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98 STAT. 1081

(2) identify those hospitals which meet such definition, and make such identity available to the Committee on Ways and Means of the House of Representatives and the Committee on Finance of the Senate. PROSPECTIVE PAYMENT WAGE INDEX

SEC. 2316. (a) The Secretary of Health and Human Services, in consultation with the Secretary of Labor, shall conduct a study to develop an appropriate index for purposes of adjusting payment amounts under section 1886(d) of the Social Security Act to reflect area differences in average hospital wage levels, as required under paragraphs (2)(H) and (3)(E) of such section, taking into account wage differences of full time and part time workers. The Secretary of Health and Human Services shall report the results of such study to the Congress not later than 30 days after the date of the enactment of this Act, including any changes which the Secretary determines to be necessary to provide for an appropriate index. Qy) The Secretary shall adjust the payment amounts for hospitals for cost reporting periods beginning on or after October 1, 1983, to reflect any changes made in the wage index pursuant to subsection (a). Any adjustment in such payments to take account of overpayments or underpayments for the first cost reporting period of a hospital to which section 1886(d) of the Social Security Act applies, shall be made by decreasing or increasing payments in the succeeding cost reporting period. (c) The Secretary shall conduct a study and report to the Congress on proposed criteria under which, in the case of a hospital that demonstrates to the Secretary in a current fiscal year that the adjustment being made under paragraph (2)(H) or (3)(E) of section 1886(d) of the Social Security Act for that hospital's discharges in that fiscal year does not accurately reflect the wage levels in the labor market serving the hospital, the Secretary, to the extent he deems appropriate, would modify such adjustment for that hospital for discharges in the subsequent fiscal year to take into account a difference in payment amounts in that current fiscal year to the hospital that resulted from such inaccuracy.

Study. 42 USC 1395WW note. 97 Stat. 152. 42 USC 1395WW. Report.

y»\n\.

Study. Report.

DEADLINE FOR REPORT ON INCLUDING PAYMENT FOR PHYSICIANS' SERVICES TO HOSPITAL INPATIENTS IN DRG PAYMENT AMOUNTS

SEC. 2317. The second sentence of section 603(a)(2)(B) of the Social Security Amendments of 1983 (Public Law 98-21) is amended by striking out "include, in a report to Congress in 1985," and inserting in lieu thereof "submit to Congress, not later than July 1, 1985, a report to Congress which includes".

42 USC 1395WW note. 97 Stat. 166.

EMERGENCY ROOM SERVICES

SEC. 2318. (a) Section 1861(v)(l)(K) of the Social Security Act is amended by inserting "(i)" after "(K)" and by adding at the end thereof the following new clause: "(ii) For purposes of clause (i), the term 'bona fide emergency services' means services provided in a hospital emergency room after the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in—

42 USC 1395x.

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 98 STAT. 1082

Ante, p. 1081.

Effective date. 42 USC 1395x note.

PUBLIC LAW 98-369—JULY 18, 1984

"(I) placing the patient's health in serious jeopardy; "(11) serious impairment to bodily functions; or "(III) serious dysfunction of any bodily organ or part.". (b) Section 1861(v)(l)(K)(i) of such Act as so designated is amended by striking out "provided in an emergency room" and inserting in lieu thereof "as defined in clause (ii)". (c) The amendments made by this section shall apply to services furnished on or after the date of the enactment of this Act. SKILLED NURSING FACILITY REIMBURSEMENT

42 USC 1395x.

Infra.

SEC. 2319. (a)(1) Section 1861(v)(l)(E) of the Social Security Act is amended by striking out clause (i) thereof, and by striking out "(ii)", (2) Section 1861(v)(7) of such Act is amended by adding at the end thereof the following new subparagraph: "(D) For further limitations on reasonable cost and determination of payment amounts for routine service costs of skilled nursing facilities, see section 1888.". (b) Title XVIII of the Social Security Act is amended by adding at the end thereof the following new section: PAYMENT TO SKILLED NURSING FACILITIES FOR ROUTINE SERVICE COSTS

42 USC I395yy.

"SEC. 1888. (a) The Secretary, in determining the amount of the payments which may be made under this title with respect to routine service costs of extended care services shall not recognize as reasonable (in the efficient delivery of health services) per diem costs of such services to the extent that such per diem costs exceed the following per diem limits, except as otherwise provided in this section: "(1) With respect to freestanding skilled nursing facilities located in urban areas, the limit shall be equal to 112 percent of the mean per diem routine service costs for freestanding skilled nursing facilities located in urban areas. "(2) With respect to freestanding skilled nursing facilities located in rural areas, the limit shall be equal to 112 percent of the mean per diem routine service costs for freestanding skilled nursing facilities located in rural areas. "(3) With respect to hospital-based skilled nursing facilities located in urban areas, the limit shall be equal to the sum of the limit for freestanding skilled nursing facilities located in urban areas, plus 50 percent of the amount by which 112 percent of the mean per diem routine service costs for hospital-based skilled nursing facilities located in urban areas exceeds the limit for freestanding skilled nursing facilities located in urban areas. "(4) With respect to hospital-based skilled nursing facilities located in rural areas, the limit shall be equal to the sum of the limit for freestanding skilled nursing facilities located in rural areas, plus 50 percent of the amount by which 112 percent of the mean per diem routine service costs for hospital-based skilled nursing facilities located in rural areas exceeds the limit for freestanding skilled nursing facilities located in rural areas. In applying this subsection the Secretary shall make appropriate adjustments to the labor related portion of the costs based upon an appropriate wage index.

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license: Creative Commons - Attribution Share-Alike - https://creativecommons.org/licenses/by-sa/4.0/


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98 STAT. 1083

"(b) With respect to a hospital-based skilled nursing facility, the Secretary shall recognize as reasonable the portion of the cost differences between hospital-based and freestanding skilled nursing facilities attributable to excess overhead allocations (as determined by the Secretary) resulting from the reimbursement principles under this title, notwithstanding the limits set forth in paragraph (3) or (4) of subsection (a). "(c) The Secretary may make adjustments in the limits set forth in subsection (a) with respect to any skilled nursing facility to the extent the Secretary deems appropriate, based upon case mix or circumstances beyond the control of the facility.". (c) The amendments made by subsections (a) and (b) shall apply to cost reporting periods beginning on or after July 1, 1984. (d) Notwithstanding limits on the cost of skilled nursing facilities which may have been issued under section 1861(v) of the Social Security Act prior to the date of the enactment of this Act, in the case of cost reporting periods beginning on or after October 1, 1982, and prior to July 1, 1984, the cost limits for routine services for urban and rural hospital-based skilled nursing facilities shall be 112 percent of the mean of the respective routine costs for urban and rural hospital-based skilled nursing facilities. (e) The Secretary of Health and Human Services shall submit to the Congress, prior to December 1, 1984, the report required under section 605(b) of the Social Security Amendments of 1983. (fKl) The Secretary of Health and Human Services shall report to the Committee on Finance of the Senate and the Committee on Ways and Means of the House of Representatives, prior to August 1, 1984, the proposals developed, as required under section 1135(c) of the Social Security Act, for prospective reimbursement of skilled nursing facilities. (2) The Secretary of Health and Human Services shall submit to the Congress, prior to December 1, 1984, a report on the range of options for prospective payment of skilled nursing facilities under title XVIII of the Social Security Act. The report shall take into account case mix differences among skilled nursing facilities. The report shall analyze the feasibility of permitting inclusion of payments to hospital-beised facilities within the DRG payment system under section 1886(d) of such Act.

Effective date. 42 USC 1395yy note. 42 USC 1395x note. 42 USC 1395x.

Report. 42 USC 1395x note. 97 Stat. 169. Report.

42 USC 1320b-5. Report.

42 USC 1395.

97 Stat. 152. 42 USC 1395WW.

PAYMENT FOR COSTS OF HOSPITAL-BASED MOBILE INTENSIVE CARE UNITS

SEC. 2320. (a)(1) In the case of a project described in subsection (b), the Secretary of Health and Human Services shall provide, except as provided in paragraph (2), that the amount of payments to hospitals covered under the project during the period described in paragraph (3) shall include payments for their operation of hospitalbased mobile intensive care units (as defined by State statute) if the State provides satisfactory assurances that the total amount of payments to such hospitals under titles XVIII and XIX of the Social Security Act under the demonstration project (including any such additional amount of payment) would not exceed the total amount of payments which would have been paid under such titles if the demonstration project were not in effect. (2) Paragraph (1) shall not apply if the State in which the project is located notifies the Secretary, within 30 days after the date of the

42 USC 1395b-l note.

42 USC 1395, 1396.

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 98 STAT. 1084

42 USC 1395WW.

42 USC 1395b-l.

42 USC 1395c.

PUBLIC LAW 98-369—JULY 18, 1984

enactment of this section, that the State does not want paragraph (1) to apply to that project. (3) The period referred to in paragraph (1) begins on the date of the enactment of this section and continues so long as the Secretary continues the Statewide waiver referred to in subsection (b), but in no case ends earlier than 90 days after the date final regulations to implement section 1886(c) of the Social Security Act are published, (b) The project referred to in subsection (a) is the statewide demonstration project established in the State of New Jersey under section 402 of the Social Security Amendments of 1967, as amended by section 2220t)) of the Social Security Amendments of 1972 (Public Law 92-603), which project provides for payments to hospitals in the State on a prospective basis and related to a clsissification of patients by diagnosis-related groups. (c) Payment for services described in this section shall be considered to be payments for services under part A of title XVIII of the Social Security Act. COST SHARING FOR DURABLE MEDICAL EQUIPMENT FURNISHED AS A HOME HEALTH BENEFIT

42 USC 1395f. 97 Stat. 152.

SEC. 2321. (a)(1) The matter in section 1814(b) of the Social Security Act preceding paragraph (1) is amended by inserting "and other than a home health agency with respect to durable medical equipment" after "hospice care". (2) Section 1814 of such Act is amended by adding at the end thereof the following new subsection: "Payments to Home Health Agencies for Durable Medical Equipment

42 USC I395x.

42 USC 1395CC.

42 USC 1395Z.

42 USC 1395CC. Post, p. 1085.

"(k) The amount paid to any home health agency with respect to durable medical equipment for which payment may be made under this part shall be— "(1) the lesser of— "(A) the reasonable cost of such equipment, as determined under section 1861(v), or "(B) the customary charges with respect to such equipment, less the amount the home health agency may charge as described in section 1866(a)(2)(A)(ii), but in no case may the payment for such equipment exceed 80 percent of such reasonable cost, or "(2) if such equipment is furnished by a public home health agency free of charge or at nominal charge to the public, the amount which the Secretary finds will provide fair compensation to the home health agency.". (b)(1) The matter in section 1833(a)(2)(A) of such Act preceding clause (i) is amended by inserting "(other than durable medical equipment)" after "home health services". (2) The matter in section 1833(a)(2)(B) of such Act preceding clause (i) is amended by inserting "items and" after "other'. (c) Section 1866(a)(2)(A)(ii) of such Act is amended by inserting "or which are durable medical equipment furnished as home health services" after "part B". (d)(1) The first sentence of section 1833(f)(1) of such Act is amended by striking out "as described in section 1861(s)(6)".

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 PUBLIC LAW 98-369—JULY 18, 1984

98 STAT. 1085

(2) Section 1833(f)(2) of such Act is amended— (A) by striking out "the 20 percent" and inserting in lieu thereof "any", and (B) by striking out "under subsection (a)". (3) Section 1833(f)(3) of such Act is amended by striking out "paragraph (1)" and inserting in lieu thereof "subsection (a)". (4)(A) Subsection (f) of section 1833 of such Act is redesignated as section 1889, is assigned the heading "PURCHASE OF DURABLE MEDICAL EQUIPMENT", and is moved to and inserted at the end of part C after the section added by section 2319 of this title. (B) Paragraphs (1) through (4) of such section 1889 are redesignated as subsections (a) through (d), respectively. (e)(1) Section 1861(m)(5) of such Act is amended by striking out ", and the use of medical applicances" and inserting in lieu thereof "and durable medical equipment". (2) Section 1861(s)(6) of such Act is amended by striking out everything after "durable medical equipment" up to the semicolon. (3) Section 1861 of such Act is amended by inserting after subsection (m) the following:

42 USC 1395/. ^"/>"a-

42 USC I395zz.

42 USC I395x.

i^;:;

sy; i

"Durable Medical Equipment "(n) The term 'durable medical equipment' includes iron lungs, oxygen tents, hospital beds, and wheelchairs (which may include a power-operated vehicle that may be appropriately used as a wheelchair, but only where the use of such a vehicle is determined to be necessary on the basis of the individual's medical and physical condition and the vehicle meets such safety requirements as the Secretary may prescribe) used in the patient's home (including an institution used at his home other than an institution that meets the requirements of subsection (e)(1) or (j)(l) of this section), whether furnished on a rental basis or purchased.". (4) Section 1861(cc)(l)(G) of such Act is amended by striking out ", appliances, and equipment, including the purchase or rental of equipment" and inserting in lieu thereof "and durable medical equipment". (f) Section 1814(j)(2) of such Act is amended— (1) by redesignating subparagraphs (B) and (C) as subparagraphs (C) and (D), respectively, and (2) by inserting the following after subparagraph (A): "(B) Subsection (k)(l)(B).". (g) The amendments made by this section shall apply to items and services furnished on or after the date of the enactment of this Act.

'n^u<^

97 Stat. 152. 42 USC 1395f.

Effective date. 42 USC 1395f note.

SERVICES OF A CUNICAL PSYCHOLOGIST PROVIDED TO MEMBERS OF AN HMO

SEC. 2322. (a) Section 1861(s)(2)(H) of the Social Security Act is 42 USC I395x. amended by inserting "(i)" after "(H)", by adding "and" at the end of clause (i) as so designated, and by adding at the end thereof the following new clause: "(ii) services furnished pursuant to a risk-sharing contract under section 1876(g) to a member of an eligible organization by 42 USC 1395mm. a clinical psychologist (as defined by the Secretary), and such services and supplies furnished as an incident to his services to such a member as would otherwise be covered under this part if

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 98 STAT. 1086

Effective date. 42 USC 1395x note.

PUBLIC LAW 98-369—JULY ife, 1984

furnished by a physician or as an incident to a physician's service; and", (b) The amendments made by subsection (a) shall be effective with respect to services furnished on or after the date of the enactment of this Act. COVERAGE OF ADMINISTRATION OF HEPATITIS B VACCINE

42 USC 1395x.

42 USC 1395/.

42 USC 1395CC.

42 USC 1395Z. Supra.

42 USC 1395rr.

Effective date. 42 USC 1395/ note. 42 USC 1395/ note. 42 USC 1395J.

SEC. 2323. (a) Section 1861(s)(10) of the Social Security Act is (1) by inserting "(A)" after "(10)"; (2) by striking out the period at the end thereof and inserting in lieu thereof "; and"; and (3) by adding at the end thereof the following new subparagraph: "(B) hepatitis B vaccine and its administration, furnished to an individual who is at high or intermediate risk of contracting hepatitis B (as determined by the Secretary under regulations).". (b)(1) Paragraphs (1)(B), (2)(A), and (3) of section 1833(a) of such Act are each amended by striking out "1861(s)(10)" and inserting in lieu thereof "1861(s)(10XA)". (2) Section 1833(b)(l) of such Act is amended by striking out "ISGKsXlO)" and inserting in lieu thereof "1861(s)(10)(A)". (3) The last sentence of section 1866(a)(2)(A) of such Act is amended by striking out "1861(s)(10)" and inserting in lieu thereof "1861(s)(10XA)'' (4) Section 1833 of such Act is amended by adding at the end thereof the following new subsection: "(k) With respect to services described in section 1861(s)(10XB), the Secretary may provide, instead of the amount of payment otherwise provided under this part, for payment of such an amount or amounts as reasonably reflects the general cost of efficiently providing such services.". (c) Section 1881(b) of such Act is amended by adding at the end thereof the following new paragraph: "(11) Hepatitis B vaccine and its administration, when provided to a patient determined to have end stage renal disease, shall not be included as dialysis services for purposes of payment under any prospective payment amount or comprehensive fee established under this section. Payment for such vaccine and its administration shall be made separately in accordance with section 1833.". (d) The amendments made by this section apply to services furnished on or after September 1, 1984. (e) The Secretary shall monitor the provision of hepatitis B vaccine under part B of title XVIII of the Social Security Act, and shall review any changes in medical technology which may have an effect on the amounts which should be paid for such service. C O V E R A G E OF H E M O P H I U A CLOTTING FACTOR

42 USC I395x. j^,

SEC. 2324. (a) Section 1861(s)(2) of the Social Security Act is amended by striking out "and" at the end of subparagraph (G) and by adding at the end thereof the following new subparagraph: "(I) blood clotting factors, for hemophilia patients competent to use such factors to control bleeding without medical or other

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 PUBLIC LAW 98-369—JULY 18, 1984

98 STAT. 1087

supervision, and items related to the administration of such factors, subject to utilization controls deemed necessary by the Secretary for the efficient use of such factors;". (b) The amendments made by subsection (a) shall be effective with respect to items and services purchased on or after the date of the enactment of this Act.

Effective date. 42 USC 1395x note.

PAYMENT FOR DEBRIDEMENT OF MYCOTIC TOENAILS

SEC. 2325. The Secretary shall provide, pursuant to section 1862(a) of the Social Security Act, that payment will not be made under part B of title XVIII of such Act for a physician's debridement of mycotic toenails to the extent such debridement is performed for a patient more frequently than once every 60 days, unless the medical necessity for more frequent treatment is documented by the billing physician.

42 USC 1395y note. 42 USC 1395y. 42 USC 1395J.

CONTRACTS FOR MEDICARE CLAIMS PROCESSING

SEC. 2326. (a) During each of the fiscal years 1985 and 1986, the Secretary of Health and Human Services may enter into not more than two agreements under section 1816 of the Social Security Act, and not more than two contracts under section 1842 of such Act, on the basis of competitive bidding, without regard to the nominating process under section 1816(a) of such Act during the term of the agreement. Such procedure may be used only for the purpose of replacing an agency or organization or carrier which over a period of time has been in the lowest 20th percentile of agencies and organizations or carriers having agreements or contracts under the respective section, as measured by the Secretary's cost and performance criteria. Any agency or organization or carrier selected on the basis of competitive bidding must perform all of the duties listed in section 1816(a)(l) of such Act, or the duties listed in paragraphs (1) through (4) of section 1842(a) of such Act, as the case may be, and must be a health insuring organization (as determined by the Secretary). (b) Section 1816(e)(4) of the Social Security Act is amended by adding at the end thereof the following new sentence: "By not later than July 1, 1987, the Secretary shall limit the number of such regional agencies or organizations to not more than ten.". (c)(1) Section 1816(f) of such Act is amended by striking out ", by regulation," in clause (2), and by adding at the end thereof the following: "Such standards and criteria shall be published in the Federal Register, and opportunity shall be provided for public comment prior to implementation.". (2) Section 1842(b)(2) of such Act is amended by adding at the end thereof the following new sentence: "The Secretary shall publish in the Federal Register standards and criteria for the efficient and effective performance of contract obligations under this section, and opportunity shall be provided for public comment prior to implementation.". (d)(1) Section 1816(c) of such Act is amended by adding at the end the following new sentence: "The Secretary shall provide that in determining the necessary and proper cost of administration, the Secretary shall, with respect to each agreement, take into account the amount that is reasonable and adequate to meet the costs which

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

42 USC 1395h.

Federal Register, publication. 42 USC 1395u. Federal Register, publication.

42 USC 1395h.

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 98 STAT. 1088

42 USC 1395u.

Effective date. 42 USC 1395h note. Study.

42 USC 1395h, 1395U.

Report.

PUBLIC LAW 98-369—JULY 18, 1984

must be incurred by an efficiently and economically operated agency or organization in carrying out the terms of its agreement.". (2) Section 1842(c) of such Act is amended by adding at the end the following new sentence: "The Secretary shall provide that in determining a carrier's necessary and proper cost of administration, the Secretary shall, with respect to each contract, take into account the amount that is reasonable and adequate to meet the costs which must be incurred by an efficiently and economically operated carrier in carrying out the terms of its contract.". (3) The amendments made by this subsection shall apply to agreements and contracts entered into or renewed after September 30, 1984. (e)(1) The Comptroller General shall conduct a study on— (A) the ability of the Administrator of the Health Care Financing Administration to manage competitive bidding for agreements and contracts under sections 1816 and 1842 of the Social Security Act, and on the relative costs and efficiency of such competitive agreements and contracts as compared to current cost reimbursement for such agreements and contracts; (B) the need (if any) for eliminating the provider nomination procedure under section 1816(a) of such Act; (C) the disparities (if any) in costs and quality of claims processing among the various entities performing claims processing pursuant to sections 1816 and 1842 of such Act; (D) whether the standards of the Secretary of Health and Human Services for evaluating costs and performance of intermediaries and carriers are adequate and properly applied; and (E) whether the Secretary's statutory authority is sufficient to deal with inefficient intermediaries and carriers either through the contract negotiation and budget review process or through the process for termination or nonrenewal of contracts. (2) The Comptroller General shall submit a report on the results of such study to the Congress not later than 12 months after the date of the enactment of this Act. PART II—ADMINISTRATIVE AND MISCELLANEOUS CHANGES REPEAL OF EXCLUSION OF FOR-PROFIT ORGANIZATIONS FROM RESEARCH AND DEMONSTRATION GRANTS

42 USC 1310. 42 USC 1395b-l.

Effective date. 42 USC 1310 note.

SEC. 2331. (a) Section 1110(a)(1) of the Social Security Act is amended by striking out "nonprofit". (b) The first sentence of section 402(a)(1) of the Social Security Amendments of 1967 (Public Law 90-248) is amended by striking out "nonprofit". (c) The amendments made by this section shall become effective on the date of the enactment of this Act. PRESIDENTIAL APPOINTMENT OF AND PAY LEVEL FOR THE ADMINISTRATOR OF THE HEALTH CARE FINANCING ADMINISTRATION

SEC. 2332. (a) Title XI of the Social Security Act is amended by inserting after section 1116 the following new section:

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 PUBLIC LAW 98-369—JULY 18, 1984

98 STAT. 1089

APPOINTMENT OF THE ADMINISTRATOR OF THE HEALTH CARE FINANCING ADMINISTRATION

"SEC. 1117. The Administrator of the Health Care Financing 42 USC 1317 Administration shall be appointed by the President by and with the advice and consent of the Senate.". (b) Section 5315 of title 5, United States Code, is amended by adding at the end thereof the following: "Administrator of the Health Care Financing Administration.". (c) The amendments made by this section shall apply to appoint- Effective date. 42 USC 1317 ments made after the date of the enactment of this Act. note. EXCLUSION OF CERTAIN ENTITIES OWNED OR CONTROLLED BY INDIVIDUALS CONVICTED OF MEDICARE- OR MEDICAID-RELATED CRIMES

SEC. 2333. (a) Section 1128 of the Social Security Act is amended— 42 USC i320a-7. (1) by redesignating subsections (b), (c), and (d) as subsections (c), (d), and (e), respectively, and (2) by inserting after subsection (a) the following new subsection: "(b) Whenever the Secretary determines, with respect to an entity, that a person who has a direct or indirect ownership or control interest of 5 percent or more in the entity, or who is an officer, director, agent, or managing employee (as defined in section 1126(b)) of such entity, is a person described in section 1126(a), the 42 USC i320a-5. Secretary— "(1) may bar from participation in the program under title XVIII, for such period as he may deem appropriate, each such 42 USC 1395. entity otherwise eligible to participate in such program; "(2) shall promptly notify each appropriate State agency administering or supervising the administration of a State plan approved under title XIX of the fact and circumstances of the 42 USC 1396. determination, and may require each such agency to bar the entity from participation under the State plan for such period as he specifies, which may not exceed the period established pursuant to paragraph (1); and "(3) shall promptly notify the appropriate State or local agency or authority having responsibility for the licensing or certification of such entity of the fact and circumstances of such determination, request that appropriate investigations be made and sanctions invoked in accordance with applicable State law and policy, and request that such State or local agency or authority keep the Secretary and the Inspector General of the Department of Health and Human Services fully and currently informed with respect to any actions taken in response to such request.". (b) Section 1128(e) of such Act (as redesignated by subsection (a)(D) is amended— (1) by inserting "or entity" after "Any person", and (2) by striking out "(a) or (b)" and inserting in lieu thereof "(a), (b), or (c)". (c) The amendments made by this section become effective on the Effective date. date of the enactment of this Act and shall apply to convictions of 42 USC 1320a-7 note. persons occurring after such date.

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 98 STAT. 1090

PUBLIC LAW 98-369—JULY 18, 1984 PROVIDER REPRESENTATION IN PEER REVIEW ORGANIZATIONS

42 USC 1320C-2.

42 USC 1395mm. Effective date. 42 USC 1320C-2 note.

SEC. 2334. (a) Section 1153(b)(3) of the Social Security Act is amended by inserting "(A)" after "(3)" and by adding at the end thereof the following new subparagraph: "(B) For purposes of subparagraph (A), an entity shall not be considered to be affiliated with a health care facility or association of facilities by reason of management, ownership, or common control if the management, ownership, or common control consists only of not more than 20 percent of the members of the governing board of the entity being affiliated (through management, ownership, or common control) with one or more of such facilities or associations.". (b) Section 1153(b)(2)(A) of such Act is amended— (1) by striking out "an entity which directly" and inserting in lieu thereof "an entity (other than a self-insured employer) which directly"; and (2) by adding at the end thereof the following new sentence: "For purposes of this paragraph, an entity shall not be considered to be affiliated with another entity which makes payments (directly or indirectly) to any practitioner or provider, by reason of management, ownership, or common control, if the management, ownership, or common control consists only of one individual member of the governing board being affiliated (through management, ownership, or common control) with a health maintenance organization or competitive medical plan which is an 'eligible organization' as defined in section 1876(b).". (c) The amendments made by this section shall become effective on the date of the enactment of this Act. REPEAL O F SPECIAL TUBERCULOSIS TREATMENT REQUIREMENTS UNDER MEDICARE AND MEDICAID

42 USC 1395f

42 USC I395x.

42 USC I395z.. 42 USC 1395CC.

SEC. 2335. (a) Section 1814(a) of the Social Security Act is amended— (1) in paragraph (2), by striking out subparagraph (B) and redesignating subparagraphs (C), (D), and (E) as subparagraphs (B), (C), and (D), respectively; (2) in paragraph (3), by striking out "and inpatient tuberculosis hospital services"; (3) by striking out paragraph (5) and redesignating paragraphs (6), (7), and (8) as paragraphs (5), (6), and (7), respectively; and (4) in the matter following paragraph (7) (as so redesignated), by striking out "(D), or (E)" and inserting in lieu thereof "or (D)". (b)(l) Subsections (d) and (g) of section 1861 of such Act are repealed. (2) The fifth sentence of section 1861(e) of such Act is amended by striking out "or tuberculosis unless it is a tuberculosis hospital (as defined in subsection (g)) or". (3) Section 1861(j) of such Act is amended in the matter following paragraph (15) by striking out "or tuberculosis". (c) Section 1863 of such Act is amended by striking out "(g)(4),". (d) Section 1866 of such Act is amended— (1) in subsection (b)(3), by striking out "tuberculosis hospital services and"; and

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 PUBLIC LAW 98-369—JULY 18, 1984 (2) in subsection (d), by striking out "inpatient tuberculosis hospital services and". (e) Section 1902(a)(28) of such Act is amended by striking out "and tuberculosis". (f) Section 1905(a) of such Act is amended by striking out "tuberculosis or" each place it appears in paragraphs (1), (4)(A), (14), and (15) and in the subdivision (B) after paragraph (18). (g) The amendments made by this section shall become effective on the date of the enactment of this Act.

STAT. 1091

42 USC 1396a. 42 USC 1396d.

Effective date. 42 USC 1395f note.

ACCESS TO HOME HEALTH SERVICES

SEC. 2336. (a) Sections 1814(a) and 1835(a) of the Social Security Act are each amended by adding at the end the following new sentence: "For purposes of the preceding sentence, service by a physician as an uncompensated officer or director of a home health agency shall not constitute having a significant ownership interest in, or a significant financial or contractual relationship with, such agency.". (b) The third sentence of section 1814(a) of the Social Security Act and the fourth sentence of section 1835(a) of such Act are each amended by inserting before the period at the end the following: ", except that such prohibition shall not apply with respect to a home health agency which is a sole community home health agency (as determined by the Secretary)". (c)(1) The amendments made by subsection (a) shall apply to certifications and plans of care made or established on or after the date of the enactment of this Act. (2) The Secretary shall provide, not later than 90 days after the date of the enactment of this Act, for such revision of regulations as may be required to reflect the amendments made by subsection (b).

42 USC 1395f, 1395n.

Effective date. 42 USC 1395f note. Effective date. 42 USC 1395f note.

NORMALIZATION OF TRUST FUND TRANSFERS

SEC. 2337. (a) Section 1817(a) of the Social Security Act is amended— (1) by striking out "monthly on the first day of each calendar month ' in the next to last sentence and inserting in lieu thereof "from time to time", (2) by striking out "to be paid to or deposited into the Treasury during such month" in such sentence and inserting in lieu thereof "paid to or deposited into the Treasury", and (3) by striking out the last sentence. (b) The amendments made by subsection (a) shall become effective on the first day of the month following the month in which this Act is enacted.

97 Stat. 98. 42 USC 1395i.

Effective date. 42 USC 1395i note.

ENROLLMENT AND PREMIUM PENALTY WITH RESPECT TO WORKING AGED PROVISION

SEC. 2338. (a) The second sentence of section 1839(b) of the Social Security Act is amended by adding before the period at the end the following: ", but there shall not be taken into account months in which the individual has met the conditions specified in clauses (i) and (iii) of section 1862(b)(3)(A) and can demonstrate that the individual was enrolled in a group health plan described in clause (iv) of such section by reason of the individual's (or the individual's spouse's) current employment".

97 Stat. 170. 42 USC 1395r. 42 USC 1395y.

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 98 STAT. 1092 42 USC I395p.

42 USC I395y. 42 USC 13950.

42 USC I395q.

Supra.

PUBLIC LAW 98-369—JULY 18, 1984

(b) Section 1837 of such Act is amended by adding at the end the following new subsection: "(i)(l) In the case of an individual who— "(A) meets the conditions described in clauses (i) and (iii) of section 1862(b)(3)(A), "(B) at the time the individual first satisfies paragraph (1) or (2) of section 1836, is enrolled in a group health plan described in section 1862(b)(3)(A)(iv) by reason of the individual's (or the individual's spouse's) current employment, and "(C) has elected not to enroll (or to be deemed enrolled) under this section during the individual's initial enrollment period, there shall be a special enrollment period described in paragraph (3). "(2) In the case of an individual who— "(A) meets the conditions described in clauses (i) and (iii) of section 1862(b)(3)(A), "(B) 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 and 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 "(C) has not terminated enrollment under this section at any time at which the individual is not enrolled in such a group health plan by reason of the individual's (or individual's spouse's) current employment, there shall be a special enrollment period described in paragraph (3). "(3) The special enrollment period referred to in paragraphs (1) and (2) is the period— "(A) beginning with the first day of the third month before the month in which the individual attains the age of 70 and ending seven months later, or "(B) 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 186203X3XAXiv) by reason of current employment and ending seven months later, whichever period results in earlier coverage.". (c) Section 1838 of such Act is amended by adding at the end the following new subsection: "(e) Notwithstanding subsection (a), in the case of an individual who enrolls during a special enrollment period pursuant to— "(1) subparagraph (A) of section 1837(i)(3)— "(A) before the month in which he attains the age of 70, the coverage period shall begin on the first day of the month in which he has attained the age of 70, or "(B) in or after the month in which he attains the age of 70, the coverage period shall begin on the first day of the month following the month in which he so enrolls; or "(2) subparagraph (B) of section 1837(i)(3)— "(A) in the first month of the special enrollment period, the coverage period shall begin on the first day of such month, or "(B) in a month after the first month of the special enrollment period, the coverage period shall begin on the

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98 STAT. 1093

first day of the month following the month in which he so enrolls.". (d)(1) The amendment made by subsection (a) shall apply to months beginning with January 1983 for premiums for months beginning with the first month which begins more than 30 days after the date of the enactment of this Act. (2)(A) The amendments made by subsections (b) and (c) shall apply to enrollments in months beginning with the first effective month, except that in the case of any individual who would have had a special enrollment period under section 1837(i) of the Social Security Act that would have begun before such first effective month, such period shall be deemed to begin with the first day of such first effective month. (B) For purposes of subparagraph (A), the term "first effective month" means the first month which begins more than 90 days after the date of the enactment of this Act.

Effective date. 42 USC 1395r note. Effective date. 42 USC 1395p note.

Ante, p. 1092

INDIRECT PAYMENT OF SUPPLEMENTARY MEDICAL INSURANCE BENEFITS

SEC. 2339. (a) The first sentence of section 1842a))(6) of the Social Security Act, as redesignated by section 2306 of this title, is Ante, p. 1070. amended— (1) by inserting "(i)" after "(A)", (2) by striking out "(B)" and inserting in lieu thereof "(ii)", and (3) by inserting before the period the following: ", or (B) to an entity (i) which provides coverage of the services under a health ,:; i:tbenefits plan, but only to the extent that payment is not made under this part, (ii) which has paid the person who provided the service an amount (including the amount payable under this part) which that person has accepted as payment in full for the service, and (iii) to which the individual has agreed in writing that payment may be made under this part '. O> The second sentence of such section is amended by striking out t) "or (B)". CERTIFICATION OF PSYCHIATRIC HOSPITALS

SEC. 2340. (a) Section 1861(f) of the Social Security Act is amended— (1) by adding "and" at the end of paragraph (3); (2) by striking out "; and" at the end of paragraph (4) and inserting in lieu thereof a period; (3) by striking out paragraph (5); and (4) in the second sentence, by striking out "if the institution is accredited" and all that follows through "Secretary". (b) Section 1905(h)(1)(A) of such Act is amended to read as follows: "(A) inpatient services which are provided in an institution (or distinct part thereof) which is a psychiatric hospital as defined in section 1861(f);". (c) The amendments made by this section shall become effective on the date of the enactment of this Act.

42USei395x.

42 USC I396d.

Effective date. 42 USC 1395x note.

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PUBLIC LAW 98-369—JULY 18, 1984

INCLUDING PODIATRISTS IN DEFINITION OF PHYSICIAN FOR OUTPATIENT PHYSICAL THERAPY SERVICES AND INCLUDING PODIATRISTS AND DENTISTS IN DEFINITION OF " P H Y S I C I A N " FOR OUTPATIENT AMBULATORY SURGERY 42 USC 1395x.

42 USC 1395k.

42 USC 1395x.

Effective date. 42 USC 1395k note.

SEC. 2341. (a) Section 1861(p)(l) of the Social Security Act is amended by striking out "section 1861(r)(l)" and inserting in lieu thereof "paragraph (1) or (3) of section 1861(r)". (b) Section 1832(a)(2)(F)(ii) of such Act is amended by striking out "section 1861(r)(l)" and inserting in lieu thereof "paragraph (1), (2), or (3) of section 1861(r)". (c) Section 1861(r)(3) of such Act is amended— (1) by striking out "and (m)" the first place it appears and inserting in lieu thereof ", (m), and (p)(D", and (2) by inserting ", 1832(a)(2)(F)(ii)," after "1814(a)" the first place it appears. (d) The amendments made by this section apply to services furnished on or after the date of the enactment of this Act. ESTABLISHMENT BY PHYSICAL THERAPISTS OF PLANS FOR PHYSICAL THERAPY

42 USC 1395x.

42 USC 1395n.

Effective date. 42 USC 1395n note.

SEC. 2342. (a) Section 1861(p)(2) of the Social Security Act is amended by striking out ", and is periodically reviewed, by a physician (as so defined)" and inserting in lieu thereof "by a physician (as so defined) or by a qualified physical therapist and is periodically reviewed by a physician (as so defined)". (b) Section 1835(a)(2)(C)(ii) of such Act is amended by striking out ", and is periodically reviewed, by a physician" and inserting in lieu thereof "by a physician or by the qualified physical therapist providing such services and is periodically reviewed by a physician". (c) The amendments made by this section apply to plans of care established on or after the date of the enactment of this Act. HOSPICE CONTRACTING FOR CORE SERVICES

42 USC 1395x.

SEC. 2343. (a) Section 1861(ddX2XAXiiXI) of the Social Security Act is amended by inserting "except as otherwise provided in paragraph (5)," before "and" at the end thereof. (b) Section 1861(dd) of such Act is amended by adding at the end thereof the following new paragraph: "(5)(A) The Secretary may waive the requirements of paragraph (2)(A)(ii)(I) for an agency or organization with respect to all or part of the nursing care described in paragraph (I)(A) if such agency or organization— "(i) is located in an area which is not an urbanized area (as defined by the Bureau of the C!ensus); "(ii) was in operation on or before January 1, 1983; and "(iii) has demonstrated a good faith effort (as determined by the Secretary) to hire a sufficient number of nurses to provide such nursing care directly. "(B) Any waiver, which is in such form and containing such information as the Secretary may require and which is requested by an agency or organization under subparagraph (A), shall be deemed to be granted unless such request is denied by the Secretary within 60 days after the date such request is received by the Secretary. The granting of a waiver under subparagraph (A) shall not preclude the

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98 STAT. 1095

granting of any subsequent waiver request should such a waiver again become necessary.". (c) The amendments made by subsections (a) and (b) shall become effective on the date of the enactment of this Act. (d) The Secretary of Health and Human Services shall conduct a study of the necessity and appropriateness of the requirements that certain "core" services be furnished directly by a hospice, as required under section 1861(ddX2)(A)(iiXI) of the Social Security Act. The Secretary shall report the results of such study to the Congress with the report required under section 122(i)(l) of the Tax Equity and Fiscal Responsibility Act of 1982.

Effective date. 42 USC 1395x note. 42 USC 1395x note. 42 USC 1395x. Report. 42 USC 1395f note.

MEDICARE RECOVERY AGAINST CERTAIN THIRD PARTIES

S E C 2344. (a) Section 1862(b)(1) of the Social Security Act is 42 USC I395y. amended— (1) in the first sentence, by inserting "promptly" after "to be made"; (2) in the second sentence, by inserting "or could be" after "has been"; and (3) by inserting after the second sentence the following new sentences: "In order to recover payment made under this title for an item or service, the United States may bring an action against any entity which would be responsible for payment with respect to such item or service (or any portion thereof) under such a law, policy, plan, or insurance, or against any entity (including any physician or provider) which has been paid with respect to such item or service under such law, policy, plan, or insurance, and may join or intervene in any action related to the events that gave rise to the need for such item or service. The United States shall be subrogated (to the extent of payment made under this title for an item or service) to any right of an individual or any other entity to payment with respect to such item or service under such a law, policy, plan, or insurance.". (b) Section 1862(b)(2)(B) of such Act is amended— (1) in the first sentence, by inserting "or could be" after "has been"; and (2) by inserting after the first sentence the following new sentences: "In order to recover payment made under this title for an item or service, the United States may bring an action against any entity which would be responsible for payment with respect to such item or service (or any portion thereof) under such a plan, or against any entity (including any physician or provider) which has been paid with respect to such item or service under such plan, and may join or intervene in any action related to the events that gave rise to the need for such item or service. The United States shall be subrogated (to the extent of payment made under this title for an item or service) to any right of an individual or any other entity to payment with respect to such item or service under such a plan.". (c) Section 1862(b)(3)(A)(ii) of such Act is amended— (1) in the first sentence, by inserting "or could be" after "has been"; and (2) by inserting after the first sentence the following new sentences: "In order to recover payment made under this title for an item or service, the United States may bring an action against any entity which would be responsible for payment with

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 98 STAT. 1096

Effective date. 42 USC 1395y note.

PUBLIC LAW 98-369—JULY 18, 1984

respect to such item or service (or any portion thereof) under such a plan, or against any entity (including any physician or provider) which has been paid with respect to such item or service under such plan, and may join or intervene in any action related to the events that gave rise to the need for such item or service. The United States shall be subrogated (to the extent of payment made under this title for an item or service) to any right of an individual or any other entity to payment with respect to such item or service under such a plan.", (d) The amendments made by this section shall apply to items and services furnished on or after the date of the enactment of this Act. CONFIDENTIAUTY OF ACCREDITATION SURVEYS

42 USC 1395bb.

Effective date. 42 USC 1395bb note.

SEC. 2345. (a) Section 1865(a) of the Social Security Act is amended— (1) in paragraph (2), by striking out "(on a confidential basis)"; and •' (2) by adding at the end thereof the following new sentence: "The Secretary may not disclose any accreditation survey made and released to him by the Joint Commission on Accreditation of Hospitals, the American Osteopathic Association, or any other national accreditation body, of an entity accredited by such body.", (b) The amendments made by this section shall become effective on the date of the enactment of this Act, and shall apply with respect to surveys released to the Secretary on, before, or after such date. USE OF ADDITIONAL ACCREDITING ORGANIZATIONS UNDER MEDICARE

Effective date. 42 USC 1395bb. note.

SEC. 2346. (a) The third sentence of section 1865(a) of the Social Security Act is amended— (1) by striking out "section 1861(e), (j), (o), or (dd)" and inserting in lieu thereof "section 1832(a)(2)(F)(i), 1861(e), 1861(f), 1861(j), 1861(o), 1861(p)(4)(A) or (B), paragraphs (11) and (12) of '- section 1861(s), section 1861(aaX2), 1861(ccX2), or 1861(ddX2)"; and (2) by striking out "institution or agency" each place it appears and inserting in lieu thereof in each instance "entity'. (b) The amendments made by this section shall become effective on the date of the enactment of this Act. FUNDING FOR PSRO REVIEW

97 Stat. 163. 42 USC 1395cc.

42 USC 1320c. 97 Stat. 163. 42 USC 1395cc and note. 42 USC 1395cc note.

SEC. 2347. (a)(1) Section 1866(a)(l)(F) of the Social Security Act is amended by striking out "maintain an agreement" and all that follows through "under which the organization", and inserting in lieu thereof "maintain an agreement with a professional standards review organization (if there is such an organization in existence in the area in which the hospital is located) or with a utilization and quality control peer review organization which has a contract with the Secretary under part B of title XI for the area in which the hospital is located, under which the organization". (2) Section 602(1)(1) of the Social Security Amendments of 1983 is repealed. (b) Notwithstanding section 604(a)(2) of the Social Security Amendments of 1983, the requirement that a hospital maintain an

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agreement with a utilization and quality control peer review organization, as contained in section 1866(a)(l)(F) of the Social Security Act, shall become effective on November 15, 1984. 97 Stat. 163. (c)(1) Section 1153(b)(2)(A) of the Social Security Act is amended by 42 USC i320c-2. striking out "During the first twelve months in which the Secretary is entering into contracts under this section" and inserting in lieu thereof "Prior to November 15, 1984". (2) Section 1153(b)(2)(B) of such Act is amended by striking out "after the expiration of the twelve-month period referred to in subparagraph (A)" and inserting in lieu thereof "after November 14, 1984". (3) Section 1153(b)(2) of such Act is amended by striking out 97 Stat. 163. suljparagraph (C). (d) The provisions of, and amendments made by, this section shall Effective date. 42 USC 1320C-2 become effective on the date of the enactment of this Act. note.

PAYMENT FOR SERVICES FOLLOWING TERMINATION OF PARTICIPATION AGREEMENTS WITH HOME HEALTH AGENCIES OR HOSPICE PROGRAMS

SEC. 2348. (a) Section 1866(b)(4)(B) of the Social Security Act is 42 USC I395cc. amended by striking out "after the calendar year in which such termination is effective" and inserting in lieu thereof "more than 30 days after such effective date". (b) The amendment made by this section shall apply to termina Effective date. tions issued on or after the date of the enactment of this Act 42 USC 1395CC note.

E U M I N A T I O N OF H E A L T H INSURANCE B E N E F I T S ADVISORY COUNCIL

SEC. 2349. (a) Section 1867 of the Social Security Act is repealed. (b)(l) The first sentence of section 1863 of such Act is amended by striking out "the Health Insurance Benefits Advisory Council established by section 1867, appropriate State agencies," and inserting in lieu thereof "appropriate State agencies". (2) The first sentence of section 7(d)(4) of the Railroad Retirement Act of 1974 is amended by striking out "1867,". (3) Section 361 of the Social Security Amendments of 1977 (Public Law 95-216) is amended by striking out subsection (i). (c) The amendments made by this section shall become effective on the date of the enactment of this Act.

42 USC 1395dd. 42 USC 1395z.

45 USC 23 If 42 USC 907a. Effective date. 42 USC 907a note.

HEALTH M A I N T E N A N C E ORGANIZATIONS AND COMPETITIVE MEDICAL PLANS

SEC. 2350. (a)(1) Section 1876(c)(3)(A) of the Social Security Act is 42 USC I395mm. amended— (A) by inserting "(i)" after "(3)(A)", (B) by inserting "and including the 30-day period specified under clause (ii)" after "30 days duration every year", and (C) by adding at the end thereof the following new clause: "(ii) For each area served by more than one eligible organization under this section, the Secretary (after consultation with such organizations) shall establish a single 30-day period each year during which all eligible organizations serving the area must provide for open enrollment under this section. The Secretary shall determine annual per capita rates under subsection (a)(l)(A) in a manner that assures that individuals enrolling during such a 30-day period will not have premium charges increased or any additional benefits decreased for 12 months beginning on the date the individual's

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 98 STAT. 1098

42 USC 1395mm note.

42 USC 1395mm.

Effective date. 42 USC 1395mm note.

Report. 42 USC 1395mm.

Effective date. 42 USC 1395mm note.

PUBLIC LAW 98-369—JULY 18, 1984

enrollment becomes effective. An eligible organization may provide for such other open enrollment period or periods as it deems appropriate consistent with this section.". (2) The Secretary of Health and Human Services may phase in, over a period of not longer than three years, the application of the amendments made by paragraph (1) to all applicable areas in the United States if the Secretary determines that it is not administratively feasible to establish a single 30-day open enrollment period for all such applicable areas before the end of the period. (b)(1) The first sentence of section 1876(g)(2) of such Act is amended by inserting before the period at the end thereof the following: "and except that an organization (with the approval of the Secretary) may provide that a part of the value of such additional benefits be withheld and reserved by the Secretary as provided in paragraph (5)". (2) Section 1876(g) of such Act is amended by adding at the end thereof the following new paragraph: "(5) An organization having a risk-sharing contract under this section may (with the approval of the Secretary and during a period of not longer than four years) provide that a part of the value of additional benefits otherwise required to be provided by reason of paragraph (2) be withheld and reserved in the Federal Hospital Insurance Trust Fund and in the Federal Supplementary Medical Insurance Trust Fund (in such proportions as the Secretary determines to be appropriate) by the Secretary for subsequent annual contract periods, to the extent required to stabilize and prevent undue fluctuations in the additional benefits offered in those subsequent periods by the organization in accordance with paragraph (3). Any of such value of additional benefits which is not provided to members of the organization in accordance with paragraph (3) prior to the end of such period, shall revert for the use of such trust funds.". (3) The Secretary of Health and Human Services may not approve the establishment of a stabilization fund by an eligible organization under section 1876(g)(5) of the Social Security Act for any contract period beginning later than four years after the date of the enactment of this Act. (4) The Secretary of Health and Human Services shall report to the Congress with respect to the use of stabilization funds by eligible organizations under section 1876(g)(5) of the Social Security Act, and shall assess the need for such funds. The report shall be submitted not later than 54 months after the month in which this Act is enacted. (c) Section 1876(g)(4)(A) of such Act is amended— (1) by inserting "and skilled nursing facilities" after "hospitals"; (2) by inserting "or other appropriate basis for payment established under this title" after "section 1861(v))"; and (3) by striking out "hospital". (d) The amendments made by this section shall become effective on the date of the enactment of this Act. JUDICIAL REVIEW OF PROVIDER REIMBURSEMENT REVIEW BOARD DECISIONS

42 USC 139500.

SEC. 2351. (a)(1) The third sentence of section 1878(f)(1) of the Social Security Act is amended by striking out "such determination

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is rendered" and inserting in lieu thereof "notification of such determination is received". (2) The amendment made by paragraph (1) shall be effective with respect to any civil action commenced on or after the date of the enactment of this Act. (b)(1) The last sentence of section 1878(fKl) of such Act is amended by inserting "or which have obtained a hearing under subsection (b)" after "common ownership or control". (2) The amendment made by paragraph (1) shall be effective with respect to any appeal or action brought on or after the date of the enactment of this Act. (c) Notwithstanding section 604 of the Social Security Amendments of 1983 (Public Law 98-21)— (1) the amendments made by section 602(h)(2)(A) of that Act shall be effective with respect to any appeal or action brought on or after April 20, 1983; and (2) the amendments made by section 602(h)(2)(B) of that Act shall be effective with respect to any appeal or action brought on or after the date of the enactment of this Act.

Effective date. 42 USC 139500 note. 42 USC 139500.

Effective date. 42 USC 139500 note. Effective date. 42 USC 139500 note. 97 Stat. 168. 97 Stat. 163.

FLEXIBLE SANCTIONS FOR NONCOMPUANCE WITH REQUIREMENTS FOR END STAGE RENAL DISEASE FACILITIES

SEC. 2352. (a) Section 1881(c)(3) of the Social Security Act is 42 USC I395rr amended by adding at the end thereof the following new sentence: "If the Secretary determines that the facility's or provider's failure to cooperate with network plans and goals does not jeopardize patient health or safety or justify termination of certification, he may instead, after reasonable notice to the provider or facility and to the public, impose such other sanctions as he determines to be appropriate, which sanctions may include denial of reimbursement with respect to some or all patients admitted to the facility after the date of notice to the facility or provider, and graduated reduction in reimbursement for all patients.". (b) The amendment made by this section shall apply to determina- Effective date. tions made by the Secretary on or after the date of the enactment of 42 USC 1395rr note. this Act. PAYMENTS TO PROMOTE CLOSURE AND CONVERSION OF UNDERUTILIZED HOSPITAL FACILITIES

SEC. 2353. (a) The Secretary of Health and Human Services shall carry out a study and report to the Congress on the modifications required in section 1884 of the Social Security Act in order to conform the closure and conversion program authorized in that section to the prospective payment system under section 1886(d) of such Act, so as to provide assistance to hospitals which may have particular problems in converting facilities (or parts thereof) from acute care to less intensive care or in closing facilities (or parts thereof). The report shall include recommendations as to how, and whether, implementation of section 1884 as modified may result in reductions in total hospital inpatient costs and total expenditures under title XVIII of the Social Security Act. The Secretary shall submit the report prior to March 31, 1985. (b) During the period prior to March 31, 1985, and notwithstanding section 2101(c) of the Omnibus Budget Reconciliation Act of 1981

study and report. 42 USC 1395UU note. 42 USC 1395UU. 97 Stat. 152. 42 USC 1395WW.

42 USC 1395.

42 USC 1395UU note.

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PUBLIC LAW 98-369—JULY 18, 1984

(Public Law 97-35), the Secretary shall not implement section 1884 of the Social Security Act. MISCELLANEOUS TECHNICAL CORRECTIONS RELATING TO MEDICARE

42 USC 1320a-l.

42 USC 1320a-7a. 42 USC 1320a42 USC 1301.

42 USC 1395f, 1395n. 42 USC 1395i, 1395t.

42 USC 1395i-2.

42 USC 1395/.

42 USC 1395k. 42 USC 1395/. 42 USC 1395n.

SEC. 2354. (a)(1) Section 1122(b) of the Social Security Act is amended— (A) by striking out the period at the end of paragraph (1) and inserting in lieu thereof a comma, and (B) by striking out "(or the Mental Retardation Facilities and Community Mental Health Centers Construction Act of 1963)". (2) Section 1122(i)(3) of such Act is amended by striking out "5703(b)" and inserting in lieu thereof "5703". (3) Section 1128A(g) of such Act is amended by striking out "Professional Standards Review Organization" and inserting in lieu thereof "utilization and quality control peer review organization". (4) Section 1129(a) of such Act is amended by striking out "Sate" and inserting in lieu thereof "State". (5) The heading of title XI of such Act is amended by striking out "PROFESSIONAL STANDARDS REVIEW" and inserting in lieu thereof "PEER REVIEW". (b)(1) The last sentence of sections 1814(a) of such Act and the last sentence of section 1835(a) of such Act are each amended by striking out "contractural" and inserting in lieu thereof "contractual". (2) Sections 1817(c) and 1841(c) of such Act are each amended by striking out "under the Second Liberty Bond Act, as amended" and inserting in lieu thereof "under chapter 31 of title 31, United States Code". (3) Section 1818(c)(1) of such Act is amended by striking out "Act" and inserting in lieu thereof "section". (4) Section 1818(d)(2) of such Act is amended by striking out "if midway between multiples of $1" and inserting in lieu thereof ", if a multiple of 50 cents but not a multiple of $1,". (5) Section 1833(a)(2) of such Act is amended by indenting subparagraphs (A) and (B) two additional ems so as to align their left margins with the left margin of subparagraph (C) and by appropriately further indenting the clauses and subclauses of such subparagraphs. (6) Section 1832(a)(2)(F)(ii)(II) of such Act is amended by striking out "Organization" and inserting in lieu thereof "organization". (7) Section 1833(a)(1) of such Act is amended by striking out "and" at the end thereof. (8) Section 1835(a)(2) of such Act is amended— (A) by striking out "and" at the end of subparagraphs (B) and (C), and (B) by indenting subparagraph (D) two additional ems so as to align its left margin with the left margin of subparagraph (C). (9) Section 1835(e) of such Act is amended— (A) by inserting "(i)" in paragraph (2) after "written assurances that", (B) by striking out "(B)" in paragraph (2) and inserting in lieu r thereof "(ii)", (C) by striking out "return for" in paragraph (2) and inserting in lieu thereof "return of, and (D) by striking out "(1) such hospital" and "(2) the Secretary" and inserting in lieu thereof "(A) such hospital" and "(B) the Secretary", respectively.

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 PUBLIC LAW 98-369—JULY 18, 1984

98 STAT. 1101

(10) Section 1837(g)(l) of such Act is amended by striking out "section 226(a)(2)(Br and "section 1839(e)" and inserting in lieu thereof "section 226(b)" and "section 1839(d)", respectively. (11) Sections 1840(d)(l), 1840(d)(2), and 1841(h) of such Act are each amended by striking out "Civil Service Commission" and inserting in lieu thereof "Director of the Office of Personnel Management' each place it appears. (12) Section 1841(h) of such Act is amended by striking out "it" and inserting in lieu thereof "the Director". (13) Section 184203X3XBXiiXII) of such Act is amended by striking out the period following "title". (14) The seventh sentence of section 1842(b)(3) of such Act is amended by striking out "(i)" and "(ii)" and inserting in lieu thereof "(I)" and "(II)", respectively. (15) Section 1843(d)(3)(B) of such Act is amended by striking out "1937" and inserting in lieu thereof "1974". (16) Section 1844(a)(l)(B)(ii) of such Act is amended by striking out the period and inserting in lieu thereof "; plus". (17) Sections 1864(c) and 18750)) of such Act are each amended by striking out "the" after "Joint Commission on". (18) Section 1861(j)(2) of such Act is amended by striking out "provision of* and inserting in lieu thereof "provision for". (19) Section 1861(j)(13) of such Act is amended by striking out "a nursing home" and inserting in lieu thereof "an institution". (20) Section 1861(u) of such Act is amended by striking out "or" before "home health agency". (21) Section 1861(v)(l) of such Act is amended— (A) by redesignating the clause (B) in subparagraph (A) as subparagraph (B) and by indenting the first line of such subparagraph 2 spaces; (B) by aligning subparagraphs (C) and (D) flush with the left margin (but with appropriate indentation in the case of the clauses and subclauses of subparagraph (C)); and (C) by inserting a comma after "section 1832(a)(2)(B)(i)" in subparagraph (D). (22) Section 1861(v)(l)(C)(i) of such Act is amended by inserting a dash after "but only if", (23) Section 1861(v)(l)(E)(ii) of such Act is amended by striking out "uses" and inserting in lieu thereof "use". (24) Section 1861(v)(l)(I) of such Act is amended by striking out "to the Secretary, or upon request to the Comptroller General" in clauses (i) and (ii) and inserting in lieu thereof "by the Secretary, or upon request by the (]!omptroller General". (25) Section 1861(v)(3) of such Act is amended by striking out "semiprivate" and inserting in lieu thereof "semi-private". (26) Section 1861(z)(2) of such Act is amended by striking out "subparagraph (1)" and inserting in lieu thereof "paragraph (1)". (27) Section 1861(aaX2XI) of such Act is amended by striking out "utilization" and inserting in lieu thereof "utilization. (28) Section 1861(ccXlXF) of such Act is amended by striking out "self administered" and inserting in lieu thereof "self-administered". (29) Section 1861(ccX2)(F) of such Act is amended by striking out "standard establishment" and inserting in lieu thereof "standards established". (30) Section 1862(a)(12) of such Act is amended by striking out the second comma after "dental procedure".

42 USC I395p. 42 USC 1395s, lSt.

42 USC I395u. 42 USC I395v. 42 USC I395w. 42 USC I395aa, 1395/Z. 42 USC I395x.

-^

-'

42 USC 1395y.

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 98 STAT. 1102 42 USC 1395y. 42 USC 1395z. 42 USC 1395CC.

42 USC 1395ff.

42 USC 1395ii.

42 USC 1395mm.

42 USC 139500.

42 USC 1395rr.

42 USC 1395WW.

42 USC 1395f. 42 USC 1395x note. 42 USC 1316. 42 USC 1395mm note. 42 USC 1395mm note.

42 USC 1320c note. 26 USC 162.

42 USC 1320a-l note.

• i<

PUBLIC LAW 98-369—JULY 18, 1984

(31) Section 1862(b)(3)(A)(iii) of such Act is amended by inserting "before the month" after "ending with the month". (32) Section 1863 of such Act is amended by striking out "(j)(ll)" and inserting in lieu thereof "(j)(15)". (33) Section 1866(a)(1)(E) of such Act is amended by adding at the end a comma. (34) Section 1866(b) of such Act is amended by moving the aUgnment of paragraph (3) two ems to the left so as to aUgn its left margin with the left margin of paragraph (4). (35) Section 1869(b)(1)(B) of such Act is amended by striking out ", or section 1818, or section 1819" and inserting in lieu thereof "or section 1818". (36) Section 1872 of such Act is amended— (A) by striking out the comma after "206", and (B) by striking out "(f),". (37) Section 1876(b)(2)(D) of such Act is amended by striking out "paragraph (1)" and inserting in lieu thereof "subparagraph (A)". (38) Section 1876(c)(4)(A)(i) of such Act is amended by striking out "promptly as appropriate" and inserting in lieu thereof "with reasonable promptness". (39) Section 1878(c) of such Act is amended by striking out "inadmissable" and inserting in lieu thereof "inadmissible". (40) Section 1878(e) of such Act is amended by striking out ", (e), and (f)" and inserting in lieu thereof "and (e)". (41) Section 1881 of such Act is amended by striking out "endstage" and inserting in lieu thereof "end stage" each place it appears. (42) Section 1886(a)(2)(B) of such Act is amended by striking out "disportionate" and inserting in lieu thereof "disproportionate". (43) Section 1886(b)(3)(A)(ii) of such Act is amended by inserting " o f after "in the case". (44) Section 1886(d)(3)(D)(i)(I) of such Act is amended by striking out "(C)," and inserting in lieu thereof "(C))". (c)(1)(A) Section 903(a)(4) of Public Law 96-499 is amended by striking out "new paragraph". (B) Section 937(c) of Public Law 96-499 is amended by striking out "on on" and inserting in lieu thereof "on or". (2) Section 2353(h)(1) of Public Law 97-35 is amended by striking out the comma after "XIX". (3)(A) Section 114(c)(2)(C)(ii) of Public Law 97-248 is amended by inserting "and enrolled under part B" after "part A". (B) Section 114(c)(3)(E) of Public Law 97-248 is amended— (i) by striking out "section 1833(a)(1) of the Social Security Act or", and (ii) by adding before the period at the end the following: ", or reimbursement on a reasonable cost basis under section 1833(a)(1)(A) of such Act". (C) Section 149 of Public Law 97-248 is amended by striking out "part" and inserting in lieu thereof "subtitle". (d) Section 162(i)(2) of the Internal Revenue Code of 1954 is amended by striking out "213(e)" and inserting in lieu thereof "213(d)". (e)(1) Except as provided in paragraph (2), the amendments made by this section shall be effective on the date of the enactment of this Act; but none of such amendments shall be construed as changing or affecting any right, liability, status, or interpretation which existed (under the provisions of law involved) before that date.

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98 STAT. 1108

(2) The amendments made by paragraphs (1), (2), and (3) of subsection (c) shall be effective as if they had been originally included in Public Laws 96-499, 97-35, and 97-248, respectively. WAIVERS FOR SOCIAL HEALTH MAINTENANCE ORGANIZATIONS

94 Stat. 2599; 95 Stat. 357. 26 USC 1 note.

SEC. 2355. (a) In the case of a project described in subsection (b), the Secretary of Health and Human Services shall approve, with appropriate terms and conditions as defined by the Secretary, applications or protocols submitted for waivers described in subsection (c), and the evaluation of such protocols, in order to carry out such project. Such approval shall be effected not later than 30 days after the date on which the application or protocol for a waiver is submitted or not later than 30 days after the date of the enactment of this Act in the case of an application or protocol submitted before the date of the enactment of this Act. Qa) A project referred to in subsection (a) is a project— (1) to demonstrate the concept of a social health maintenance organization with the organizations as described in Project No. 18-P-9 7604/1—04 of the University Health Policy Consortium of Brandeis University; (2) which provides for the integration of health and social services under the direct financial management of a provider of services; (3) under which all medicare services will be provided by or under arrangements made by the organization at a fixed annual • prepaid capitation rate for medicare of 100 percent of the adjusted average per capita cost; (4) under which medicaid services will be provided at a rate approved by the Secretary; (5) under which all payors will share risk for no more than two years, with the organization being at full risk in the third year; (6) which is being provided funds under a grant provided by the Secretary of Health and Human Services; and (7) with respect to which substantial private funds are being provided other than under the grant referred to in paragraph (5). (c) The waivers referred to in subsection (a) are appropriate waivers of— (1) certain requirements of title XVIII of the Social Security Act, pursuant to section 402(a) of the Social Security Amend- 42 USC 1395. ments of 1967 (as amended by section 222 of the Social Security Amendments of 1972); and 42 USC 1395b-l. (2) certain requirements of title XIX of the Social Security Act, pursuant to section 1115 of such Act. 42 USC 1396, (d)(1) The Secretary of Health and Human Services shall submit a 1315. preliminary report to the Congress on the status of the projects and Report. waivers referred to in subsection (a) 45 days after the date of the enactment of this Act. (2) The Secretary shall submit a final report to the Congress on Report the projects referred to in subsection (a) not later than 42 months after the date of the enactment of this Act.

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Page:United States Statutes at Large Volume 98 Part 1.djvu/1152

 98 STAT. 1104

PUBLIC LAW 98-369—JULY 18, 1984

Subtitle B—Medicaid and Maternal and Child Health Amendments MEDICAID COVERAGE FOR PREGNANT WOMEN AND CHILDREN 42 USC 1396a.

42 USC 301, 1201, 1351, 1881, 601, 670. Post, p. 1134. 42 USC 614.

42 USC 1396d.

42 USC 601.

42 USC 607.

42 USC 606.

Effective date. 42 USC 1396a note.

42 USC 1396.

SEC. 2361. (a) Clause (i) of section 1902(a)(10)(A) of the Social Security Act is amended to read as follows: "(i) all individuals— "(I) who are receiving aid or assistance under any plan of the State approved under title I, X, XIV, or XVI, or part A or part E of title IV (including individuals eligible under this title by reason of section 402(a)(37), or considered by the State to be receiving such aid as authorized under section 414(g)), "(II) with respect to whom supplemental security income benefits are being paid under title XVI, or "(III) who are qualified pregnant women or children as defined in section 1905(n);". (b) Section 1905 of such Act is amended by adding at the end thereof the following new subsection: "(n) The term 'qualified pregnant woman or child' means— "(1) a pregnant woman who— "(A) would be eligible for aid to families with dependent children under part A of title IV (or would be eligible for such aid if coverage under the State plan under part A of title IV included aid to families with dependent children of unemployed parents pursuant to section 407) if her child had been born and was living with her in the month such aid would be paid, and such pregnancy has been medically verified; or "(B) is a member of a family which would be eligible for aid under the State plan under part A of title IV pursuant to section 407 if the plan required the payment of aid pursuant to such section; and "(2) a child who is under 5 years of age, who was born after September 30, 1983, and who meets the income and resources requirements of the State plan under part A of title IV.". (c) Section 406(g) of such Act is amended by striking out "(1)" after "(g)", by striking out paragraph (2), and by redesignating subparagraphs (A) and (B) as paragraphs (1) and (2). (d)(1) Except as provided in paragraph (2), the amendments made by this section shall apply to calendar quarters beginning on or after October 1, 1984, without regard to whether or not final regulations to carry out such amendments have been promulgated by such date. (2) In the case of a State plan for medical assistance under title XIX of the Social Security Act which the Secretary of Health and Human Services determines requires State legislation in order for the plan to meet the additional requirements imposed by the amendments made by this section, the State plan shall not be regarded as failing to comply with the requirements of such title solely on the basis of its failure to meet these additional requirements before the first day of the first calendar quarter beginning after the close of the first regular session of the State legislature that begins after the date of the enactment of this Act.

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Page:United States Statutes at Large Volume 98 Part 1.djvu/1153

 PUBLIC LAW 98-369—JULY 18, 1984

98 STAT. 1105

CLARIFICATION OF MEDICAID ENTITLEMENT FOR CERTAIN NEWBORNS

SEC. 2362. (a) Section 1902(e) of the Social Security Act is amended 42 USC I396a. by adding at the end the following new paragraph: "(4) A child born to a woman eligible for and receiving medical assistance under a State plan on the date of the child's birth shall be deemed to have applied for medical assistance and to have been found eligible for such assistance under such plan on the date of such birth and to remain eligible for such assistance for a period of one year so long as the child is a member of the woman's household and the woman remains eligible for such gissistance.". (b) The amendment made by subsection (a) shall apply to children 42 USC 1396a note. born on or after October 1, 1984. RECERTIFICATION OF SNF AND ICF PATIENTS

SEC. 2363. (a)(1) Section 1902(a) of the Social Security Act, as amended by section 2303(g) of this title, is amended— (A) in paragraph (30)— (i) by inserting "(A)" after "(30)", and (ii) by adding at the end the following new subparagraph: "(B) provide, under the program described in subparagraph (A), that— "(i) each admission to a hospital, skilled nursing facility, intermediate care facility, or hospital for mental diseases is reviewed or screened in accordance with criteria established by medical and other professional personnel who are not themselves directly responsible for the care of the patient involved, and who do not have a significant financial interest in any such institution and are not, except in the case of a hospital, employed by the institution providing the care involved, and "(ii) the information developed from such review or screening, along with the data obtained from prior reviews of the necessity for admission and continued stay of patients by such professional personnel, shall be used as the basis for establishing the size and composition of the sample of admissions to be subject to review and evaluation by such personnel, and any such sample may be of any size up to 100 percent of all admissions and must be of sufficient size to serve the purpose of (I) identifying the patterns of care being provided and the changes occurring over time in such patterns so that the need for modification may be ascertained, and (II) subjecting admissions to early or more extensive review where information indicates that such consideration is warranted to a hospital, skilled nursing facility, intermediate care facility, or hospital for mental diseases;"; and (B) by striking out "and" at the end of paragraph (42), by striking out the period at the end of paragraph (43) and inserting in lieu thereof "; and", and by inserting after paragraph (43) the following new paragraph: "(44) in each case for which payment for inpatient hospital services, skilled nursing facility services, intermediate care fa cility services, or inpatient mental hospital services is made under the State plan—

31-194 0 - 86 - 37: QL. 3 Part 1

42 USC 1396a. Ante, p. 1064.

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Page:United States Statutes at Large Volume 98 Part 1.djvu/1154

 PUBLIC LAW 98-369—JULY 18, 1984

98 STAT. 1106 '

42 USC 1396b.

42 USC 1396b.

Post, p. 1109.

Ante, pp. 1066, 1105.

"(A) a physician certifies at the time of admission, or, if later, the time the individual applies for medical assistance under the State plan (and the physician, or a physician assistant or nurse practitioner under the supervision of a physician, recertifies, where such services are furnished over a period of time, in such cases, at least as often as required under section 1903(g)(6) (or, in the case of services that are intermediate care facility services provided in an institution for the mentally retarded, every year), and accompanied by such supporting material, appropriate to the case involved, as may be provided in regulations of the Secretary), that such services are or were required to be given on an inpatient basis because the individual needs or needed such services, and "(B) such services were furnished under a plan established and periodically reviewed and evaluated by a physician.". (2) Section 1903(g)(1) of such Act is amended— (A) in the matter preceding subparagraph (A), by striking out "care as an inpatient" and all that follows through "hospital for mental diseases on" and inserting in lieu thereof "inpatient hospital services or intermediate care facility services for 60 days, skilled nursing facility services for 30 days, or inpatient mental hospital services for", (B) in the matter before subparagraph (A), by striking out "which for purposes of this section means the four calendar quarters ending with June 30," and by striking out "in the same fiscal year", and (C) by striking out "(including tuberculosis hospitals)" and all that follows through the end of subparagraph (D) and inserting in lieu thereof ", skilled nursing facility services, or intermediate care facility services furnished beyond 60 days (or inpatient mental hospital services furnished beyond 90 days), such State has an effective program of medical review of the care of patients in mental hospitals, skilled nursing facilities, and intermediate care facilities pursuant to paragraphs (26) and (31) of section 1902(a) whereby the professional management of each case is reviewed and evaluated at least annually by independent professional review teams.". (4) Section 1903(g) of such Act is further amended by striking out paragraph (6) and inserting in lieu thereof the following: "(6)(A) Recertifications required under section 1902(a)(44) shall be conducted at least every 60 days in the case of inpatient hospital services. "(B) Such recertifications in the case of skilled nursing facility services shall be conducted at least— "(i) 30 days after the date of the initial certification, "(ii) 60 days after the date of the initial certification, "(iii) 90 days after the date of the initial certification, and "(iv) every 60 days thereafter. "(C) Such recertifications in the case of intermediate care facility services shall be conducted at least— "(i) 60 days after the date of the initial certification, "(ii) 180 days after the date of the initial certification, "(iii) 12 months after the date of the initial certification, "(iv) 18 months after the date of the initial certification, "(v) 24 months after the date of the initial certification, and

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Page:United States Statutes at Large Volume 98 Part 1.djvu/1155

 PUBLIC LAW 98-369—JULY 18, 1984

98 STAT. 1107

"(vi) every 12 months thereafter. "(D) For purposes of determining compliance with the schedule established by this paragraph, a recertification shall be considered to have been done on a timely basis if it was performed not later than 10 days after the date the recertification was otherwise required and the State establishes good cause why the physician or other person making such recertification did not meet such schedule.". (b) Section 1903 of such Act is further amended by adding at the 42 USC 1396b. end the following new paragraph: "(7) It is the duty and responsibility of the Secretary to assure that standards which govern the provision of care in skilled nursing facilities and intermediate care facilities under plans approved under this title, and the enforcement of such standards, are adequate to protect the health and safety of residents and to promote the effective and efficient use of public moneys.". (c) The amendments made by subsection (a) apply to calendar Effective date. quarters beginning on or after the date of the enactment of this Act, 42 USC 1396b except that, in the case of individuals admitted to skilled nursing note. facilities before such date, the amendments made by such subsection shall not require recertifications sooner or more frequently than were required under the law in effect before such date. WAIVER OF CERTAIN MEMBERSHIP REQUIREMENTS FOR CERTAIN HEALTH MAINTENANCE ORGANIZATIONS

SEC. 2364. Section 1903(m)(2) of the Social Security Act is amended— (1) by inserting "except as provided under subparagraph (F)," in subparagraph (A)(vi) after "(I)", and (2) by adding at the end the following new subparagraphs: "(E) In the case of a health maintenance organization that— "(i) is a nonprofit organization with at least 25,000 members, "(ii) is and has been a qualified health maintenance organization (as defined in section 1310(d) of the Public Health Service Act) for a period of at least four years, "(iii) provides basic health services through members of the staff of the organization, "(iv) is located in an area designated as medically underserved under section 1302(7) of the Public Health Service Act, and "(v) previously received a waiver of the requirement described in subparagraph (A)(ii) under section 1115, the Secretary may modify or waive the requirement described in subparagraph (A)(ii) but only if the Secretary determines that special circumstances warrant such modification or waiver and that the organization has taken and is taking reasonable efforts to enroll individuals who are not entitled to benefits under the State plan approved under this title or under title XVIII. "(F)(i) In the case of a contract with a health maintenance organization described in clause (ii), a State plan may restrict the period in which requests for termination of enrollment without cause under subparagraph (A)(vi)(I) are permitted to the first month of each period of enrollment, each such period of enrollment not to exceed six months in duration, but only if the State provides notification, at least twice per year, to individuals enrolled with such organization of the right to terminate such enrollment and the restriction on the

42 USC 1396b.

42 USC 300e-9.

42 USC 300e-l. 42 USC 1315.

42 USC 1395.

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Page:United States Statutes at Large Volume 98 Part 1.djvu/1156

 98 STAT. 1108

42 USC 300e-9.

42 USC 254b, 254c. 40 USC app. 1.

PUBLIC LAW 98-369—JULY 18, 1984

exercise of this right. Such restriction shall not apply to requests for termination of enrollment for cause. "(ii) A health maintenance organization referred to in clause (i) is an organization which— "(I) is a qualified health maintenance organization (as defined in section 1310(d) of the Public Health Service Act) or a health maintenance organization which is receiving (and has received during the previous two years) a grant of at least $100,000 under section 329(d)(1)(A) or 330(d)(1) of the Public Health Service Act or is receiving (and has received during the previous two years) at least $100,000 (by grant, subgrant, or subcontract) under the Appalachian Regional Development Act of 1965, and "(II) meets the requirement of subparagraph (A)(ii).". INCREASE IN MEDICAID CEILING AMOUNT FOR PUERTO RICO, THE VIRGIN ISLANDS, GUAM, THE NORTHERN MARIANA ISLANDS, AND AMERICAN SAMOA

42 USC 1308.

SEC. 2365. (a) Section 1108(c) of the Social Security Act is amended to read as follows: 42 USC 1396. "(c) The total amount certified by the Secretary under title XIX with respect to a fiscal year for payment to— "(1) Puerto Rico shall not exceed $63,400,000; "(2) the Virgin Islands shall not exceed $2,100,000; "(3) Guam shall not exceed $2,000,000; "(4) the Northern Mariana Islands shall not exceed $550,000; and "(5) American Samoa shall not exceed $1,150,000.". 42 USC 1308 (b) The amendment made by subsection (a) shall be effective for note. fiscal years beginning on or after October 1, 1983. PAYMENT FOR PSYCHIATRIC HOSPITAL SERVICES 42 USC 1396a note.

SEC. 2366. The provisions of section 1902(a)(13) of the Social Security Act, in so far as they require a reduction of the amount of payment otherwise to be made to a public psychiatric hospital due to the level of care received in such hospital, shall not apply to payments to hospitals before July 1, 1985, and such a reduction made for payments during the 12-month period ending June 30, 1986, and during the 12-month period ending June 30, 1987, shall be one-third and two-thirds, respectively, of the amount of the reduction which would have been made without regard to this section. MANDATORY ASSIGNMENT OF RIGHTS OF PAYMENT BY MEDICAID RECIPIENTS

42 USC 1396a. Ante, pp. 1066, 1105.

42 USC 1396k.

SEC. 2367. (a) Section 1902(a) of the Social Security Act (as amended by sections 2303 and 2363 of this title) is amended— (1) by striking out "and" at the end of paragraph (43); (2) by striking out the period at the end of paragraph (44) and inserting in lieu thereof "; and"; and (3) by inserting after paragraph (44) the following new paragraph: "(45) provide for mandatory assignment of rights of payment for medical support and other medical care owed to recipients, in accordance with section 1912.".

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Page:United States Statutes at Large Volume 98 Part 1.djvu/1157

 PUBLIC LAW 98-369—JULY 18, 1984

98 STAT. 1109

(b) Section 1912(a) of such Act is amended by striking out "State 42 USC 1396k plan for medical assistance may" and inserting in lieu thereof "State plan for medical assistance shall". (c)(1) Except as provided in paragraph (2), the amendments made Effective date. 42 USC 1396a by this section shall become effective on October 1, 1984. (2) In the case of a State plan for medical assistance under title note. XIX of the Social Security Act which the Secretary of Health and 42 USC 1396 Human Services determines requires State legislation in order for the plan to meet the additional requirement imposed by the amendments made by this section, the State plan shall not be regarded as failing to comply with the requirements of such title solely on the basis of its failure to meet this additional requirement before the first day of the first calendar quarter beginning after the close of the first regular session of the State legislature that begins after the date of the enactment of this Act. REQUIREMENTS FOR MEDICAL REVIEW AND INDEPENDENT PROFESSIONAL REVIEW UNDER MEDICAID

SEC. 2368. (a) Section 1902(a)(31) of the Social Security Act is 42 USC I396a. amended to read as follows: "(31) with respect to skilled nursing facility services (and with respect to intermediate care facility services, where the State plan includes medical assistance for such services) provide— "(A) with respect to each patient receiving such services, for a written plan of care, prior to admission to or authorization of benefits in such facility, in accordance with regulations of the Secretary, and for a regular program of independent professional review (including medical evaluation) which shall periodically review his need for such services; "(B) with respect to each skilled nursing or intermediate care facility within the State, for periodic onsite inspections of the care being provided to each person receiving medical assistance, by one or more independent professional review teams (composed of a physician or registered nurse and other appropriate health and social service personnel), including with respect to each such person (i) the adequacy of the services available to meet his current health needs and promote his maximum physical well-being, (ii) the necessity and desirability of his continued placement in the facility, and (iii) the feasibility of meeting his health care needs through alternative institutional or noninstitutional services; and pj J"(C) for full reports to the State agency by each independent professional review team of the findings of each inspection under subparagraph (B), together with any recommendations;". (b) Section 1902(a)(26) of such Act is amended to read as follows: "(26) if the State plan includes medical assistance for inpatient mental hospital services, provide— "(A) with respect to each patient receiving such services, for a regular program of medical review (including medical evaluation) of his need for such services, and for a written plan of care; "(Bj for periodic inspections to be made in all mental institutions within the State by one or more medical review

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Page:United States Statutes at Large Volume 98 Part 1.djvu/1158

 98 STAT. 1110

Effective date. 42 USC 1396a note.

PUBLIC LAW 98-369—JULY 18, 1984

teams (composed of physicians and other appropriate health and social service personnel) of the care being provided to each person receiving medical assistance, including (i) the adequacy of the services available to meet his current health needs and promote his maximum physical wellbeing, (ii) the necessity and desirability of his continued placement in the institution, and (iii) the feasibility of meeting his health care needs through alternative institutional or noninstitutional services; and "(C) for full reports to the State agency by each medical review team of the findings of each inspection under subparagraph (B), together with any recommendations;", (c) The amendments made by this section shall become effective on the date of the enactment of this Act. FLEXIBILITY IN SETTING PAYMENT RATES FOR HOSPITALS FURNISHING LONG-TERM CARE SERVICES UNDER MEDICAID

42 USC 1396/.

42 USC 1396a. Effective date. 42 USC 1396/ note.

SEC. 2369. (a)(1) Section 1913(b)(l) of the Social Security Act is amended by striking out "Payment" and inserting in lieu thereof "Except as provided in paragraph (3), payment". (2) Section 1913(b) of such Act is amended by adding at the end thereof the following new paragraph: "(3) Pajnment to all such hospitals, for any skilled nursing or intermediate care facility services furnished pursuant to subsection (a), may be made at a payment rate established by the State in accordance with the requirements of section 1902(a)(13)(A).". (b) The amendments made by this section shall apply to payments for services furnished after the date of the enactment of this Act. AUTHORITY OF THE SECRETARY TO ISSUE AND ENFORCE SUBPOENAS UNDER MEDICAID

SEC. 2370. (a) Title XIX of the Social Security Act is amended by adding at the end thereof the following new section: " APPLICATION O F PROVISIONS OF TITLE II RELATING TO SUBPOENAS 42 USC 1396q. 42 USC 405. Effective date. 42 USC 1396q note.

"SEC. 1918. The provisions of subsections (d) and (e) of section 205 of this Act shall apply with respect to this title to the same extent as they are applicable with respect to title II.". (b) The amendment made by this section shall become effective on the date of the enactment of this Act. M E D I C A I D C U N I C ADMINISTRATION

42 USC 1396d.

Effective date. 42 USC 1396d note.

SEC. 2371. (a) Section 1905(a)(9) of the Social Security Act is amended to read as follows: "(9) clinic services furnished by or under the direction of a physician, without regard to whether the clinic itself is administered by a physician;'. (b) The amendment made by subsection (a) shall apply to services furnished on or after the date of the enactment of this Act. I N C R E A S E IN AUTHORIZATION FOR MATERNAL AND CHILD HEALTH BLOCK GRANT

42 USC 701.

SEC. 2372. (a) Section 501(a) of the Social Security Act is amended by striking out "$373,000,000 for fiscal year 1982 and for each fiscal

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