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Introduced in House (06/27/2000)

Medicare Guaranteed and Defined Rx Benefit and Health Provider Relief Act of 2000 - Title I: Medicare Prescription Medicine Benefit Program - Amends title XVIII (Medicare) of the Social Security Act (SSA) to add a new part D (Prescription Medicine Benefit for the Aged and Disabled) which establishes a voluntary insurance program to provide defined prescription medicine benefits, including pharmacy services, for eligible individuals who are aged or disabled or who have end-stage renal disease, and who voluntarily elect to enroll. States that the program shall be financed from enrollee premium payments together with contributions from funds appropriated by the Federal Government.

(Sec. 101) Requires the Secretary of Health and Human Services (HHS) to submit to Congress a legislative proposal for: (1) the delivery of home infusion therapy services under Medicare; and (2) a system of payment for such a benefit that coordinates items and services furnished under Medicare parts B (Supplementary Medical Insurance) and D.

Creates within the Federal Supplemental Medical Insurance Trust Fund the Prescription Medicine Insurance Account.

Directs the Secretary to provide for administration of part D benefits through a private benefit administrator for certain enrolled individuals residing in each geographic service area or, where that is impossible, with a fiscal intermediary under Medicare part A (Hospital Insurance) or a carrier under Medicare part B.

Requires the Secretary to: (1) ensure that all beneficiaries have guaranteed access to the full range of pharmaceuticals under part D, with special attention to access, pharmacist counseling, and delivery in rural and hard-to-serve areas, including use of incentives such as bonus payments to retail pharmacists in rural areas and extra payments to the benefit administrator for the cost of rapid delivery of pharmaceuticals; and (2) develop and implement the Employer Incentive Program that encourages employers and other sponsors of employment-based health care coverage who meet specified requirements to provide adequate prescription medicine benefits to retired individuals, and maintain existing benefit programs, by subsidizing, in part, the cost of providing coverage under qualifying plans.

Provides for part D enrollment for individuals whose employment-based retiree health coverage ends under certain conditions.

Authorizes appropriations.

(Sec. 102) Amends SSA title XIX (Medicaid), with regard to the prescription medicine benefit for certain low-income individuals, to provide for coverage of part D premiums as medical assistance for individuals dually eligible for other SSA assistance or for other medical care.

Requires State Medicaid plans to provide that, in the case of any individual whose eligibility for medical assistance is not limited to Medicare or Medicare medicine cost-sharing, and for whom the State elects to pay monthly premiums under part D, the State will purchase all prescription medicines for such individual in accordance with the provisions part D, without regard to whether the basic benefit limitation for such individual has been reached.

Requires Government payment of Medicare medicine cost-sharing for qualified Medicare beneficiaries and for Medicare beneficiaries with incomes between 100 and 150 percent of the Federal poverty line.

Amends SSA title XVIII part D to outline special eligibility, enrollment, and copayment rules for low-income individuals, which include options for continuation of Medicaid coverage or enrollment under such part.

(Sec. 103) Provides that if the mid-summer 2000 budget estimate prepared by the Director of the Congressional Budget Office results in a higher-than-projected level of projected on-budget surplus over the ten fiscal year period beginning with FY 2001, there shall be (beginning with FY 2003) transfers to the Prescription Medicine Insurance Account in a fiscal year to offset the costs attributable to provisions added to Medicare by this Act that relate to catastrophic benefit payments in that fiscal year.

(Sec. 104) Directs the Comptroller General of the United States to analyze and report to Congress on an ongoing basis about the part D prescription medicine benefit program.

Directs the Secretary to: (1) report to Congress on possible tax and trade law changes to encourage increased original research on new pharmaceutical breakthrough products designed to address disease and illness; (2) study and report to Congress on methods used by the pharmaceutical industry to advertise and sell to consumers and to educate and sell to providers; and (3) study and report to Congress on the costs of, and needs for, pharmaceutical research, and the role that the taxpayer provides in encouraging such research.

Requires the Secretary to report to Congress on the retail price of major pharmaceutical products in various developed nations, compared to prices for the same or similar products in the United States.

Title II: Improvement In Beneficiary Services - Subtitle A: Improvement of Medicare Coverage and Appeals Process - Amends SSA title XVIII to revise requirements with respect to Medicare determinations and appeals, including initial determinations, expedited determinations, and publication on the Internet of decisions of hearings of the Secretary.

(Sec. 201) Amends SSA title XVIII part C (Medicare+Choice) to apply the limitations on liability of qualified independent contractors to certain Medicare+Choice independent contractors who conduct reconsiderations of initial determinations.

(Sec. 202) Amends SSA title XVIII to limit the liability of beneficiaries for repayment with respect to Medicare claims not paid or paid incorrectly.

Includes in the explanation of Medicare benefits statement lists of each item or service furnished and the amount of the individual's liability for payment, as well as the toll-free telephone number for information and questions concerning the statement, individual liability for payment, and appeal rights.

(Sec. 203) Amends SSA title XI to revise the meaning of waiver of coinsurance and deductible amounts (excluded from the meaning of unlawful remuneration subject to civil monetary penalties) to include a waiver offered as part of a supplemental insurance policy or retiree health plan.

Subtitle B: Establishment of Medicare Ombudsman - Establishes a Medicare Ombudsman within the Health Care Financing Administration of the HHS Department to: (1) receive complaints, grievances, and requests for information submitted by a Medicare beneficiary concerning the Medicare program; and (2) provide assistance with respect to such complaints, grievances, and requests.

Title III: Medicare+Choice Reforms; Preservation of Medicare Part B Drug Benefit - Subtitle A: Medicare+Choice Reforms - Amends SSA title XVIII part C with regard to calculation of annual Medicare+Choice capitation rates to: (1) reduce the national per capita Medicare+Choice growth percentage for 2001 and 2002; (2) remove permanently application of budget neutrality beginning in 2002; (3) increase the minimum payment amount for 2002; (4) increase the update for payment areas with only one or no Medicare+Choice contracts; and (5) permit higher negotiated rates in certain Medicare+Choice payment areas below the national average.

(Sec. 307) Amends SSA title XVIII part C to provide for a ten year phase-in of the risk adjustment to the capitation rate based on data from all settings.

Subtitle B: Preservation of Medicare Coverage of Drugs and Biologicals - Amends SSA title XVIII to: (1) cover under Medicare part B injectable and infusable drugs and biologicals which are not usually self-administered by the patient (currently only drugs and biologicals which cannot be self-administered are covered under Medicare part B); and (2) revise Medicare coverage for immunosuppressive drugs, establishing a part D catastrophic limit on part B copayments for such drugs.

Subtitle C: Improvement of Certain Preventive Benefits - Amends SSA title XVIII to allow coverage of annual screening pap smear and pelvic exams.

Title IV: Adjustments to Payment Provisions of the Balanced Budget Act - Subtitle A: Payments for Inpatient Hospital Services - Amends SSA title XVIII to eliminate the reduction in the hospital market basket update for FY 2001.

(Sec. 402) Eliminates specified further reductions in indirect medical education (IME) and in disproportionate share hospital (DSH) payments (and freezes Medicaid DSH payments) for FY 2001.

(Sec. 404) Revises the formula for the increase in base payment to certain Puerto Rico hospitals for inpatient hospital discharges.

Subtitle B: Payments for Skilled Nursing Services - Amends SSA title XVIII to eliminate the reduction in the skilled nursing facility (SNF) market basket update for FY 2001.

(Sec. 412) Extends through 2002 the moratorium on therapy caps.

Subtitle C: Payments for Home Health Services - Amends SSA title XVIII to delay for one more year the application of the 15 percent reduction on payment limits for home health services.

(Sec. 422) Applies the full market basket update for home health services for FY 2001.

Subtitle D: Rural Provider Provisions - Amends SSA title XVIII to eliminate the scheduled reduction in hospital outpatient market basket increase for rural hospitals in 2001 and 2002.

Subtitle E: Other Providers - Amends SSA title XVIII to increase the update in the renal dialysis composite rate.

Subtitle F: Provision for Additional Adjustments - Provides for specified aggregate amounts from estimated Social Security surpluses for the five fiscal year and ten fiscal year periods beginning in FY 2001 for additional improvements to the Medicare and Medicaid programs and payments to providers.