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Compilation of the Social Security Laws, Vol II
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SEC. 4011.[42 U.S.C. 1395w-23 note] A—MEDICARE+CHOICE COMPETITIVE PRICING DEMONSTRATION PROJECT.
(a) Establishment of Project.—The Secretary of Health and Human Services (in this subchapter referred to as the “Secretary”) shall establish a demonstration project (in this subchapter referred to as the “project”) under which payments to Medicare+Choice organizations in medicare payment areas in which the project is being conducted are determined in accordance with a competitive pricing methodology established under this subchapter.
(b) Designation of 7 Medicare Payment Areas Covered by Project.—
(1) In general.—The Secretary shall designate, in accordance with the recommendations of the Competitive Pricing Advisory Committee under paragraphs (2) and (3), medicare payment areas as areas in which the project under this subchapter will be conducted. In this section, the term “Competitive Pricing Advisory Committee” means the Competitive Pricing Advisory Committee established under section 4012(a).
(2) Initial designation of 4 areas.—
(A) In general.—The Competitive Pricing Advisory Committee shall recommend to the Secretary, consistent with subparagraph (B), the designation of 4 specific areas as medicare payment areas to be included in the project. Such recommendations shall be made in a manner so as to ensure that payments under the project in 2 such areas will begin on January 1, 1999, and in 2 such areas will begin on January 1, 2000.
(B) Location of designation.—Of the 4 areas recommended under subparagraph (A), 3 shall be in urban areas and 1 shall be in a rural area.
(3) Designation of additional 3 areas.—Not later than December 31, 2001, the Competitive Pricing Advisory Committee may recommend to the Secretary the designation of up to 3 additional, specific medicare payment areas to be included in the project.
(c) Project Implementation.—
(1) In general.—Subject to paragraph (2), the Secretary shall for each medicare payment area designated under subsection (b)—
(A) in accordance with the recommendations of the Competitive Pricing Advisory Committee—
(i) establish the benefit design among plans offered in such area, and
(ii) structure the method for selecting plans offered in such area; and
(B) in consultation with such Committee—
(i) establish methods for setting the price to be paid to plans, including, if the Secretaries determines appropriate, the rewarding and penalizing of Medicare+Choice plans in the area on the basis of the attainment of, or failure to attain, applicable quality standards, and
(ii) provide for the collection of plan information (including information concerning quality and access to care), the dissemination of information, and the methods of evaluating the results of the project.
(2) Consultation.—The Secretary shall take into account the recommendations of the area advisory committee established in section 4012(b), in implementing a project design for any area, except that no modifications may be made in the project design without consultation with the Competitive Pricing Advisory Committee. In no case may the Secretary change the designation of an area based on recommendations of any area advisory committee.
(d) Monitoring and Report.—
(1) Monitoring impact.—Taking into consideration the recommendations of the Competitive Pricing Advisory Committee and the area advisory committees, the Secretary shall closely monitor and measure the impact of the project in the different areas on the price and quality of, and access to, medicare covered services, choice of health plans, changes in enrollment, and other relevant factors
(2) Report.—Not later than December 31, 2002, the Secretary shall submit to Congress a report on the progress under the project under this subchapter, including a comparison of the matters monitored under paragraph (1) among the different designated areas. The report may include any legislative recommendations for extending the project to the entire medicare population.
(e) Waiver Authority.—The Secretary of Health and Human Services may waive such requirements of title XVIII of the Social Security Act (as amended by this Act) as may be necessary for the purposes of carrying out the project.
(f) Relationship to Other Authority.—Except pursuant to this subchapter, the Secretary of Health and Human Services may not conduct or continue any medicare demonstration project relating to payment of health maintenance organizations, Medicare+Choice organizations, or similar prepaid managed care entities on the basis of a competitive bidding process or pricing system described in subsection (a).
(g) No Additional Costs to Medicare Program.—The aggregate payments to Medicare+Choice organizations under the project for any designated area for a fiscal year may not exceed the aggregate payments to such organizations that would have been made under title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.), as amended by section 4001, if the project had not been conducted.
(h) Definitions.—Any term used in this subchapter which is also used in part C of title XVIII of the Social Security Act, as amended by section 4001, shall have the same meaning as when used in such part.
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SEC. 4016. [42 U.S.C. 1395b-1 note] MEDICARE COORDINATED CARE DEMONSTRATION PROJECT.
(a) Demonstration Projects.—
(1) In general.—The Secretary of Health and Human Services (in this section referred to as the “Secretary”) shall conduct demonstration projects for the purpose of evaluating methods, such as case management and other models of coordinated care, that—
(A) improve the quality of items and services provided to target individuals; and
(B) reduce expenditures under the medicare program under title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.) for items and services provided to target individuals.
(2) Target individual defined.—In this section, the term “target individual” means an individual that has a chronic illness, as defined and identified by the Secretary, and is enrolled under the fee-for-service program under parts A and B of title XVIII of the Social Security Act (42 U.S.C. 1395c et seq.; 1395j et seq.).
(b) Program Design.—
(1) Initial design.—The Secretary shall evaluate best practices in the private sector of methods of coordinated care for a period of 1 year and design the demonstration project based on such evaluation.
(2) Number and project areas.—Not later than 2 years after the date of enactment of this Act, the Secretary shall implement at least 9 demonstration projects, including—
(A) 5 projects in urban areas;
(B) 3 projects in rural areas; and
(C) 1 project within the District of Columbia which is operated by a nonprofit academic medical center that maintains a National Cancer Institute certified comprehensive cancer center.
(3) Expansion of projects; implementation of demonstration project results.—
(A) Expansion of projects.—If the initial report under subsection (c) contains an evaluation that demonstration projects—
(i) reduce expenditures under the medicare program; or
(ii) do not increase expenditures under the medicare program and increase the quality of health care services provided to target individuals and satisfaction of beneficiaries and health care providers;
the Secretary shall continue the existing demonstration projects and may expand the number of demonstration projects.
(B) Implementation of demonstration project results.—If a report under subsection (c) contains an evaluation as described in subparagraph (A), the Secretary may issue regulations to implement, on a permanent basis, the components of the demonstration project that are beneficial to the medicare program.
(c) Report to Congress.—
(1) In general.—Not later than 2 years after the Secretary implements the initial demonstration projects under this section, and biannually thereafter, the Secretary shall submit to Congress a report regarding the demonstration projects conducted under this section.
(2) Contents of report.—The report in paragraph (1) shall include the following:
(A) A description of the demonstration projects conducted under this section.
(B) An evaluation of—
(i) the cost-effectiveness of the demonstration projects;
(ii) the quality of the health care services provided to target individuals under the demonstration projects;
(iii) beneficiary and health care provider satisfaction under the demonstration project.
(C) Any other information regarding the demonstration projects conducted under this section that the Secretary determines to be appropriate.
(d) Waiver Authority.—The Secretary shall waive compliance with the requirements of title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.) to such extent and for such period as the Secretary determines is necessary to conduct demonstration projects.
(e) Funding.—
(1) Demonstration projects.—
(A) In general.—
(i) State projects.—Except as provided in clause (ii), the Secretary shall provide for the transfer from the Federal Hospital Insurance Trust Fund and the Federal Supplementary Insurance Trust Fund under title XVIII of the Social Security Act (42 U.S.C. 1395i, 1395t), in such proportions as the Secretary determines to be appropriate, of such funds as are necessary for the costs of carrying out the demonstration projects under this section.
(ii) Cancer hospital.—In the case of the project described in subsection (b)(2)(C), amounts shall be available only as provided in any Federal law making appropriations for the District of Columbia.
(B) Limitation.—In conducting the demonstration project under this section, the Secretary shall ensure that the aggregate payments made by the Secretary do not exceed the amount which the Secretary would have paid if the demonstration projects under this section were not implemented.
(2) Evaluation and report.—There are authorized to be appropriated such sums as are necessary for the purpose of developing and submitting the report to Congress under subsection (c).
SEC. 4018[42 U.S.C. 1395w-21 note] MEDICARE ENROLLMENT DEMONSTRATION PROJECT.
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(a) Demonstration Project.—
(1) Establishment.—The Secretary shall implement a demonstration project (in this section referred to as the “project”) for the purpose of evaluating the use of a third-party contractor to conduct the Medicare+Choice plan enrollment and disenrollment functions, as described in part C of title XVIII of the Social Security Act (as added by section 4001 of this Act), in an area.
(2) Consultation.—Before implementing the project under this section, the Secretary shall consult with affected parties on—
(A) the design of the project;
(B) the selection criteria for the third-party contractor; and
(C) the establishment of performance standards, as described in paragraph (3).
(3) Performance standards.—
(A) In general.—The Secretary shall establish performance standards for the accuracy and timeliness of the Medicare+Choice plan enrollment and disenrollment functions performed by the third-party contractor.
(B) Noncompliance.—In the event that the third-party contractor is not in substantial compliance with the performance standards established under subparagraph (A), such enrollment and disenrollment functions shall be performed by the Medicare+Choice plan until the Secretary appoints a new third-party contractor.
(b) Report to Congress.—The Secretary shall periodically report to Congress on the progress of the project conducted pursuant to this section.(c) Waiver Authority.—The Secretary shall waive compliance with the requirements of part C of title XVIII of the Social Security Act (as amended by section 4001 of this Act) to such extent and for such period as the Secretary determines is necessary to conduct the project.
(d) Duration.—A demonstration project under this section shall be conducted for a 3-year period.
(e) Separate From Other Demonstration Projects.—A project implemented by the Secretary under this section shall not be conducted in conjunction with any other demonstration project.
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SEC. 4105. [42 U.S.C. 1395x note] DIABETES SELF-MANAGEMENT BENEFITS.
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(c) Establishment of Outcome Measures for Beneficiaries With Diabetes.—
(1) In general.—The Secretary of Health and Human Services, in consultation with appropriate organizations, shall establish outcome measures, including glysolated hemoglobin (past 90-day average blood sugar levels), for purposes of evaluating the improvement of the health status of medicare beneficiaries with diabetes mellitus.
(2) Recommendations for modifications to screening benefits.—Taking into account information on the health status of medicare beneficiaries with diabetes mellitus as measured under the outcome measures established under paragraph (1), the Secretary shall from time to time submit recommendations to Congress regarding modifications to the coverage of services for such beneficiaries under the medicare program.
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SEC. 4202.[42 U.S.C. 1395ww note] PROHIBITING DENIAL OF REQUEST BY RURAL REFERRAL CENTERS FOR CLASSIFICATION ON BASIS OF COMPARABILITY OF WAGES.
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(b) Continuing Treatment of Previously Designated Centers.—
(1) In general.—Any hospital classified as a rural referral center by the Secretary of Health and Human Services under section 1886(d)(5)(C) of the Social Security Act for fiscal year 1991 shall be classified as such a rural referral center for fiscal year 1998 and each subsequent fiscal year.
(2) Budget neutrality.—The provisions of section 1886(d)(8)(D) of the Social Security Act shall apply to reclassifications made pursuant to paragraph (1) in the same manner as such provisions apply to a reclassification under section 1886(d)(10) of such Act.
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SEC. 4207. [42 USC 1395b-1 note] INFORMATICS, TELEMEDICINE, AND EDUCATION DEMONSTRATION PROJECT.
(a) Purpose and Authorization.—
(1) In general.—Not later than 9 months after the date of enactment of this section, the Secretary of Health and Human Services shall provide for a demonstration project described in paragraph (2).
(2) Description of project.—
(A) In general.—The demonstration project described in this paragraph is a single demonstration project to use eligible health care provider telemedicine networks to apply high-capacity computing and advanced networks to improve primary care (and prevent health care complications) to medicare beneficiaries with diabetes mellitus who are residents of medically underserved rural areas or residents of medically underserved inner- city areas.
(B) Medically underserved defined.—As used in this paragraph, the term “medically underserved” has the meaning given such term in section 330(b)(3) of the Public Health Service Act (42 U.S.C. 254b(b)(3)).
(3) Waiver.—The Secretary shall waive such provisions of title XVIII of the Social Security Act as may be necessary to provide for payment for services under the project in accordance with subsection (d).
(4) Duration of project.—The project shall be conducted over a 8-year period.
(b) Objectives of Project.—The objectives of the project include the following:
(1) Improving patient access to and compliance with appropriate care guidelines for individuals with diabetes mellitus through direct telecommunications link with information networks in order to improve patient quality-of-life and reduce overall health care costs.
(2) Developing a curriculum to train health professionals (particularly primary care health professionals) in the use of medical informatics and telecommunications.
(3) Demonstrating the application of advanced technologies, such as video-conferencing from a patient’s home, remote monitoring of a patient’s medical condition, interventional informatics, and applying individualized, automated care guidelines, to assist primary care providers in assisting patients with diabetes in a home setting.
(4) Application of medical informatics to residents with limited English language skills.
(5) Developing standards in the application of telemedicine and medical informatics.
(6) Developing a model for the cost-effective delivery of primary and related care both in a managed care environment and in a fee-for-service environment.
(c) Eligible Health Care Provider Telemedicine Network Defined.—For purposes of this section, the term “eligible health care provider telemedicine network” means a consortium that includes at least one tertiary care hospital (but no more than 2 such hospitals), at least one medical school, no more than 4 facilities in rural or urban areas, and at least one regional telecommunications provider and that meets the following requirements:
(1) The consortium is located in an area with a high concentration of medical schools and tertiary care facilities in the United States and has appropriate arrangements (within or outside the consortium) with such schools and facilities, universities, and telecommunications providers, in order to conduct the project.
(2) The consortium submits to the Secretary an application at such time, in such manner, and containing such information as the Secretary may require, including a description of the use to which the consortium would apply any amounts received under the project and the source and amount of non-Federal funds used in the project.
(3) The consortium guarantees that it will be responsible for payment for all costs of the project that are not paid under this section and that the maximum amount of payment that may be made to the consortium under this section shall not exceed the amount specified in subsection (d)(3).
(d) Coverage as Medicare Part B Services.—
(1) In general.—Subject to the succeeding provisions of this subsection, services related to the treatment or management of (including prevention of complications from) diabetes for medicare beneficiaries furnished under the project shall be considered to be services covered under part B of title XVIII of the Social Security Act.
(2) Payments.—
(A) In general.—Subject to paragraph (3), payment for such services shall be made at a rate of 50 percent of the costs that are reasonable and related to the provision of such services. In computing such costs, the Secretary shall include costs described in subparagraph (B), but may not include costs described in subparagraph (C).
(B) Costs that may be included.—The costs described in this subparagraph are the permissible costs (as recognized by the Secretary) for the following:
(i) The acquisition of telemedicine equipment for use in patients’ homes (but only in the case of patients located in medically underserved areas).
(ii) Curriculum development and training of health professionals in medical informatics and telemedicine.
(iii) Payment of telecommunications costs (including salaries and maintenance of equipment), including costs of telecommunications between patients’ homes and the eligible network and between the network and other entities under the arrangements described in subsection (c)(1).
(iv) Payments to practitioners and providers under the medicare programs.
(C) Costs not included.—The costs described in this subparagraph are costs for any of the following:
(i) The purchase or installation of transmission equipment (other than such equipment used by health professionals to deliver medical informatics services under the project).
(ii) The establishment or operation of a telecommunications common carrier network.
(iii) Construction (except for minor renovations related to the installation of reimbursable equipment) or the acquisition or building of real property.
(3) Limitation.—The total amount of the payments that may be made under this section shall not exceed $60,000,000 for the period of the project (described in subsection (a)(4)).
(4) Limitation on cost-sharing.—The project may not impose cost sharing on a medicare beneficiary for the receipt of services under the project in excess of 20 percent of the costs that are reasonable and related to the provision of such services.
(e) Reports.—The Secretary shall submit to the Committee on Ways and Means and the Committee Commerce of the House of Representatives and the Committee on Finance of the Senate interim reports on the project and a final report on the project within 6 months after the conclusion of the project. The final report shall include an evaluation of the impact of the use of telemedicine and medical informatics on improving access of medicare beneficiaries to health care services, on reducing the costs of such services, and on improving the quality of life of such beneficiaries.
(f) Definitions.—For purposes of this section:
(1) Interventional informatics.—The term “interventional informatics” means using information technology and virtual reality technology to intervene in patient care.
(2) Medical informatics.—The term “medical informatics” means the storage, retrieval, and use of biomedical and related information for problem solving and decision-making through computing and communications technologies.
(3) Project.—The term “project” means the demonstration project under this section.
SEC. 4409. [42 U.S.C. 1395ww note] GEOGRAPHIC RECLASSIFICATION FOR CERTAIN DISPROPORTATIONATELY LARGE HOSPITALS.
(a) New Guidelines for Reclassification.—Notwithstanding the guidelines published under section 1886(d)(10)(D)(i)(I) of the Social Security Act (42 U.S.C. 1395ww(d)(10)(D)(i)(I)), the Secretary of Health and Human Services shall publish and use alternative guidelines under which a hospital described in subsection (b) qualifies for geographic reclassification under such section for a fiscal year beginning with fiscal year 1998.
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SEC. 4410. [42 U.S.C. 1395ww note] FLOOR ON AREA WAGE INDEX.
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(a) In General.—For purposes of section 1886(d)(3)(E) of the Social Security Act (42 U.S.C. 1395ww(d)(3)(E)) for discharges occurring on or after October 1, 1997, the area wage index applicable under such section to any hospital which is not located in a rural area (as defined in section 1886(d)(2)(D) of such Act (42 U.S.C. 1395ww(d)(2)(D)) may not be less than the area wage index applicable under such section to hospitals located in rural areas in the State in which the hospital is located.
(b) Implementation.—The Secretary of Health and Human Services shall adjust the area wage index referred to in subsection (a) for hospitals not described in such subsection in a manner which assures that the aggregate payments made under section 1886(d) of the Social Security Act (42 U.S.C. 1395ww(d)) in a fiscal year for the operating costs of inpatient hospital services are not greater or less than those which would have been made in the year if this section did not apply.
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SEC. 4804. STUDY AND REPORTS.
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(c) [42 U.S.C. 1395b-6 note] Information Included in Annual Recommendations.—The Medicare Payment Advisory Commission shall include in its annual report under section 1805(b)(1)(B) of the Social Security Act recommendations on the methodology and level of payments made to PACE providers under sections 1894(d) and 1934(d) of such Act and on the treatment of private, for-profit entities as PACE providers.
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[Internal References.—SSAct Title XVIII heading, §§1805 and 1886 have footnotes referring to P.L. 105-33.]
