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1 the first day of the sixth calendar month following the month

2 in which this Act is enacted.

3 VISITS AWAY FROM INSTITUTION BY PATIENTS OF SKILLED

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NURSING OR INTERMEDIATE CARE FACILITIES

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Sec. 23. Section 1903 of the Social Security Act is

6 amended by adding:

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“(1) In the administration of this title, the fact that an

8 individual who is an inpatient of a skilled nursing or inter9 mediate care facility leaves to make visits outside the facility 10 shall not conclusively indicate that he does not need services 11 which the facility is designed to provide; however, the fre12 quency and length of visits away shall be considered, to13 gether with other evidence, in determining whether the in14 dividual is in need of the facility's services.”.

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ESTABLISHMENT OF HEALTH CARE FINANCING

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ADMINISTRATION

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SEC. 30. (a) Section 702 of the Social Security Act is

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(1) by inserting “(a)” immediately after “SEC.

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(2) by adding at the end the following subsection: 22 “(b) The Secretary shall establish, within the De23 partment of Health, Education, and Welfare, a separate 24 organization to be known as the Health Care Financing 25 Administration (which shall include the functions and per

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1 sonnel of administrative entities known as of January 1, 1977

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as the ‘Bureau of Health Insurance', the ‘Medical Services

3 Administration', the ‘Bureau of Quality Assurance' (includ4 ing the National Professional Standards Review Council), 6 and the Office of Long-Term Care and related research 6 and statistical units (including the Division of Health Inī surance Studies of the Social Security Administration) 8 which shall be under the direction of the Assistant Secre9 tary for Health Care Financing, who shall report directly 10 to the Secretary and who shall have policy and adminis11 trative responsibility (including policy and administrative 12 responsibility with respeot to health care standards and certi13 fication requirements as they apply to practitioners and in14 stitutions) for the programs established by titles XVIII 15 and XIX, part B of title XI, for the renal dispase program 16 established by seetion 226 and any other health care financ17 ing programs as may be established under this Act. The 18 Assistant Secretary may not have any other duties or func19 tions assigned to him which would prevent him from carrying 20 out the duties required under the preceding sentence on a full21 time basis.

22 (b) (1) There shall be in the Department of Health, 28 Education, and Welfare an Assistant Secretary for Health 24 Çare Financing... who shall be appointed by the President, 25 by and with the advice and consent of the Senate.

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(2) Section 5315 of title 5, United States Code, is

2 amended in paragraph (17) by striking out “(5)” and 3 inserting in lieu thereof “(6)”.

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STATE MEDICAID ADMINISTRATION

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Sec. 31. (a) Section 1902 (a) is amended by adding at

6 the end the following:

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“(37) provide

“(A) for making eligibility determinations on the basis of applications for coverage, within fortyfive days of the date of application for all individuals: (i) receiving aid or assistance (or who except for income and resources would be eligible for aid or assistance) under a plan of the State approved under title IV, part A, (ii) receiving aid or

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assistance (or who except for income and resources

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would be eligible for assistance) under any plan

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of the State approved under title I, X, or XVI (for the aged and the blind), or (ii) with respect to whom supplemental security income benefits are being paid (or who would except for income and resources be eligible to have paid with respect to them supplemental security income benefits) under title XVI on the basis of age or blindness; and

“(B) for making eligibility determina

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tions based upon applications for coverage, within

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sixty days of application for all individuals:

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(i) receiving aid or assistance (or who except for income and resources would be eligible for aid or assistance) on the basis of disability under any plan of the State approved under title XIV or XVI, or (ii) for whom supplemental security income benefits are being paid (or who would except for income and resources be eligible to have paid to them supplemental security income benefits) under title XVI based upon disability;

“(C) for making redeterminations of eligibility for persons specified in subparagraphs (A) and (B): (i) when required based upon information the agency has previously obtained on anticipated changes in the individual's situation, (ii) within thirty days after receiving information on changes in an individual's circumstances which may affect his eligibility, and (iii) periodically but not less often than every six months for persons specified in subparagraph (A) (i), and not less often than annually for persons specified in subparagraph (A) (ii) and (A) (iii); “(38) establish procedures to assure

assure accurate determinations of eligibility and provide that the error

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rate for eligibility determinations made on or after October 1, 1977, shall not exceed the rate specified in

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section 1911 (b); and

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“ (39) establish payment procedures to assure that (A) 95 percent of claims for which no further written

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information or substantiation is required to make payment, be paid within thirty days of receipt of the claim from a provider, and that 99 percent of such claims be paid within ninety days, and (B) both prepayment and postpayment claims review procedures are performed, including

“(i) review, on a reasonable sample or more extensive basis, to determine the accuracy of data submitted and processed;

“(ii) review to determine that the provider is a participating provider;

“(iii) review to determine whether the service is covered under the State's plan;

“ (iv) review to determine whether the recip·ient is eligible;

(v) review of care and services provided

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'where such review has not been assumed by an

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organization designated by the Secretary under part B of title XI of this Act;

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92-202 0.77.5

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