Text: S.3120 — 102nd Congress (1991-1992)All Information (Except Text)

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S 3120 IS
102d CONGRESS
2d Session
S. 3120
To amend title XIX of the Social Security Act to make technical corrections
and clarifications related to sections 4401 through 4801 of the Omnibus
Budget Reconciliation Act of 1990, and to make conforming medicare amendments.
IN THE SENATE OF THE UNITED STATES
August 3 (legislative day, JULY 23), 1992
Mr. BENTSEN (for himself and Mr. PACKWOOD) introduced the following bill;
which was read twice and referred to the Committee on Finance
A BILL
To amend title XIX of the Social Security Act to make technical corrections
and clarifications related to sections 4401 through 4801 of the Omnibus
Budget Reconciliation Act of 1990, and to make conforming medicare amendments.
  Be it enacted by the Senate and House of Representatives of the United
  States of America in Congress assembled,
SECTION 1. SHORT TITLE; REFERENCES IN ACT; EFFECTIVE DATE.
  (a) SHORT TITLE- This Act may be cited as the `Medicaid Technical Corrections
  and Clarification Act of 1992'.
  (b) REFERENCES IN ACT- In this Act--
  (1) The term `OBRA-1990' refers to the Omnibus Budget Reconciliation Act
  of 1990 (Public Law 101-508).
  (2) The term `SSA' refers to the Social Security Act.
  (c) EFFECTIVE DATE- Except as otherwise provided, the amendments made by
  this Act shall take effect as if included in the enactment of OBRA-1990.
SEC. 2. CORRECTIONS RELATING TO SECTION 4401 (REIMBURSEMENT FOR PRESCRIBED
DRUGS).
  (a) SECTION 1903, SSA-
  (1) IN GENERAL- Paragraph (10) of section 1903(i) of the SSA (42
  U.S.C. 1396b(i)), as inserted by section 4401(a)(1)(B) of OBRA-1990,
  is amended to read as follows:
  `(10)(A) with respect to covered outpatient drugs unless--
  `(i) there is a rebate agreement in effect under section 1927 with respect
  to such drugs;
  `(ii) section 1927(a)(3) applies; or
  `(iii) section 1927(j) applies; and
  `(B) with respect to an innovator multiple source drug (as defined in
  section 1927(k)) dispensed on or after July 1, 1991, if, under applicable
  State law, a less expensive multiple source drug could have been dispensed,
  unless such innovator multiple source drug is priced at or below the upper
  payment limit for such drug;'.
  (2) CONFORMING AMENDMENT- The section heading of section 4401(a)(1) of
  OBRA-1990 is amended by striking `and drug use review'.
  (b) SECTION 1902, SSA- Section 1902(a)(54) of the SSA (42
  U.S.C. 1396a(a)(54)), as inserted by section 4401(a)(2)(C) of OBRA-1990,
  is amended--
  (1) in subparagraph (A) by striking `1927(k)(6)' and inserting `1927(k)'; and
  (2) by striking `reporting requirements' and all that follows through
  `1927' and inserting `requirements of section 1927'.
  (c) SECTION 1927, SSA- (1) Section 1927(a) of the SSA (42 U.S.C. 1396r-8(a)),
  as inserted by section 4401(a)(3) of OBRA-1990, is amended--
  (A) in paragraph (1)--
  (i) by amending the second sentence to read as follows: `Any such agreement
  entered into prior to April 1, 1991, shall be deemed to have been entered
  into on January 1, 1991, and the amount of the rebate under such agreement
  shall be calculated as if the agreement had been entered into on January 1,
  1991.', and
  (ii) in the third sentence, by striking `March' and inserting `April';
  (B) in paragraph (2)--
  (i) by striking `first', and
  (ii) by striking the period at the end and inserting the following: `,
  except that such paragraph (and section 1903(i)(10)) shall not apply to
  drugs dispensed before April 1, 1991, if the Secretary determines that
  there were extenuating circumstances with respect to the first calendar
  quarter of 1991.'.
  (C) by amending paragraph (3) to read as follows:
  `(3) AUTHORIZING PAYMENT FOR DRUGS NOT COVERED UNDER REBATE AGREEMENTS-
  Paragraph (1) and section 1903(i)(10) shall not apply to the dispensing
  of a covered outpatient drug if--
  `(A) the State has made a determination that the availability of such drug
  is essential to the health of beneficiaries under the State plan;
  `(B) the drug has been given a rating of 1-A by the Food and Drug
  Administration; and
  `(C)(i) the physician has obtained approval for the use of the drug in
  advance of dispensing such drug in accordance with a prior authorization
  program described in subsection (d)(4), or
  `(ii) the Secretary has reviewed and approved the State's determination
  under subparagraph (A).'; and
  (D) in paragraph (4)--
  (i) by striking `in compliance with' and inserting `in effect under', and
  (ii) by striking `coverage of the manufacturer's drugs' and inserting
  `ingredient costs of the manufacturer's covered outpatient drugs covered'.
  (2) Section 1927(b) of the SSA (42 U.S.C. 1396r-8(b)), as inserted by
  section 4401(a)(3) of OBRA-1990, is amended--
  (A) in paragraph (1)(A)--
  (i) by striking `each calendar quarter (or periodically in accordance
  with a schedule specified by the Secretary)' and inserting `for a rebate
  period', and
  (ii) by striking `dispensed under the plan during the quarter (or other
  period as the Secretary may specify)' and inserting `dispensed after December
  31, 1990, for which payment was made under the State plan for such period',
  (B) in paragraph (2)(A)--
  (i) by striking `calendar quarter' and `the quarter' and inserting `rebate
  period' and `the period', respectively,
  (ii) by striking `dosage units' and inserting `units of each dosage form
  and strength and package size',
  (iii) by inserting `after December 31, 1990, for which payment was made'
  after `dispensed', and
  (iv) by striking `during' and inserting `for';
  (C) in paragraph (3)(A)--
  (i) in clause (i), by striking `quarter' each place it appears and inserting
  `rebate period under the agreement',
  (ii) in clause (i), by striking the open parenthesis before `for' and the
  close parenthesis after `drugs',
  (iii) in clause (i), by striking `subsection (c)(2)(B)) for covered
  outpatient drugs' and inserting `subsection (c)(1)(C)) for each covered
  outpatient drug', and
  (iv) in clause (ii), by inserting a comma after `this section' and after
  `1990';
  (D) in paragraph (3)(B)--
  (i) by striking `$100,000' and inserting `$10,000',
  (ii)  by striking `about charges or prices', and
  (iii) by striking `or knowingly provides false information';
  (E) in paragraph (3)(C)--
  (i) in clause (i)--
  (I) by striking `increased by', and
  (II) by striking `, and, if' and inserting `. If',
  (ii) in clause (ii), by inserting `under subparagraph (A)' after `provides
  false information', and
  (iii) in clause (ii), by striking `Such civil money penalties are' and
  inserting `Any such civil money penalty shall be';
  (F) in paragraph (3)(D), by striking `wholesaler,' the first time it
  appears and inserting `wholesaler or the'; and
  (G) in paragraph (4)(B)--
  (i) in clause (ii), by striking `such period' and inserting `the calendar
  quarter beginning at least 60 days',
  (ii) in clause (ii), by striking `of the notice' and all through `the
  agreement).' and inserting `the manufacturer provides notice to the
  Secretary.',
  (iii) by redesignating clause (iii) as clause (iv) and inserting after
  clause (ii) the following new clause:
  `(iii) NOTICE TO STATES- In the case of a termination under this
  subparagraph, the Secretary shall provide notice of such termination to
  the States within not less than 30 days before the effective date of such
  termination.', and
  (iv) by adding at the end the following new sentence: `Failure of a State to
  provide any advance notice of such a termination as required by regulation
  shall not affect the State's right to terminate coverage of the drugs
  affected by such termination as of the effective date of such termination.'.
  (3) Section 1927(c) of the SSA (42 U.S.C. 1396r-8(c)), as inserted by
  section 4401(a)(3) of OBRA-1990, is amended--
  (A) by amending paragraph (1) to read as follows:
  `(1) BASIC REBATE FOR SINGLE SOURCE DRUGS AND INNOVATOR MULTIPLE SOURCE
  DRUGS-
  `(A) IN GENERAL- Except as provided in paragraph (2), the amount of the
  rebate for a rebate period with respect to each dosage form and strength
  of a single source drug or an innovator multiple source drug shall be
  equal to the product of--
  `(i) the total number of units of each dosage form and strength paid for
  under the State plan in the period reported by the State under subsection
  (b)(2), and
  `(ii) subject to subparagraph (B)(ii), the greater of--
  `(I) the difference between the average manufacturer price and the best
  price (as defined in subparagraph (C)) for the dosage form and strength
  of the drug, or
  `(II) the minimum rebate percentage (specified in subparagraph (B)(i))
  of such average manufacturer price,
for the period.
  `(B) RANGE OF REBATES REQUIRED-
  `(i) MINIMUM REBATE PERCENTAGE- For purposes of subparagraph (A)(ii)(II),
  the `minimum rebate percentage' for rebate periods beginning--
  `(I) before January 1, 1993, is 12.5 percent, and
  `(II) after December 31, 1992, is 15 percent.
  `(ii) TEMPORARY LIMITATION ON MAXIMUM REBATE AMOUNT- In no case shall the
  amount applied under subparagraph (A)(ii) for a rebate period beginning--
  `(I) before January 1, 1992, exceed 25 percent of the average manufacturer
  price, or
  `(II) after December 31, 1991, and before January 1, 1993, exceed 50
  percent of the average manufacturer price.
  `(C) BEST PRICE DEFINED- For purposes of this section, the term `best price'
  means, with respect to a single source drug or innovator multiple source
  drug of a manufacturer, the lowest price available from the manufacturer
  to any wholesaler, retailer, provider, nonprofit or for-profit entity, or
  governmental entity within the United States (excluding depot prices and
  single award contract prices, as defined by the Secretary, of any agency of
  the Federal Government). The term `best price' shall be inclusive of cash
  discounts, free goods, volume discounts, and rebates (other than rebates
  under this section) and shall be determined without regard to special
  packaging, labeling, or identifiers on the dosage form or product or package,
  and shall not take into account prices that are merely nominal in amount.';
  (B) by amending paragraph (2) to read as follows:
  `(2) ADDITIONAL REBATE FOR SINGLE SOURCE AND INNOVATOR MULTIPLE SOURCE DRUGS-
  `(A) 1991 THROUGH 1993- The amount of the rebate for a rebate period
  beginning before January 1, 1994, with respect to each dosage form and
  strength of a single source drug or an innovator multiple source drug,
  is increased by an amount equal to the product of--
  `(i) the total number of units of such dosage form and strength dispensed
  after December 31, 1990, for which payment was made under the State plan
  for the period reported by the State under subsection (b)(2), and
  `(ii) the amount (if any) by which--
  `(I) the average manufacturer price for the dosage form and strength of
  the drug for the period, exceeds
  `(II) the average manufacturer price for such dosage form and strength for
  the calendar quarter beginning July 1, 1990, increased by the percentage
  by which the average of the consumer price indices for all urban consumers
  (U.S. city average) for months during the rebate period exceeds such index
  for September 1990.
In the case of a covered outpatient drug approved by the Food and Drug
Administration after October 1, 1990, subclause (II) of clause (ii) shall be
applied by substituting `the first full calendar quarter after the drug was
marketed' for `the calendar quarter beginning July 1, 1990' and `the month
prior to the first month of the first full calendar quarter after the drug
was marketed' for `September 1990'.
  `(B) AFTER 1993- Except as provided in subparagraph (D), the amount of the
  rebate for a rebate period beginning after December 31, 1993, is increased
  by an amount equal to the product of--
  `(i) the total number of all units of the single source and innovator
  multiple source drugs of a manufacturer for which payment was made under the
  State plan for the period reported by the State under subsection (b)(2), and
  `(ii) the amount (if any) by which--
  `(I) the current weighted average manufacturer price (as defined in
  subparagraph (C)(i)) for the single source and innovator multiple source
  drugs of the manufacturer for the period, exceeds
  `(II) the base weighted average manufacturer price for such drugs of
  such manufacturer (as defined in subparagraph (C)(ii)), increased by the
  percentage by which the average of the consumer price indices for all
  urban consumers (U.S. city average) for months during the rebate period
  exceeds such index for September 1990.
  `(C) Weighted average manufacturer price determinations-
  `(i) CURRENT WEIGHTED AVERAGE MANUFACTURER PRICE DEFINED- For purposes of
  subparagraph (B), and except as provided in subparagraph (D), the term
  `current weighted average manufacturer price' means, with respect to a
  rebate period, the amount described in clause (iii) divided by the amount
  described in clause (iv).
  `(ii) BASE WEIGHTED AVERAGE MANUFACTURER PRICE- For purposes of subparagraph
  (B), and except as provided in subparagraph (D), the term `base weighted
  average manufacturer price' means, with respect to a rebate period, the
  amount described in clause (iii) (by substituting in subclause (I) of such
  clause `the average manufacturer price for each drug for the calendar quarter
  beginning July 1, 1990 (or, in the case of a covered outpatient drug approved
  for marketing after October 1, 1990, as of the first full calendar quarter
  after the drug was marketed)' for `the average manufacturer price for each
  drug for such period'), divided by the amount described in clause (iv).
  `(iii) TOTAL DOLLAR VOLUME (BASED ON CURRENT PRICE AND CURRENT DISPENSING)-
  The amount described in this clause for a manufacturer for a rebate period
  is the sum of the products (for all single source and innovator multiple
  source drugs of the manufacturer for which payment was made under the
  State plan for the period) of--
  `(I) the average manufacturer price for each such drug for such period, and
  `(II) the total number of units of each such drug paid for under the plan
  for the period.
  `(iv) TOTAL UNITS PAID FOR- The amount described in this clause for a
  manufacturer for a rebate period is the sum of the total number of units of
  the single source  and innovator multiple source drugs of the manufacturer
  paid for under the State plan for the period.
  `(D) EXCLUSION OF CERTAIN NEW DRUGS-
  `(i) IF UNDUE HARDSHIP- The Secretary may exclude certain drugs approved
  by the Food and Drug Administration on or after October 1, 1990, from the
  calculation of the weighted average manufacturer price under subparagraph
  (C) if the manufacturer demonstrates, through a petition in a form and
  manner prescribed by the Secretary, that undue hardship on the manufacturer
  would result if the drug is included in the calculation. The Secretary may
  promulgate guidelines to restrict the conditions under which the Secretary
  may consider such petitions.
  `(ii) DETERMINATION OF REBATE FOR EXCLUDED DRUGS- If a drug is excluded under
  clause (i) from the calculation of a rebate, the amount of the additional
  rebate with respect to that drug shall be determined as specified in
  subparagraph (A).
  `(E) USE OF ALTERNATIVE FORMULA- For rebate periods beginning during the
  2-year period beginning January 1, 1992, the Secretary shall compare
  the total amount of additional rebates under subparagraph (A) to such
  total amount if subparagraph (B) applied to such rebate periods. No later
  than January 1, 1994, the Secretary shall report to the Congress on such
  comparisons and make any recommendations with respect to an alternative
  formula for the purpose of calculating the additional rebate.'; and
  (C) by amending paragraph (3) to read as follows:
  `(3) REBATE FOR OTHER DRUGS-
  `(A) IN GENERAL- The amount of the rebate paid to a State for a rebate
  period with respect to each dosage form and strength of covered outpatient
  drugs (other than single source drugs and innovator multiple source drugs)
  shall be equal to the product of--
  `(i) the applicable percentage (as described in subparagraph (B)) of
  the average manufacturer price for the dosage form and strength for the
  period, and
  `(ii) the total number of units of such dosage form and strength dispensed
  after December 31, 1990, for which payment was made under the State plan
  for the period reported by the State under subsection (b)(2).
  `(B) APPLICABLE PERCENTAGE DEFINED- For purposes of subparagraph (A)(i),
  the `applicable percentage' for rebate periods beginning--
  `(i) before January 1, 1994, is 10 percent, and
  `(ii) after December 31, 1993, is 11 percent.'.
  (4)(A) Section 1927(d) of the SSA (42 U.S.C. 1396r-8(d)), as inserted by
  section 4401(a)(3) of OBRA-1990, is amended--
  (i) in paragraph (1)--
  (I) in subparagraph (A), by striking `(6)' and `(5)' and inserting `(5)'
  and `(4)', respectively, and
  (II) in subparagraph (B)(i), by striking `(k)(6)' and inserting `subsection
  (k)(5)';
  (ii) in paragraph (2)--
  (I) in subparagraph (A), by striking `anorexia or weight gain' and inserting
  `weight gain or loss', and
  (II) by inserting after subparagraph (K) the following new subparagraph:
  `(L) other drugs specified by the Secretary pursuant to paragraph (3).';
  (iii) in paragraph (3)--
  (I) by striking `The Secretary shall' and inserting `Subject to paragraph
  (5), the Secretary shall',
  (II) by striking `(except with respect' and all that follows through
  `of this paragraph)',
  (III) by striking `described in paragraph (2)', and
  (IV) by inserting `described in paragraph (2)' after `medical uses,';
  (iv) by striking paragraph (4) and by redesignating paragraphs (5) through
  (7) as paragraphs (4) through (6);
  (v) in paragraph (4), as so redesignated, by striking `(k)(6)' and inserting
  `(k)(5)';
  (vi) in paragraph (5), as so redesignated--
  (I) by striking `for coverage' and inserting `from coverage', and
  (II) by striking `any new biological or drug' and inserting `any biological
  or drug which is a new chemical or molecular entity';
  (vii) in paragraph (6), as so redesignated, by striking `provided' and
  inserting `if'; and
  (viii) by striking the second sentence of paragraph (6), as so redesignated,
  and paragraph (8) and inserting the following:
  `(7) CONSTRUCTION WITH RESPECT TO FRAUD AND ABUSE- Nothing in this section
  shall be construed to restrict the authority of a State to apply sanctions
  under this Act against any person or organization for fraud or abuse.'.
  (B) Section 1927(d)(4) of the SSA (42 U.S.C. 1396r-8(d)(4)), as redesignated
  by subparagraph (A)(iv), shall first apply to drugs dispensed on or after
  July 1, 1991.
  (5) Section 1927(e) of the SSA (42 U.S.C. 1396r-8(e)), as inserted by
  section 4401(a)(3) of OBRA-1990, is amended to read as follows:
  `(e) DENIAL OF FEDERAL FINANCIAL PARTICIPATION IN CERTAIN CASES- Section
  1903(i)(10)(B) shall apply to payments made by the Secretary to a State
  under section 1903 with respect to innovator multiple source drugs dispensed
  on or after July 1, 1991.'.
  (6) Section 1927(f) of the SSA (42 U.S.C. 1396r-8(f)), as inserted by
  section 4401(a)(3) of OBRA-1990, is amended to read as follows:
  `(f) PHARMACY REIMBURSEMENT LIMITS-
  `(1) No reductions in reimbursement limits-
  `(A) IN GENERAL- During the period beginning on January 1, 1991, and ending
  on December 31, 1994--
  `(i) a State may not reduce the payment limits established by regulation
  under this title with respect to the ingredient cost of a covered outpatient
  drug or the dispensing fee for such a drug below the limits in effect as
  of January 1, 1991, and
  `(ii) except as provided in paragraph (2), the Secretary may not change
  the regulations under sections 447.331 through 447.334 of title 42, Code
  of Federal Regulations, in effect on November 5, 1990, governing the limits
  described in clause (i).
  `(B) SPECIAL RULE- If a State is not in compliance with the regulations
  described in subparagraph (A)(ii), subparagraph (A)(i) shall not apply to
  such State until such State is in compliance with such regulations.
  `(2) ESTABLISHMENT OF UPPER PAYMENT LIMITS FOR CERTAIN MULTIPLE SOURCE DRUGS-
  The Secretary shall establish an upper limit on the amount of payment
  which is eligible for Federal financial participation under this title
  for each multiple source drug for which the Food and Drug Administration
  has rated at least 3 formulations of such drug as therapeutically and
  pharmaceutically equivalent, regardless of whether all the formulations
  of such drug are rated as so equivalent.'.
  (7) Section 1927(g) of the SSA (42 U.S.C. 1396r-8(g)), as inserted by
  section 4401(a)(3) of OBRA-1990, is amended to read as follows:
  `(g) DRUG USE REVIEW-
  `(1) REQUIREMENT FOR DRUG USE REVIEW PROGRAM-
  `(A) IN GENERAL- Except as provided in subparagraph (B), each State shall
  provide, by not later than January 1, 1993, for a drug use review program
  for covered outpatient drugs which--
  `(i) meets the requirements of paragraph (2), and
  `(ii) assures that prescriptions for such drugs are appropriate, medically
  necessary, and not likely to result in adverse medical results.
  `(B) TREATMENT OF NURSING FACILITIES- A State is not required in such State's
  drug use review program to provide for drug use review with respect to drugs
  dispensed to residents of nursing facilities which are in compliance with
  the requirements of subsections (b)(4)(A)(iii) and (c)(1)(D) of section 1919.
  `(2) REQUIREMENTS OF PROGRAM-
  `(A) PROSPECTIVE DRUG USE REVIEW-
  `(i) IN GENERAL- Each drug use review program shall provide for a review of
  drug therapy before each prescription is filled or delivered to an individual
  receiving benefits under this title. The review shall be designed to identify
  potential drug therapy problems due to therapeutic duplication, drug-disease
  contraindications, drug interactions (including serious interactions with
  nonprescription or over-the-counter drugs), incorrect drug dosage or duration
  of drug treatment, drug-allergy interactions, and clinical abuse or misuse.
  `(ii) STANDARDS FOR COUNSELING BY PHARMACISTS- As part of the prospective
  drug use review program of a State, applicable State law shall establish
  standards for counseling by pharmacists of individuals receiving benefits
  under this title. Such standards shall include, at a minimum, the following:
  `(I) The pharmacist must offer to discuss with each individual receiving
  benefits under this title or caregiver of such individual (in person,
  face-to-face whenever practicable, or through access to a telephone service
  which is toll free for long-distance calls) who presents a prescription,
  matters which in the exercise of the pharmacist's professional judgment
  (consistent with State law respecting the provision of such information),
  the pharmacist deems significant, which may include the following:
  `(aa) The name and description of the medication.
  `(bb) The dosage form, dosage, route of administration, and duration of
  drug therapy.
  `(cc) Special directions and precautions for preparation, administration
  and use by the patient.
  `(dd) Common severe side or adverse effects or interactions and therapeutic
  contraindications that may be encountered, including their avoidance,
  and the action required if they occur.
  `(ee) Techniques for self-monitoring drug therapy.
  `(ff) Proper storage.
  `(gg) Prescription refill information.
  `(hh) Action to be taken in the event of a missed dose.
  `(II) A reasonable effort must be made by the pharmacist to obtain, record,
  and maintain at least the following information regarding individuals
  receiving benefits under this title:
  `(aa) Name, address, telephone number, date of birth, (or age) and gender.
  `(bb) Individual history where significant, including disease state or
  states, known allergies and drug reactions, and a comprehensive list of
  medications and relevant devices.
  `(cc) Pharmacist comments relevant to the individual's drug therapy.
Nothing in this clause shall be construed as requiring a pharmacist to
provide consultation when an individual receiving benefits under this title
or caregiver of such individual refuses such consultation.
  `(B) RETROSPECTIVE DRUG USE REVIEW- The program shall provide, through
  mechanized drug claims processing and information retrieval systems
  (approved by the Secretary under section 1903(r)) or otherwise, for the
  ongoing periodic examination of claims data and other records in order
  to identify patterns of fraud, abuse, gross overuse, or inappropriate or
  medically unnecessary care, among physicians, pharmacists and individuals
  receiving benefits under this title, or associated with specific drugs or
  groups of drugs.
  `(C) STANDARDS-
  `(i) IN GENERAL- The program shall, on an ongoing basis, assess data on drug
  use against explicit standards determined by the State (using the sources
  described in clause (ii) as the basis for determining the standards for
  such assessment). Such assessment shall include monitoring for therapeutic
  appropriateness, overutilization and underutilization, appropriate use of
  generic products, therapeutic duplication, drug-disease contraindications,
  drug-drug interactions, incorrect drug dosage or duration of drug treatment,
  and clinical abuse or misuse and introduce remedial strategies in order
  to improve the quality of care and to conserve program funds or personal
  expenditures.
  `(ii) SOURCES- The sources described in this clause are the American Hospital
  Formulary Service Drug Information, the United States Pharmacopeia-Drug
  Information, the American Medical Association Drug Evaluations, and the
  peer-reviewed medical literature.
  `(D) EDUCATION AND INTERVENTION- The program shall provide for, either
  directly or through contracts with accredited health care educational
  institutions, State medical societies or State pharmacists' associations or
  societies or other organizations as specified by the State, and using data
  provided by the State drug use review board on common drug therapy problems--
  `(i) ongoing educational outreach programs to educate practitioners on
  common drug therapy problems with the aim of improving prescribing or
  dispensing practices; and
  `(ii) ongoing interventions for physicians and pharmacists targeted toward
  common drug therapy problems or individuals identified in the course of
  retrospective drug use reviews performed under this subsection, including,
  in appropriate instances, at least the following:
  `(I) written, oral, or electronic reminders containing patient-specific or
  drug-specific (or both) information and suggested changes in prescribing
  or dispensing practices, communicated in a manner designed to ensure the
  privacy of patient-related information;
  `(II) use of face-to-face discussions between health care professionals
  who are experts in rational drug therapy and selected prescribers and
  pharmacists who have been targeted for educational intervention, including
  discussion of optimal prescribing, dispensing, or pharmacy care practices,
  and followup face-to-face discussions; and
  `(III) intensified review or monitoring of selected prescribers or
  dispensers.
  `(3) STATE DRUG USE REVIEW BOARD-
  `(A) ESTABLISHMENT- Each State shall establish a drug use review board
  (hereafter in this paragraph referred to as the `DUR Board').
  `(B) MEMBERSHIP- The members of the DUR Board shall include health care
  professionals who have recognized knowledge and expertise in one or more
  of the following:
  `(i) The clinically appropriate prescribing of covered outpatient drugs.
  `(ii) The clinically appropriate dispensing and monitoring of covered
  outpatient drugs.
  `(iii) Drug use review, evaluation, and intervention.
  `(iv) Medical quality assurance.
The membership of the DUR Board shall be made up of at least  1/3  but no
more than 50 percent licensed and actively practicing physicians and at least
1/3  but no more than 50 percent licensed and actively practicing pharmacists.
  `(C) RESPONSIBILITIES- The DUR Board shall--
  `(i) approve the standards and criteria for drug use review;
  `(ii) recommend policies and procedures for the prospective and retrospective
  drug use review, education, and interventions required by this subsection;
  `(iii) compile data on common drug therapy problems; and
  `(iv) evaluate the effectiveness of the drug use review program in improving
  the quality of drug therapy and make recommendations for modifications
  as necessary.
  `(4) ANNUAL REPORT- Each State shall submit an annual report to the Secretary
  which shall include a description of the nature and scope of the drug use
  review program, a summary of the interventions used, and an assessment
  of the impact of such interventions on improving quality of care. Such
  report shall also include an estimate of the cost savings resulting from
  the operation of such program.
  `(5) RESPONSIBILITY OF SECRETARY- By July 1 of each year beginning with 1994,
  the Secretary shall submit an annual report to the Congress evaluating the
  effectiveness of States' drug use review programs utilizing each State's
  annual report.'.
  (8) Section 1927(h)(2)(A) of the SSA (42 U.S.C. 1396r-8(h)(2)(A)), as
  inserted by section 4401(a)(3) of OBRA-1990, is amended by inserting
  `develops or' before `acquires'.
  (9) Section 1927(i)(2) of the SSA (42 U.S.C. 1396r-8(i)(2)), as inserted
  by section 4401(a)(3) of OBRA-1990, is amended--
  (A) by striking subparagraph (C); and
  (B) by redesignating subparagraphs (D), (E), and (F) as subparagraphs (C),
  (D), and (E), respectively.
  (10) Section 1927(j) of the SSA (42 U.S.C. 1396r-8(j), as inserted by
  section 4401(a)(3) of OBRA-1990, is amended to read as follows:
  `(j) Exemption for Certain Health Maintenance Organizations and Hospitals-
  `(1) IN GENERAL- Except as provided in paragraph (2), the requirements
  of this section shall not apply with respect to covered outpatient drugs
  dispensed by--
  `(A) a health maintenance organization; or
  `(B) a hospital that dispenses covered outpatient drugs using a drug
  formulary system, and bills the plan no more than the hospital's purchasing
  costs for covered outpatient drugs (as determined under the State plan).
  `(2) CONSTRUCTION IN DETERMINING BEST PRICE- Nothing in paragraph (1)
  shall be construed as excluding amounts paid by the entities described in
  such paragraph for covered outpatient drugs from the determination of the
  best price (as defined in subsection (c)(1)(C)) for such drugs.'.
  (11) Section 1927(k) of the SSA (42 U.S.C. 1396r-8(k)), as inserted by
  section 4401(a)(3) of OBRA-1990, is amended--
  (A) in paragraph (1)--
  (i) by striking `calendar quarter' and inserting `rebate period', and
  (ii) by inserting before the period at the end the following: `, after
  deducting customary prompt pay discounts';
  (B) in paragraph (2)--
  (i) in the matter before clause (i) of subparagraph (A), strike `paragraph
  (5)' and insert `subparagraph (D)';
  (ii) in subparagraph (A)--
  (I) in clause (i), by striking `for safety and effectiveness' and by striking
  `or which is approved under section 505(j) of such Act'; and
  (II) by striking `and' at the end thereof;
  (iii) in subparagraph (B),
  (I) in clause (i), by striking `prescription,' and inserting `prescription;';
  (II) in clause (ii), by striking `, and' and inserting `; and'; and
  (III) by striking `and' at the end thereof;
  (iv) by striking the period at the end of subparagraph (C) and inserting
  `; and'; and
  (v) by adding at the end the following new subparagraph:
  `(D) a drug which may be sold without a prescription (commonly referred to
  as an `over-the-counter drug'), if the drug is prescribed by a physician
  (or other person authorized to prescribe under State law).';
  (C) in paragraph (3)--
  (i) in subparagraph (E), by striking `**** emergency room visits',
  (ii) in subparagraph (F), by striking `sevices' and inserting `services
  and services provided by an intermediate care facility for the mentally
  retarded',
  (iii) in subparagraph (H), by inserting `services' after `dialysis',
  (iv) in the matter following subparagraph (H), by striking `which is used'
  and inserting `for which a National Drug Code number is not required by
  the Food and Drug Administration or when such drug or product is used', and
  (v) in the matter following subparagraph (H), by inserting `as defined in
  paragraph (5)' after `indication';
  (D) by striking paragraph (4) and redesignating paragraphs (5), (6), and
  (7) as paragraphs (4), (5), and (6), respectively;
  (E) by amending paragraph (4), as so redesignated, to read as follows:
  `(4) MANUFACTURER- The term `manufacturer' means, with respect to a covered
  outpatient drug, an entity which holds a National Drug Code number for
  such drug.';
  (F) in paragraph (5), as so redesignated, by striking `, which appears'
  and all that follows and inserting `which is listed in any of the sources
  described in subsection (g)(2)(C)(ii), but not including the peer-reviewed
  medical literature.';
  (G) in paragraph (6), as so redesignated--
  (i) in subparagraph (A)(i), by striking `calendar quarter' and inserting
  `rebate period',
  (ii) in subparagraph (A)(i), by striking `paragraph (5)' and inserting
  `paragraph (2)(D)',
  (iii) in subparagraph (A)(ii), by striking `an original new' and inserting
  `a new',
  (iv) in subparagraph (A)(ii), by inserting `or product licensing application'
  after `application',
  (v) in subparagraph (A)(iv), by striking `an original new' and inserting
  `a new',
  (vi) in subparagraph (A)(iv), by inserting `or product licensing application'
  after `application',
  (vii) in subparagraph (A)(iv), by striking `distributers' and inserting
  `distributors',
  (viii) in subparagraph (C)(i), by striking `pharmaceuutically' and inserting
  `pharmaceutically', and
  (ix) in subparagraph (C)(iii), by striking `, provided that' and inserting
  `if'; and
  (H) by inserting after paragraph (6), as redesignated, the following
  new paragraph:
  `(7) REBATE PERIOD- The term `rebate period' means, with respect to
  an agreement under subsection (a), a calendar quarter or other period
  specified by the Secretary with respect to the payment of rebates under
  such agreement.'.
  (12) Section 1927 of the SSA (42 U.S.C. 1396r-8), as inserted by section
  4401(a)(3) of OBRA-1990, is further amended by adding at the end the
  following:
  `(l) Miscellaneous Provisions-
  `(1) LIMITATIONS ON COVERAGE OF OUTPATIENT DRUGS- Nothing in section
  1902(a)(54)(A) shall be construed as preventing a State from restricting
  the amount, duration, and scope of coverage of covered outpatient drugs
  consistent with section 1902(a)(30).
  `(2) RELATION TO MAXIMUM ALLOWABLE COST LIMITATIONS- This section shall
  not supersede or affect provisions relating to maximum allowable cost
  limitations for payment by States for covered outpatient drugs, and rebates
  under this section shall be made without regard to whether or not payment
  by the State for such drugs is subject to such limitations or the amount
  of such cost limitations.'.
  (d) FUNDING- Section 4401(b)(2) of OBRA-1990 is amended by striking the
  semicolon and all that follows and inserting a period.
  (e) DEMONSTRATION PROJECTS- Section 4401(c)(1) of OBRA-1990 is amended--
  (1) in subparagraph (A), by striking `1992' and inserting `1993';
  (2) in subparagraph (A), by striking `10' and inserting `5'; and
  (3) in subparagraph (C), by striking `regiment' and inserting `regimen'.
  (f) STUDIES- Section 4401(d) of OBRA-1990 is amended--
  (1) in paragraph (1)(A), by striking `other institutional facilities,'
  and inserting `nursing facilities, intermediate care facilities for the
  mentally retarded,';
  (2) in paragraph (1)(B), by striking `under this subsection' and inserting
  `under this paragraph';
  (3) in paragraph (1)(B)(i), by striking `under this section' and inserting
  `under section 1927 of the Social Security Act';
  (4) in paragraph (1)(B)(ii)--
  (A) by striking `drug use review' the second time it appears and inserting
  `the type of drug use review that is', and
  (B) by striking `under this section' and inserting `under such section';
  (5) in paragraph (1)(B)(iii), by striking `under this title' and inserting
  `under title XIX of the Social Security Act';
  (6) in paragraph (1)(C), by striking `May 1, 1991' and inserting `May
  1, 1992';
  (7) in paragraph (2), by striking `an annual report' and inserting
  `a report';
  (8) in paragraph (3)--
  (A) in subparagraph (A), by striking `, acting in consultation with the
  Comptroller General,',
  (B) by indenting subparagraph (B) an additional 2 ems, and
  (C) in subparagraph (B), by striking `December 31, 1991, the Secretary
  and the Comptroller General' and inserting `June 1, 1993, the Secretary';
  (9) in paragraph (4)(A), by striking `each' and by striking the semicolon
  and inserting a comma;
  (10) in paragraph (4)(B), by striking `December 31, 1991' and inserting
  `January 1, 1993';
  (11) in paragraph (5)--
  (A) by striking `Secretary of Health and Human Services' and inserting
  `Comptroller General',
  (B) by striking `under this title' and inserting `under State medicaid
  programs', and
  (C) by striking the second sentence and inserting the following new sentence:
  `The Comptroller General shall report to the Congress on the study not
  later than January 1, 1993.'; and
  (12) in paragraph (6), by striking `1 year after the date of enactment of
  this subsection' and inserting `January 1, 1993'.
SEC. 3. CORRECTIONS RELATING TO SECTION 4402 (ENROLLMENT UNDER GROUP HEALTH
PLANS).
  Section 4402(b) of OBRA-1990 is amended by striking `1903(u)(1)(C)(iv)
  (42 U.S.C. 1396b(u)(1)(C)(iv))' and inserting `1903(u)(1)(D)(iv) (42
  U.S.C. 1396b(u)(1)(D)(iv))'.
SEC. 4. CORRECTIONS RELATING TO SECTION 4501 (LOW-INCOME MEDICARE
BENEFICIARIES).
  (a) Section 1902(a)(10)(E)(iii) of the SSA (42 U.S.C. 1396a(a)(10)(E)(iii)),
  as added by section 4501(b)(3) of OBRA-1990, is amended by striking `cost
  sharing' and inserting `cost-sharing'.
  (b) Section 1905(p)(4)(B) of the SSA (42 U.S.C. 1396d(p)(4)(B)), as
  amended by section 4501(c)(1) of OBRA-1990, is amended by striking
  `1902(a)(10)(E)(iii)' and inserting `section 1902(a)(10)(E)(iii)'.
SEC. 5. CORRECTIONS RELATING TO SECTION 4601 (CHILD HEALTH).
  (a) Section 1902(a)(10)(A)(i)(VII) of the SSA (42
  U.S.C. 1396a(a)(10)(A)(i)(VII)), as added by section 4601(a)(10)(A)(iii)
  of OBRA-1990, is amended by striking `family;' and inserting `family; and'.
  (b) Section 1902(l) of the SSA (42 U.S.C. 1396a(l)), as amended by section
  4601(a)(1)(C) of OBRA-1990, is amended--
  (1) in paragraph (1)(C), by striking `children' after `(C)';
  (2) in paragraph (3), by striking `(a)(10)(A)(i)(VII),,' and inserting
  `(a)(10)(A)(i)(VII),'; and
  (3) in paragraph (4)(B), by inserting a comma before `(a)(10)(A)(i)(VI),'.
  (c) Section 1925 of the SSA (42 U.S.C. 1396r-6), as amended by section
  4601(a) of OBRA-1990, is amended--
  (1) in subsection (a)(3)(C), by striking `(i)(VI)' and inserting `(i)(VI),',
  and
  (2) in subsection (b)(3)(C)(i), by striking `(i)(IV) (i)(VI) (i)(VII), ,'
  and inserting `(i)(IV), (i)(VI), (i)(VII),'.
SEC. 6. CORRECTIONS RELATING TO SECTION 4602 (OUTREACH LOCATIONS).
  (a) Section 1902(a)(55) of the SSA (42 U.S.C. 1396a(a)(55)), as added by
  section 4602(a)(3) of OBRA-1990, is amended--
  (1) in the matter preceding subparagraph (A)--
  (A) by striking `subsection' and inserting `paragraph', and
  (B) by striking `(a)' each place it appears; and
  (2) in subparagraph (A), by striking `1905(1)(2)(B)' and inserting
  `1905(l)(2)(B)'.
  (b) Section 1902(l)(1) of the SSA (42 U.S.C. 1396a(l)(1)) is amended by
  striking `who are not described in any of subclauses (I) through (III)
  of subsection (a)(10)(A)(i) and'.
SEC. 7. CORRECTIONS RELATING TO SECTION 4604 (PAYMENT FOR HOSPITAL SERVICES
FOR CHILDREN UNDER 6 YEARS OF AGE).
  (a) Section 1902(a)(10) of the SSA (42 U.S.C. 1396a(a)(10)) is amended
  in clause (X) in the matter following subparagraph (F) by striking `under
  one year of age' and inserting `under 6 years of age'.
  (b) Section 1902(s) of the SSA (42 U.S.C. 1396a(s)), as added by section
  4604(a) of OBRA-1990, is amended to read as follows:
  `(s) In order to meet the requirements of subsection (a)(56), the State
  plan must provide that payments to hospitals under the plan for inpatient
  services furnished to infants who have not attained the age of 1 year (or,
  in the case of such an individual who is an inpatient on his first birthday,
  until such individual is discharged) shall--
  `(1) if made on a prospective basis (whether per diem, per case, or
  otherwise) provide for an outlier adjustment in payment amounts for
  medically necessary inpatient hospital services involving exceptionally
  high costs or exceptionally long lengths of stay;
  `(2) not be limited by the imposition of day limits; and
  `(3) not be limited by the imposition of dollar limits (other than dollar
  limits resulting from prospective payments as adjusted pursuant to paragraph
  (1)).'.
  (c) Section 1923(a)(2)(C) of the SSA (42 U.S.C. 1396r-4(a)(2)(C)) is
  amended by striking `provided on or after July 1, 1989,' and all that
  follows and inserting the following: `involving exceptionally high costs
  or exceptionally long lengths of stay--
  `(i) for individuals under 1 year of age, in the case of services provided
  on or after July 1, 1989, and on or before June 30, 1991; and
  `(ii) for individuals under 6 years of age, in the case of services provided
  on or after July 1, 1991.'.
SEC. 8. CORRECTIONS RELATING TO SECTION 4703 (PAYMENT ADJUSTMENTS FOR
DISPROPORTIONATE SHARE HOSPITALS).
  (a) Section 1923(c) of the SSA (42 U.S.C. 1396r-4(c)) is amended--
  (1) in paragraph (2), by striking `paragraph (b)(3)' and inserting
  `subsection (b)(3)';
  (2) by striking the period at the end of paragraph (3)(B) and inserting
  a comma; and
  (3) in the third sentence, by striking `the payment adjustment described in
  paragraph (2)' and inserting `a payment adjustment described in paragraph
  (2) or (3)'.
  (b) Effective December 22, 1987, section 1923(d)(2)(A)(ii) of the SSA
  (42 U.S.C. 1396r-4(d)(2)(A)(ii)) is amended by striking `the date of the
  enactment of this Act' and inserting `December 22, 1987'.
  (c) Section 4703(d) of OBRA-1990 is amended by striking `412(a)(2)' and
  inserting `4112(a)(2)'.
SEC. 9. CORRECTIONS RELATING TO SECTION 4704 (FEDERALLY-QUALIFIED HEALTH
CENTERS).
  (a) Clause (ix) of section 1903(m)(2)(A) of the SSA (42
  U.S.C. 1396b(m)(2)(A)), as added by section 4704(b)(1)(C) of OBRA-1990,
  is amended--
  (1) by striking `of such center' the first place it appears;
  (2) by striking `federally qualified' and inserting `Federally-qualified';
  and
  (3) by moving such clause 2 ems to the left.
  (b) Section 1903(m)(2)(B) of the SSA (42 U.S.C. 1396b(m)(2)(B)), as amended
  by section 4704(b)(2) of OBRA-1990, is amended by striking `except with
  respect to clause (ix) of subparagraph (A),' and inserting `(except with
  respect to clause (ix) of such subparagraph)'.
  (c) Section 1905(l)(2) of the SSA (42 U.S.C. 1396d(l)(2)), as amended by
  section 4704(c) of OBRA-1990, is amended--
  (1) in subparagraph (A)--
  (A) by striking `Federally-qualififed' and inserting `Federally-qualified',
  and
  (B) by striking `an patient' and inserting `a patient', and
  (2) in subparagraph (B)--
  (A) in the matter preceding clause (i), by striking `a entity' and inserting
  `an entity',
  (B) by striking `or' at the end of clause (i),
  (C) by striking the semicolon at the end of clause (ii)(II) and inserting
  a comma,
  (D) by moving clause (ii) 4 ems to the left,
  (E) by striking the comma at the end of clause (iii) and inserting `,
  or', and
  (F) by striking `and includes an outpatient health program' and all that
  follows through `for good cause shown.' and inserting the following:
  `(iv) is an outpatient health program or facility operated by a tribe
  or tribal organization under the Indian Self-Determination Act (Public
  Law 93-638).
In applying clause (iii), the Secretary may waive any requirement referred
to in such clause for up to 2 years for good cause shown.'.
SEC. 10. CORRECTIONS RELATING TO SECTION 4708 (SUBSTITUTE PHYSICIANS).
  Section 1902(a)(32)(C) of the SSA (42 U.S.C. 1396a(a)(32)(C)), as added
  by section 4708(a)(3) of OBRA-1990, is amended to read as follows:
  `(C) payment may be made to a physician for physicians' services (and
  services furnished incident to such services) furnished by a second physician
  to patients of the first physician if (i) the first physician is unavailable
  to provide the services; (ii) the services are furnished pursuant to an
  arrangement between the two physicians that (I) is informal and reciprocal,
  or (II) involves per diem or other fee-for-time compensation for such
  services; (iii) the services are not provided by the second physician over
  a continuous period of more than 60 days; and (iv) the claim form submitted
  to the carrier for such services includes the second physician's unique
  identifier (provided under the system established under subsection (x))
  and indicates that the claim meets the requirements of this clause for
  payment to the first provider.'.
SEC. 11. CORRECTIONS RELATING TO SECTION 4711 (HOME AND COMMUNITY CARE FOR
FRAIL ELDERLY).
  (a) Section 1929 of the SSA (42 U.S.C. 1396t), as added by section 4711(b)
  of OBRA-1990, is amended--
  (1) in subsection (c)(2)(F), by moving the second sentence 2 ems to
  the right;
  (2) in subsection (d)(2)(F)(ii), by striking `they manage' and inserting
  `it manages';
  (3) in subsection (d)(2)(F)(iii), by inserting `the agency or organization'
  after `(iii)';
  (4) in subsection (e)(2)(B), by striking `fiscal year 1989' and inserting
  `fiscal year 1990';
  (5) in subsection (f)(1), by striking `Community care' and inserting
  `community care';
  (6) in subsection (g)(1)--
  (A) by striking `SETTINGS' and inserting `SETTING'; and
  (B) in subparagraph (B), by striking `setting.' and inserting `setting in
  which home and community care under this section is provided.';
  (7) in subsection (g)(2), by striking `community care' the second, third,
  and fourth place it appears and inserting `home and community care';
  (8) in subsection (h)(1)--
  (A) by amending subparagraph (A) to read as follows:
  `(A) a nonresidential setting that serves 8 or more individuals; or'; and
  (B) in subparagraph (B)--
  (i) by striking `more than 8' and inserting `8 or more'; and
  (ii) by inserting `(other than merely board)' after `personal services';
  (9) in subsection (h)(2), by striking `community care' the second and
  third place it appears and inserting `home and community care';
  (10) in the first sentence of subsection (j)(1)(A), by striking `the State
  may terminate the provider's participation under the State plan and may
  provide in addition for a civil money penalty' and inserting `the State
  may provide for a civil money penalty and, in addition, may terminate the
  provider's participation under the State plan';
  (11) in the first sentence of subsection (j)(2)(B), by striking `the
  Secretary may terminate the provider's participation under the State plan and
  may provide, in addition, for a civil money penalty under subparagraph (C)'
  and inserting `the Secretary may provide for a civil money penalty under
  subparagraph (C) and, in addition, terminate the provider's participation
  under the State plan';
  (12) in subsection (k)(1)(A)(i)--
  (A) by striking `(d)(2)(E)' and inserting `(d)(2)', and
  (B) by striking `settings,' and inserting `settings),';
  (13) in subsection (l), by striking `State wideness' and inserting
  `Statewideness';
  (14) in subsection (m)--
  (A) in paragraph (1), by striking `The amount of funds' and inserting
  `Except as provided in paragraph (5), the amount of funds',
  (B) in paragraph (2)--
  (i) by striking `Individual Community Care Plan' and inserting `individual
  community care plan', and
  (ii) by striking `an election period is the period of 4 or more calendar
  quarters' and inserting `an election period is a Federal fiscal year
  (or in the case of States described in paragraph (4)(C)(ii), the period
  beginning on April 1, 1993, and ending on September 30, 1993)',
  (C) by amending paragraph (4) to read as follows:
  `(4) ALLOCATION OF MEDICAL ASSISTANCE-
  `(A) IN GENERAL- All of the funds available to be expended under paragraph
  (1) during a fiscal year shall be available as Federal medical assistance
  to the States electing to provide services under this section during such
  fiscal year.
  `(B) GENERAL ALLOCATION FORMULA- For each fiscal year, beginning with
  fiscal year 1994, a State which has provided a notice to the Secretary
  under paragraph (6)(A) shall be allocated an amount of the funds that may be
  expended under paragraph (1) for such fiscal year equal to the product of--
  `(i) the total amount of funds that may be expended under paragraph (1)
  for such fiscal year; and
  `(ii) the amount determined by dividing--
  `(I) the number of individuals age 65 or older residing in such State
  during such fiscal year, by
  `(II) the total number of individuals age 65 or older residing in all
  States which have submitted notices to the Secretary under such paragraph
  during such fiscal year.
  `(C) SPECIAL ALLOCATION FORMULA FOR FISCAL YEAR 1993-
  `(i) FIRST 6-MONTH PERIOD- For the period beginning on October 1, 1992,
  and ending on March 31, 1993, each State for which a State plan amendment
  to provide home and community care under this section has been approved by
  the Secretary as of the date of enactment of this Act shall be allocated
  an amount of the funds available under paragraph (1) for fiscal year 1993
  equal to the product of--
  `(I) $65,000,000; and
  `(II) the amount determined by dividing--
  `(aa) the number of individuals age 65 or older residing in such State
  during such fiscal year, by
  `(bb) the total number of individuals age 65 or older residing in all
  States which are providing home and community care under this section on
  the date of enactment of this Act.
  `(ii) SECOND 6-MONTH PERIOD- For the period beginning on April 1, 1993,
  and ending on September 30, 1993, a State which has provided a notice
  to the Secretary under paragraph (6)(B) shall be allocated an amount of
  the funds available under paragraph (1) for fiscal year 1993 equal to the
  amount such State would receive under the formula set forth in subparagraph
  (B) by substituting--
  `(I)  `(6)(B)' for `(6)(A)', and
  `(II) `$65,000,000' for `the total amount of funds that may be expended
  under paragraph (1) for such fiscal year'.
  `(D) REALLOCATION OF FUNDS-
  `(i) FORMULA FOR REALLOCATION-
  `(I) GENERAL RULE- Except as provided in subclause (II), within 60 days
  after the end of each fiscal year, beginning with fiscal year 1993,
  the Secretary shall pay to each State which provided services under this
  section during such fiscal year an amount equal to the product of--
  `(aa) the total amount of funds that may be expended under paragraph (1) for
  such fiscal year which remain available at the end of such fiscal year; and
  `(bb) the amount determined by dividing the unavailable Federal amount
  (as defined in clause (ii)) for such State by the total unavailable Federal
  amount for all the States which provided services under this section during
  such fiscal year.
  `(II) SPECIAL RULE- The amount determined for payment to a State under
  subclause (I) shall not exceed the unavailable Federal amount for such State.
  `(ii) DEFINITION- For purposes of this subparagraph, the term `unavailable
  Federal amount' means the excess of--
  `(I) the amount a State would have received in Federal medical assistance
  based on such State's expenditures for services provided under this section
  but for the allocation under subparagraph (B), over
  `(II) the amount of Federal medical assistance allocated to such State
  under subparagraph (B).', and
  (D) by adding at the end the following new paragraphs:
  `(5) CARRYOVER OF FUNDS TO NEXT FISCAL YEAR- Beginning with fiscal year
  1993, any funds available under paragraph (1) for a fiscal year which
  remain available after the application of subparagraphs (B), (C), and (D)
  of paragraph (4) shall be available under paragraph (1) to be expended in
  the following fiscal year.
  `(6) NOTICE TO STATES OF AMOUNTS AVAILABLE FOR ASSISTANCE-
  `(A) IN GENERAL-
  `(i) NOTICE TO SECRETARY- In order to receive Federal medical assistance
  for expenditures for home and community care under this section for any
  fiscal year (beginning with fiscal year 1994), a State shall submit not
  later than 3 months before the beginning of such fiscal year a notice to
  the Secretary of its intention to provide such care.
  `(ii) NOTICE TO STATES- Not later than 2 months before the beginning of
  each fiscal year (beginning with fiscal year 1994), the Secretary shall
  notify each State that has submitted a notice to the Secretary under clause
  (i) for the fiscal year of the amount of Federal medical assistance that
  will be available to the State for such fiscal year (as established under
  paragraph (4)(B)).
  `(B) SPECIAL RULE FOR FISCAL YEAR 1993-
  `(i) NOTICE TO SECRETARY- In order to receive Federal medical assistance
  for expenditures for home and community care under this section for the
  period beginning on April 1, 1993, and ending on September 30, 1993, a
  State shall submit not later than March 1, 1993, a notice to the Secretary
  of its intention to provide such care.
  `(ii) NOTICE TO STATES- Not later than April 1, 1993, the Secretary shall
  notify each State that has submitted a notice to the Secretary under clause
  (i) for the period beginning on April 1, 1993, and ending on September 30,
  1993, of the amount of Federal medical assistance that will be available to
  the State for such period (as established under paragraph (4)(C)(ii)).'; and
  (15) by adding at the end the following new subsection:
  `(n) COMMUNITY CARE SETTING DEFINED- In this section, the term `community
  care setting' means a small community care setting (as defined in subsection
  (g)(1)) or a large community care setting (as defined in subsection
  (h)(1)).'.
  (b) Section 1905(r)(5) of the SSA (42 U.S.C. 1396d(r)(5)) is amended by
  striking `1905(a)' and inserting `subsection (a) (other than services
  described in paragraph (22) or (23) of such subsection)'.
  (c) Section 4711(f) of OBRA-1990 is amended by striking `Act' each place
  it appears and inserting `section'.
SEC. 12. CORRECTIONS RELATING TO SECTION 4712 (COMMUNITY SUPPORTED LIVING
ARRANGEMENTS).
  (a) Section 1930 of the SSA (42 U.S.C. 1396u), as added by section 4712(b)(2)
  of OBRA-1990, is amended--
  (1) in subsection (b)--
  (A) by striking `title the term,' and inserting `title, the term',
  (B) by striking `guardian' and inserting `guardian or', and
  (C) by striking `3 other' and inserting `3';
  (2) in subsection (d)--
  (A) in the matter preceding paragraph (1), by striking `program,' and
  inserting `program', and
  (B) in the second sentence, by striking `plan' each place it appears and
  inserting `program'; and
  (3) in subsection (i), by striking `FUNDS' and inserting `FUNDS'.
  (b) Section 4712(c) of OBRA-1990 is amended--
  (1) in paragraph (1), by inserting `of section 1930 of the Social Security
  Act' after `subsection (h)'; and
  (2) in paragraph (2), by striking `this section' and inserting `such
  section'.
SEC. 13. CORRECTION RELATING TO SECTION 4713 (COBRA CONTINUATION COVERAGE).
  (a) Section 1902(a)(10) of the SSA (42 U.S.C. 1396a(a)(10)) is amended in
  the matter following subparagraph (F)--
  (1) by striking `; and (XI)' and inserting `, (XI)';
  (2) by striking `individuals, and (XI)' and inserting `individuals, and
  (XII); and
  (3) by striking `COBRA continuation premiums' and inserting `COBRA premiums'.
  (b) Section 1902(u)(3) of the SSA (42 U.S.C. 1396a(u)(3)), as added by
  section 4713(a)(2) of OBRA-1990, is amended by striking `title VI' and
  inserting `part 6 of subtitle B of title I'.
SEC. 14. CORRECTION RELATING TO SECTION 4716 (MEDICAID TRANSITION FOR FAMILY
ASSISTANCE).
  Section 4716(a) of OBRA-1990 is amended by striking `AMENDMENTS- Subsection
  (f) of section' and inserting `IN GENERAL- Section'.
SEC. 15. CORRECTIONS RELATING TO SECTION 4721 (PERSONAL CARE SERVICES).
  Section 1905(a)(7) of the SSA (42 U.S.C. 1396d(a)(7)), as amended by
  section 4721(a) of OBRA-1990, is amended to read as follows:
  `(7)(A) home health services; and (B) personal care services which are
  (i) prescribed by a physician for an individual in accordance with a
  plan of treatment, (ii) provided by an individual who is qualified to
  provide such services and who is not a member of the individual's family,
  (iii) supervised by a registered nurse, (iv) furnished in a home or other
  location, and (v) furnished to an individual who is not an inpatient or
  resident of a nursing facility;'.
SEC. 16. CORRECTIONS RELATING TO SECTION 4723 (MEDICAID SPENDDOWN OPTION).
  Section 1903(f)(2) of the SSA (42 U.S.C. 1396b(f)(2)), as amended by section
  4723(a) of OBRA-1990, is amended by striking `to the State, provided that'
  and inserting `to the State if'.
SEC. 17. CORRECTIONS RELATING TO SECTION 4724 (OPTIONAL STATE DISABILITY
DETERMINATIONS).
  Section 1902(v) of the SSA (42 U.S.C. 1396a(v)), as added by section 4724
  of OBRA-1990, is amended--
  (1) by striking `(v)(1)' and inserting `(v)'; and
  (2) by striking `of the Social Security Act'.
SEC. 18. CORRECTION RELATING TO SECTION 4732 (SPECIAL RULES FOR HEALTH
MAINTENANCE ORGANIZATIONS).
  Section 1903(m)(2)(F)(i) of the SSA (42 U.S.C. 1396b(m)(2)(F)(i)), as
  amended by section 4732(b)(2)(B) of OBRA-1990, is amended by striking `or'
  before `with an eligible organization'.
SEC. 19. CORRECTIONS RELATING TO SECTION 4741 (HOME AND COMMUNITY-BASED
WAIVERS).
  The first sentence of section 1915(d)(3) of the SSA (42 U.S.C. 1396n(d)(3))
  is amended by striking the period at the end and inserting the following:
  `, and a waiver of the requirements of section 1902(a)(23) (relating to
  choice of providers) insofar as such requirements relate to the provision
  of case management services and the State provides assurances satisfactory
  to the Secretary that a waiver of such requirements will not substantially
  limit access to such services).'
SEC. 20. CORRECTIONS RELATING TO SECTION 4745 (LOW INCOME FAMILIES
DEMONSTRATION PROJECT).
  Section 4745(e)(1) of OBRA-1990 is amended by adding at the end the following
  new sentence: `Such sums as may be available under the limitations set
  forth in this paragraph for fiscal years 1993 and 1994 shall be available
  until expended.'.
SEC. 21. CORRECTIONS RELATING TO SECTION 4747 (COVERAGE OF HIV-POSITIVE
INDIVIDUALS).
  Section 4747 of OBRA-1990 is amended--
  (1) in subsection (a), by striking `subsection (c)' and inserting `subsection
  (b)';
  (2) in subsection (b)(2)--
  (A) by striking `preventative' each place it appears and inserting
  `preventive', and
  (B) by adding a period at the end of subparagraph (J);
  (3) in subsection (c)(1)--
  (A) by striking `subsection (c)' and inserting `subsection (b)', and
  (B) by striking `paragraphs (1) and (2) of';
  (4) in subsection (d)--
  (A) by striking `paragraph (3)' and inserting `subsection (b)', and
  (B) by striking `paragraph (1)' and inserting `subsection (a)'; and
  (5) in subsection (f), by adding at the end the following new sentence:
  `Such sums as may be available under the limitation set forth in this
  paragraph for fiscal year 1993 shall be available until expended.'.
SEC. 22. CORRECTION RELATING TO SECTION 4751 (ADVANCED DIRECTIVES).
  Section 1903(m)(1)(A) of the SSA (42 U.S.C. 1396b(m)(1)(A)), as amended
  by section 4751(b)(1) of OBRA-1990, is amended--
  (1) by striking `1902(w)' and inserting `1902(w) and'; and
  (2) by striking `1902(a)' and inserting `1902(w)'.
SEC. 23. CORRECTIONS RELATING TO SECTION 4752 (PHYSICIANS' SERVICES).
  (a) The paragraph (58) of section 1902(a) of the SSA (42 U.S.C. 1396a(a))
  added by section 4752(c)(1)(C) of OBRA-1990 is amended by striking
  `subsection (v)' and inserting `subsection (x)'.
  (b) Subparagraphs (A) and (B) of the paragraph (14) of section 1903(i)
  of the SSA (42 U.S.C. 1396b(i)) added by section 4752(e)(2) of OBRA-1990
  are each amended--
  (1) by striking `or' at the end of clause (v);
  (2) by redesignating clause (vi) as clause (vii); and
  (3) by inserting after clause (v) the following new clause:
  `(vi) delivers such services in the emergency department of a hospital
  participating in the state plan approved under this title, or'.
SEC.  24. CORRECTIONS RELATING TO SECTION 4801 (NURSING HOME REFORM).
  (a) Section 1919(b)(3)(C)(i)(I) of the SSA (42 U.S.C. 1396r(b)(3)(C)(i)(I)),
  as amended by section 4801(e)(3) of OBRA-1990, is amended by striking
  `not to exceed' before `14 days'.
  (b) Section 1919(b)(5)(D) of the SSA (42 U.S.C. 1396r(b)(5)(D)), as amended
  by section 4801(a)(4) of OBRA-1990, is amended by striking the comma before
  `or a new competency evaluation program.'.
  (c) Section 1919(b)(5)(G) of the SSA (42 U.S.C. 1396r(b)(5)(G)) is amended by
  striking `or licensed or certified social worker' and inserting `licensed
  or certified social worker, registered respiratory therapist, or certified
  respiratory therapy technician'.
  (d) Section 1919(f)(2)(B)(i) of the SSA (42 U.S.C. 1396r(f)(2)(B)(i))
  is amended by striking `facilities,' and inserting `facilities (subject
  to clause (iii)),'.
  (e) Section 1919(f)(2)(B)(iii)(I)(c) of the SSA (42
  U.S.C. 1396r(f)(2)(B)(iii)(I)(c)) is amended by striking `clauses' each
  place it appears and inserting `clause'.
  (f) Section 1919(g)(5)(B) of the SSA (42 U.S.C. 1396r(g)(5)(B)) is amended
  by striking `paragraphs' and inserting `paragraph'.
  (g) Section 4801(a)(6)(B) of OBRA-1990 is amended--
  (1) by striking `The amendments' and inserting `(i) The amendments';
  (2) by redesignating clauses (i) through (v) as subclauses (I) through
  (V); and
  (3) by adding at the end the following new clause:
  `(ii) Notwithstanding clause (i) and subject to section 1919(f)(2)(B)(iii)(I)
  of the Social Security Act (as amended by subparagraph (A)), a State
  may approve a training and competency evaluation program or a competency
  evaluation program offered by or in a nursing facility described in clause
  (i) if, during the previous 2 years, none of the subclauses of clause (i)
  applied to the facility.'.
SEC. 25. OTHER TECHNICAL CORRECTIONS.
  (a) Section 1905(o)(1)(A) of the SSA (42 U.S.C. 1396d(o)(1)(A)) is amended--
  (1) in the first sentence, by striking `intermediate care facility services'
  and inserting `for nursing facility services or intermediate care facility
  services for the mentally retarded'; and
  (2) in the second sentence, by striking `or intermediate care facility'
  and inserting `(for purposes of title XVIII), a nursing facility, or an
  intermediate care facility for the mentally retarded'.
  (b) Section 1915(d) of the SSA (42 U.S.C. 1396n(d)) is amended--
  (1) by striking `skilled nursing facility or intermediate care facility'
  each place it appears in paragraphs (1), (2)(B), and (2)(C) and inserting
  `nursing facility';
  (2) in paragraph (2)(B)(i), by striking `skilled nursing or intermediate
  care facility' and inserting `nursing facility';
  (3) in paragraph (5)(A), by striking `under' the first place it appears
  and inserting `(or, in the case of waiver years beginning on or after
  October 1, 1990, with respect to nursing facility services and home and
  community-based services) under'; and
  (4) in paragraph (5)(B)--
  (A) in clause (i), by striking `furnished' and inserting `(or, with respect
  to waiver years beginning on or after October 1, 1990, for nursing facility
  services) furnished'; and
  (B) in clause (iii)(I), by striking `(regardless' and inserting `(or,
  with respect to waiver years beginning on or after October 1, 1990, which
  comprise nursing facility services) (regardless'.
SEC. 26. CORRECTIONS TO DESIGNATIONS OF NEW PROVISIONS.
  (a) PARAGRAPHS ADDED TO SECTION 1902(a)- Section 1902(a) of the SSA (42
  U.S.C. 1396a(a)) is amended--
  (1) by striking `and' at the end of paragraph (54);
  (2) in the paragraph (55) inserted by section 4602(a)(3) of OBRA-1990,
  by striking the period at the end and inserting a semicolon;
  (3) by redesignating the paragraph (55) inserted by section 4604(b)(3)
  of OBRA-1990 as paragraph (56), by transferring and inserting it after the
  paragraph (55) inserted by section 4602(a)(3) of such Act, and by striking
  the period at the end and inserting a semicolon;
  (4) by placing paragraphs (57) and (58), inserted by section 4751(a)(1)(C)
  of OBRA-1990, immediately after paragraph (56), as redesignated by paragraph
  (3);
  (5) in the paragraph (58) inserted by section 4751(a)(1)(C) of OBRA-1990,
  by striking the period at the end and inserting `; and'; and
  (6) by redesignating the paragraph (58) inserted by section 4752(c)(1)(C)
  of OBRA-1990 as paragraph (59) and by transferring and inserting it after
  the paragraph (58) inserted by section 4751(a)(1)(C) of such Act.
  (b) PARAGRAPHS ADDED TO SECTION 1903(i)- Section 1903(i) of the SSA (42
  U.S.C. 1396b(i)), as amended by section 2(b)(2) of the Medicaid Voluntary
  Contribution and Provider-Specific Tax Amendments of 1991, is amended--
  (1) by redesignating the paragraph (12) inserted by section 4752(a)(2)
  of OBRA-1990 as paragraph (11), by transferring and inserting it after
  the paragraph (10) inserted by section 4401(a)(1)(B) of OBRA-1990, and by
  striking the period at the end and inserting a semicolon;
  (2) by redesignating the paragraph (14) inserted by section 4752(e)
  of OBRA-1990 as paragraph (12), by transferring and inserting it after
  paragraph (11), as redesignated by paragraph (2), and by striking the
  period at the end and inserting `; or'; and
  (3) by redesignating the paragraph (11) inserted by section 4801(e)(16)(A)
  of OBRA-1990 as paragraph (13) and by transferring and inserting it after
  paragraph (12), as redesignated by paragraph (3), and by striking `; or'
  and inserting a period.
  (c) PARAGRAPHS ADDED TO SECTION 1905(a)-
  (1) IN GENERAL- Section 1905(a) of the SSA (42 U.S.C. 1396d(a)) is amended--
  (A) by striking `and' at the end of paragraph (21);
  (B) in paragraph (24), by striking the comma at the end and inserting `;
  and'; and
  (C) by redesignating paragraphs (22), (23), and (24) as paragraphs (24),
  (22), and (23), respectively, and by transferring and inserting paragraph
  (24) after paragraph (23), as so redesignated.
  (2) CONFORMING AMENDMENTS- (A) Effective July 1, 1991, section
  1902(a)(10)(C)(iv) of the SSA (42 U.S.C. 1396a(a)(10)(C)(iv)), as amended
  by section 4755(c)(1)(A) of OBRA-1990, is amended by striking `through
  (21)' and inserting `through (23)'.
  (B) Effective July 1, 1991, section 1902(j) of the SSA (42 U.S.C. 1396a(j)),
  as amended by section 4711(d)(1) of OBRA-1990, is amended by striking
  `through (22)' and inserting `through (24)'.
  (d) FINAL SECTIONS- Section 1928 of the SSA (42 U.S.C. 1396s), as
  redesignated by section 4401(a)(3) of OBRA-1990, is amended--
  (1) by transferring such section to the end of title XIX of the SSA; and
  (2) by redesignating such section as section 1931.
SEC.  27. CORRECTIONS RELATING TO SECTION 4008 (CONFORMING AMENDMENTS TO
MEDICARE).
  (a) Section 1819(b)(5)(D) of the SSA (42 U.S.C. 1395i-3(b)(5)(D)), as
  amended by section 4008(h)(1)(D) of OBRA-1990, is amended by striking the
  comma before `or a new competency evaluation program.'.
  (b) Section 1819(b)(5)(G) of the SSA (42 U.S.C. 1395i-3(b)(5)(G)) is
  amended by striking `or licensed or certified social worker' and inserting
  `licensed or certified social worker, registered respiratory therapist,
  or certified respiratory therapy technician'.
  (c) Section 1819(f)(2)(B)(i) of the SSA (42 U.S.C. 1395i-3(f)(2)(B)(i))
  is amended by striking `facilities,' and inserting `facilities (subject
  to clause (iii)),'.
  (d) Section 1819(f)(2)(B)(iii)(I)(c) of the SSA (42
  U.S.C. 1395i-3(f)(2)(B)(iii)(I)(c)) is amended by striking `clauses'
  each place it appears and inserting `clause'.
  (e) Section 1819(g)(5)(B) of the SSA (42 U.S.C. 1395i-3(g)(5)(B)) is
  amended by striking `paragraphs' and inserting `paragraph'.
  (f) Section 4008(h)(1)(F)(ii) of OBRA-1990 is amended--
  (1) by striking `The amendments' and inserting `(I) The amendments';
  (2) by striking `nursing facility' each place it appears and inserting
  `skilled nursing facility';
  (3) by redesignating subclauses (I) through (V) as clauses (aa) through
  (ee); and
  (4) by adding at the end the following new subclause:
  `(II) Notwithstanding subclause (I) and subject to section
  1819(f)(2)(B)(iii)(I) of the Social Security Act (as amended by clause
  (i)), a State may approve a training and competency evaluation program or a
  competency evaluation program offered by or in a skilled nursing facility
  described in subclause (I) if, during the previous 2 years, clause (aa),
  (bb), (cc), (dd), or (ee) of subclause (I) did not apply to the facility.'.