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Table of Contents: 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

If the Health Insurance Portabilty and Accountability Act (HIPAA) represented the first third of the President's health care reform effort, certainly the Balanced Budget Act of 1997 represents the second third.

Based on the length of the document and the breadth of the changes, however, it could be argued that the Balanced Budget Act of 1997 should constitute the last two-thirds of the President's health care reform effort. At any rate, here is a hyper-linked wrap-around version of the Act.

Be sure to check GPO's line item veto page for updates concerning the vetoed provisions of this Act.

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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
  • Sec. 4006. Medicare+Choice MSA.
• 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
  • Sec. 4031. Medigap protections.
  • Sec. 4032. Addition of high deductible medigap policies.
• 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
  • Sec. 4571. Part B premium.
• 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.