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Balanced Budget Act

Health Hippo: Balanced Budget Act of 1997


Medicare+Choice Program ~ Prevention Initiatives ~ Rural Initiatives ~ Fraud and Abuse Provisions ~ Provisions Relating to Part A Only ~ Provisions Relating to Part B Only ~ Provisions Relating to Parts A and B ~ Medicaid ~ Programs of All-Inclusive Care for the Elderly ~ State Children’s Health Insurance Program


An Act

To provide for reconciliation pursuant to subsections (b)(1) and
(c) of section 105 of the concurrent resolution on the budget for
fiscal year 1998. This Act may be cited as the Balanced Budget Act of
1997.


TITLE IV–MEDICARE, MEDICAID, AND CHILDREN’S
HEALTH PROVISIONS

 

SEC. 4000. AMENDMENTS TO SOCIAL SECURITY ACT AND REFERENCES TO
OBRA; TABLE OF CONTENTS OF TITLE.

 

(a) Amendments to Social Security Act.–Except as otherwise
specifically provided, whenever in this title an amendment is
expressed in terms of an amendment to or repeal of a section or
other provision, the reference shall be considered to be made to
that section or other provision of the Social Security Act.

 

(b) References to OBRA.–In this title, the terms OBRA-1986”,
OBRA-1987”, OBRA-1989”, OBRA-1990”, and OBRA-1993” refer to
the Omnibus Budget Reconciliation Act of 1986 (Public Law 99-509),
the Omnibus Budget Reconciliation Act of 1987 (Public Law
100-203), the Omnibus Budget Reconciliation Act of 1989 (Public
Law 101-239), the Omnibus Budget Reconciliation Act of 1990
(Public Law 101-508), and the Omnibus Budget Reconciliation Act of
1993 (Public Law 103-66), respectively.

 

(c) Table of Contents of Title.–The table of contents of this
title is as follows:

Subtitle A: Medicare+Choice Program

  • Chapter 1–Medicare+Choice Program
  • SUBCHAPTER A–MEDICARE+CHOICE PROGRAM
    • Sec. 4001 Establishment of
      Medicare+Choice program.

      • Part C–Medicare+Choice Program
        • Sec. 1851
          Eligibility, election, and enrollment.

        • Sec. 1852 Benefits
          and beneficiary protections.

        • Sec. 1853 Payments
          to Medicare+Choice organizations.

        • Sec. 1854
          Premiums.

        • Sec. 1855
          Organizational and financial requirements for
          Medicare+Choice organizations; provider-sponsored
          organizations.

        • Sec. 1856
          Establishment of standards.

        • Sec. 1857 Contracts
          with Medicare+Choice organizations.

        • Sec. 1859
          Definitions; miscellaneous provisions.
    • Sec. 4002 Transitional
      rules for current medicare HMO program.

    • Sec. 4003 Conforming
      changes in medigap program.
  • SUBCHAPTER B–SPECIAL RULES FOR MEDICARE+CHOICE MEDICAL
    SAVINGS ACCOUNTS

  • Chapter 2–Demonstrations
  • SUBCHAPTER A–MEDICARE+CHOICE COMPETITIVE PRICING
    DEMONSTRATION PROJECT

    • Sec. 4011 Medicare
      prepaid competitive pricing demonstration project.

    • Sec. 4012
      Administration through the Office of Competition; advisory
      committee.

    • Sec. 4013 Project design based on FEHBP competitive
      bidding model.
  • SUBCHAPTER B–SOCIAL HEALTH MAINTENANCE ORGANIZATIONS
    • Sec. 4014 Social health
      maintenance organizations (SHMOs).
  • SUBCHAPTER C–MEDICARE SUBVENTION DEMONSTRATION PROJECT FOR
    MILITARY RETIREES

    • Sec. 4015 Medicare
      subvention demonstration project for military retirees.
  • SUBCHAPTER D–OTHER PROJECTS
    • Sec. 4016 Medicare
      coordinated care demonstration project.

    • Sec. 4017 Orderly
      transition of municipal health service demonstration
      projects.

    • Sec. 4018 Medicare
      enrollment demonstration project.

    • Sec. 4019 Extension of
      certain medicare community nursing organization demonstration
      projects.
  • Chapter 3–Commissions
    • Sec. 4021 National
      Bipartisan Commission on the Future of Medicare.

    • Sec. 4022 Medicare
      Payment Advisory Commission.
  • Chapter 4–Medigap Protections
  • Chapter 5–Tax Treatment of Hospitals Participating in
    Provider- Sponsored Organizations

    • Sec. 4041 Tax treatment
      of hospitals which participate in provider- sponsored
      organizations.

Subtitle B: Prevention Initiatives

  • Sec. 4101 Screening
    mammography.

  • Sec. 4102 Screening pap
    smear and pelvic exams.

  • Sec. 4103 Prostate cancer
    screening tests.

  • Sec. 4104 Coverage of
    colorectal screening.

  • Sec. 4105 Diabetes
    self-management benefits.

  • Sec. 4106 Standardization of
    medicare coverage of bone mass measurements.

  • Sec. 4107 Vaccines outreach
    expansion.

  • Sec. 4108 Study on
    preventive and enhanced benefits.

Subtitle C: Rural Initiatives

  • Sec. 4201 Medicare rural
    hospital flexibility program.

  • Sec. 4202 Prohibiting denial
    of request by rural referral centers for reclassification on basis
    of comparability of wages.

  • Sec. 4203 Hospital
    geographic reclassification permitted for purposes of
    disproportionate share payment adjustments.

  • Sec. 4204
    Medicare-dependent, small rural hospital payment extension.

  • Sec. 4205 Rural health
    clinic services.

  • Sec. 4206 Medicare
    reimbursement for telehealth services.

  • Sec. 4207 Informatics,
    telemedicine, and education demonstration project.

Subtitle D: Anti-Fraud and Abuse Provisions and Improvements in Protecting Program Integrity

  • Chapter 1–Revisions To Sanctions for Fraud and Abuse
    • Sec. 4301 Permanent
      exclusion for those convicted of 3 health care related
      crimes.

    • Sec. 4302 Authority to
      refuse to enter into medicare agreements with individuals or
      entities convicted of felonies.

    • Sec. 4303 Exclusion of
      entity controlled by family member of a sanctioned
      individual.

    • Sec. 4304 Imposition of
      civil money penalties.
  • Chapter 2–Improvements In Protecting Program Integrity
    • Sec. 4311 Improving
      information to medicare beneficiaries.

    • Sec. 4312 Disclosure of
      information and surety bonds.

    • Sec. 4313 Provision of
      certain identification numbers.

    • Sec. 4314 Advisory
      opinions regarding certain physician self-referral
      provisions.

    • Sec. 4315 Replacement of
      reasonable charge methodology by fee schedules.

    • Sec. 4316 Application of
      inherent reasonableness to all part B services other than
      physicians’ services.

    • Sec. 4317 Requirement to
      furnish diagnostic information.

    • Sec. 4318 Report by GAO
      on operation of fraud and abuse control program.

    • Sec. 4319 Competitive
      bidding demonstration projects.

    • Sec. 4320 Prohibiting
      unnecessary and wasteful medicare payments for certain
      items.

    • Sec. 4321
      Nondiscrimination in post-hospital referral to home health
      agencies and other entities.
  • Chapter 3–Clarifications And Technical Changes
    • Sec. 4331 Other fraud
      and abuse related provisions.

Subtitle E: Provisions Relating to Part A Only

  • Chapter 1–Payment of PPS Hospitals
    • Sec. 4401 PPS hospital
      payment update.

    • Sec. 4402 Maintaining
      savings from temporary reduction in capital payments for PPS
      hospitals.

    • Sec. 4403
      Disproportionate share.

    • Sec. 4404 Medicare
      capital asset sales price equal to book value.

    • Sec. 4405 Elimination of
      IME and DSH payments attributable to outlier payments.

    • Sec. 4406 Increase base
      payment rate to Puerto Rico hospitals.

    • Sec. 4407 Certain
      hospital discharges to post acute care.

    • Sec. 4408
      Reclassification of certain counties as large urban areas under
      medicare program.

    • Sec. 4409 Geographic
      reclassification for certain disproportionately large
      hospitals.

    • Sec. 4410 Floor on area
      wage index.
  • Chapter 2–Payment of PPS-Exempt Hospitals
  • SUBCHAPTER A–GENERAL PAYMENT PROVISIONS
    • Sec. 4411 Payment
      update.

    • Sec. 4412 Reductions to
      capital payments for certain PPS-exempt hospitals and
      units.

    • Sec. 4413 Rebasing.
    • Sec. 4414 Cap on TEFRA
      limits.

    • Sec. 4415 Bonus and
      relief payments.

    • Sec. 4416 Change in
      payment and target amount for new providers.

    • Sec. 4417 Treatment of
      certain long-term care hospitals.

    • Sec. 4418 Treatment of
      certain cancer hospitals.

    • Sec. 4419 Elimination of
      exemptions for certain hospitals.
  • SUBCHAPTER B–PROSPECTIVE PAYMENT SYSTEM FOR PPS-EXEMPT
    HOSPITALS

    • Sec. 4421 Prospective
      payment for inpatient rehabilitation hospital services.

    • Sec. 4422 Development of
      proposal on payments for long-term care hospitals.
  • Chapter 3–Payment for Skilled Nursing Facilities
    • Sec. 4431 Extension of
      cost limits.

    • Sec. 4432 Prospective
      payment for skilled nursing facility services.
  • Chapter 4–Provisions Related to Hospice Services
    • Sec. 4441 Payments for
      hospice services.

    • Sec. 4442 Payment for
      home hospice care based on location where care is
      furnished.

    • Sec. 4443 Hospice care
      benefits periods.

    • Sec. 4444 Other items
      and services included in hospice care.

    • Sec. 4445 Contracting
      with independent physicians or physician groups for hospice
      care services permitted.

    • Sec. 4446 Waiver of
      certain staffing requirements for hospice care programs in
      nonurbanized areas.

    • Sec. 4447 Limitation on
      liability of beneficiaries for certain hospice coverage
      denials.

    • Sec. 4448 Extending the
      period for physician certification of an individual’s terminal
      illness.

    • Sec. 4449 Effective
      date.
  • Chapter 5–Other Payment Provisions
    • Sec. 4451 Reductions in
      payments for enrollee bad debt.

    • Sec. 4452 Permanent
      extension of hemophilia pass-through payment.

    • Sec. 4453 Reduction in
      part A medicare premium for certain public retirees.

    • Sec. 4454 Coverage of
      services in religious nonmedical health care institutions under
      the medicare and medicaid programs.

Subtitle F: Provisions Relating to Part B Only

  • Chapter 1–Services of Health Professionals
  • SUBCHAPTER A–PHYSICIANS’ SERVICES
    • Sec. 4501 Establishment
      of single conversion factor for 1998.

    • Sec. 4502 Establishing
      update to conversion factor to match spending under sustainable
      growth rate.

    • Sec. 4503 Replacement of
      volume performance standard with sustainable growth rate.

    • Sec. 4504 Payment rules
      for anesthesia services.

    • Sec. 4505 Implementation
      of resource-based methodologies.

    • Sec. 4506 Dissemination
      of information on high per discharge relative values for
      in-hospital physicians’ services.

    • Sec. 4507 Use of private
      contracts by medicare beneficiaries.
  • SUBCHAPTER B–OTHER HEALTH CARE PROFESSIONALS
    • Sec. 4511 Increased
      medicare reimbursement for nurse practitioners and clinical
      nurse specialists.

    • Sec. 4512 Increased
      medicare reimbursement for physician assistants.

    • Sec. 4513 No x-ray
      required for chiropractic services.
  • Chapter 2–Payment For Hospital Outpatient Department Services
    • Sec. 4521 Elimination of
      formula-driven overpayments (FDO) for certain outpatient
      hospital services.

    • Sec. 4522 Extension of
      reductions in payments for costs of hospital outpatient
      services.

    • Sec. 4523 Prospective
      payment system for hospital outpatient department services.

  • Chapter 3–Ambulance Services
    • Sec. 4531 Payments for
      ambulance services.

    • Sec. 4532 Demonstration
      of coverage of ambulance services under medicare through
      contracts with units of local government.
  • Chapter 4–Prospective Payment for Outpatient Rehabilitation
    Services

    • Sec. 4541 Prospective
      payment for outpatient rehabilitation services.
  • Chapter 5–Other Payment Provisions
    • Sec. 4551 Payments for
      durable medical equipment.

    • Sec. 4552 Oxygen and
      oxygen equipment.

    • Sec. 4553 Reduction in
      updates to payment amounts for clinical diagnostic laboratory
      tests; study on laboratory tests.

    • Sec. 4554 Improvements
      in administration of laboratory tests benefit.

    • Sec. 4555 Updates for
      ambulatory surgical services.

    • Sec. 4556 Reimbursement
      for drugs and biologicals.

    • Sec. 4557 Coverage of
      oral anti-nausea drugs under chemotherapeutic regimen.

    • Sec. 4558 Renal
      dialysis-related services.

    • Sec. 4559 Temporary
      coverage restoration for portable electrocardiogram
      transportation.
  • Chapter 6–Part B Premium and Related Provisions
  • SUBCHAPTER A–DETERMINATION OF PART B PREMIUM AMOUNT
  • SUBCHAPTER B–OTHER PROVISIONS RELATED TO PART B PREMIUM
    • Sec. 4581 Protections
      under the medicare program for disabled workers who lose
      benefits under a group health plan.

    • Sec. 4582 Governmental
      entities eligible to elect to pay part B premiums for eligible
      individuals.

Subtitle G: Provisions Relating to Parts A and B

  • Chapter 1–Home Health Services and Benefits
  • SUBCHAPTER A–PAYMENTS FOR HOME HEALTH SERVICES
    • Sec. 4601 Recapturing
      savings resulting from temporary freeze on payment increases
      for home health services.

    • Sec. 4602 Interim
      payments for home health services.

    • Sec. 4603 Prospective
      payment for home health services.

    • Sec. 4604 Payment based
      on location where home health service is furnished.
  • SUBCHAPTER B–HOME HEALTH BENEFITS
    • Sec. 4611 Modification of
      part A home health benefit for individuals enrolled under part
      B.

    • Sec. 4612 Clarification
      of part-time or intermittent nursing care.

    • Sec. 4613 Study on
      definition of homebound.

    • Sec. 4614 Normative
      standards for home health claims denials.

    • Sec. 4615 No home health
      benefits based solely on drawing blood.

    • Sec. 4616 Reports to
      Congress regarding home health cost containment.
  • Chapter 2–Graduate Medical Education
  • SUBCHAPTER A–INDIRECT MEDICAL EDUCATION
    • Sec. 4621 Indirect
      graduate medical education payments.

    • Sec. 4622 Payment to
      hospitals of indirect medical education costs for
      Medicare+Choice enrollees.
  • SUBCHAPTER B–DIRECT GRADUATE MEDICAL EDUCATION
    • Sec. 4623 Limitation on
      number of residents and rolling average FTE count.

    • Sec. 4624 Payments to
      hospitals for direct costs of graduate medical education of
      Medicare+Choice enrollees.

    • Sec. 4625 Permitting
      payment to nonhospital providers.

    • Sec. 4626 Incentive
      payments under plans for voluntary reduction in number of
      residents.

    • Sec. 4627 Medicare
      special reimbursement rule for primary care combined residency
      programs.

    • Sec. 4628 Demonstration
      project on use of consortia.

    • Sec. 4629
      Recommendations on long-term policies regarding teaching
      hospitals and graduate medical education.

    • Sec. 4630 Study of
      hospital overhead and supervisory physician components of
      direct medical education costs.
  • Chapter 3–Provisions Relating to Medicare Secondary Payer
    • Sec. 4631 Permanent
      extension and revision of certain secondary payer
      provisions.

    • Sec. 4632 Clarification
      of time and filing limitations.

    • Sec. 4633 Permitting
      recovery against third party administrators.
  • Chapter 4–Other Provisions
    • Sec. 4641 Placement of
      advance directive in medical record.

    • Sec. 4642 Increased
      certification period for certain organ procurement
      organizations.

    • Sec. 4643 Office of the
      Chief Actuary in the Health Care Financing Administration.

    • Sec. 4644 Conforming
      amendments to comply with congressional review of agency
      rulemaking.

Subtitle H: Medicaid

  • Chapter 1–Managed Care
    • Sec. 4701 State option of
      using managed care; change in terminology.

    • Sec. 4702 Primary care
      case management services as State option without need for
      waiver.

    • Sec. 4703 Elimination of
      75:25 restriction on risk contracts.

    • Sec. 4704 Increased
      beneficiary protections.

    • Sec. 4705 Quality
      assurance standards.

    • Sec. 4706 Solvency
      standards.

    • Sec. 4707 Protections
      against fraud and abuse.

    • Sec. 4708 Improved
      administration.

    • Sec. 4709 6-month
      guaranteed eligibility for all individuals enrolled in managed
      care.

    • Sec. 4710 Effective
      dates.
  • Chapter 2–Flexibility In Payment of Providers
    • Sec. 4711 Flexibility in
      payment methods for hospital, nursing facility, ICF/MR, and
      home health services.

    • Sec. 4712 Payment for
      center and clinic services.

    • Sec. 4713 Elimination of
      obstetrical and pediatric payment rate requirements.

    • Sec. 4714 Medicaid
      payment rates for certain medicare cost-sharing.

    • Sec. 4715 Treatment of
      veterans’ pensions under Medicaid.
  • Chapter 3–Federal Payments to States
    • Sec. 4721 Reforming
      disproportionate share payments under State medicaid
      programs.

    • Sec. 4722 Treatment of
      State taxes imposed on certain hospitals.

    • Sec. 4723 Additional
      funding for State emergency health services furnished to
      undocumented aliens.

    • Sec. 4724 Elimination of
      waste, fraud, and abuse.

    • Sec. 4725 Increased
      FMAPs.

    • Sec. 4726 Increase in
      payment limitation for territories.
  • Chapter 4–Eligibility
    • Sec. 4731 State option
      of continuous eligibility for 12 months; clarification of State
      option to cover children.

    • Sec. 4732 Payment of
      part B premiums.

    • Sec. 4733 State option
      to permit workers with disabilities to buy into medicaid.

    • Sec. 4734 Penalty for
      fraudulent eligibility.

    • Sec. 4735 Treatment of
      certain settlement payments.
  • Chapter 5–Benefits
    • Sec. 4741 Elimination of
      requirement to pay for private insurance.

    • Sec. 4742 Physician
      qualification requirements.

    • Sec. 4743 Elimination of
      requirement of prior institutionalization with respect to
      habilitation services furnished under a waiver for home or
      community-based services.

    • Sec. 4744 Study and
      report on EPSDT benefit.
  • Chapter 6–Administration and Miscellaneous
    • Sec. 4751 Elimination of
      duplicative inspection of care requirements for ICFS/MR and
      mental hospitals.

    • Sec. 4752 Alternative
      sanctions for noncompliant ICFS/MR.

    • Sec. 4753 Modification
      of MMIS requirements.

    • Sec. 4754 Facilitating
      imposition of State alternative remedies on noncompliant
      nursing facilities.

    • Sec. 4755 Removal of
      name from nurse aide registry.

    • Sec. 4756 Medically
      accepted indication.

    • Sec. 4757 Continuation
      of State-wide section 1115 medicaid waivers.

    • Sec. 4758 Extension of
      moratorium.

    • Sec. 4759 Extension of
      effective date for State law amendment.

Subtitle I: Programs of All-Inclusive Care for the Elderly (PACE)

  • Sec. 4801 Coverage of PACE
    under the medicare program.

  • Sec. 4802 Establishment of
    PACE program as medicaid State option.

  • Sec. 4803 Effective date;
    transition.

  • Sec. 4804 Study and
    reports.

Subtitle J: State Children’s Health Insurance Program

  • Chapter 1–State Children’s Health Insurance Program
    • Sec. 4901 Establishment
      of program.

      • TITLE XXI–STATE CHILDREN’S HEALTH INSURANCE PROGRAM
      • Sec. 2101 Purpose;
        State child health plans.

      • Sec. 2102 General
        contents of State child health plan; eligibility;
        outreach.

      • Sec. 2103 Coverage
        requirements for children’s health insurance.

      • Sec. 2104
        Allotments.

      • Sec. 2105 Payments to
        States.

      • Sec. 2106 Process for
        submission, approval, and amendment of State child health
        plans.

      • Sec. 2107 Strategic
        objectives and performance goals; plan administration.

      • Sec. 2108 Annual
        reports; evaluations.

      • Sec. 2109
        Miscellaneous provisions.

      • Sec. 2110
        Definitions.
  • Chapter 2–Expanded Coverage of Children Under Medicaid
    • Sec. 4911 Optional use
      of State child health assistance funds for enhanced medicaid
      match for expanded medicaid eligibility.

    • Sec. 4912 Medicaid
      presumptive eligibility for low-income children.

    • Sec. 4913 Continuation
      of medicaid eligibility for disabled children who lose SSI
      benefits.
  • Chapter 3–Diabetes Grant Programs
    • Sec. 4921 Special
      diabetes programs for children with Type I diabetes.

    • Sec. 4922 Special
      diabetes programs for Indians.

    • Sec. 4923 Report on
      diabetes grant programs.

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