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Introduced in House (10/17/1995)

TABLE OF CONTENTS:

Title XV (sic): Medicare

Subtitle A: MedicarePlus Program

Subtitle B: Preventing Fraud and Abuse

Subtitle C: Regulatory Relief

Subtitle D: Medical Liability Reform

Subtitle E: Teaching Hospitals and Graduate Medical

Education

Subtitle F: Provisions Relating to Medicare Part A

Subtitle G: Provisions Relating to Medicare Part B

Subtitle H: Provisions Relating to Medicare Parts A and B

Subtitle I: Clinical Laboratories

Subtitle J: Lock-Box Provisions for Medicare Part B

Savings from Growth Reductions

Title XV (sic): Medicare - Medicare Preservation Act of 1995 - Subtitle A: MedicarePlus Program - Amends titles XI and XVIII (Medicare) of the Social Security Act (SSA) and related Internal Revenue Code provisions, restructuring the current Medicare program, creating a new MedicarePlus program within it, with certain organizational changes involving the Health Care Financing Administration (HCFA) as well, while also providing for corresponding tax treatments involving MedicarePlus medical savings accounts (MSAs) (created for paying the qualified medical expanses of the account holder) and distributions, and other specified MedicarePlus-related matters, such as the tax treatment of hospitals participating in provider-sponsored organizations and associated penalties with regard to such tax-related matters. Includes chiefly among such restructuring measures the following items.

(Sec. 15001) Gives individuals entitled to benefits under Medicare part A (Hospital Insurance) and enrolled under Medicare part B (Supplementary Medical Insurance) the opportunity to elect Medicare coverage annually during specified periods under either the new MedicarePlus benefit package or through the existing fee-for-service system under such parts. Describes the former package as comprising various specified products and services, including contributions to newly provided for MedicarePlus MSAs as well as a separate fee-for-service component, offered under certain provider- and union-sponsored plans by qualified MedicarePlus organizations: (1) certified as meeting certain applicable standards pursuant to respective State or Federal certification process; and (2) under contract with the Secretary of Health and Human Services (HHS) in accordance with various specified contract requirements with respect to the items and services offered.

(Sec. 15002) Outlines special election rules relevant to choice of coverage, including coverage elected through the MedicarePlus package under the newly added Medicare part C (MedicarePlus Organizations and High Deductible/Medisave Products) as well as through existing fee-for-service packages in which unenrolled individuals who initially fail to make an election during the appropriate period are deemed to have enrolled.

Includes among special rules under this subtitle those specifically relevant under new Medicare part C to: (1) MedicarePlus organization licensing, payment, periodic certification, and other specified organization-related matters involving, among other things, product standards, premiums, and cost-sharing, physician and other provider participation, coverage determinations, advance directives, and quality assurance programs; (2) MedicarePlus MSA and Medicare part B premium discount rebate tax treatment; (3) MedicarePlus high deductible/Medisave products, including with regard to the individuals electing such products and the benefits covered; (4) coordinated acute and long-term care benefits under a MedicarePlus product; and (5) provider service network antitrust measures.

Directs the Secretary to provide for demonstration projects permitting MediGrant programs under SSA title XXI to be treated as MedicarePlus organizations for qualified MediGrant-eligible individuals in order to demonstrate primary, acute, and long-term care delivery via integrated delivery networks emphasizing noninstitutional care.

(Sec. 15003) Revises Medicare supplemental health insurance policy certification provisions concerned with the unlawful duplication of health benefits coverage. Requires a report by the Secretary to the Congress on certain duplication issues.

(Sec. 15004) Sets forth transition rules for current Medicare health maintenance organization (HMO) programs, eliminating the "50/50" enrollment rule.

(Sec. 15031) Establishes the Medicare Payment Review Commission under the Medicare program (replacing the Prospective Payment Assessment Commission and the Physician Payment Review Commission which are hereby abolished). Requires such Commission to review program payment policies (including those under the new MedicarePlus program) for appropriate recommendations to the Congress concerning such policies. Authorizes appropriations.

(Sec. 15032) Creates the Commission on the Effect of the Baby Boom Generation on the Medicare Program to: (1) examine the financial impact on the Medicare program of the significant increase in the number of Medicare-eligible individuals which will occur beginning about 2010 and lasting for approximately 25 years; and (2) make specific recommendations to the Congress respecting a comprehensive approach to preserve Medicare for the period during which such individuals are Medicare-eligible. Authorizes appropriations.

(Sec. 15033) Makes the HCFA Administrator a secretarial, as opposed to a presidential, appointee as currently provided for under SSA title XI.

Subtitle B: Preventing Fraud and Abuse - Outlines various specified measures designed for preventing fraud and abuse under Medicare, including among them: (1) special outreach and other efforts by the Secretary which include establishing a beneficiary incentive program for collecting information on fraud and abuse under Medicare and a voluntary disclosure program for Medicare violators to disclose wrongdoing; (2) revisions to current sanctions which include new intermediate sanctions for Medicare HMO violations; (3) establishment of the Medicare Integrity Program and an associated Anti-Fraud and Abuse Trust Fund (trust Fund) in the Treasury for specified anti-fraud and abuse activities under Medicare; (4) permitting carriers to carry out prior authorization for certain items of durable medical equipment; (5) establishment by the Attorney General of a national health care anti-fraud task force, including representatives of various specified Federal departments, agencies, and offices, for coordination of Federal law enforcement activities relating to health care fraud and abuse; (6) an HCFA-sponsored study of the adequacy of quality assurance and consumer protection programs under Medicare part C for a report to the Congress; and (7) establishment of civil monetary penalties under SSA title XI for false home health services certifications by physicians, as well as sanctions under such title for offenses involving fraud, false statement, theft, or embezzlement under Medicare or a State health care program. Provides: (1) appropriations from such trust fund to carry out the Medicare Integrity Program; and (2) appropriations from the trust funds supporting the Medicare program for the HHS Inspector General for Medicare-related anti-fraud and abuse matters.

(Sec. 1511) Directs the Secretary to establish and operate certain pilot projects for implementing innovative approaches to monitor claims payment under Medicare.

Subtitle C: Regulatory Relief - Outlines various specified revisions to Medicare physician referral prohibitions and SSA title XI anti-kickback and other penalties, among other such revisions made under SSA and the Omnibus Budget Reconciliation Act of 1993 designed for Medicare regulatory relief. Includes among such revisions: (1) repeal of physician referral prohibitions based on compensation arrangements; (2) new exceptions to physician referral prohibitions for shared facility and other specified services; (3) repeal of the Medicare and Medicaid Coverage Data Bank; (4) various specified miscellaneous technical changes with regard to such matters as the imposition of civil monetary penalties and the level of knowledge required and the application of anti-kickback penalties to certain actions involving referrals; and (5) issuance of advisory opinions under SSA title XI.

(Sec. 15214) Directs the Secretary to publish a notice in the Federal Register soliciting proposals for: (1) modifications to existing safe harbors; (2) additional safe harbors; and (3) special fraud alerts. Requires publication of such proposals in the Register and issuance of final implementing rules by the Secretary as appropriate after consideration of any public comments received.

(Sec. 15216) Provides for prior notice of changes in billing and claims processing requirements for physicians' services.

(Sec. 15221) Outlines various specified measures designed for promoting physician self-policing, including an exemption from Federal antitrust and similar State laws for certain activities of medical self-regulated entities.

Subtitle D: Medical Liability Reform - Outlines various specified measures designed for addressing health care liability issues, including changes establishing: (1) a statute of limitations for health care liability actions; (2) a limitation on noneconomic damages; and (3) standards for alternative dispute resolution used to resolve such an action or claim.

Subtitle E: Teaching Hospitals and Graduate Medical Education - Outlines a new SSA title XXII (Teaching Hospitals and Graduate Medical Education Trust Fund): (1) establishing in the Treasury the Teaching Hospital and Graduate Medical Education Trust Fund consisting of the Indirect-Costs Medical Education Account, the Medicare Direct-Costs Medical Education Account, and the General Direct-Costs Medical Education Account; (2) governing payments from such trust fund to teaching hospitals, with certain adjustments as prescribed, in accordance with various special rules for the costs of operating approved medical residency training programs; and (3) providing for a certain temporary advisory panel for developing recommendations for the Congress with regard to such matters as teaching hospital and graduate medical education financing, Federal policies on international medical graduates, and medical school dependence on service-generated income. Makes various specified appropriations to the trust fund, with certain individual trust fund component allocations, including certain transfers to such components out of the Medicare trust funds, for medical education direct and indirect costs. Authorizes appropriations.

(Sec. 15412) Modifies current payment policies under Medicare regarding graduate medical education, including setting a limitation on the number of full-time equivalent residents for certain fiscal years and reducing payments for alien residents with regard to the direct costs of graduate medical education.

Subtitle F: Provisions Relating to Medicare Part A - Outlines various specified technical revisions in Medicare Part A rural and urban hospital and skilled nursing facility payment provisions, providing for various reductions in payment updates and other adjustments and payment-related changes. Includes chiefly among such technical revisions: (1) a reduction in payments to hospitals for enrollees' bad debts; (2) the establishment of the rural emergency access care hospital program; (3) the establishment of a program of incentives for cost-effective management of covered non-routine services of skilled nursing facilities; and (4) standards for the certification of skilled nursing facilities.

(Sec. 15508) Makes certain conforming amendments with regard to the certification of Christian Science providers.

(Sec. 15511) Requires the Medicare Payment Review Commission established by this title to study and report to the Congress on the impact of the designation of hospitals as sole community hospitals under the Medicare program on the delivery of health care services to individuals in rural areas.

(Sec. 15527) States that, in order to ensure that Medicare beneficiaries are furnished appropriate extended care services, the Secretary shall establish and implement a medical review process to examine the effect of the amendments made by this subtitle on the quality of extended care services furnished to Medicare beneficiaries.

(Sec. 15528) Requires the Medicare Payment Review Commission to report to the Congress on the system under which payment is made under Medicare for extended care services of skilled nursing facilities.

(Sec. 15531) Makes specified changes under the Social Security Amendments of 1983 with regard to the amount of certain taxes credited to the Federal Hospital Insurance Trust Fund.

Subtitle G: Provisions Relating to Medicare Part B - Outlines various specified technical revisions to physician, certain outpatient hospital, and clinical diagnostic laboratory services payment provisions, chief among them: (1) replacing the volume performance standard with sustainable growth rate and establishing a single conversion factor for 1996; (2) eliminating formula-driven overpayments; and (3) reducing updates to payment amounts for laboratory tests. Makes other similar specified payment changes with regard to items of durable medical equipment, while also providing for a freeze in any inflation updates in payment amounts for ambulatory surgical center services.

(Sec. 15607) Bases payment to rural emergency access care hospitals on the payment for outpatient rural primary care hospital services.

(Sec. 15608) Provides for ensuring payment for physician and nurse jointly furnished anesthesia services for a single case.

(Sec. 15609) Directs the Secretary to treat the State of Wisconsin as a single fee schedule area for physicians' services while ensuring budget neutrality.

(Sec. 15609A) Provides for the payment of ambulance services in accordance with a certain fee schedule to be established by the Secretary pursuant to specified considerations.

(Sec. 15609B) Applies the standards for physical or occupational therapy services furnished by traditional providers to such services furnished by physicians in an outpatient setting.

(Sec. 15611) Provides for extension of and other specified changes with regard to the Medicare part B premium.

(Sec. 15612) Details additions to Medicare part B premium requirements concerning part B premium amounts to provide for certain premium increases for individuals with modified adjusted gross incomes for a taxable year in excess of certain described threshold amounts. Provides for the disclosure under the Internal Revenue Code of certain tax return information for purposes related to such income-related reduction in Medicare subsidy.

(Sec. 15621) Addresses administration, coverage, and billing policies for clinical diagnostic laboratory tests by requiring adoption of uniform policies concerning such matters in accordance with a specifically outlined process.

(Sec. 15622) Places restrictions on direct billing for laboratory services, with appropriate sanctions for enforcement.

(Sec. 15631) Requires the Secretary to establish a certain task force to recommend quality standards for durable medical equipment.

Subtitle H: Provisions Relating to Medicare Parts A and B - Amends SSA title XVIII to provide for Medicare payment for home health services in accordance with various specified guidelines.

(Sec. 15701) Includes payment for prosthetics and orthotics along with payment for durable medical equipment under Medicare part A.

(Sec. 15702) Provides for maintaining savings resulting from a temporary freeze on payment increases for home health services.

(Sec. 15703) Provides for an extension under the Omnibus Budget Reconciliation Act of 1986 of the waiver of presumption of lack of knowledge of exclusion from coverage for home health agencies.

(Sec. 15704) Requires the Secretary to submit recommendations to the Congress regarding an appropriate methodology for making payments under Medicare for home health services furnished by Christian Science providers meeting certification and other applicable requirements to be providers under Medicare.

(Sec. 15705) Extends the period for home health agency certification.

(Sec. 15711) Revises provisions with regard to Medicare as secondary payer.

(Sec. 15721) Provides for a "failsafe budget mechanism" under Medicare as outlined for adjusting payments under that program for certain applicable items and services in order to achieve various specified Medicare budget targets beginning in FY 1996. Requires a report by the Board of Trustees of the Federal Hospital Insurance Trust Fund on the growth in Medicare part A expenditures.

(Sec. 15731) Establishes the Medicare Information Advisory Committee, and directs the Secretary, with its help, to adopt standards for Medicare information transactions and data elements and modifications to existing standards in order to reduce the administrative costs of providing and paying for health care, and to make Medicare information uniformly available for electronic exchange. Sets out penalties for standards violations.

(Sec. 15741) Provides that: (1) nothing in Medicare may be construed to prohibit part A or B coverage of items and services associated with a medical device used in furnishing inpatient hospital services solely because it is unapproved, if it is an investigational device used instead of an approved one; and (2) the amount of Medicare payment for any item or service associated with an investigational device used in furnishing such hospital services may not exceed the payment amount which would have been made under Medicare for the item or service if it were associated with the use of an approved device.

(Sec. 15742) Excludes from Medicare coverage items or services used for euthanasia.

(Sec. 15743) Outlines certain competitive bidding demonstration requirements for selected Medicare items and services.

(Sec. 15744) Provides for the disclosure under Medicare of criminal convictions relating to the provision of home health services to any person upon request.

(Sec. 15745) Requires renal dialysis facilities to make services available on a 24-hour basis.

Subtitle I: Clinical Laboratories - Amends the Public Health Service Act to exempt clinical laboratories in physician offices not performing pap smear analysis from certification requirements under such Act.

Subtitle J: Lock-Box Provisions for Medicare Part B Savings from Growth Reductions - Creates in the Treasury the Federal Medicare Growth Reduction Trust Fund for savings in Medicare part B resulting from this Act for expenditure after a certain period to carry out the Medicare program.