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100 STAT. 171

(2) in clause (iii), by striking out "and ending with the month before the month in which such individual attains the age of 70". (b) EXTENSION OF AGE DISCRIMINATION PROVISIONS.—

(1) Section 4(g)(1) of the Age Discrimination in Employment Act of 1967 (29 U.S.C. 623(g)(l)) is amended by striking out "through 69" and inserting in lieu thereof "or older" each place it appears. (2) Section 12(a) of such Act (29 U.S.C. 631(a)) is amended by inserting "(except the provisions of section 4(g))" after "Act'. (3) Section 4 of such Act (29 U.S.C. 623) is amended by redesignating the second subsection (g), added by section 802 of the Older Americans Act Amendments of 1984, as subsection 98 Stat. 1792. (h). (c) CONFORMING AMENDMENTS.—

(1) SPECIAL ENROLLMENT PERIOD.—Paragraph (3) of section

1837(i) of the Social Security Act (42 U.S.C. 1395p(i)(3)) is amended to read as follows: "(3) The special enrollment period referred to in paragraphs (1) and (2) is the period beginning with the first day of the first month in which the individual is no longer enrolled in a group health plan described in section 1862(b)(3)(A)(iv) by reason of current employment and ending seven months later.". (2) EFFECTIVE DATE OF ENROLLMENT.—Subsection (e) of section 1838 of the Social Security Act (42 U.S.C. 1395q) is amended to read as follows: "(e) Notwithstanding subsection (a), in the case of an individual who enrolls during a special enrollment period pursuant to section 1837(i)(3)— "(1) in the first month of the special enrollment period, the coverage period shall begin on the first day of that month, or "(2) in a month after the first month of the special enrollment period, the coverage period shall begin on the first day of the month following the month in which the individual so enrolls." (d) EFFECTIVE DATES.—(1) The amendments made by subsection (a) shall apply with respect to items and services furnished on or after May 1, 1986. (2) The amendments made by subsections (b) and (c) shall become effective on May 1, 1986.

42 USC 1395y.

42 USC 1395p.

42 USC I395y note. 42 USC I395p note.

SEC. 9202. PAYMENTS TO HOSPITALS FOR DIRECT COSTS OF MEDICAL EDUCATION.

(a) MEDICARE PAYMENT METHODOLOGY.—Section 1886 of the Social Security Act (42 U.S.C. 1395ww) is amended by adding at the end the following new subsection: "(h) PAYMENTS FOR DIRECT GRADUATE MEDICAL EDUCATION COSTS.— "(1) SUBSTITUTION OF SPECIAL PAYMENT RULES.—Notwithstand-

ing section 1861(v), instead of any amounts that are otherwise 42 USC I395x. payable under this title with respect to the reasonable costs of hospitals for direct graduate medical education costs, the Secretary shall provide for payments for such costs in accordance with paragraph (3) of this subsection. In providing for such payments, the Secretary shall provide for an allocation of such payments between part A and part B (and the trust funds established under the respective parts) as reasonably reflects the proportion of direct graduate medical education costs of

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 100 STAT. 172

PUBLIC LAW 99-272—APR. 7, 1986 hospitals associated with the provision of services under each respective part. "(2) DETERMINATION OF HOSPITAL-SPECIFIC APPROVED FTE RESIDENT AMOUNTS.—The Secretary shall determine, for each hos-

pital with an approved medical residency training program, an approved FTE resident amount for each cost reporting period beginning on or after July 1, 1985, as follows: "(A) DETERMINING ALLOWABLE AVERAGE COST PER FTE RESIDENT IN A HOSPITAL'S BASE PERIOD.—The Secretary shall

determine, for the hospital's cost reporting period that began during fiscal year 1984, the average amount recognized as reasonable under this title for direct graduate medical education costs of the hospital for each full-timeequivalent resident. "(B)

UPDATING TO THE FIRST COST REPORTING PERIOD.—

"(i) IN GENERAL.—The Secretary shall update each average amount determined under subparagraph (A) by the percentage increase in the consumer price index during the 12-month cost reporting period described in such subparagraph. "(ii) EXCEPTION.—The Secretary shall not perform an update under clause (i) in the case of a hospital if the hospital's reporting period, described in subparagraph (A), began on or after July 1, 1984, and before October 1, 1984. "(C) AMOUNT FOR FIRST COST REPORTING PERIOD.—For the

first cost reporting period of the hospital beginning on or after July 1, 1985, the approved FTE resident amount for the hospital is equal to the amount determined under paragraph (B) increased by 1 percent. "(D) AMOUNT FOR SUBSEQUENT COST REPORTING PERIODS.—

,,

For each subsequent cost reporting period, the approved FTE resident amount for the hospital is equal to the amount determined under this paragraph for the previous cost reporting period updated, through the midpoint of the period, by projecting the estimated percentage change in the consumer price index during the 12-month period ending at that midpoint, with appropriate adjustments to reflect previous under- or over-estimations under this subparagraph in the projected percentage change in the consumer price index. "(E) TREATMENT OF CERTAIN HOSPITALS.—In the case of a hospital that did not have an approved medical residency training program or was not participating in the program under this title for a cost reporting period beginning during fiscal year 1984, the Secretary shall, for the first such period for which it has such a residency training program and is participating under this title, provide for such approved FTE resident amount as the Secretary determines to be appropriate, based on approved FTE resident amounts for comparable programs. "(3) HOSPITAL PAYMENT AMOUNT PER RESIDENT.—

"(A) IN GENERAL.—The payment amount, for a hospital cost reporting period beginning on or after July 1, 1985, is equal to the product of— "(i) the aggregate approved amount (as defined in subparagraph (B)) for that period, and

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-5Sj* ^

100 STAT. 173

"(ii) the hospital's medicare patient load (as defined in subparagraph (O) for that period. "(B) AGGREGATE APPROVED AMOUNT.—As used in subparagraph (A), the term 'aggregate approved amount' means, for a hospital cost reporting period, the product of— "(i) the hospital's approved FTE resident amount (determined under paragraph (2)) for that period, and "(ii) the weighted average number of full-timeequivalent residents (as determined under paragraph (4)) in the hospital's approved medical residency training programs in that period. "(C) MEDICARE PATIENT LOAD.—As used in subparagraph (A), the term 'medicare patient load' means, with respect to a hospital's cost reporting period, the fraction of the total number of inpatient-bed-days (as established by the Secretary) during the period which are attributable to patients with respect to whom payment may be made under part A. '(4) DETERMINATION OF FULL-TIME-EQUIVALENT RESIDENTS.—

"(A) RULES.—The Secretary shall establish rules consistent with this paragraph for the computation of the number of full-time-equivalent residents in an approved medical residency training program. "(B)

ADJUSTMENT FOR PART-YEAR OR PART-TIME RESI-

DENTS.—Such rules shall take into account individuals who serve as residents for only a portion of a period with a hospital or simultaneously with more than one hospital. "(C) WEIGHTING FACTORS FOR CERTAIN RESIDENTS.—Sub-

ject to subparagraph (E), such rules shall provide, in calculating the number of full-time-equivalent residents in an approved residency program— "(i) before July 1, 1986, for each resident the weighting factor is 1.00, "(ii) on or after July 1, 1986, for a resident who is in the resident's initial residency period (as defined in paragraph (5)(F)), the weighting factor is 1.00, "(iii) on or after July 1, 1986, and before July 1, 1987, for a resident who is not in the resident's initial residency period (as defined in paragraph (5)(F)), the weighting factor is.75, and "(iv) on or after July 1, 1987, for a resident who is not in the resident's initial residency period (as defined in paragraph (5)(F)), the weighting factor is.50. "(E) FOREIGN MEDICAL GRADUATES REQUIRED TO PASS FMGEMS EXAMINATION. —

"(i) IN GENERAL.—Except as provided in clause (ii), such rules shall provide that, in the case of an individual who is a foreign medical graduate (as defined in paragraph (5)(D)), the individual shall not be counted as a resident on or after July 1, 1986, unless— "(I) the individual has passed the FMGEMS examination (as defined in paragraph (5)(E)), or "(II) the individual has previously received certification from, or has previously passed the examination of, the Educational Commission for Foreign Medical Graduates.

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 100 STAT. 174

PUBLIC LAW 99-272—APR. 7, 1986 "(ii) TRANSITION FOR CURRENT FMGS.—On or after July 1, 1986, in the case of a foreign medical graduate who— "(I) has served as a resident before July 1, 1986, and is serving as a resident after that date, but "(II) has not passed the FMGEMS examination or a previous examination of the Educational Commission for Foreign Medical Graduates before July 1, 1986,, the individual shall be counted as a resident at a rate equal to one-half of the rate at which the individual would otherwise be counted. "(5) DEFINITIONS AND SPECIAL RULES.—As used in this subsection: "(A) APPROVED MEDICAL RESIDENCY TRAINING PROGRAM.—

The term 'approved medical residency training program' means a residency or other postgraduate medical training program participation in which may be counted toward certification in a specialty or subspecialty and includes formal postgraduate training programs in geriatric medicine approved by the Secretary. "(B) CONSUMER PRICE INDEX.—As used in this paragraph, the term 'consumer price index' refers to the Consumer Price Index for All Urban Consumers (United States city average), as published by the Secretary of Commerce. "(C) DIRECT GRADUATE MEDICAL EDUCATION COSTS.—The

term 'direct graduate medical education costs' means direct costs of approved educational activities for approved medical residency training programs. "(D) FOREIGN MEDICAL GRADUATE.—The term 'foreign medical graduate' means a resident who is not a graduate i.w T

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of—

"(i) a school of medicine accredited by the Liaison Committee on Medical Education of the American Medical Association and the Association of American Medical Colleges (or approved by such Committee as meeting the standards necessary for such accreditation), "(ii) a school of osteopathy accredited by the American Osteopathic Association, or approved by such Association as meeting the standards necessary for such accreditation, or "(iii) a school of dentistry or podiatry which is accredited (or meets the standards for accreditation) by an organization recognized by the Secretary for such purpose. "(E) FMGEMS EXAMINATION.—The term 'FMGEMS examination' means parts I and II of the Foreign Medical Graduate Examination in the Medical Sciences recognized by the Secretary for this purpose. "(F) INITIAL RESIDENCY PERIOD.—The term 'initial residency period' means the period of board eligibility plus one year, except that— "(i) except as provided in clause (ii), in no case shall the initial period of residency exceed an aggregate period of formal training of more than five years for any individual, and

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100 STAT. 175

"(ii) a period, of not more than two years, during which an individual is in a geriatric residency or fellowship program which meets such criteria as the Secretary may establish, shall be treated as part of the initial residency period, but shall not be counted against any limitation on the initial residency period. The initial residency period shall be determined, with respect to a resident, as of the time the resident enters the residency training program. "(G) PERIOD OF BOARD ELIGIBILITY.— "(i) GENERAL RULE.—Subject to clauses (ii) and (iii),

the term 'period of board eligibility' means, for a resident, the minimum number of years of formal training necessary to satisfy the requirements for initial board eligibility in the particular specialty for which the resident is training. "(ii) APPLICATION OF 1985 - I 9 8 6 DIRECTORY.—Except as

provided in clause (iii), the period of board eligibility shall be such period specified in the 1985-1986 Directory of Residency Training Programs published by the Accreditation Council on Graduate Medical Education. "(iii) CHANGES IN PERIOD OF BOARD ELIGIBILITY.—On or after July 1, 1989, if the Accreditation Council on Graduate Medical Education, in its Directory of Residency Training Programs— "(I) increases the minimum number of years of formal training necessary to satisfy the require-i.L, ments for a specialty, above the period specified in its 1985-1986 Directory, the Secretary may increase the period of board eligibility for that specialty, but not to exceed the period of board eligibility specified in that later Directory, or "(II) decreases the minimum number of years of formal training necessary to satisfy the requirements for a specialty, below the period specified in its 1985-1986 Directory, the Secretary may decrease the period of board eligibility for that specialty, but not below the period of board eligibility
 * J

specified in that later Directory. "(H) RESIDENT.—The term 'resident' includes an intern or other participant in an approved medical residency training program.". (b) EFFECTIVE DATE.—The amendment made by subsection (a) 42 USC 1395WW shall apply to hospital cost reporting periods beginning on or after note. July 1, 1985. (c) STUDIES BY SECRETARY.—(1) The Secretary of Health and 42 USC 1395WW Human Services shall conduct a study with respect to approved note. educational activities relating to nursing and other health professions for which reimbursement is made to hospitals under title XVIII of the Social Security Act. The study shall address— 42 USC 1395. (A) the types and numbers of such programs, and number of students supported or trained under each program; (B) the fiscal and administrative relationships between the hospitals involved and the schools with which the programs and students are affiliated; and (C) the types and amounts of expenses of such programs for which reimbursement is made, and the financial and other

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 100 STAT. 176

Ante, p. 171.

42 USC 1395WW note. 42 USC 1395.

42 USC 1395u note.

42 USC 1395WW note.

42 USC 1395WW note.

PUBLIC LAW 99-272—APR. 7, 1986

contributions which accrue to the hospital as a consequence of having such programs. The Secretary shall report the results of such study to the Committee on Finance of the Senate and the Committees on Ways and Means and Energy and Commerce of the House of Representatives prior to December 31, 1987. (2) The Secretary shall conduct a separate study of the advisability of continuing or terminating the exception under section 1886(h)(5)(F)(ii) of the Social Security Act for geriatric residencies and fellowships, and of expanding such exception to cover other educational activities, particularly those which are necessary to meet the projected health care needs of Medicare beneficiaries. Such study shall also examine the adequacy of the supply of faculty in the field of geriatrics. The Secretary shall report the results of such study to the committees described in paragraph (1) prior to July 1, 1990. (d) GAO STUDY.—(1) The Comptroller General shall conduct a study of the variation in the amounts of payments made under title XVIII of the Social Security Act with respect to patients in different teaching hospital settings and in the amounts of such payments which are made with respect to patients who are treated in teaching and nonteaching hospital settings. Such study shall identify the components of such payments (including payments with respect to inpatient hospital services, physicians' services, and capital costs, and, in the case of teaching hospital patients, payments with respect to direct and indirect teaching costs) and shall account, to the extent feasible, for any variations in the amounts of the payment components between teaching and nonteaching settings and among different teaching settings. (2) In carrying out such study, the Comptroller General may utilize a sample of hospital patients and any other data sources which he deems appropriate, and shall, to the extent feasible, control for differences in severity of illness levels, area wage levels, levels of physician reasonable charges for like services and procedures, and for other factors which could affect the comparability of patients and of payments between teaching and nonteaching settings and among teaching settings. The information obtained in the study shall be coordinated with the information obtained in conducting the study of teaching physicians' services under section 2307(c) of the Deficit Reduction Act of 1984. (3) The Comptroller General shall report the results of the study to the committees described in subsection (c)(1) prior to December 31, 1987. (e)

REPORT

ON

UNIFORMITY

OF

APPROVED

FTE

RESIDENT

AMOUNTS.—The Secretary of Health and Human Services shall report to the committees described in subsection (c)(1), not later than December 31, 1987, on whether section 1886(h) of the Social Security Act should be revised to provide for greater uniformity in the approved FTE resident amounts established under paragraph (2) of that section, and, if so, how such revisions should be implemented. (f) STUDY ON FOREIGN MEDICAL GRADUATES.—The Secretary of

Health and Human Services shall study, and report to the committees described in subsection (c)(1), not later than December 31, 1987, respecting the use of physicians who are foreign medical graduates (within the meaning ot section 1886(h)(5)(D) of the Social Security Act) in the provision of health care services (particularly inpatient

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100 STAT. 177

and outpatient hospital services) to medicare beneficiaries. Such study shall evaluate— (1) the types of services provided; (2) the cost of providing such services, relative to the cost of other physicians providing the services or other approaches to providing the services; (3) any deficiencies in the quality of the services provided, and methods of assuring the quality of such services; and (4) the impact on costs of and access to services if medicare payment for hospitals' costs of graduate medical education of foreign medical graduates were phased out. (g) ESTABLISHING PHYSICIAN IDENTIFIER SYSTEM.—The Secretary of

Health and Human Services shall establish a system, for implementation not later than July 1, 1987, which provides for a unique identifier for each physician who furnishes services for which payment may be made under title XVIII of the Social Security Act. (h) PAPERWORK REDUCTION.—Chapter 35 of title 44, United States Code, shall not apply to information required for purposes of carrying out this section and the amendments made by this section.

42 USC 1395WW note.

42 USC 1395. 42 USC 1395WW note. 44USe 3501 et seq.

(i) PROHIBITING A LIMIT O N INCREASES O N DIRECT MEDICAL EDUCATION COSTS.—(1) Section 1861(v)(l) of the Social Security Act (42

U.S.C. 1395x(v)(l)), as amended by section 9107(b) of this title, is further amended by adding at the end the following new subparagraph: "(Q) Except as otherwise explicitly authorized, the Secretary is not authorized to limit the rate of increase on allowable costs of approved medical educational activities.". (2) The amendment made by paragraph (1) shall apply to cost 42 USC 1395x note. reporting periods beginning on or after July 1, 1985. (j) SPECIAL TREATMENT OF STATES FORMERLY UNDER WAIVER.—In

the case of a hospital in a State that has had a waiver approved under section 1886(c) of the Social Security Act, for cost reporting periods beginning on or after January 1, 1986, if the waiver is terminated— (1) the Secretary of Health and Human Services shall permit the hospital to change the method by which it allocates administrative and general costs to the direct medical education cost centers to the method specified in the medicare cost report; (2) the Secretary may make appropriate adjustments in the regional adjusted DRG prospective payment rate (for the region in which the State is located), based on the assumption that all teaching hospitals in the State use the medicare cost report; and (3) the Secretary shall adjust the hospital-specific portion of payment under section 1886(d) of such Act for any such hospital that actually chooses to use the medicare cost report. The Secretary shall implement this subsection based on the best available data.

42 USC 1395WW note. ^n^e, p. 161. '

SEC. 9204. MORATORIUM ON LABORATORY PAYMENT DEMONSTRATION.

(a) MORATORIUM.—Prior to January 1, 1987, the Secretary of Health and Human Services shall not conduct any demonstration projects relating to competitive bidding as a method of purchasing laboratory services under title XVIII of the Social Security Act. The Secretary may contract for the design of, and site selection for, such demonstration projects.

42 USC 1395ww note. contracts. 42 USC 1395.

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Rh civil and not to the military branch of the public service. The history of Indian management shows many failures and miscarriages, which patriotic citizens look back upon with keen regret; but it is a mistaken opinion that these failures and miscarriages would have been avoided had the control of Indian affairs been intrusted to another branch of the public service than that which now conducts it. The period during which the management of Indian affairs was in military hands need only be carefully studied to cure any fair-minded man of such a delusion.

Last year I set forth the fact that the normal condition of the Indians is not, as is believed by many, turbulence and hostility to the whites; that it must not be the only nor the principal object of an Indian policy merely to keep the Indians quiet, and that to keep them quiet the constant presence and pressure of force is not required; that of the 71 Indian agencies then existing, now reduced to 67, there are only 11 which have military posts in their immediate vicinity, and only 14 with a military force within one to-three days' march; that those in a state of hostility usually form but a very small percentage of the whole Indian population; that of the 250,000 Indians in the United States there have been since the pacification of the Sioux at no time more than a few hundred in hostile conflict with the whites; that such partial disturbances have not been provoked by the absence nor prevented by the presence of a military force; that of the four disturbances which occurred within the last three years three broke out in the immediate presence of such a military force, and only one without it; that a very large majority of Indian reservations are in a condition of uninterrupted quiet without the presence of a soldier; that the more civilized an Indian tribe becomes, the more certainly can its peaceable and orderly conduct be depended upon, and that the progress of civilization and the maintenance of peace among the Indians have always gone hand in hand. I am by no means unmindful of the difficulties connected with the management of the Indians by civil officers, which difficulties consist partly in finding men peculiarly qualified for so delicate a task, and in maintaining the integrity and working efficiency of the service. These difficulties, formidable as they may appear, can be and have been in a great measure overcome by constant watchfulness and careful direction. Complaints that the Indians do not obtain the goods appropriated for by Congress, or obtain them only in inferior quality, are disappearing. Cases of peculation and gross misconduct on the part of Indian agents have become exceedingly rare, so much so that even the reports of military officers who had been the most watchful, ever ready and willing critics of the Indian service while in the hands of civilians, have become almost entirely silent upon this subject as to the present management. I do not see any reason why this condition of things cannot be maintained in the future by the application of the same means, and why the same pride of calling which inspires other branches of the service should not be kept alive among the officials of the Indian Department. That the service is not perfect, as, perhaps, no
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 100 STAT. 178

42 USC 1395.

42 USC 1395y note.

42 USC 1395y.

42 USC 1395h.

PUBLIC LAW 99-272—APR. 7, 1986

(b) COOPERATION IN STUDY.—The Secretary of Health and Human Services and the Comptroller General shall assist representatives of clinical laboratories in the industry's conduct of a study to determine whether methods exist which are better than competitive bidding for purposes of utilizing competitive market forces in setting payment levels for laboratory services under title XVIII of the Social Security Act. If such a study is conducted by the clinical laboratory industry, the Secretary and the Comptroller General shall comment on such study and submit such comments and the study to the Senate Committee on Finance and the House Committees on Ways and Means and Energy and Commerce. SEC. 9205. HOME HEALTH WAIVER OF LIABILITY.

The Secretary of Health and Human Services shall, for purposes of determining whether payments to a home health agency should be denied pursuant to section 1862(a)(1)(A) of the Social Security Act, apply a presumption of compliance (2.5 percent) in the same manner as under the regulations in effect as of July 1, 1985. Such presumption shall apply until 12 months after the date on which ten regional intermediaries have commenced operations to service home health agencies, as required under section 1816(e)(4) of the Social Security Act.

Subpart B—Other Provisions SEC. 9211. PROVISIONS RELATING TO HEALTH MAINTENANCE ORGANIZATIONS AND COMPETITIVE MEDICAL PLANS. (a) FINANCIAL RESPONSIBILITY FOR PATIENTS HOSPITALIZED ON THE EFFECTIVE DATE OF AN ENROLLMENT OR DISENROLLMENT.—(1) SubsecContracts. 42 USC 1395WW.

.aft:

tion (c) of section 1876 of the Social Security Act (42 U.S.C. 1395mm) is amended by adding at the end the following new paragraph: "(7) A risk-sharing contract under this section shall provide that in the case of an individual who is receiving inpatient hospital services from a subsection (d) hospital (as defined in section 1886(d)(1)(B)) as of the effective date of the individual's— "(A) enrollment with an eligible organization under this section— "(i) payment for such services until the date of the individual's discharge shall be made under this title as if the individual were not enrolled with the organization, "(ii) the organization shall not be financially responsible for payment for such services until the date after the date of the individual's discharge, and "(iii) the organization shall nonetheless be paid the full amount otherwise payable to the organization under this section; or "(B) termination of enrollment with an eligible organization under this section— "(i) the organization shall be financially responsible for payment for such services after such date and until the date of the individual's discharge, "(ii) payment for such services during the stay shall not be made under section 1886(d), and "(iii) the organization shall not receive any payment with respect to the individual under this section during the period the individual is not enrolled.".

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100 STAT. 179

(2) Subsection (a)(3) of such section is amended by striking out "Payments" and inserting in lieu thereof "Subject to subsection (c)(7), payments". (3) Subsection (a)(6) of such section is amended by striking out " I f and inserting in lieu thereof "Subject to subsection (c)(7), if. (b) DiSENROLLMENTS.— (1) EFFECTIVE DATE.—Subsection (c)(3)(B) of such section is

amended by striking out "a full calendar month after" and inserting in lieu thereof "the date on which". (2) INFORMATION.—Such subsection is further amended by adding at the end the following: "In the case of an individual's termination of enrollment, the organization shall provide the individual with a copy of the written request for termination of enrollment and a written explanation of the period (ending on the effective date of the termination) during which the individual continues to be enrolled with the organization and may not receive benefits under this title other than through the organization.". . f -i (c) REVIEW OF MARKETING MATERIAL.—Subsection (c)(3)(C) of such section is amended by adding at the end the following: "No brochures, application forms, or other promotional or informational material may be distributed by an organization to (or for the use of) individuals eligible to enroll with the organization under this section unless (i) at least 45 days before its distribution, the organization has submitted the material to the Secretary for review and (ii) the Secretary has not disapproved the distribution of the material. The Secretary shall review all such material submitted and shall disapprove such material if the Secretary determines, in the Secretary's discretion, that the material is materially inaccurate or misleading or otherwise makes a material misrepresentation.". (d) PROMPT PUBLICATION OF AAPCC.—Subsection (a)(1)(A) of such section is amended by inserting after "The Secretary shall annually determine" the following: ", and shall publish not later than September 7 before the calendar year concerned". (e) EFFECTIVE DATES.— 42 USC 1395mm (1) FINANCIAL RESPONSIBILITY.—The amendments made by ^°^^subsection (a) shall apply to enrollments and disenrollments that become effective on or after the date of the enactment of this Act. (2) DISENROLLMENTS.—The amendments made by subsection (b) shall apply to requests for termination of enrollment submitted on or after May 1, 1986. (3) MATERIAL REVIEW.—(A) The amendment made by subsection (c) shall not apply to material which has been distributed before July 1, 1986. (B) Such amendment also shall not apply so as to require the submission of material which is distributed before July 1, 1986. (C) Such amendment shall also not apply to material which the Secretary determines has been prepared before the date of the enactment of this Act and for which a commitment for distribution has been made, if the application of such amendment would constitute a hardship for the organization involved. (4) PUBLICATION.—The amendment made by subsection (d) shall apply to determinations of per capita rates of payment for 1987 and subsequent years. (5) NECESSARY MODIFICATION OF CONTRACTS.—The Secretary of

Health and Human Services shall provide for such changes in

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 100 STAT. 180 42 USC 1395 mm.

PUBLIC LAW 99-272—APR. 7, 1986 the risk-sharing contracts which have been entered into under section 1876 of the Social Security Act as may be necessary to conform to the requirements imposed by the amendments made by this section on a timely basis.

SEC. 9213. REMOVAL OF PROHIBITION ON COMMENTS BY MEDICARE AND SOCIAL SECURITY ACTUARIES RELATING TO ECONOMIC ASSUMPTIONS. (a) FEDERAL OLD-AGE AND DISABILITY INSURANCE TRUST FUND.—

Section 201(c) of the Social Security Act (42 U.S.C. 401(c)) is amended by striking out ": Provided, That the certification shall not refer to economic assumptions underlying the Trustee's report, and shall" and inserting in lieu thereof ". Such report shall". (b) MEDICARE TRUST FUNDS.—Sections 1817(b) and 1841(b) of such Act (42 U.S.C. 1395i(b), 1395t(b)) are each amended by striking out ": Provided, That the certification shall not refer to economic assumptions underlying the Trustee's report". 42 USC 401 note. (c) EFFECTIVE DATE.—The amendments made by this section shall become effective on the date of the enactment of this Act. SEC. 9214. LIMITATION ON MERGER OF END STAGE RENAL DISEASE NETWORKS. 42 USC 1395rr note. 42 USC 1395rr.

The Secretary of Health and Human Services shall maintain renal disease network organizations as authorized under section 1881(c) of the Social Security Act, and may not merge the network organizations into other organizations or entities. The Secretary may consolidate such network organizations, but only if such consolidation does not result in fewer than 14 such organizations being permitted to exist. SEC. 9215. EXTENSION OF CERTAIN MEDICARE MUNICIPAL HEALTH SERVICES DEMONSTRATION PROJECTS.

Maryland. Ohio. Wisconsin. California. 42 USC 1395b-l note. 42 USC 1395b-l.

The Secretary of Health and Human Services shall extend, for a period of three additional years, approval of four municipal health services demonstration projects (located in Baltimore, Cincinnati, Milwaukee, and San Jose) authorized under section 402(a) of the Social Security Amendments of 1967. SEC. 9216. AUDIT AND MEDICAL CLAIMS REVIEW

.„

(a) INCREASE IN ACTIVITIES FOR FISCAL YEARS 1986, 42 USC 1395h note.

42 USC 1395h note.

1987,

AND

1988.—Section 118 of the Tax Equity and Fiscal Responsibility Act of 1982 (96 Stat. 355) is amended— (1) by striking out "for fiscal years 1983, 1984, and 1985", (2) by striking out "such fiscal years" and inserting in lieu thereof "fiscal years 1983, 1984, and 1985, and $105,000,000 for each of fiscal years 1986, 1987, and 1988", and (3) by striking out "the purpose of carrying out provider cost audits and reviews of medical necessity" and inserting in lieu thereof "purposes of carrying out provider cost audits, of reviewing medical necessity, and of recovering third-party liability payments". (b) EFFECTIVE DATE.—The amendments made by subsection (a) shall apply to fiscal years beginning with fiscal year 1986. SEC. 9217. LIVER TRANSPLANTS.

(a) The Senate finds that:

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 PUBLIC LAW 99-272—APR. 7, 1986

100 STAT. 181

(1) There have been more than 600 liver transplants since 1963 and the one year survival rate at qualified institutions is now greater than 70 percent. (2) There are 4,000 to 4,700 potential candidates in the United States each year who require a liver transplant, but only a small percentage would be eligible for Medicare coverage. (3) There are currently individuals on waiting lists for liver transplants who will die without Medicare coverage. (4) After extensive review and consideration of all the avail,pj j'«, able data, an National Institutes of Health expert panel concluded liver transplantation is "a therapeutic modality for end-stage liver disease that deserves broader application" in a limited number of centers where they can be carried out under optimal conditions. (5) National Institutes of Health further recommended that liver transplants be done in individuals under 18 years of age. (6) The CHAMPUS program, after considering all relevant data, determined that there was no scientific basis for limiting liver transplants to children under 18 years of age. (7) The Department of Health and Human Services has determined that liver transplantation is no longer an experimental procedure only for children under 18. (b) Based upon the above findings, it is the sense of the Senate that: (1) For the purposes of title XVIII of the Social Security Act, 42 USC 1395. the Secretary immediately reconsider the Medicare liver transplant coverage decision and implement a policy under which a liver transplant shall not be considered to be an experimental procedure for Medicare beneficiaries solely because an individual is over 18 years of age. . j >j; (2) A liver transplant shall be covered under such title when -'^o.i reasonable and medically necessary. (3) The Secretary shall place appropriate limiting criteria on coverage, including those relating to the patient's condition, the .^ -^^^., disease state, and the institution providing the care, so as to ' ^ >.j ensure the highest quality of medical care demonstrated to be consistent with successful outcomes. SEC. 9218. STUDIES RELATING TO PHYSICAL THERAPISTS AND OTHER PROFESSIONALS. (a) SUPERVISION OF HOME HEALTH SERVICES.—The Secretary of

Health and Human Services shall conduct a study of the advisability of changing the requirements of title XVIII of the Social Security Act to allow home health services to be provided under the supervision of a physical therapist or other health care professional, rather than requiring the supervision of a physician or registered nurse. Cb) OFFICE REQUIREMENT.—The Secretary of Health and Human Services shall conduct a study on the advisability of deleting the requirement under such title that a physical therapist must have an office equipped with specified equipment, even if such therapist provides all such services in patients' homes. (c) REPORTS.—The Secretary shall report the results of the studies to the Congress prior to October 1, 1986. SEC. 9219. TECHNICAL CORRECTIONS. (a) WORKING AGED TECHNICAL CORRECTIONS.—

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Page:United States Statutes at Large Volume 100 Part 1.djvu/218

 100 STAT. 182

PUBLIC LAW 99-272—APR. 7, 1986 (1) PREMIUM PENALTY.—The second sentence of section 1839(b) of the Social Security Act (42 U.S.C. 1395r(b)), as amended by section 2338(a) of the Deficit Reduction Act of 1984, is amended by striking out "months in which" and all that follows through "clause (iv) of such section" and inserting in lieu thereof "months during which the individual has attained the age of 65 and for which the individual can demonstrate that the individual was enrolled in a group health plan described in section 1862(b)(3)(A)(iv)". (2) SPECIAL ENROLLMENT PERIODS.—Section 1837(i) of the Social Security Act (42 U.S.C. 1395p), as added by section 2338(b) of the Deficit Reduction Act of 1984, is amended— (A) in paragraph (1), by amending subparagraph (A) to read as follows: "(A) has attained the age of 65,"; and (B) in paragraph (2), by redesignating subparagraph (C) as subparagraph (D) and by amending subparagraphs (A) and (B) to read as follows: "(A) has attained the age of 65; "(B)(i) has enrolled (or has been deemed to have enrolled) in the medical insurance program established under this part during the individual's initial enrollment period, or (ii) is an individual described in paragraph (1)(B); "(C) has enrolled in such program during any subsequent special enrollment period under this subsection during which the individual was not enrolled in a group health plan described in section 1862(b)(3)(A)(iv) by reason of the individual's (or individual's spouse's) current employment; and".

' 42 USC 1395y.

(3) EFFECTIVE DATES.—

42 USC 1395r note. 42 USC I395p note. gji|v

(A) The amendment made by paragraph (1) shall apply to months beginning with January 1983 for premiums for months beginning with the first month that begins more than 30 days after the date of the enactment of this Act. (B)(i) The amendments made by paragraph (2) shall apply to enrollments in months beginning with the first effective month (as defined in clause (ii)), except that in the case of any individual who would have a special enrollment period under section 1837(i) of the Social Security Act that would have begun after November 1984 and before the first effective month, the period shall be deemed to begin with the first day of the first effective month. (ii) For purposes of clause (i), the term "first effective month" means the first month that begins more than 90 days after the date of the enactment of this Act.

(b) MISCELLANEOUS TECHNICAL CORRECTIONS.—

(1)(A) Subclause (III) of section 1842(b)(7)(B)(ii) of the Social Security Act (42 U.S.C. 1395ua))(7)(B)(ii)), as added by section 2307(a)(2)(G) of the Deficit Reduction Act of 1984, is amended by indenting it two additional ems to the right so as to align its left margin with the left margins of subclauses (I) and (II) of that section. (B) Section 1861(n) of the Social Security Act (42 U.S.C. 1395x(n)), as inserted by section 2321(e)(3) of the Deficit Reduction Act of 1984, is amended by striking out "at his home" and inserting in lieu thereof "as his home". (C) Section 1888(b) of the Social Security Act (42 U.S.C. 1395yy0>)), as added by section 2319(b) of the Deficit Reduction

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Page:United States Statutes at Large Volume 100 Part 1.djvu/219

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100 STAT. 183

Act of 1984, is amended by striking out "notwithstanding" and inserting in lieu thereof "notwithstanding". (D) The amendments made by this paragraph shall be effec- 42 USC 1395u tive as if they had been originally included in the Deficit note. Reduction Act of 1984. (2)(A) Clause (iii) of section 1842(b)(7)(B) of the Social Security Act (42 U.S.C. 1395u(b)(7)(B)), as added by section 3(b)(6) of Public Law 98-617, is amended by moving its alignment two additional ems to the left so as to align its left margin with the left margins of clauses (i) and (ii) of that section. (B) The amendment made by subparagraph (A) shall be effec- 42 USC 1395U tive as if it had been originally included in Public Law 98-617. note. (3)(A) Section 1861(v)(l)(G)(i) of the Social Security Act (42 U.S.C. 1395x(b)(l)(G)(i)), as amended by section 602(d)(1) of the Social Security Amendments of 1983, is amended by inserting, in the matter after subclause (III), "on the basis o f after "(during such period)". (B) The amendment made by subparagraph (A) shall be effec- 42 USC 1395x tive as if it had been originally included in the Social Security note. Amendments of 1983. SEC. 9220. EXTENSION OF ON LOK WAIVER. (a) CONTINUED APPROVAL.— (1) MEDICARE WAIVERS.—Notwithstanding

any limitations contained in section 222 of the Social Security Amendments of 1972 and section 402(a) of the Social Security Amendments of 42 USC 1395b-l 1967, the Secretary of Health and Human Services shall con- and note, 139511. 1395b-l. tinue approval of the risk-sharing application (described in 42 USC 1395b-l 42 u section 603(c)(1) of Public Law 98-21) for waivers of certain note.s e requirements of title XVIII of the Social Security Act after the 42 USC 1395. end of the period described in that section. (2) MEDICAID WAIVERS.—Notwithstanding any limitations contained in section 1115 of the Social Security Act, the Secretary 42 USC 1315. shall approve any application of the Department of Health Services, State of California, for a waiver of requirements of title XIX of such Act in order to continue carrying out the 42 USC 1396. demonstration project referred to in section 603(c)(2) of Public Law 98-21 after the end of the period described in that section. (b) TERMS, CONDITIONS, AND PERIOD OF APPROVAL.—The Secretary's approval of an application (or renewal of an application) under this section— (1) shall be on the same terms and conditions as applied with respect to the corresponding application under section 603(c) of Public Law 98-21 as of July 1, 1985, except that requirements relating to collection and evaluation of information for demonstration purposes (and not for operational purposes) shall not apply; and (2) shall remain in effect until such time as the Secretary finds that the applicant no longer complies with the terms and conditions described in paragraph (1). SEC. 9221. CONTINUATION OF "ACCESS: MEDICARE" DEMONSTRATION PROJECT.

(a) APPROVAL OF APPLICATION.—The Secretary of Health and Human Services shall approve any application for a waiver of any requirement of titles XVIII and XIX of the Social Security Act necessary to provide for the continuation, through September 30,

42 USC 1395, 1396.

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Page:United States Statutes at Large Volume 100 Part 1.djvu/220

 100 STAT. 184 42 USC 1395b-l and note, 1395/Z. 42 USC 1395b-l.

PUBLIC LAW 99-272—APR. 7, 1986

1986, of the "Access: Medicare" demonstration project carried out pursuant to section 222 of the Social Security Amendments of 1972 and section 402(a) of the Social Security Amendments of 1967 by Monroe County Long Term Care Program, Inc. (b) TERMS AND CONDITIONS.—The Secretary's approval of an ap-

plication (or renewal of an application) under subsection (a) shall be on the same terms and conditions as applied to the demonstration project as in effect on August 31, 1985.

PART 3—PROVISIONS RELATING TO PART B OF MEDICARE Subpart A—Payment-Related Provisions SEC. 9301. MEDICARE PHYSICIAN PAYMENT PROVISIONS. (a) EXTENSION OF CURRENT FREEZE ON PAYMENT RATES THROUGH 42 USC 1395WW note.

APRIL 30, 1986.—Section 5(c) of the Emergency Extension Act of 1985 (Public Law 99-107), as amended by section 9101(a) of this title, is further amended by adding at the end the following new paragraph: "(2) PHYSICIAN PAYMENTS.—For purposes of subsection (b), the term 'extension period' means the period beginning on October 1, 1985, and ending on April 30, 1986." (b) EXTENSION OF CERTAIN PROVISIONS THROUGH DECEMBER 31,

1986.— (1) EXTENSION.—Section 1842(b)(4) of the Social Security Act (42 U.S.C. 1395u(b)(4)) is amended— (A) in subparagraph (A)— (i) by inserting "(i)" after "(4)(A)", and (ii) by adding at the end the following new clauses: "(ii)(I) In determining the prevailing charge levels under the third and fourth sentences of paragraph (3) for physicians' services furnished during the 8-month period beginning May 1, 1986, by a physician who is not a participating physician (as defined in subsection (h)(1)) at the time of furnishing the services, the Secretary shall not set any level higher than the same level as was set for the 12month period beginning July 1, 1983. "(II) In determining the prevailing charge levels under the fourth sentence of paragraph (3) for physicians' services furnished during the 8-month period beginning May 1, 1986, by a physician who is a participating physician (as defined in subsection (h)(1)) at the time of furnishing the services, the Secretary shall permit an additional one percentage point increase in the increase otherwise permitted under that sentence. "(iii) In determining the prevailing charge levels under the third and fourth sentences of paragraph (3) for physicians' services furnished during a 12-month period beginning on or after January 1, 1987, by a physician who is not a participating physician (as defined in subsection (h)(1)) at the time of furnishing the services, the Secretary shall not set any level higher than the same level as was set for services furnished during the previous calendar year (without regard to clause (ii)(II)) for physicians who were participating physicians during that year."; (B) in subparagraph (B)— "t (i) by inserting "(i)" after "(B)", and ^^ _.;,, (ii) by adding at the end the following new clause:

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 PUBLIC LAW 99-272—APR. 7, 1986

100 STAT. 185

"(ii) In determining the reasonable charge under paragraph (3) for physicians' services furnished during the 8-month period beginning May 1, 1986, by a physician who is not a participating physician (as defined in subsection (h)(1)) at the time of furnishing the services— "(I) if the physician was not a participating physician at any time during the 12-month period beginning on October 1, 1984, the customary charges shall be the same customary charges as were recognized under this section for the 12-month period beginning July 1, 1983, and "(II) if the physician was a participating physician at any time during the 12-month period beginning on October 1, 1984, the physician's customary charges shall be determined based upon the physician's actual charges billed during the 12-month period ending on March 31, 1985."; (C) in subparagraph (C)— (i) by inserting "(i)" after "'(C)", (ii) by striking out "(A)" and inserting in lieu thereof "(A)(i)" each place it appears, and (iii) by adding at the end the following new clause: "(ii) In determining the prevailing charge levels under the third and fourth sentences of paragraph (3) for physicians' services furnished during the periods beginning after December 31, 1986, by a physician who was not a participating physician on that date, the Secretary shall treat the level as set under subparagraph (A)(ii) as having fully provided for the economic changes which would have been taken into account but for the limitations contained in subparagraph (A)(ii)."; and (D) in subparagraph (D)— (i) by striking out "In determining" and all that follows through "subsection (h)(1))" and insert in lieu thereof "(i) In determining the customary charges for physicians' services furnished during the 8-month period beginning May 1, 1986, or the 12-month period beginning January 1, 1987, by a physician who was not a participating physician (as defined in subsection (h)(1)) on September 30, 1985", and (ii) by adding at the end the following new clauses: "(ii) In determining the customary charges for physicians' services furnished during the 12-month period beginning January 1, 1987, by a physician who is not a participating physician (as defined in subsection (h)(1)) on April 30, 1986, the Secretary shall not recognize increases in actual charges for services furnished during the 7-month period beginning on October 1, 1985, above the level of the physician's actual charges billed during the 3-month period ending on June 30, 1984. "(iii) In determining the customary charges for physicians' services furnished during the 12-month period beginning January 1, 1987, or January 1, 1988, by a physician who is not a participating physician (as defined in subsection (h)(1)) on December 31, 1986, the Secretary shall not recognize increases in actual charges for services furnished during the 8-month period beginning on May 1, 1986, above the level of the physician s actual charges billed during the 3-month period ending on June 30, 1984.". (2) CONTINUED ENFORCEMENT.—The first sentence of section 1842(j)(l) of such Act (42 U.S.C. 1395u(j)(l)) is amended to read as follows: "In the case of a physician who is not a participating physician for items and services furnished during a portion of the 30-month period beginning July 1, 1984, the Secretary shall

,^. ^ "-' *

,-^ ~.o,-

.

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Page:Collodi - The Story of a Puppet, translation Murray, 1892.djvu/126

 want to remain with him always and never to leave him again, never again! . . . Oh, little Fairy, tell me that it is not true that you are dead! . . . If you really love me. . . if you really love your little brother, come to life again. . . come to life as you were before! . . . Does it not grieve you to see me alone and abandoned by everybody? . . . If assassins come they will hang me again to the branch of a tree. . . and then I should die indeed. What do you imagine that I can do here alone in the world? Now that I have lost you and my papa, who will give me food? Where shall I go to sleep at night? Who will make me a new jacket? Oh, it would be better, a hundred times better, that I should die also! Yes, I want to die. . . ih! ih! ih!'

And in his despair he tried to tear his hair; but his hair, being made of wood, he could not even have the satisfaction of sticking his fingers into it.

Just then a large Pigeon flew over his head, and stopping with distended wings called down to him from a great height:

'Tell me, child, what are you doing there?'

'Don't you see? I am crying!' said Pinocchio, raising his head towards the voice and rubbing his eyes with his jacket.

'Tell me,' continued the Pigeon, 'amongst your companions, do you happen to know a puppet who is called Pinocchio?'


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Page:United States Statutes at Large Volume 100 Part 1.djvu/222

 100 STAT. 186

PUBLIC LAW 99-272—APR. 7, 1986 monitor the physician's actual charges to individuals enrolled under this part for physicians' services during that portion of that period.".

42 USC 1395U note.

42 USC 1395U.

42 USC 1395u note.

(3) PERIOD FOR ENTERING PARTICIPATION AGREEMENTS.—The

Secretary of Health and Human Services shall provide, during the month of April 1986, that physicians and suppliers may enter into an agreement under section 1842(h)(1) of the Social Security Act for the 8-month period beginning May 1, 1986, or terminate such an agreement previously entered into for fiscal year 1986. In the case of a physician or supplier who entered into such an agreement for fiscal year 1986, the physician or supplier shall be deemed to have entered into such agreement for such 8-month period and for each succeeding year unless the physician or supplier terminates such agreement before the beginning of the respective period. At the beginning of such 8-month period, the Secretary shall publish a new directory (described in section 1842(h)(4) of that Act, as redesignated by subsection (c)(3)(D) of this section) of participating physicians and suppliers. (4) EFFECTIVE DATE.—The amendments made by this subsection shall apply to services furnished on or after May 1, 1986. (c) INCENTIVES FOR PARTICIPATING PHYSICIAN PROGRAM.— (1) 15-MONTH EXTENSION OF TRANSFER OF FUNDS FOR

42 USC 1395u.

CARRIERS.—Section 2306(e) of the Deficit Reduction Act of 1984 (Public Law 98-369; 98 Stat. 1073) is amended— (A) by striking out "and 1985" and inserting in lieu thereof ", 1985, and 1986", (B) by striking out "the amendments made by this section" and inserting in lieu thereof "subsections (b)(4), (h), and (j) of section 1842 of the Social Security Act", (C) by striking out "and" before "not less", (D) by inserting before the period at the end the following: ", and not less than $18,000,000 for fiscal year 1986", and (E) by adding at the end the following new sentences: "A significant proportion of such funds shall be used for the expansion of the participating physician and supplier program and for the development of professional relations staffs dedicated to addressing the billing and other problems of physicians and suppliers participating in that program. Such funds for fiscal year 1986 are available for obligation until December 31, 1986.". (2) IMPROVEMENT OF PARTICIPATING PHYSICIAN DIRECTORIES.—

Section 1842(i) of the Social Security Act (42 U.S.C. 1395u(i)) is amended— (A) in the first sentence of paragraph (2)— (i) by striking out "a directory" and inserting in lieu thereof "directories (for appropriate local geographic areas)", and (ii) by inserting "for that area" before "for that fiscal year"; (B) in the second sentence of paragraph (2), by striking out "The directory" and inserting in lieu thereof "Each directory"; ,,_.,^,.^^.•,••,..•.,,.,.rru-..-••..-•,(C) in paragraph (3)—

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Page:U.S. Department of the Interior Annual Report 1880.djvu/20

 service is, I willingly concede; but I am also convinced that the substitution of military management would not in itself obviate existing difficulties, but would add others in effect likely to prove still more serious.

A careful investigation of the subject will convince any fair-minded inquirer that military management will not be more economical in the point of pecuniary outlays than the civil management is now. Of greater importance is the ascertained fact that the Indians have generally a strong dislike for military control—not for the mere reason that the presence of an armed force is distasteful to them, for the success of our Indian police system shows that they submit to the restraints imposed upon them by such a force with great willingness, and exercise the police regulations under the direction of prudent agents with great alacrity; but there is a variety of other reasons for their repugnance which it would lead me too far to mention. It is easy to understand that if the management of Indian affairs were turned over to the military service the interests of the Indians and the interests and convenience of the Army might not always agree; and it is from no disrespect to the Army when I express the opinion that under such circumstances it might sometimes be questionable which interests would have the preference. It is certainly true, and within my own knowledge, that some military officers have shown great aptitude for the management of Indians in their peaceful pursuits and relations; but it is also true that the very spirit of the calling of military men is apt to suggest the application of force as one of the first resorts, even in the cases where peaceful teaching and patient guiding are most required. There have been many instances of this kind. Without going into a full statement of all the reasons upon which my conviction in this respect is based, I will simply quote, with the strongest possible approval, the recommendation of the Peace Commission of 1868, couched in the following language: “This brings us to consider the much mooted question whether the bureau should belong to the civil or military department of the government. To determine this properly we must first know what is to be the future treatment of the Indians. If we intend to have war with them, the bureau should go the Secretary of War; if we intend to have peace, it should be in the civil department. Under the plan which we have suggested, the chief duties of the bureau will be to educate and instruct in the peaceful arts; in other words, to civilize the Indians. The military arm of the government is not the most admirably adapted to discharge duties of this character. We have the highest possible appreciation of the officers of the Army, and fully recognize their proverbial integrity and honor; but we are satisfied that not one in a thousand would like to teach Indian children to read and write, or Indian men to sow and reap. These are emphatically civil, and not military, occupations.” This report was signed by William T. Sherman, then Lieutenant-General of the Army, Brig. Gen. William S. Harney, Bvt. Maj. Gen. Alfred H. Terry, and Bvt. Maj. Gen. C. C. Augur.


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Page:United States Statutes at Large Volume 100 Part 1.djvu/223

 PUBLIC LAW 99-272—APR. 7, 1986

'

100 STAT. 187

(i) by striking out "directory" the first place it appears and inserting in lieu thereof "the directories", and (ii) by striking out "directory" the second place it appears and inserting in lieu thereof "the appropriate area directory or directories"; and (D) in paragraph (4)— (i) by striking out "directory" and inserting in lieu thereof "the directories", and (ii) by adding at the end the following: "The Secretary shall provide that each appropriate area directory is sent to each participating physician located in that area.".

"

- -^

,..

(3) EUMINATION OF PHYSICIAN ASSIGNMENT RATE LIST.—Section

,,:

1842(i) of such Act is further amended— 42 USC I395u. (A) by striking out "(i)(D" and all that follows through the end of paragraph (1), (B) by striking out "subsection (h)(D" in paragraph (2) and inserting in lieu thereof "paragraph (1)", (C) by striking out "list and" each place it appears in paragraphs (3) and (4), and (D) by redesignating paragraphs (2) through (4) as paragraphs (4) through (6) of subsection (h), respectively. (4)

INFORMATION O N THE PARTICIPATING PHYSICIAN A N D

SUP-

PLIER PROGRAM IN EXPLANATIONS OF MEDICARE BENEFITS FOR

UNASSiGNED CLAIMS.—Section 1842(h) of such Act, as previously amended by this subsection, is further amended by adding at the end the following new paragraphs: "(7) The Secretary shall provide that each explanation of benefits provided under this part for services furnished in the United States, in conjunction with the payment of claims under section 1833(a)(l) (made other than on an assignment-related basis, described in paragraph (8)), shall include— "(A) a reminder of the participating physician and supplier program established under this subsection (including the limitation on charges that may be imposed by such physicians and suppliers), and "(B) the toll-free telephone number or numbers, maintained under paragraph (2), at which an individual enrolled under this part may obtain information on participating physicians and suppliers. "(8) For purposes of this title, a claim is considered to be paid on an 'assignment-related basis' if the claim is paid on the beisis of an assignment described in subsection (b)(3)(B)(ii), in accordance with subsection (b)(6)(B), or under the procedure described in section 1870(fKl).". (5) EFFECTIVE DATE.—Section 1842(b)(7) of the Social Security Act, as added by paragraph (4) of this subsection, shall apply to explanations of benefits provided on or after such date (not later than October 1, 1986) as the Secretary of Health and Human Services shall specify. (d) CHANGING CUSTOMARY AND PREVAIUNG CHARGE UPDATES FOR PHYSICIAN SERVICES AND OTHER PART B SERVICES FROM OCTOBER TO JANUARY.— (1) PAYMENT UPDATES.—Section 1842(b)(3) of the Social Secu-

rity Act (42 U.S.C. 1395u(b)(3)) is amended—

42 USC 1395Z.

•H'J

42 USC 1395gg. 42 USC 1395U note.

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 100 STAT. 188

42 USC 1395u.

42 USC 1395u note. 42 USC 1395u note. 42 USC 1395J.

PUBLIC LAW 99-272—APR. 7, 1986 (A) in subparagraph (F), by striking out "(ending on September 30)"; (B) in the third sentence, by striking out "March 31" and all that follows through "of each year)" and inserting in lieu thereof "June 30 last preceding the start of the calendar year"; and (C) in the eighth sentence, by striking out "the twelvemonth period beginning on October 1 in". (2) PARTICIPATION AGREEMENTS.—Section 1842(h)(l) of such Act is amended— (A) in the second sentence— (i) by striking out "before October 1" and inserting in lieu thereof "before the beginning", (ii) by striking out "on the basis of an assignment" and all that follows through "1870(f)(1)" and inserting in lieu thereof "on an assignment-related basis", and (iii) by striking out "the 12-month period beginning on October 1 of'; and (B) in the third sentence— (i) by striking out "after October 1" and inserting in lieu thereof "after the beginning", and (ii) by striking out "12-month period beginning on such October 1" and inserting in lieu thereof "year". (3) DIRECTORIES.—The first sentence of section 1842(i)(2) of such Act (which is redesignated as section 1842(h)(4) by subsection (c)(3)(D)), is further amended by striking out "fiscal" each place it appears. (4) EFFECTIVE DATE.—The amendments made by this subsection shall apply to items and services furnished on or after October 1, 1986. (5) TRANSITION.—Notwithstanding any other provision of law, for purposes of making payment under part B of title XVIII of the Social Security Act, customary and prevailing charges (and the lowest charges determined under the sixth sentence of section 1842(b)(3) of such Act) for items and services furnished during the period beginning on October 1, 1986, and ending on December 31, 1986, shall be determined on the same basis as for items and services furnished on September 30, 1986.

SEC. 9303. PAYMENT FOR CLINICAL LABORATORY SERVICES. (a) CHANGING MONTH OF ANNUAL UPDATE FROM JULY TO JANUARY.—

42 USC 1395Z.

42 USC 1395/ note. 42 USC 1395Z note.

(1) IN GENERAL.—Section 1833(h) of the Social Security Act (42 U.S.C. 13951(h)) is amended— (A) by striking out "June 30, 1987" and "July 1, 1987" and inserting in lieu thereof "December 31, 1987" and "January 1, 1988", respectively, each place either appears, and (B) in paragraph (2), by inserting "(to become effective on January 1 of each year)' after "adjusted annually". (2) EFFECTIVE DATE.—The amendments made by paragraph (1) shall apply to clinical laboratory diagnostic tests performed on or after July 1, 1986. (3) TRANSITION.—The Secretary of Health and Human Services shall provide that the annual adjustment under section 1833(h) of the Social Security Act for 1986— (A) shall take effect on January 1, 1987, i.

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100 STAT. 189

(B) shall apply for the 12-month period beginning on that date, and (C) shall take into account the percentage increase or decrease in the Consumer Price Index for all urban consumers (United States city average) occurring over an 18-month period, rather than over a 12-month period. (b) PROVIDING CEILING ON RATES.—

(1) CEILING ON PAYMENTS.—Paragraphs (l)(D)(i) and (2)(D)(i) of section 1833(a) of the Social Security Act (42 U.S.C 13951(a)) are each amended by inserting after "lesser of the amount determined under such fee schedule" the following: ", the limitation amount for that test determined under subsection (h)(4)(B),". (2) ESTABLISHMENT OF LIMITATION AMOUNT.—Section 1833(h)(4) of such Act is amended by inserting "(A)" after "(4)" and by adding at the end the following new subparagraph: "(B) For purposes of subsections (a)(l)(D)(i) and (a)(2)(D)(i), the limitation amount for a clinical diagnostic laboratory test performed— "(i) on or after July 1, 1986, and before January 1, 1988, is equal to 115 percent of the median of all the fee schedules established for that test for that laboratory setting under paragraph (1), or "(ii) after December 31, 1987, and so long as a fee schedule for the test has not been established on a nationwide basis, is equal to 110 percent of the median of all the fee schedules established for that test for that laboratory setting under paragraph (1).". (3)

METHOD

OF PAYMENT FOR NON-INDEPENDENT LABORA-

TORIES.—Section 1833(h)(5)(C) of such Act is amended by striking out "which is independent of a physician's office or" and inserting in lieu thereof "other than". (4) EXTENDING MEDICARE PROFICIENCY EXAMINATION AUTHOR-

ITY.—Section 1123(a) of such Act (42 U.S.C. 1320a-2(a)) is amended by striking out "September 30, 1983" and inserting in lieu thereof "September 30, 1987". (5) EFFECTIVE DATES.—(A) The amendments made by paragraphs (1) and (2) shall apply to clinical diagnostic laboratory tests performed on or after July 1, 1986. (B) The amendment made by paragraph (3) shall apply to clinical diagnostic laboratory tests performed on or after January 1, 1987. (C) The amendment made by paragraph (4) shall take effect on the date of the enactment of this Act. (c) REPORT ON MINIMUM STANDARDS FOR CLINICAL LABORATORIES THAT ARE PART OF, OR ASSOCIATED WITH, PHYSICIANS' OFFICES.—The

Secretary of Health and Human Services shall report to Congress, not later than 12 months after the date of the enactment of this Act, on the standards that might be established under the medicare program for clinical laboratories which are part of or associated with a physician's office to assure the health and safety of individuals with respect to whom the laboratories perform clinical diagnostic laboratory tests for which payment may be made under the program. In recommending standards, the Secretary shall consider the differences in the scope, type, and complexity of tests performed by such laboratories and such other factors as may indicate a need for different standards for laboratories with different characteristics.

42 USC 1395Z note. 42 USC 1395/ note. 42 USC l320a-2 note.

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 PUBLIC LAW 99-272—APR. 7, 1986

100 STAT. 190

SEC. 9304. DETERMINATIONS OF INHERENT REASONABLENESS OF CHARGES AND CUSTOMARY CHARGES FOR CERTAIN FORMER HOSPITALCOMPENSATED PHYSICIANS. (a)

REGULATIONS RELATING TO INHERENT REASONABLENESS OF

CHARGES.—Section 1842(b) of the Social Security Act (42 U.S.C. 1395u(b)) is amended by adding at the end the following new paragraph: "(8) The Secretary by regulation shall— "(A) describe the factors to be used in determining the cases (of particular items or services) in which the application of this subsection results in the determination of a reasonable charge that, by reason of its grossly excessive or grossly deficient amount, is not inherently reasonable, and "(B) provide in those cases for the factors that will be considered in establishing a reasonable charge that is realistic and equitable.". 42 USC 1395u

note.

(b) COMPUTATION OF CuSTOMARY CHARGES FOR CERTAIN FORMER HOSPITAL-COMPENSATED PHYSICIANS.—(1) In applying section 1842(b)

of the Social Security Act to payment for physicians' services performed during the 8-month period beginning May 1, 1986, in the case of a physician who at anytime during the period beginning on October 31, 1982, and ending on January 31, 1985, was a hospitalcompensated physician (as defined in paragraph (3)) but who, as of February 1, 1985, was no longer a hospital-compensated physician, the physician's customary charges shall— (A) be based upon the physician's actual charges billed during the 12-month period ending on March 31, 1985, and (B) in the case of a physician who was not a participating physician (as defined in section 1842(h)(l) of the Social Security Act) on September 30, 1985, and who is not such a physician on May 1, 1986, be deflated (to take into account the legislative freeze on actual charges for nonparticipating physicians' services) by multiplying the physician's customary charges by.85. (2) In applying section 1842(b) of the Social Security Act to payment for physicians' services performed during the 8-month period beginning May 1, 1986, in the case of a physician who during the period beginning on February 1, 1985, and ending on December 31, 1986, changes from being a hospital-compensated physician to not being a hospital-compensated physician, the physician's customary charges shall be determined in the same manner as if the physician were considered to be a new physician. (3) In this subsection, the term "hospital-compensated physician" means, with respect to services furnished to patients of a hospital, a physician who is compensated by the hospital for the furnishing of physicians' services for which payment may be made under this part. SEC. 9305. PHYSICIAN PAYMENT REVIEW COMMISSION AND DEVELOPMENT OF RELATIVE VALUE SCALE. (a) ESTABLISHMENT OF COMMISSION.—Part B of title XVIII of the Social Security Act is amended by adding at the end the following new section: PHYSICIAN PAYMENT REVIEW COMMISSION

42 USC 1395W-1.

r

"SEC. 1845. (a)(1) The Director of the Congressional Office of Technology Assessment (hereinafter in this section referred to as

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100 STAT. 191

the 'Director' and the 'Office', respectively) shall provide for the appointment of a Physician Payment Review Commission (hereinafter in this section referred to as the 'Commission'), to be composed of individuals with expertise in the provision and financing of physicians' services appointed by the Director (without regard to the provisions of title 5, United States Code, governing appointments in the competitive service). "(2) The Commission shall consist of 11 individuals. Members of the Commission shall first be appointed no later than May 1, 1986, for a term of three years, except that the Director may provide initially for such shorter terms as will insure that (on a continuing basis) the terms of no more than four members expire in any one year. "(3) The membership of the Commission shall include physicians, other health professionals, individuals skilled in the conduct and interpretation of biomedical, health services, and health economics research, and representatives of consumers and the elderly. The Director shall seek nominations from a wide range of groups, including— "(A) national organizations representing physicians, including medical specialty organizations, "(B) organizations representing the elderly and consumers, "(C) national organizations representing medical schools, "(D) national organizations representing hospitals, including teaching hospitals, and "(E) national organizations representing health benefits programs. "(b)(1) The Commission shall make recommendations to the Congress, not later than March 1 of each year (beginning with 1987), regarding adjustments to the reasonable charge levels for physicians' services recognized under section 1842(b) and changes in the methodology for determining the rates of payment, and for making payment, for physicians' services under this title and other items and services under this part. "(2) In making its recommendations, the Commission shall— "(A) consider, and make recommendations on the feasibility and desirability of reducing, the differences in payment amounts for physicians' services under this part which are based on differences in geographic location or specialty; "(B) review the input costs (including time, professional skills, and risks) associated with the provision of different physicians' services; "(C) identify those charges recognized as reasonable under section 1842(b) which are significantly out-of-line, based on the 42 USC I395u. considerations of subparagraphs (A) and (B); "(D) assess the likely impact of different adjustments in pay ment rates, particularly their impact on physician participation in the participation program established under section 1842(h) and on beneficiary access to necessary physicians' services; "(E) make recommendations on ways to increase physician participation in that participation program and the acceptance of payment under this part on an assignment-related basis; "(F) make recommendations respecting the advisability and feasibility of making changes in the payment system for physicians' services under this part based on (i) the Secretary's study under section 603(b)(2) of the Social Security Amendments of 1983 (relating to payments for physicians' services furnished to 42 USC I395b-l note.

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Page:United States Statutes at Large Volume 100 Part 1.djvu/228

 100 STAT. 192

PUBLIC LAW 99-272—APR. 7, 1986

hospital inpatients on the basis of diagnosis-related groups) and (ii) the Office's report under section 2309 of the Deficit Reduc42 USC 1395/ tion Act of 1984 (relating to physician reimbursement under note. this part); "(G) identify those procedures, involving the use of assistants at surgery, for which payment for those assistants should not be made under this title without prior approval; and "(H) identify those procedures for which an opinion of a second physician should be required before payment is made under this title. "(3) The Commission also shall advise and make recommendations to the Secretary respecting the development of the relative value scale under subsection (e). "(c)(1) The following provisions of section 1886(e)(6) shall apply to 42 USC 1395WW. the Commission in the same manner as they apply to the Prospective Payment Assessment Commission: "(A) Subparagraph (C) (relating to staffing and administration generally). "(B) Subparagraph (D) (relating to compensation of members). "(C) Subparagraph (F) (relating to access to information), "(D) Subparagraph (G) (relating to reports and use of funds). "(E) Subparagraph (H) (relating to periodic GAO audits). "(F) Subparagraph (J) (relating to requests for appropriations). "(2) In order to carry out its functions, the Commission shall collect and assess information on medical and surgical procedures and services, including information on regional variations of medical practice. In collecting and assessing information, the Commission shall— "(A) utilize existing information, both published and unpublished, where possible, collected and assessed either by its own staff or under other arrangements made in accordance with this section, "(B) carry out, or award grants or contracts for, original research and experimentation, where existing information is inadequate for the development of useful and valid guidelines by the Commission, and "(C) adopt procedures allowing any interested party to submit information with respect to physicians' services (including new practices, such as the use of new technologies and treatment modalities), which information the Commission shall consider in making reports and recommendations to the Secretary and Congress. "(d) There are authorized to be appropriated such sums as may be necessary to carry out the provisions of this section. Such sums shall be payable from the Federal Supplementary Medical Insurance Trust Fund.". (b)

42 USC 1396.

DEVELOPMENT OF RELATIVE VALUE SCALE FOR PHYSICIANS'

SERVICES.—Section 1845 of the Social Security Act, as added by subsection (a), is further amended by adding at the end the following new subsection: "(e)(1) The Secretary shall develop a relative value scale that establishes a numerical relationship among the various physicians' services for which payment may be made under this part or under State plans approved under title XIX. "(2) In developing the scale, the Secretary shall consider among other items—

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100 STAT. 193

"(A) the report of the Office of Technology Assessment under section 2309 of the Deficit Reduction Act of 1984, "(B) the recommendations of the Physician Payment Review Commission under subsection (b)(3), and "(C) factors with respect to the input costs for furnishing particular physicians' services, such as— "(i) the differences in costs of furnishing services in different settings, "(ii) the differences in skill levels and training required to perform the services, and "(iii) the time required, and risk involved, in furnishing different services. "(3) The Secretary shall complete the development of the relative value scale under this section, and report to Congress on the development, not later than July 1, 1987. The report shall include recommendations for the application of the scale to payment for physicians' services furnished under this part on or after January 1, 1988.".

42 USC 1395/ note.

Reports.

SEC. 9306. LIMITATION ON MEDICARE PAYMENT FOR POST-CATARACT SURGERY PATIENTS. (a) DETERMINATION OF SEPARATE PAYMENT AMOUNTS FOR PROS-

THETIC LENSES AND PROFESSIONAL SERVICES.—Section 1842(b) of the

Social Security Act (42 U.S.C. 1395u(b)) is amended by adding after paragraph (8), added by section 9304(a) of this title, the following new paragraph: "(9) In providing payment for cataract eyeglasses and cataract contact lenses, and professional services relating to them, under this part, each carrier shall— "(A) provide for separate determinations of the payment amount for the eyeglasses and lenses and of the payment amount for the professional services of a physician (as defined in section 1861(r)), and "(B) not recognize as reasonable for such eyeglasses and lenses more than such amount as the Secretary establishes in guidelines relating to the inherent reasonableness of charges for such eyeglasses and lenses.". (b) EFFECTIVE DATE.—The amendments made by this section shall apply to items and services furnished on or after April 1, 1986.

42 USC 1395x.

42 USC 1395u note.

SEC. 9307. PAYMENT FOR ASSISTANTS AT SURGERY FOR CERTAIN CATARACT OPERATIONS AND OTHER OPERATIONS.

(a) LIMITATION ON PAYMENT.—Section 1862(a) of the Social Security Act (42 U.S.C. 1395y(a)) is amended— (1) by striking out "or" at the end of paragraph (13), (2) by striking out the period at the end of paragraph (14) and inserting in lieu thereof "; or", and (3) by adding at the end the following new paragraph: "(15) which are for services of an assistant at surgery in a cataract operation unless, before the surgery is performed, the appropriate utilization and quality control peer review organization (under part B of title XI) or a carrier under section 1842 has approved of the use of such an assistant in the surgical procedure based on the existence of a complicating medical condition.". (b) ADDITIONAL PRO FUNCTIONS.—Section 1154(a)(8) of such Act (42 U.S.C. 1320c-3(a)(8)) is amended by inserting before the period at

7i_iQA n _ RQ _ q: Of.? Part i

42 USC 1320c. 42 USC 1395u.

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 100 STAT. 194 Ante, p. 193.

PUBLIC LAW 99-272—APR. 7, 1986

the end the following: "or as may be required to carry out section 1862(a)(15)". (c) PROHIBITION FOR SUBMITTING BILL FOR WHICH PAYMENT MAY

42 USC 1395y note.

42 USC 1320C-3 note.

NOT B E MADE.—Section 1842 of such Act (42 U.S.C. 1395u) is amended— (1) in subsection (j)(2), by inserting "or subsection (k)" after "paragraph (1)", and (2) by adding at the end the following new subsection: "(k)(l) If a physician knowingly and willfully bills an individual enrolled under this part for charges for services as an assistant at surgery for which payment may not be made by reason of section 1862(a)(15), the Secretary may apply sanctions against such physician in accordance with subsection (j)(2). "(2) If a physician knowingly and willfully bills an individual enrolled under this part for charges that includes a charge for an assistant at surgery for which payment may not be made by reason of section 1862(a)(15), the Secretary may apply sanctions against such physician in accordance with subsection (j)(2).". (d) EXTENSION OF PROHIBITION TO OTHER PROCEDURES.—The Secretary of Health and Human Services, after consultation with the Physician Payment Review Commission, shall develop recommendations and guidelines respecting other surgical procedures for which an assistant at surgery is generally not medically necessary and the circumstances under which the use of an assistant at surgery is generally appropriate but should be subject to prior approval of an appropriate entity. The Secretary shall report to Congress, not later than January 1, 1987, on these recommendations and guidelines. (e) EFFECTIVE DATE.—The amendments made by this section shall apply to services performed on or after April 1, 1986.

Subpart B—Benefits and Other Provisions SEC. 9313. PART B PREMIUM.

Section 1839 of the Social Security Act (42 U.S.C. 1395r) is amended— (1) in subsection (e), by striking out '1988" and inserting in lieu thereof "1989" each place it appears; (2) in subsection (f)(1), by striking out "or 1986" and inserting in lieu thereof ", 1986, or 1987"; and (3) in subsection (f)(2), by striking out "or 1987" and inserting in lieu thereof ", 1987, or 1988". SEC. 9314. DEMONSTRATION OF PREVENTIVE HEALTH SERVICES UNDER MEDICARE. 42 USC 1395b-l note.

42 USC 1395.

(a) DEMONSTRATION PROGRAM.—The Secretary of Health and Human Services (hereinafter in this section referred to as the "Secretary") shall establish a 4-year demonstration program designed to reduce disability and dependency through the provision of preventive health services to individuals entitled to benefits under title XVIII of the Social Security Act (hereinafter in this section referred to as "medicare beneficiaries"). (b) PREVENTIVE HEALTH SERVICES UNDER DEMONSTRATION PRO-

GRAM.—The preventive health services to be made available under the demonstration program shall include— (1) health screenings, (2) health risk appraisals, (3) immunizations, and

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Page:United States Statutes at Large Volume 100 Part 1.djvu/231

 PUBLIC LAW 99-272—APR. 7, 1986

100 STAT. 195

(4) counseling on and instruction in— (A) diet and nutrition, (B) reduction of stress, (C) exercise and exercise programs, (D) sleep regulation, (E) injury prevention, (F) prevention of alcohol and drug abuse, (G) prevention of mental health disorders, (H) self-care, including use of medication, and (I) reduction or cessation of smoking. (c) CONDUCT OF PROGRAM.—The demonstration program shall— (1) be conducted under the direction of accredited public or private nonprofit schools of public health or preventive medicine departments accredited by the Council on Education for Public Health; (2) be conducted in no fewer than five sites, which sites shall be chosen so as to be geographically diverse and shall be readily accessible to a significant number of medicare beneficiaries; (3) involve community outreach efforts at each site to enroll the maximum number of medicare beneficiaries in the program; and (4) be designed— (A) to test alternative methods of payment for preventive health services, including payment on a prepayment basis as well as payment on a fee-for-service basis, (B) to permit a variety of appropriate health care providers to furnish preventive health services, including physicians, health educators, nurses, allied health personnel, dieticians, and clinical psychologists, and (C) to facilitate evaluation under subsection (d). (d) EVALUATION.—The Secretary shall evaluate the demonstration project in order to determine— (1) the short-term and long-term costs and benefits of providing preventive health services for medicare beneficiaries, including any reduction in inpatient services resulting from providing the services, and (2) what practical mechanisms exist to finance preventive health services under title XVIII of the Social Security Act. (e) REPORTS TO CONGRESS.—(1) Not later than three years after the date of the enactment of this Act, the Secretary shall submit a preliminary report to the Committees on Ways and Means and Energy and Commerce of the House of Representatives and to the Committee on Finance of the Senate on the progress made in the demonstration program, including a description of the sites at which the program is being conducted and the preventive health services being provided at the different sites. (2) Not later than five years after the date of the enactment of this Act, the Secretary shall submit a final report to those Committees on the demonstration program and shall include in the report— (A) the evaluation described in subsection (d), and (B) recommendations for appropriate legislative changes to incorporate payment for cost-effective preventive health services into the medicare program. (f) FUNDING.—Expenditures made for the demonstration program shall be made from the Federal Supplementary Medical Insurance Trust Fund (established by section 1841 of the Social Security Act). Grants and payments under contracts may be made either in ad-

Schools and colleges,

42 USC 1395.

42 USC I395t.

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 100 STAT. 196

42 USC 1395.

PUBLIC LAW 99-272—APR. 7, 1986

vance or by way of reimbursement, as may be determined by the Secretary, and shall be made in such installments and on such conditions as the Secretary finds necessary to carry out the purpose of this section. Funding for the demonstration program shall not exceed $4,000,000 over the duration of the program. (g) WAIVER OF MEDICARE REQUIREMENTS.—The Secretary shall waive compliance with such requirements of title XVIII of the Social Security Act to the extent and for the period the Secretary finds necessary for the conduct of the demonstration program. SEC. 9315. EXTENSION OF GAO REPORTING DATE.

42 USC 1395h note.

(a) EXTENSION.—Section 2326(e)(2) of the Deficit Reduction Act of 1984 (98 Stat. 1088) is amended by striking out "12 months after the date of the enactment of this Act" and inserting in lieu thereof "May 1, 1986". (b) EFFECTIVE DATE.—The amendment made by this section shall apply as though it were included in the Deficit Reduction Act of 1984 as originally enacted.

PART 4—PEER REVIEW ORGANIZATIONS SEC. 9401. 100 PERCENT PEER REVIEW OF CERTAIN SURGICAL PROCEDURES. 42 USC 1320C-3.

Infra.

(a) REQUIREMENT.—Section 1154(a) of the Social Security Act (42 U.S.C. 1395c-3(a)) is amended by adding at the end thereof the following new paragraph: "(12) The organization shall perform the review, referral, and other functions required under section 1164.". (b) ADDITIONAL PEER REVIEW FUNCTIONS.—Part B of title XI of the Social Security Act is amended by adding at the end the following new section: "lOO PERCENT PEER REVIEW FOR CERTAIN SURGICAL PROCEDURES

42 USC 1320C-13. 42 USC 1320C-3.

"SEC. 1164. (a) 100 PERCENT REVIEW FUNCTION.—

"(1) IN GENERAL.—Each utilization and quality control peer review organization shall perform the review described in section 1154(a)(1) for 100 percent of the surgical procedures specified pursuant to subsection (b). "(2) TIMING OF REVIEW.—

"(A) IN GENERAL.—Except as provided in subparagraph (B), the review required under paragraph (1) shall be performed— "(i) before the performance of the procedure, in the case of an outpatient procedure, or "(ii) before admission to the hospital for the provision of services in connection with the procedure, in the case of a procedure performed on an inpatient basis. "(B) EXCEPTION.—The review with respect to a procedure need not be performed by the time specified in subparagraph (A) in cases of a medical emergency and under such other circumstances as the Secretary may specify. "(b) SPECIFICATION OF SURGICAL PROCEDURES AND QUALIFIED REVIEWERS.—

"(1) IN CONTRACT.—The contract with each organization under this part shall specify at least 10 surgical procedures to be covered under this section.

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Page:U.S. Department of the Interior Annual Report 1880.djvu/21

Rh Under the circumstances described in this report, it must be evident that the mission of Indian management will henceforth be, more than ever, a mission of peace and not a mission of war. The principal agencies which must be depended upon for the solution of the Indian problem are work, education, the permanent settlement upon agricultural and pasture lands, security of title, and equal protection of the law. All these are civil agencies, and the more the land interests of the Indians press into the foreground, the more necessary will it be that Indian management be connected with that branch of the service which has the administration of public lands under its special control.

It has also been suggested that the Indian service, owing to its importance, should cease to be a mere bureau in the Interior and be intrusted to an independent department. I should consider this advisable only if the head of that department could at the same time hold a place in the Cabinet, enabling him to make his views heard in its deliberations and to communicate on equal terms with the heads of the other departments of the executive branch of the government. But this would involve the larger question whether it would be wise to increase the number of Cabinet officers, and until this question is decided in the affirmative it would in my opinion be most advantageous to the public interest to permit the Indian service to remain under the direction of the Secretary of the Interior, to be thus represented in the executive council.

Finally, I desire to say that it has not been the policy of this department under my administration, while avoiding all unnecessary outlays of money, to cut down expenses merely for the purpose of making a striking exhibition of economy. The history of Indian affairs shows that ill-judged parsimony has not unfrequently led to serious trouble and very costly complications. I am now convinced that generous appropriations for agricultural implements, for stock cattle to be distributed among Indians, and for educational facilities, made at this time, when the temper of our whole Indian population is such as to receive such aid in the right spirit, and to use the advantages conferred for general and rapid advancement, will produce results certain to accelerate the solution of the greatest difficulties we have so far been contending with, and, consequently, to bring about a great saving of money in the future. When an Indian lives in a house which he considers his own and that of his family, as now thousands of families are living and many more thousands desire to live; when he cultivates his acres, has them fenced by his own labor, and enjoys the product of his agricultural work, either by his own consumption or the sale of a surplus; when he owns his plow and his wagon, and uses the latter, with his ponies, in freighting, by which he earns liberal wages; when he has his cows, and swine, and poultry on his land, the care of which he finds useful and profitable; when he can send his children to school, and begins to hope that they may become as civilized and prosperous as white people, he will soon cease to think of leading the life of a nomad, and the thought of war


text:
Page:Collodi - The Story of a Puppet, translation Murray, 1892.djvu/127

 'Pinocchio? . . . Did you say Pinocchio?' repeated the puppet, jumping quickly to his feet. 'I am Pinocchio!'

The Pigeon at this answer descended rapidly to the ground. He was larger than a turkey.

'Do you also know Geppetto?' he asked.

'If I know him! He is my poor papa! Has he perhaps spoken to you of me? Will you take me to him? Is he still alive? Answer me for pity's sake: is he still alive?'

'I left him three days ago on the seashore.'

'What was he doing?'

'He was building a little boat for himself, to cross the ocean. For more than three months that poor man has been going all round the world looking for you. Not having succeeded in finding you he has now taken it into his head to go to the distant countries of the new world in search of you.'

'How far is it from here to the shore?' asked Pinocchio breathlessly.

'More than six hundred miles.'

'Six hundred miles! Oh, beautiful Pigeon, what a fine thing it would be to have your wings! . . .'

'If you wish to go, I will carry you there.'

'How?'

'Astride on my back. Do you weigh much?'


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100 STAT. 197

"(2) SELECTION GUIDELINES.—

"(A) IN GENERAL.—The specification of procedures shall be consistent with selection guidelines established by the Secretary under paragraph (3). The procedures specified shall be included among the surgical procedures which the Secretary has identified as reasonably being able to meet such guidelines. "(B) EXCEPTION.—The Secretary may permit an organization to include among the procedures specified under paragraph (1) procedures not identified by the Secretary under paragraph (2)(A) if to do so would be cost effective and consistent with the criteria described in paragraph (3). "(3) CRITERIA.—The Secretary shall establish such guidelines and identify such surgical procedures consistent with the following criteria: "(A) The procedure is one which generally can be postponed without undue risk to the patient. "(B) The procedure is a high volume procedure among patients who are covered under the programs established under title XVIII or is a high cost procedure. 42 USC 1395. "(C) The procedure has a comparatively high rate of nonconflrmation upon examination by another qualified physician, there is substantial geographic variation in the rates of performance of the procedure, or there are other reasons why pre-procedure review for 100 percent of the procedures would be cost effective. "(4) QUALIFICATIONS OPINIONS.—

FOR PHYSICIANS

PROVIDING

SECOND

"(A) IN GENERAL.—The Secretary shall specify, for each procedure identified under paragraphs (2) and (3), the type or types of board certified or board eligible specialists who may conduct a second opinion, required under subsection (c), based upon the nature of the procedure. "(B)

FREEDOM OF CHOICE OF PATIENT TO CHOOSE PHYSI-

CIAN.—Subject to paragraphs (C) and (D), the patient may choose any physician of the proper specialty under subparagraph (A) to provide the second opinion. "(C) PHYSICIANS PROHIBITED FROM PROVIDING SECOND OPIN-

IONS.—For purposes of this section, a second opinion may not be provided by a physician who is affiliated with, or has a common financial interest with, the physician who rendered the first opinion that the procedure was necessary. "(D) RESTRICTED LIST.—In accordance with guidelines of the Secretary, an organization may disqualify a physician from providing a second opinion under this section because of the gross unreliability of the second opinions provided. '(c) REQUIRING A SECOND OPINION IN CERTAIN CASES.— "(1) DETERMINATIONS BY ORGANIZATION.—In the case of a

review performed pursuant to subsection (a), the organization shall determine, based on such review, that the surgical procedure— "(A) is reasonable and medically necessary, "(B) is not reasonable and medically necessary, or "(C) may be considered reasonable and necessary, but, because of questions as to the medical appropriateness of performing the procedure, it is appropriate to require the patient to seek a second opinion as to the necessity and

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