may be imposed under paragraph (1)(B) on such individual's home if— "(A) the spouse of such individual, "(B) such individual's child who is under age 21, or (with respect to States eligible to participate in the State program established under title XVI) is blind or permanently and totally disabled, or (with respect to States which are not eligible to

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 PUBLIC LAW 97-248—SEPT. 3, 1982

96 STAT. 371

participate in such program) is blind or disabled as defined in section 1614, or 42 USC 1382c. "(C) a sibling of such individual (who has an equity interest in such home and who was residing in such individual's home for a period of at least one year immediately before the date of the individual's admission to the medical institution), is lawfully residing in such home. "(3) Any lien imposed with respect to an individual pursuant to paragraph (1)(B) shall dissolve upon that individual's discharge from the medical institution and return home. "(b)(1) No adjustment or recovery of any medical assistance correctly paid on behalf of an individual under the State plan may be made, except— "(A) in the case of an individual described in subsection (a)(1)(B), from his estate or upon sale of the property subject to a lien imposed on account of medical assistance paid on behalf of such individual, and "(B) in the case of any other individual who was 65 years of age or older when he received such assistance, from his estate. "(2) Any adjustment or recovery under paragraph (1) may be made only after the death of the individual's surviving spouse, if any, and only at a time— "(A) when he has no surviving child who is under age 21, or (with respect to States eligible to participate in the State program established under title XVI) is blind or permanently and 42 USC 1381. totally disabled, or (with respect to States which are not eligible to participate in such program) is blind or disabled as defined in section 1614; and "(B) in the case of a lien on an individual's home under subsection (a)(1)(B), when— "(i) no sibling of the individual (who was residing in the individual's home for a period of at least one year immediately before the date of the individual's admission to the medical institution), and "(ii) no son or daughter of the individual (who was residing in the individual's home for a period of at least two years immediately before the date of the individual's admission to the medical institution, and who establishes to the satisfaction of the State that he or she provided care to such individual which permitted such individual to reside at home rather than in an institution), is lawfully residing in such home and has lawfully resided in such home on a continuous basis since the date of the individual's admission to the medical institution. "(c)(1) Notwithstanding any other provision of this title, an individual who would otherwise be eligible for medical assistance under the State plan approved under this title may be denied such assistance if such individual would not be eligible for such medical assistance but for the fact that he disposed of resources for less than fair market value. If the State plan provides for the denial of such assistance by reason of such disposal of resources, the State plan shall specify a procedure for implementing such denial which, except as provided in paragraph (2), is not more restrictive than the procedure specified in section 1613(c) of this Act, and which may 42 USC 1382b. provide for a waiver of denial of such assistance in any instance where the State determines that such denial would work an undue hardship.

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