Consolidated Omnibus BudgetReconciliation Act of 1985

SEC. 9108.[42 U.S.C. 1395wwnote] CONTINUATION OF MEDICAREREIMBURSEMENT WAIVERS FOR CERTAIN HOSPITALS PARTICIPATING IN REGIONALHOSPITAL REIMBURSEMENT DEMONSTRATIONS.

(a) Continuation ofWaivers.—A hospital reimbursement control systemwhich, on January 1, 1985, was carrying out a demonstration under acontract which had been approved by the Secretary of Health and HumanServices pursuant to section 222(a) of the Social Security Amendments of1972, or under section 402 of the Social Security Amendments of 1967 (asamended by section 222(b) of the Social Security Amendments of 1972), shallbe deemed to meet the requirements of section 1886(c)(1)(A) of the SocialSecurity Act if such system applies—

(1) to substantially all non-Federalacute care hospitals (as defined by the Secretary) in the geographic areaserved by such system on January 1, 1985, and

(2) tothe review of at least 75 percent of—

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(A) all revenues or expenses in suchgeographic area for inpatient hospital services, and

(B) revenues or expensesin such geographic area for inpatient hospital services provided under theState’s plan approved under title XIX.

(b) Approval.—In the caseof a hospital cost control system described in subsection (a), therequirements of section 1886(c) of the Social Security Act which apply toStates shall instead apply to such system and, for such purposes, anyreference to a State is deemed a reference to such system.

(c) Effective date.—Thissection shall become effective on the date of the enactment of thisAct.

SEC. 9114.[42 U.S.C. 1395wwnote] INFORMATION ON IMPACT OF PPSPAYMENTS ON HOSPITALS.

(a) Disclosure ofInformation.—The Secretary of Health and HumanServices shall make available to the Prospective Payment AssessmentCommission, the Congressional Budget Office, the Comptroller General, andthe Congressional Research Service the most current information on thepayments being made under section 1886 of the Social Security Act toindividual hospitals. Such information shall be made available in a mannerthat permits examination of the impact of such section on hospitals.

(b)Confidentiality.—Information disclosed undersubsection (a) shall be treated as confidential and shall not be subject tofurther disclosure in a manner that permits the identification ofindividual hospitals.

SEC. 9122. REQUIREMENT FOR MEDICAREHOSPITALS TO PARTICIPATE IN CHAMPUS AND CHAMPVA PROGRAMS.

(d)[42 U.S.C. 1395c note]Report.—The Secretary of Health and Human Servicesshall report to Congress periodically on the number of hospitals that haveterminated or failed to renew an agreement under section 1866 of the SocialSecurity Act as a result of the additional conditions imposed under theamendments made by subsection (a).

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SEC. 9128.[NoneAssigned] SENSE OF THE SENATE WITHRESPECT TO INPATIENT HOSPITAL DEDUCTIBLE.

In view of the $92 Medicare hospital deductible increase that wentinto effect January 1, 1986, it is the sense of the Senate that theCommittee on Finance should report legislation which will reformcalculation of the annual increase in such deductible so that it is moreconsistent with annual increases in Medicare payments to hospitals.

(h)[42 U.S.C. 1395w note]Paperwork Reduction.—Chapter 35 of title 44, UnitedStates Code, shall not apply to information required for purposes ofcarrying out this section and the amendments made by this section.

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(j)[42 U.S.C. 1395w note]Special Treatment of States Formerly Under Waiver.—Inthe case of a hospital in a State that has had a waiver approved undersection 1886(c) of the Social Security Act or section 402 of the SocialSecurity Amendments of 1967, for cost reporting periods beginning on orafter January 1, 1986, if the waiver is terminated—

(1) the Secretary of Health andHuman Services shall permit the hospital to change the method by which itallocates administrative and general costs to the direct medical educationcost centers to the method specified in the medicare cost report;

(2) the Secretary maymake appropriate adjustments in the regional adjusted DRG prospectivepayment rate (for the region in which the State is located), based on theassumption that all teaching hospitals in the State use the medicare costreport; and

(3) the Secretary shalladjust the hospital-specific portion of payment under section 1886(d) ofsuch Act for any such hospital that actually chooses to use the medicarecost report.

The Secretary shall implement this subsection based on thebest available data.

SEC. 9204.MORATORIUMON LABORATORY PAYMENT DEMONSTRATION.

(b)[42 U.S.C. 1395w note]Cooperation in Study.—The Secretary of Health andHuman Services and the Comptroller General shall assist representatives ofclinical laboratories in the industry’s conduct of a study todetermine whether methods exist which are better than competitive biddingfor purposes of utilizing competitive market forces in setting paymentlevels for laboratory services under title XVIII of the Social SecurityAct. If such a study is conducted by the clinical laboratory industry, theSecretary and the Comptroller General shall comment on such study andsubmit such comments and the study to the Senate Committee on Finance andthe House Committees on Ways and Means and Energy and Commerce.

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SEC. 9217.LIVERTRANSPLANTS.

(a)[None Assigned] The Senate findsthat:

(1) There have been more than 600liver transplants since 1963 and the one year survival rate at qualifiedinstitutions is now greater than 70 percent.

(2) There are 4,000 to4,700 potential candidates in the United States each year who require aliver transplant, but only a small percentage would be eligible forMedicare coverage.

(3) There are currentlyindividuals on waiting lists for liver transplants who will die withoutMedicare coverage.

(4) After extensivereview and consideration of all the available data, an National Institutesof Health expert panel concluded liver transplantation is “atherapeutic modality for end-stage liver disease that deserves broaderapplication” in a limited number of centers where they can becarried out under optimal conditions.

(5) National Institutesof Health further recommended that liver transplants be done in individualsunder 18 years of age.

(6) The CHAMPUS program,after considering all relevant data, determined that there was noscientific basis for limiting liver transplants to children under 18 yearsof age.

(7) The Department ofHealth and Human Services has determined that liver transplantation is nolonger an experimental procedure only for children under 18.

(b) Based upon the above findings, it is the sense ofthe Senate that:

(1) For the purposes of title XVIIIof the Social Security Act, the Secretary immediately reconsider theMedicare liver transplant coverage decision and implement a policy underwhich a liver transplant shall not be considered to be an experimentalprocedure for Medicare beneficiaries solely because an individual is over18 years of age.

(2) A liver transplantshall be covered under such title when reasonable and medicallynecessary.

(3) The Secretary shallplace appropriate limiting criteria on coverage, including those relatingto the patient’s condition, the disease state, and the institutionproviding the care, so as to ensure the highest quality of medical caredemonstrated to be consistent with successful outcomes.

SEC. 9517. MODIFYINGAPPLICATION OF MEDICAID HMO PROVISIONS FOR CERTAIN HEALTH CENTERS.

(c)* * *

(2)[42 U.S.C. 1396bnote] (A) Except as provided in subparagraph (B) and inparagraph (3), the amendments made by paragraph (1) shall apply toexpenditures incurred for health insuring organizations which first becomeoperational on or after January 1, 1986. For purposes of this paragraph, ahealth insuring organization is not considered to be operational until thedate on which it first enrolls patients.

(B) In the case of ahealth insuringorganization.—

(i) which first becomes operational on or after January 1, 1986, but

(ii) for which theSecretary of Health and Human Services has waived, under section 1915(b) ofthe Social Security Act and before such date, certain requirements ofsection 1902 of such Act,

clauses (ii) and (vi) of section1903(m)(2)(A) of such Act shall not apply during the period for which suchwaiver is effective.

(C) In the case of the HartfordHealth Network, Inc., clauses (ii) and (vi) of section 1903(m)(2)(A) of theSocial Security Act shall not apply during the period for which a waiver bythe Secretary of Health and Human Services, under section 1915(b) of suchAct, of certain requirements of section 1902 of such Act is in effect(pursuant to a request for a waiver under section 1915(b) of such Actsubmitted before January 1, 1986).

(D) Nothing in section1903(m)(1)(A) of the Social Security Act shall be construed as requiring ahealth-insuring organization to be organized under the health maintenanceorganization laws of a State.

(3)(A)[42 U.S.C. 1396bnote] Subject to subparagraph (C), in the case of up to 3health insuring organizations which are described in subparagraph (B), inthe case of any health insuring organization described in such subparagraphthat is operated by a public entity established by Ventura County, and inthe case of any health insuring organization described in such subparagraphthat is operated by a public entity established by Merced County, whichfirst become operational on or after January 1, 1986, and which aredesignated by the Governor, and approved by the Legislature, of California,the amendments made by paragraph (1) shall not apply.

(B) A health insuring organizationdescribed in this subparagraph is one that—

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(i) is operated directly by a publicentity established by a county government in the State of California undera State enabling statute;

(ii) enrolls all medicaidbeneficiaries residing in the county or counties in which itoperates;

(iii) meets therequirements for health maintenance organizations under the Knox-Keene Act(Cal. Health and Safety Code, section 1340 et seq.) and the Waxman-DuffyAct (Cal. Welfare and Institutions Code, section 14450 et seq.);

(iv) assures a reasonablechoice of providers, which includes providers that have historically servedmedicaid beneficiaries and which does not impose any restriction whichsubstantially impairs access to covered services of adequate quality wheremedically necessary;

(v) provides for apayment adjustment for a disproportionate share hospital (as defined underState law consistent with section 1923 of the Social Security Act) in amanner consistent with the requirements of such section; and

(vi) provides forpayment, in the case of childrens’ hospital services provided tomedicaid beneficiaries who are under 21 years of age, who are children withspecial health care needs under title V of the Social Security Act, and whoare receiving care coordination services under such title, at ratesdetermined by the California Medical Assistance Commission.

(C) Subparagraph (A) shall not apply with respect to any period for which theSecretary of Health and Human Services determines that the number ofmedicaid beneficiaries enrolled with health insuring organizationsdescribed in subparagraph (B) exceeds 16 percent of the number of suchbeneficiaries in the State of California.

(D) In this paragraph,the term “medicaid beneficiary” means an individual who isentitled to medical assistance under the State plan under title XIX of theSocial Security Act, other than a qualified medicare beneficiary who isonly entitled to such assistance because of section 1902(a)(10)(E) of suchtitle.

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SEC. 9524.[NoneAssigned] WISCONSIN HEALTH MAINTENANCEORGANIZATION WAIVER.

The waiver granted to the State of Wisconsin pursuant to section1915(b) of the Social Security Act relating to the requirements of section1903(m) of such Act in conjunction with a waiver of the requirements ofsection 1902(a)(23) of such Act shall, upon request by the State, bereinstated, and shall be renewable for terms of 2 years, subject to theshowings required generally under section 1915(b) of such Act.

SEC. 9529. MEDICAIDCOVERAGE RELATING TO ADOPTION ASSISTANCE AND FOSTER CARE.

(b)* * *

(2)[42 U.S.C. 1396anote] In the case of an adoption assistance agreement(other than an agreement under part E of title IV of the Social SecurityAct) entered into before the date of the enactment of thisAct—

(A) the requirements of subdivisions(aa) and (bb) of section 1902(a)(10)(A)(ii)(VIII) of the Social SecurityAct shall be deemed to be met if the State agency responsible for adoptionassistance agreements determines that—

(i) at the time of adoptiveplacement the child had special needs for medical or rehabilitative carethat made the child difficult to place; and

(ii) there is in effectwith respect to such child an adoption assistance agreement between theState and an adoptive parent or parents; and

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(B) therequirement of subdivision (cc) of such section shall be deemed to be metif the child was found by the State to be eligible for medical assistanceprior to such agreement being entered into.

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SEC. 12114.[42 U.S.C. 418note] Notwithstanding any provision of section 218 of theSocial Security Act, the Secretary of Health and Human Services shall, uponthe request of the Governor of Connecticut, modify the agreement under suchsection between the Secretary and the State of Connecticut to provide thatservice performed after the date of the enactment of this Act by members ofthe Division of the State Police within the Connecticut Department ofPublic Safety, who are hired on or after May 8, 1984, and who are membersof the tier II plan of the Connecticut State Employees Retirement System,shall be covered under such agreement.

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[Internal References.—SSAct §218 heading, §§1903(m)and 1915(b) have footnotes referring to P.L.99-272.]