(3A) (E) of such section (as amended by paragraph (1) of this subsection) shall be effective only to determinations made under section 1842 (b) (3A) (B) (i) (II) and (ii) of such Act for fiscal years beginning after September 30, 1976. AGREEMENTS OF PHYSICIANS TO ACCEPT ASSIGNMENT OF CLAIMS SEC. 21. (a)(1) Part C of title XVIII of the Social Security Act is amended by adding immediately after section 1867 the following new section: "AGREEMENTS OF PHYSICIANS TO ACCEPT ASSIGNMENT OF CLAIMS "SEC. 1868. (a) For purpose of this section "(1) the term 'participating physician' means a doctor of medicine or osteopathy who has in effect an agreement entered into pursuant to this section (except that, with respect to any claim for payment under this part for services performed outside the United States, no physician shall be considered to be a participating physician), and "(2) the term 'nonparticipating physician' means a doctor of medicine or osteopathy who does not have in effect such an agreement. "(b) (1) Any physician who desires to do so may enter into an agreement with the Secretary under this section under which the physician agrees to accept, with respect to any service performed by him for an individual who is enrolled under part B, an assignment of claim (which shall be in such form as may be prescribed under regulations of the Secretary) the terms of which provide that "(A) all claims which such individual would, except for such assignment, have under part B for payment for such service are conferred upon such physician and such physician accepts such assignment in lieu of any such payment, and "(B) the reasonable charge for such service (as determined under this title) will be the full charge therefor. "(2) An agreement under this section may be terminated by either party upon 'thirty days' notice to the other party (filed in such form and manner as may be prescribed in regulations of the Secretary). "(b) Notwithstanding any other provision of this title, no payment under part B shall be made, on the basis of an assignment of claim, to any physician for or on account of physicians' services performed by him, if such physician is a nonparticipating physician. "(c) In order to assure the expeditious processing of claims by participating physicians for services performed by them, the Secretary shall establish procedures and develop appropriate forms under which— "(1) each such physician will submit his claims on a simplified and multiple-listing basis rather than on an individual patient basis, "(2) there will, within five working days after any particular batch of such claims is received from such a physician, be paid to him an amount with respect thereto which is based on an estimate of the precise amount due (with the payment made with respect to any such batch of claims being increased or reduced, as is appropriate, on account of any prior payment, based on a previous estimate, being greater or lesser than the precise amount due); and "(3) any such estimate, with respect to any batch of such claims submitted by such a physician, shall be designed to assure that the amount thereof is not less than 50 per centum of the amount which is estimated to be payable hereunder with respect thereto, and such estimate shall be made on the assumption that all patients with respect to whom such claims relate have met the deductible imposed by section 1833 (b). "(d) (1) In addition to other payments authorized to be made to carry out the insurance program established by part B of this title, there are hereby authorized to be made such payments as may be necessary to provide for the payment of 'administrative cost-savings allowances' as specified in the succeeding provisions of this subsection. "(2) (A) With respect to each batch of claims submitted on a multiple-listing basis by a participating physician in accordance with the procedures established pursuant to subsection (c), there shall (subject to subparagraph (B)) be paid to such physician, an administrative cost-savings allowance equal to $1 multiplied by the number of patients for whom payment for services was claimed in such batch of claims and any such amounts shall be treated as an administrative expense for the administration of the insurance program established by part B of this title. "(B) Not more than $1 shall be payable under subparagraph (A) to a physician with respect to any particular patient on account of services provided to such patient by such physician in more than one instance in any week. If a physician provides to a patient in two or more visits services which ordinarily would be provided in a single visit, then not more than $1 shall be payable under subparagraph (A) with respect to such patient on account of such services. "(e) (1) Notwithstanding the preceding provisions of this section, no administrative cost-savings allowance shall be payable on account of any physicians' services performed in a hospital for an individual (whether on an inpatient or outpatient basis) unless— "(A) such services are in the form of surgical services or anesthesiological services, or "(B) such services are physicians' services (other than those referred to in subparagraph (A)) performed by a physician (as an attending or consulting physician) whose office or regular place of practice is at a locale other than in such hospital, and the physician concerned ordinarily bills directly (and not through such hospital) for his services, and no administrative cost-savings allowance shall be payable on account of services which consist solely of laboratory and X-ray services (or either of such services) performed outside the office of the physician claiming payment therefor.". (2) The amendments made by paragraph (1) shall take effect on July 1, 1977. (b) On and after the effective date of the amendments made by subsection (a), the authority contained in section 1842 (b) (3) (B)(ii) of the Social Security Act shall not be applicable to participating or nonparticipating physicians as defined in section 1868 of such Act. HOSPITAL-ASSOCIATED PHYSICIANS SEC. 22. (a) (1) Section 1861 (q) of the Social Security Act is amended by adding "(1)" immediately after "(q)" and by adding, immediately before the period at the end thereof, the following: "; except that such term does not include any service that a physician may perform as an educator, an executive, or a researcher; or any patient care service unless such service (A) is personally performed by or personally directed by a physician for the benefit of such patient and (B) is of such a nature that its performance by a physician is customary and appropriate". (2) Section 1861 (q) is further amended by adding the following new paragraphs at the end thereof: (2) In the case of anesthesiology services, a procedure would be considered to be 'personally performed' in its entirety by a physician only where the physician performs the following activities: "(A) preanesthetic evaluation of the patient; "(B) prescription of the anesthesia plan; "(C) personal participation in the most demanding procedures in this plan, including those of induction and emergence; "(D) following the course of anesthesia administration at frequent intervals; "(E) remaining physicially available for the immediate diagnosis and treatment of emergencies; and "(F) providing indicated postanesthesia care: Provided, however, That during the performance of the activities described in subparagraphs (C), (D), and (E), such physician is not responsible for the care of more than one other patient. Where a physician performs the activities described in subparagraphs (A), (B), (D), and (E) and another individual performs the activities described in subparagraph (C), such physician will be deemed to have personally directed the services if he was responsible for no more than four patients while performing the activities described in subparagraphs (D) and (E) and the reasonable charge for such personal direction shall not exceed one-half the amount that would have been payable if he had personally performed the procedure in its entirety. "(3) Pathology services shall be considered 'physicians' services' only where the pathologist personally performs acts or makes decisions with respect to a patient's diagnosis or treatment which require the exercise of medical judgment. These include operating room and clinical consultations, the required interpretation of the significance of any material or data derived from a human being, the aspiration or removal of marrow or other materials, and the administration of test materials or isotopes. Such services shall not include such services as: the performance of autopsies; and services performed in carrying out responsiblities for supervision, quality control, and for various other aspects of a clinical - laboratory's operations that are customarily performed by nonphysician personnel. (3) Section 1861 (b) of such Act is amended (A) by striking out "or" at the end of paragraph (6), (B) by striking out the period at the end of paragraph (7) and inserting in lieu of such "; or", and (C) by adding at the end thereof the following new paragraph: "(8) a physician, if the services provided by such physician are not physicians' services within the meaning of subsection (q).". (b) (1) Section 1861 (s) of the Social Security Act is amended by adding the following sentence at the end thereof: "The term 'medical and other health services' shall not include the services described in paragraphs (2) (A) and (3) if furnished to the inpatients of a hospital unless the Secretary finds that, because of the size of the hospital or for some other reason acceptable to him, it would be less efficient to have such services furnished by such hospital (or by others under arrangement with them made by the hospital) than to have them furnished by another party.". (2) Section 1842(b) (3A) of such Act, as added by section 20 of this Act, is tamended by adding the following new subparagraphs at the end thereof: "(G) The charges of a physician or other person which are related to the income or receipts of a hospital or any subdivision thereof shall not be taken into consideration in determing his customary charge pursuant to subparagraph (A) to the extent that such charges exceed an amount equal to the salary which would reasonably have been paid for such services (together with any additional costs that would have been incurred by the hospital) to the physician performing them if they had been performed in an employment relationship with such hospital plus the cost of such other expenses (including a reasonable allowance for traveltime and other reasonable types of expense related to any differences in acceptable methods of organization for the provision of such services) incurred by such physician, as the Secretary may in regulations determine to be appropriate.”. (c) Section 1861 (v) of the Social Security Act is amended by adding at the end thereof the following new paragraph: "(8) (A) Where physicians' services are furnished under an arrangement (including an arrangement under which the physician performing such services is compensated therefor on a basis which is related to the amount of the income or receipts of the hospital or any department or other subdivision thereof) with a hospital or medical school, the amount included in any payment to such hospital under this title as the reasonable cost of such services (as furnished under such arrangement) shall not exceed an amount equal to the salary which would reasonably have been paid for such services (together with any additional costs that would have been incurred by the hospital) to the physician performing them if they had been performed in an employment relationship with such hospital (rather than under such arrangement) plus the cost of such other expenses (including a reasonable allowance for traveltime and other reasonable types of expense related to any differences in acceptable methods of organization for the provision of such services) incurred by such physician, as the Secretary may in regulations determine to be appropriate.". (d) (1) Section 1833 (a) (1) (B) of the Social Security Act is amended by inserting "(except as otherwise provided in subsection (h))" immediately after "amounts paid shall". (2) Section 1833 (b) (2) of such Act is amended by inserting "(except as otherwise provided in subsection (h))" immediately after "amount paid shall". (3) Section 1833 of such Act is further amended by adding at the end thereof the following new subsection: "(h) The provisions of subsection (a) (1) (B) and clause (2) of the first sentence of subsection (b) shall not be applicable for expenses incurred for services referred to therein unless the physician performing such services has entered into an agreement with the Secretary under which such physician agrees to be compensated therefor on the basis of an assignment the terms of which are de-scribed in section 1842 (b) (3) (B) (ii).”. (e) The amendments made by this section shall, except for the amendment made by subsection (d), apply with respect to services furnished after the first day of the first accounting period of the hospital with respect to which such services were furnished which begins after the month following the month of enactment of this Act. The amendment made by subsection (d) shall be effective on -July 1, 1977. PAYMENT FOR PHYSICIANS' SERVICES UNDER MEDICAID SEC. 23. Section 1902 (a) (13) of the Social Security Act is amended- "(F) effective July 1, 1977, that the amount which shall be paid under the plan for any physician service provided outside of a hospital setting thereunder shall not be less than 80 per centum of the reasonable charge for such service (as determined under title XVIII) ;”. PAYMENT FOR CERTAIN ANTIGENS UNDER PART B OF MEDICARE SEC. 24. (a) Section 1861 (s) (2) of the Social Security Act is amended(1) by striking out "and" at the end of clause (C), (2) by inserting "and" at the end of clause (D), and (3) by adding after clause (D) the following new clause: (E) antigens (subject to quantity limitations prescribed in regulations of the Secretary) prepared by an allergist for a particular patient, including antigens so prepared which are forwarded to another qualified person for administration to such patient, from time to time, by or under the supervision of another physician;". (b) The amendment made by subsection (a) shall be applicable with respect to items furnished on and after the first day of the first calendar month which begins more than thirty days after the date of enactment of this Act. PAYMENT UNDER MEDICARE OF CERTAIN PHYSICIANS' FEES ON ACCOUNT OF SERVICES FURNISHED TO A DECEASED INDIVIDUAL SEC. 25. (a) Section 1870 (f) of the Social Security Act is amended, in the matter following clause (2) thereof, by (1) inserting "(A)" immediately after ", and only if", and (2) by inserting immediately before the period the following: “, or (B) the spouse or other legally designated representative of such individual requests (in such form and manner as the Secretary shall by regulations prescribe) that payment for such services without regard to clause (A)". (b) The amendment made by subsection (a) shall be effective with respect to payments made on and after the first day of the first calendar month which begins more than thirty days after the date of enactment of this Act. PROHIBITION AGAINST ASSIGNMENT OF FEES BY PHYSICIANS AND OTHERS SEC. 26. (a) Section 1842 (b) (5) of the Social Security Act is amended by adding at the end thereof the following new sentence: "Any payment for a -service, which under the provisions of the preceding sentence may be made directly to the physician or other person furnishing such service, may not be made to a person claiming such payment under an assignment, including a power of attorney (other than an assignment established by or pursuant to the order of a court of competent jurisdiction from such physician or other person furnishing such service); but nothing in this paragraph shall be construed to preclude any agent, of the physician or other person furnishing the service, from receiving any such payment, if (but only if) such agent does so pursuant to an agency agreement under which the compensation to be paid to the agent for his services for or in connecton with the billing and/or collection of any such payment is unrelated (directly or indirectly) to the amount of the billing and/or payment (or the aggregate of similar billings and/or payments), and is not dependent upon the actual collection of any such payment (or the aggregate of such payments). (b) Section 1902(a) (32) of such Act is amended (1) by inserting "(A)” immediately after "provide that", (2) by redesignating clauses (A) and (B) as clauses (i) and (ii), respectively, and (3) by adding immediately before the semicolon at the end thereof the following: ", and (B) any payment for a service, which under the provisions of subparagraph (A) may be made directly to the physician or other person furnishing such service, may not be made to a person claiming such payment under an assignment, including a power of attorney (other than an assignment established by or pursuant to the order of a court of competent jurisdiction from such physcian or other person furnishing such service); but nothing in this paragraph shall be construed to preclude any agent, of the physician or other person furnishing the service, from receiving any such payment, if (but only if) such agent does so pursuant to an agency agreement under which the compensation to be paid to the agent for his services for or in connection with the billing and/or collection of any such payment is unrelated (directly or indirectly) to the amount of the payment (or the aggregate of similar billings and/or payments) and is not dependent upon the actual collection of any such payment (or the aggregate of such payments).". (c) The amendments made by this section shall take effect on the first day of the first calendar month which begins not less than sixty days after the date of enactment. REIMBURSEMENT RATES UNDER MEDICAID FOR SKILLED NURSING AND INTERMEDIATE CARE FACILITIES SEC. 30. Section 1902 (a) (13) (E) of the Social Security Act is amended by inserting "(and which may, at the option of the State, include a reasonable profit for the facility)" immediately after "cost related basis". MEDICAID CERTIFICATION AND APPROVAL OF SKILLED NURSING FACILITIES SEO. 31. (a) Section 1910 of the Social Security Act is amended to read as follows: "CERTIFICTION AND APPROVAL OF SKILLED NURSING FACILITIES “SEC. 1910. (a) The Secretary shall make an agreement with any State which is able and willing to do so under which the services of the State health agency or other appropriate State or local agencies (which ever are utilized by the Secretary pursuant to section 1864 (a)) will be utilized by him for the purpose of determining whether an institution in such State qualifies as a skilled nursing facility for purposes of section 1902 (a) (28). To the extent that the Secretary finds it appropriate, any institution which such a State or local agency certifies to him to be a skilled nursing facility may be treated as such by the Secretary. "(b) The Secretary shall advise the State agency administering the medical assistance plan of his approval or disapproval of any institution certified to him as a qualified skilled nursing facility for purposes of section 1902 (a) (28) and specify for each such institution the period (not to exceed twelve months) for which approval is granted, except that the Secretary may extend such term for a period not exceeding two months, where the health and safety of patients will not be jeopardized thereby, if he finds that such extension is necessary to prevent irreparable harm to such facility or hardship to the individuals being furnished items or services by such facility or if he finds it impracticable within such twelve-month period to determine whether such facility is complying with the provisions of this title and regulations thereunder. The State agency may enter into an agreement for the provision of services and the making of payments under the plan with any skilled nursing facility approved by the Secretary for a period not to exceed the period of approval specified. "(c) The Secretary may cancel the approval of any skilled nursing facility at any time if he finds that the skilled nursing facility fails to meet the requirements contained in section 1902 (a) (28), or if he finds grounds for termination of his agreement with such institution pursuant to section 1866(b). In such event the Secretary shall notify the State agency and the skilled nursing facility that the approval of eligibility of such institution to participate in the programs established by this title and title XVIII shall be terminated at such time as may be specified by the Secretary. The approval of eligibility of any such institu |