Medicare and Medicaid Budget Reconciliation Amendments of 1985

Summary

Medicare and Medicaid Budget Reconciliation Amendments of 1985 - Title I: Medicare Programs - Amends part B (Supplementary Medical Insurance) of title XVIII (Medicare) of the Social Security Act to direct the Director of the Congressional Office of Technology Assessment to provide for the appointment of a Physician Payment Review Commission which shall include physicians, other health professionals, health researchers, and consumer representatives. Requires the Commission to annually make recommendations to the Congress regarding adjustments to the reasonable charge levels for physicians' services and changes in the methodology for determining the rates of payment, and for making payment, for physicians' services under Medicare and other items and services under part B. Requires the Commission to also advise and make recommendations to the Secretary concerning the development of the relative value scale. Authorizes appropriations. Directs the Secretary to develop a relative value scale that establishes a numerical relationship among the various physicians' services for which payment may be made under part B or State plans approved under title XIX (Medicaid) of the Act. Requires a report from the Secretary to Congress concerning the relative value scale. Revises provisions relating to the dates for revising payments for clinical laboratory services. Sets limits on regional payment rates. Requires a report from the Secretary to the Congress concerning standards for clinical laboratories. Revises payment provisions with respect to durable medical equipment. Provides that, among other things, with respect to durable medical equipment furnished on or after October 1, 1986, the prevailing charge level may not exceed the percentage increase in the Consumer Price Index. Requires payment on an assignment basis for durable medical equipment furnished on a rental basis and for oxygen therapy services. Extends, for one year, the current freeze on physician charge levels for nonparticipating physicians under part B, while providing incentives for participating physicians. Eliminates the physician assignment rate list. Requires, in the case of all covered employed individuals, that payment for health care items or services, to the extent possible, be made by the individual's group health plan before Medicare payments will be made. Defines the "special enrollment period" referred to in part B as the period beginning with the first day of the first month in which an individual is no longer enrolled in a group health plan by reason of current employment and ending seven months later. Amends the Age Discrimination in Employment Act of 1967 to prohibit an employer from discriminating against an employee over age 65 under the employer's group health plan. Prohibits payment for a surgical procedure listed by the Secretary unless a second opinion regarding such surgery is obtained. Provides that the second opinion need not agree with the first opinion in order for payment to be made. Directs the Secretary to establish a list of at least ten surgical procedures to which the second opinion requirement applies. Directs the Secretary to enter into contracts with utilization and quality control peer review organizations under which such organizations serve as referral centers for the second opinions required by this Act. Permits the patient to choose any qualified physician, except one affiliated with the initial physician, to provide the second opinion. Provides that a second opinion need not be obtained if: (1) to delay surgery would be a risk to the patient; (2) no physician is available, within reasonable limits, to provide the second opinion; and (3) the surgery is to be performed on a patient who is a member of a health maintenance organization or competitive medical plan having a risk sharing contract with the Secretary. Requires physicians, hospitals, and ambulatory surgical centers to notify patients of the second opinion requirement. Sets forth sanctions for noncompliance. Directs the Secretary to notify physicians, hospitals, ambulatory surgical centers, and Medicare beneficiaries of the requirements of this Act. Waives the deductible and copayments with respect to the second opinion. Sets forth effective date, regulation, and study provisions. Prohibits coverage for an assistant in a cataract operation unless, before surgery, the appropriate utilization and quality control peer review organization has approved the use of an assistant because of a complicating medical condition. Directs the Secretary: (1) after consultation with the Prospective Payment Assessment Commission, to develop recommendations and guidelines respecting other surgical procedures for which an assistant at surgery is generally not medically necessary and the circumstances under which an assistant is appropriate; and (2) to report to the Congress with recommendations and guidelines. Provides coverage for all services provided by a doctor of optometry. Permits an individual to be represented by a provider during a Medicare related hearing or appeal. Permits, under part B, an administrative hearing if the amount in controversy is more than $500 and judicial review if the amount in controversy is more than $1,000. Directs the Secretary to establish a Task Force on Long-Term Health Care Policies. Requires the Task Force to develop guidelines for long-term health care policies and report to the Secretary and Congress. Requires the Secretary: (1) to provide for the dissemination of the report to each of the States; and (2) annually report to Congress concerning such guidelines. Directs the Secretary to provide for the extension of the waiver of certain Medicare and Medicaid (title XIX of the Act) requirements with respect to the On Lok Senior Health Services program. Title II: Medicaid Program - Amends title XIX (Medicaid) of the Act to: (1) include within the definition of "qualified pregnant woman" any woman who meets the income and resources requirements under part A (Aid to Families with Dependent Children) of title IV of the Act; (2) provide that the making available to covered pregnant women of pregnancy-related services shall not require the making available of such services to other individuals; and (3) provide that a woman who, while pregnant, is eligible for, has applied for, and has received Medicaid, shall be deemed, for purposes of the provision of all pregnancy-related and post-partum medical assistance under Medicaid, to remain pregnant until the end of the 60-day period beginning on the last day of her pregnancy. Defines the term "habilitation services" as used in title XIX. Provides for the coverage as home or community-based services of services provided to individuals who would otherwise continue to receive inpatient hospital services because they are dependent on ventilator support the cost of which is reimbursed under Medicaid. Makes other revisions concerning home and community-based services with respect to: (1) total expenditures for such services; (2) expenditures for certain disabled patients; and (3) maintenance income standards. Permits an eligible individual to receive hospice care under Medicaid. Requires a State's Medicaid plan to provide for payment to hospitals for direct medical education costs. Sets forth the procedures to be followed in determining the amount of such payments, including the determination of an approved full-time equivalent resident amount. Sets forth special rules for foreign medical graduates. Requires a report from the Secretary to the Congress. Sets forth provisions relating to the eligibility of an individual with a trust. Prohibits payment for organ transplant procedures unless the State plan provides for written standards respecting the coverage of such procedures and unless such standards contain specified provisions. Provides that for Medicaid purposes, any individual receiving aid or assistance under part E (Foster Care and Adoption Assistance) of title IV of the Act shall be deemed to be receiving such aid or assistance from the State in which the individual actually resides. Requires a report from the Secretary to the Congress concerning Medicaid payments for hospitals serving disproportionate numbers of low income patients. Lists provisions of laws directly affecting Medicaid.

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2 official files

• Reported to House amended, Part I

  summary · EN · 11 September 1985

  Open at official source

• Introduced in House

  summary · EN · 30 July 1985

  Open at official source

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