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Studies and recommendations....
Limitation on certain physician referrals
Limitation on liability of beneficiary where medicare claims are 1135 disallowed.
Application of certain provisions of title II
Indian health service facilities
Medicare coverage for end stage renal disease patients
Hospital providers of extended care services
Payments to promote closing and conversion of underutilized 1179 hospital facilities.
Withholding of payments for certain medicaid providers
Payment to hospitals for inpatient hospital services
Payment of provider-based physicians and payment under cer- 1239 tain percentage arrangements.
Payment to skilled nursing facilities for routine service costs
Redesignated and transferred as 1862(e)(2).]
Conditions of participation for home health agencies; home 1249
Offset of payments to individuals to collect past-due obligations
Payments to, and coverage of benefts under, programs of all- 1260 inclusive care for the elderly (PACE).
Prospective payment for home health services
Medicare subvention demonstration project for military retirees 1273
PROHIBITION AGAINST ANY FEDERAL INTERFERENCE
SEC. 1801. [42 U.S.C. 1395] Nothing in this title shall be construed to authorize any Federal officer or employee to exercise any supervision or control over the practice of medicine or the manner in which medical services are provided, or over the selection, tenure, or compensation of any officer or employee of any institution, agency, or person providing health services; or to exercise any supervision or control over the administration or operation of any such institution, agency, or person.
FREE CHOICE BY PATIENT GUARANTEED
SEC. 1802. [42 U.S.C. 1395a] (a) BASIC FREEDOM OF CHOICE.— Any 3 individual entitled to insurance benefits under this title may obtain health services from any institution, agency, or person qualified to participate under this title if such institution, agency, or person undertakes to provide him such services.
(b) USE OF PRIVATE CONTRACTS BY MEDICARE BENEFICIARIES.— (1) IN GENERAL.-Subject to the provisions of this subsection, nothing in this title shall prohibit a physician or practitioner
3P.L. 105-33, §4507(a)(2)(A), struck out “Any" and substituted "(a) BASIC FREEDOM OF CHOICE.-Any", applicable with respect to contracts entered into on and after January 1, 1998.
from entering into a private contract with a medicare beneficiary for any item or service
(A) for which no claim for payment is to be submitted under this title, and
(B) for which the physician or practitioner receives
(i) no reimbursement under this title directly or on a capitated basis, and
(ii) receives no amount for such item or service from an organization which receives reimbursement for such item or service under this title directly or on a capitated basis.
(2) BENEFICIARY PROTECTIONS.—
(A) IN GENERAL.-Paragraph (1) shall not apply to any contract unless
(i) the contract is in writing and is signed by the medicare beneficiary before any item or service is provided pursuant to the contract;
(ii) the contract contains the items described in subparagraph (B); and
(iii) the contract is not entered into at a time when the medicare beneficiary is facing an emergency or urgent health care situation.
(B) ITEMS REQUIRED TO BE INCLUDED IN CONTRACT.-Any contract to provide items and services to which paragraph (1) applies shall clearly indicate to the medicare beneficiary that by signing such contract the beneficiary
(i) agrees not to submit a claim (or to request that the physician or practitioner submit a claim) under this title for such items or services even if such items or services are otherwise covered by this title;
(ii) agrees to be responsible, whether through insurance or otherwise, for payment of such items or services and understands that no reimbursement will be provided under this title for such items or services;
(iii) acknowledges that no limits under this title (including the limits under section 1848(g)) apply to amounts that may be charged for such items or services;
(iv) acknowledges that Medigap plans under section 1882 do not, and other supplemental insurance plans may elect not to, make payments for such items and services because payment is not made under this title; and
(v) acknowledges that the medicare beneficiary has the right to have such items or services provided by other physicians or practitioners for whom payment would be made under this title. Such contract shall also clearly indicate whether the physician or practitioner is excluded from participation under the medicare program under section 1128. (3) PHYSICIAN OR PRACTITIONER REQUIREMENTS.
(A) IN GENERAL.-Paragraph (1) shall not apply to any contract entered into by a physician or practitioner unless
an affidavit described in subparagraph (B) is in effect during the period any item or service is to be provided pursuant to the contract.
(B) AFFIDAVIT.-An affidavit is described in this subparagraph if
(i) the affidavit identifies the physician or practitioner and is in writing and is signed by the physician or practitioner;
(ii) the affidavit provides that the physician or practitioner will not submit any claim under this title for any item or service provided to any medicare beneficiary (and will not receive any reimbursement or amount described in paragraph (1)(B) for any such item or service) during the 2-year period beginning on the date the affidavit is signed; and
(iii) a copy of the affidavit is filed with the Secretary no later than 10 days after the first contract to which such affidavit applies is entered into.
(C) ENFORCEMENT.-If a physician or practitioner signing an affidavit under subparagraph (B) knowingly and willfully submits a claim under this title for any item or service provided during the 2-year period described in subparagraph (B)(ii) (or receives any reimbursement or amount described in paragraph (1)(B) for any such item or service) with respect to such affidavit
(i) this subsection shall not apply with respect to any items and services provided by the physician or practitioner pursuant to any contract on and after the date of such submission and before the end of such period; and
(ii) no payment shall be made under this title for any item or service furnished by the physician or practitioner during the period described in clause (i) (and no reimbursement or payment of any amount described in paragraph (1)(B) shall be made for any such item or service).
(4) LIMITATION ON ACTUAL CHARGE AND CLAIM SUBMISSION REQUIREMENT NOT APPLICABLE.-Section 1848(g) shall not apply with respect to any item or service provided to a medicare beneficiary under a contract described in paragraph (1). (5) DEFINITIONS.—In this subsection:
(A) MEDICARE BENEFICIARY.-The term "medicare beneficiary" means an individual who is entitled to benefits under part A or enrolled under part B.
(B) PHYSICIAN.-The term "physician" has the meaning given such term by section 1861(r)(1).
(C) PRACTITIONER.-The term "practitioner" has the meaning given such term by section 1842(b)(18)(C). 4
OPTION TO INDIVIDUALS TO OBTAIN OTHER HEALTH INSURANCE
SEC. 1803. [42 U.S.C. 1395b] Nothing contained in this title shall be construed to preclude any State from providing, or any in
4P.L. 105-33, §4507(a)(1), added subsection (b), applicable with respect to contracts entered into on and after January 1, 1998.
dividual from purchasing or otherwise securing, protection against the cost of any health services.
NOTICE OF MEDICARE BENEFITS: MEDICARE AND MEDIGAP
SEC. 1804. [42 U.S.C. 1395b-2] (a) The Secretary shall prepare (in consultation with groups representing the elderly and with health insurers) and provide for distribution of a notice containing
(1) a clear, simple explanation of the benefits available under this title and the major categories of health care for which benefits are not available under this title,
(2) the limitations on payment (including deductibles and coinsurance amounts) that are imposed under this title, and
(3) a description of the limited benefits for long-term care services available under this title and generally available under State plans approved under title XIX.
Such notice shall be mailed annually to individuals entitled to benefits under part A or part B of this title and when an individual applies for benefits under part A or enrolls under part B.
(b) The Secretary shall provide information via a toll-free telephone number on the programs under this title. (c) The notice provided under subsection (a) shall include—
(1) a statement which indicates that because errors do occur and because medicare fraud, waste, and abuse is a significant problem, beneficiaries should carefully check any explanation of benefits or itemized statement furnished pursuant to section 1806 for accuracy and report any errors or questionable charges by calling the toll-free phone number described in paragraph (4);
(2) a statement of the beneficiary's right to request an itemized statement for medicare items and services (as provided in section 1806(b));
(3) a description of the program to collect information on medicare fraud and abuse established under section 203(b) of the Health Insurance Portability and Accountability Act of 1996; and
(4) a toll-free telephone number maintained by the Inspector General in the Department of Health and Human Services for the receipt of complaints and information about waste, fraud, and abuse in the provision or billing of services under this title. 6
MEDICARE PAYMENT ADVISORY COMMISSION 7
SEC. 1805. [42 U.S.C. 1395b-6] (a) ESTABLISHMENT.-There is hereby established the Medicare Payment Advisory Commission (in this section referred to as the "Commission").
5 See Vol. II, P.L. 101-239, §6011(b), with respect to determining the payment amount for services to hemophilia inpatients.
See Vol. II, P.L. 104-191, §203, with respect to beneficiary incentive programs.
P.L. 105-33, §4311(a)(1), added subsection (c), applicable with respect to notices provided on and after January 1, 1998.
'P.L. 105-33, §4022(a) added $1805. For the effective date and transition, see Vol. II, P.L. 105-33, §4022(c).
(1) REVIEW OF PAYMENT POLICIES AND ANNUAL REPORTS. -The Commission shall
(A) review payment policies under this title, including the topics described in paragraph (2);
(B) make recommendations to Congress concerning such payment policies;
(C) by not later than March 1 of each year (beginning with 1998), submit a report to Congress containing the results of such reviews and its recommendations concerning such policies; and
(D) by not later than June 1 of each year (beginning with 1998), submit a report to Congress containing an examination of issues affecting the medicare program, including the implications of changes in health care delivery in the United States and in the market for health care services on the medicare program. (2) SPECIFIC TOPICS TO BE REVIEWED.
(A) MEDICARE+CHOICE PROGRAM.-Specifically, the Commission shall review, with respect to the Medicare+Choice program under part D8, the following:
(i) The methodology for making payment to plans under such program, including the making of differential payments and the distribution of differential updates among different payment areas.
(ii) The mechanisms used to adjust payments for risk and the need to adjust such mechanisms to take into account health status of beneficiaries.
(iii) The implications of risk selection both among Medicare+Choice organizations and between the Medicare+Choice option and the original medicare feefor-service option.
(iv) The development and implementation of mechanisms to assure the quality of care for those enrolled with Medicare+Choice organizations.
(v) The impact of the Medicare+Choice program on access to care for medicare beneficiaries.
(vi) Other major issues in implementation and further development of the Medicare+ Choice program. (B) ORIGINAL MEDICARE FEE-FOR-SERVICE SYSTEM.-Specifically, the Commission shall review payment policies under parts A and B, including
(i) the factors affecting expenditures for services in different sectors, including the process for updating hospital, skilled nursing facility, physician, and other fees,
(ii) payment methodologies, and
(iii) their relationship to access and quality of care for medicare beneficiaries.
(C) INTERACTION OF MEDICARE PAYMENT POLICIES WITH HEALTH CARE DELIVERY GENERALLY.-Specifically, the
See Vol. II, P.L. 105-33, §4507(b), with respect to a report regarding the effect of private contracts by Medicare beneficiaries, and §4804(c), with respect to information to be included in MedPAC's annual recommendations.
See Vol. II, P.L. 105–277, §5202(b), with respect to initial terms for additional MedPAC members.
P.L. 105-33, §4002(f)(1), deemed "part C" as "part D", effective after August 5, 1997.