P.L. 99–509, Approved October 21, 1986 (100 Stat. 1874)

Omnibus Budget Reconciliation Act of 1986

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SEC. 9312. HEALTH MAINTENANCE ORGANIZATIONS AND COMPETITIVE MEDICAL PLANS.

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(c) [42 U.S.C. 1395mm note] (3)  *  *  *

(C)  Treatment of current waivers.—In the case of an eligible organization (or successor organization) that—

(i)  as of the date of the enactment of this Act, has been granted, under paragraph (2) of section 1876(f) of the Social Security Act, a modification or waiver of the requirement imposed by paragraph (1) of that section, but

(ii)  does not meet the requirement for such modification or waiver under the amendment made by paragraph (1) of this subsection,

the organization shall make, and continue to make, reasonable efforts to meet scheduled enrollment goals, consistent with a schedule of compliance approved by the Secretary of Health and Human Services. If the Secretary determines that the organization has complied, or made significant progress towards compliance, with such schedule of compliance, the Secretary may extend such waiver. If the Secretary determines that the organization has not complied with such schedule, the Secretary may provide for a sanction described in section 1876(f)(3) of the Social Security Act (as amended by this section) effective with respect to individuals enrolling with the organization after the date the Secretary notifies the organization of such noncompliance.

(D)  Treatment of certain waivers.—In the case of an eligible organization (or successor organization) that is described in clauses (i) and (ii) of subparagraph (C) and that received a grant or grants totaling at least $3,000,000 in fiscal year 1987 under section 329(d)(1)(A) or 330(d)(1) of the Public Health Service Act—

(i)  before January 1, 1996, section 1876(f) of the Social Security Act shall not apply to the organization;

(ii)  beginning on January 1, 1990, the Secretary of Health and Human Services shall conduct an annual review of the organization to determine the organization’s compliance with the quality assurance requirements of section 1876(c)(6) of such Act; and

(iii)  after January 1, 1990, if the organization receives an unfavorable review under clause (ii), the Secretary, after notice to the organization of the unfavorable review and an opportunity to correct any deficiencies identified during the review, may provide for the sanction described in section 1876(f)(3) of such Act effective with respect to individuals enrolling with the organization after the date the Secretary notifies the organization that the organization is not in compliance with the requirements of section 1876(c)(6) of such Act.

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(h) [42 U.S.C. 1395mm note]  Allowing Medicare Beneficiaries To Disenroll at a Local Social Security Office.—The Secretary of Health and Human Services shall provide that individuals enrolled with an eligible organization under section 1876 of the Social Security Act may disenroll, on and after June 1, 1987, at any local office of the Social Security Administration.

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SEC. 9315.  PAYMENTS FOR HOME HEALTH SERVICES.

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(b) [42 U.S.C. 1395x note]  Considerations in Establishing Limits.—In establishing limitations under section 1861(v)(1)(L) of the Social Security Act on payment for home health services for cost reporting periods beginning on or after July 1, 1986, the Secretary of Health and Human Services shall—

(1)  base such limitations on the most recent data available, which data may be for cost reporting periods beginning no earlier than October 1, 1983; and

(2)  take into account the changes in costs of home health agencies for billing and verification procedures that result from the Secretary’s changing the requirements for such procedures, to the extent the changes in costs are not reflected in such data.

Paragraph (2) shall apply to changes in requirements effected before, on, or after July 1, 1986.

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SEC. 9320.  PAYMENT FOR SERVICES OF CERTIFIED REGISTERED NURSE ANESTHETISTS.

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(i) [42 U.S.C. 1395k note]  Except as provided in subsection (k), the amendments made by this section (other than subsection (a)) shall apply to services furnished on or after January 1, 1989.

(j) [42 U.S.C. 1395k note]  Construction.—Nothing in this section or the amendments made by this section shall contravene provisions of State law relating to the practice of medicine or nursing or State law requirements or institutional requirements regarding the administration of anesthesia and its medical direction or supervision.

(k) [42 U.S.C. 1395k note]  Authorization of Continuation of Pass-Through.—

(1)  Subject to paragraph (2), the amendments made by this section shall not apply during a year (beginning with 1989) to a hospital located in a rural area (as defined for purposes of section 1886(d) of the Social Security Act) if the hospital establishes, at any time before the year to the satisfaction of the Secretary of Health and Human Services that—

(A)  as of January 1, 1988, the hospital employed or contracted with a certified registered nurse anesthetist (but not more than one full-time equivalent certified registered nurse anesthetist),

(B)  in 1987 the hospital had a volume of surgical procedures (including inpatient and outpatient procedures) requiring anesthesia services that did not exceed 500 (or such higher number as the Secretary determines to be appropriate), and

(C)  each certified registered nurse anesthetist employed by, or under contract with, the hospital has agreed not to bill under part B of title XVIII of such Act for professional services furnished by the anesthetist at the hospital.

(2)  Paragraph (1) shall not apply in in[183] a year (after 1989) to a hospital unless the hospital establishes, before the beginning of the year, that the hospital has had a volume of surgical procedures (including inpatient and outpatient procedures) requiring anesthesia services in the previous year that did not exceed 500 (or such higher number as the Secretary determines to be appropriate).

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SEC. 9334.  PAYMENT FOR CATARACT SURGICAL PROCEDURES.

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(b) [42 U.S.C. 1395u note]  Ratification of Regulations.—

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(2)  Patient protections.—In the case of any reduction in the reasonable charge for physicians’ services effected under the regulation described in paragraph (1), the provisions of section 1842(j)(1)(D) of the Social Security Act (added by the amendment made by subsection (a)(3)) shall apply in the same manner and to the same extent as they apply to a reduction in the reasonable charge for a physicians’ service effected under section 1842(b)(8) of such Act.

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SEC. 9339.  PAYMENT FOR CLINICAL DIAGNOSTIC LABORATORY TESTS.

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(d) [42 U.S.C. 1395l note]  State Standards For Directors of Clinical Laboratories.—

(1)  In general.—If a State (as defined for purposes of title XVIII of the Social Security Act) provides for the licensing or other standards with respect to the operation of clinical laboratories (including such laboratories in hospitals) in the State under which such a laboratory may be directed by an individual with certain qualifications, nothing in such title shall be construed as authorizing the Secretary of Health and Human Services to require such a laboratory, as a condition of payment or participation under such title, to be directed by an individual with other qualifications.

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SEC. 9342. [42 U.S.C. 1395b-1 note]  ALZHEIMER’S DISEASE DEMONSTRATION PROJECTS.

(a)  Demonstration Projects.—The Secretary of Health and Human Services (in this section referred to as the “Secretary”) shall conduct at least 5 (and not more than 10) demonstration projects to determine the effectiveness, cost, and impact on health status and functioning of providing comprehensive services for individuals entitled to benefits under title XVIII of the Social Security Act (in this section referred to as “medicare beneficiaries”) who are victims of Alzheimer’s disease or related disorders.

(b)  Services Under Demonstration Projects.—The services provided under demonstration projects must be designed to meet the specific needs of Alzheimer’s disease patients and may include—

(1)  case management services,

(2)  home and community-based services,

(3)  mental health services,

(4)  outpatient drug therapy,

(5)  respite care and other supportive services and counseling for family,

(6)  adult day care services, and

(7)  other in-home services.

(c)  Conduct of Projects.—The demonstration projects shall—

(1)  each be conducted over a period of 5 years;

(2)  provide each medicare beneficiary with a comprehensive medical and mental status evaluation upon entering the project and at discharge;

(3)  be conducted by an entity which either directly or by contract is able to provide such comprehensive evaluations and the additional services (described in subsection (b)) covered by the project;

(4)  be conducted in sites which are chosen so as to be geographicallydiverse and located in States with a high proportion of medicare beneficiaries and in areas readily accessible to a significant number of medicare beneficiaries; and

(5)  involve community outreach efforts at each site to enroll the maximum number of medicare beneficiaries in each project.

(d)  Evaluation and Reports.—The Secretary shall provide for an evaluation of the demonstration projects and shall submit to the Committees on Energy and Commerce and Ways and Means of the House of Representatives and the Committee on Finance of the Senate—

(1)  a preliminary report during the fourth year of the projects, which report shall include a description of the sites at which the projects are being conducted and the services being provided at the different sites, and

(2)  a final report upon completion of the projects, which report shall include recommendations for appropriate legislative changes.

(f)  [184] Funding.—Expenditures (not to exceed $58,000,000 for the projects and $5,000,000 for the evaluation of the projects) made for the demonstration projects shall be made from the Federal Supplementary Medical Insurance Trust Fund (established by section 1841 of the Social Security Act). Grants and payments under contracts may be made either in advance or by way of reimbursement, as may be determined by the Secretary, and shall be made in such installments and on such conditions as the Secretary finds necessary to carry out the purpose of this section.

(g)  Waiver of Medicare Requirements.—The Secretary shall waive compliance with the requirements of title XVIII of the Social Security Act to the extent and for the period the Secretary finds necessary for the conduct of the demonstration projects.

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SEC. 9344.  TECHNICAL AMENDMENTS AND MISCELLANEOUS PROVISIONS RELATING TO PART B.

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(2) [42 U.S.C. 1395w-1 note]  Appointment of additional members.—The Director of the Congressional Office of Technology Assessment shall appoint the two additional members of the Physician Payment Review Commission, as required by the amendment made by paragraph (1), no later than 60 days after the date of the enactment of this Act, for terms of 3 years, except that the Director may provide initially for such terms as will insure that (on a continuing basis) the terms of no more than five members expire in any one year.

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SEC. 9353.  PRO REVIEW OF QUALITY OF CARE.

(a)  *  *  *

(4) [42 U.S.C. 1320c-3 note]  Small-area analysis.—The Secretary of Health and Human Services shall provide, to at least 12 utilization and quality control peer review organizations with contracts under part B of title XI of the Social Security Act, data and data processing assistance to allow each of these organizations to review and analyze small-area variations, in the service area of the organization, in the utilization of hospital and other health care services for which payment is made under title XVIII of such Act.

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SEC. 9412.  WAIVER AUTHORITY FOR CHRONICALLY MENTALLY ILL AND FRAIL ELDERLY.

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(b) [None Assigned]  Frail Elderly Project Waivers.—

(1)  The Secretary of Health and Human Services shall grant waivers of certain requirements of titles XVIII and XIX of the Social Security Act to not more than 10 public or nonprofit private community-based organizations to enable such organizations to provide comprehensive health care services on a capitated basis to frail elderly patients at risk of institutionalization.

(2)(A)  Except as provided in subparagraph (B), the terms and conditions of a waiver granted pursuant to this subsection shall be substantially the same as the terms and conditions of the On Lok waiver (referred to in section 603k) of the Social Security Amendments of 1983 and extended by section 9220 of the Consolidated Omnibus Budget Reconciliation Act of 1985).

(B)  In order to receive a waiver under this subsection, an organization must be awarded a grant from the Robert Wood Johnson Foundation.

(C)  Subject to subparagraph (B), any waiver granted pursuant to this subsection shall be for an initial period of 3 years. The Secretary may extend such waiver beyond such initial period for so long as the Secretary finds that the organization complies with the terms and conditions described in subparagraphs (A) and (B).

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Sec. 9442. [42 U.S.C. 679a note]  MATERNAL AND CHILD HEALTH AND ADOPTION CLEARINGHOUSE.

The Secretary of Health and Human Services shall establish, either directly or by grant or contract, a National Adoption Information Clearinghouse. The Clearinghouse shall—

(1)  collect, compile, and maintain information obtained from available research, studies, and reports by public and private agencies, institutions, or individuals concerning all aspects of infant adoption and adoption of children with special needs;

(2)  compile, maintain, and periodically revise directories of information concerning—

(A)  crisis pregnancy centers,

(B)  shelters and residences for pregnant women,

(C)  training programs on adoption,

(D)  educational programs on adoption,

(E)  licensed adoption agencies,

(F)  State laws relating to adoption,

(G)  intercountry adoption, and

(H)  any other information relating to adoption for pregnant women, infertile couples, adoptive parents, unmarried individuals who want to adopt children, individuals who have been adopted, birth parents who have placed a child for adoption, adoption agencies, social workers, counselors, or other individuals who work in the adoption field;

(3)  disseminate the information compiled and maintained pursuant to paragraph (1) and the directories compiled and maintained pursuant to paragraph (2); and

(4)  upon the establishment of an adoption and foster care data collection system pursuant to section 479 of the Social Security Act, disseminate the data and information made available through that system.

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[Internal References.—SSAct §§215(i), 1833(l), 1886(e) and 1894(e) cite the Omnibus Budget Reconciliation Act of 1986. SSAct Titles XI Part B, XVIII, and §§479 and 1876 headings, 1833(l), 1842(j), and 1876(f) have footnotes referring to P.L. 99-509.]



[183]  As in original; one “in” should be stricken.

[184]  As in original. No subsection (e).