Medicare and Medicaid Related Provisions=
Medicare and Medicaid Amendments of 1980 - States that in determining the reasonable costs of services furnished by nonprofit hospitals under titles V (Maternal and Child Health), XVIII (Medicare), and XIX (Medicaid) of the Social Security Act, gifts, grants and endowments, and other specified items shall not be deducted from any operating costs of such hospitals, effective after the date of enactment of this Act. Amends title XVIII (Medicare) of such Act to authorize reimbursement for inappropriate inpatient hospital services in specified circumstances.
Provides that hospitals, under Medicare and Medicaid, reimbursed under the demonstration project reimbursement system shall continue to be reimbursed under that system until either:
(1) a third party payor reimburses such a hospital on another basis; or
(2) the rate of increase for the previous three year period in costs per inpatient admission is greater than such rate of increase in all other hospitals over the same period.
Prohibits the Secretary of Health and Human Services from providing more than a total of six Statewide Medicare hospital reimbursement demonstration projects under the Social Security Amendments of 1967 or the Social Security Amendments of 1972.
Authorizes hospitals under title XVIII which:
(1) are located in rural areas and have less than 50 beds; and
(2) have been granted a certificate of need for the provision of long-term care services to enter agreements under which their inpatient hospital facilities may be used to furnish services which if furnished by a skilled nursing facility would constitute extended care services.
Authorizes the Secretary of Health and Human Services to enter into such an agreement on a demonstration basis with any hospital which is not in a rural area and which has more than 50 beds if such hospital otherwise complies with the requirements of this Act. Provides Medicaid coverage for skilled nursing facility services and intermediate care facility services furnished by a hospital which has in effect an agreement under title XVIII. Authorizes the Secretary to reduce the Federal share of Medicaid payments to a State with respect to expenditures by providers that participate or have participated in the Medicare program and from which the Secretary has been unable to recover Medicare payments or information concerning Medicare overpayments.
Extends until December 31, 1981, the program conducted by the Secretary to determine the proficiency of individuals who do not otherwise meet formal qualifications criteria to perform the duties of certain health care personnel.
Requires any entity receiving payments under the Medicaid program to comply with certain financial reporting requirements.
Amends part A (General Provisions) of title XI of the Act to exclude from participation in Medicare or Medicaid any physician or other individual convicted of a criminal offense related to such individual's participation in either program or the program of grants to States for services.
Requires, as a condition for payment to any State under titles V (Maternal and Child Health and Crippled Children's Services) or XIX of the Act for costs incurred in the performance of audits of entities which also provide services under title XVIII, that such audits be coordinated with audits of entities performed for purposes of title XVIII. Directs the Secretary:
(1) to establish one or more projects to demonstrate the feasibility of creating a single coordinated appeal hearing to adjudicate those administrative cost items which are determined under such a coordinated audit and which such entities dispute and appeal; and
(2) to provide for the review of the feasibilty of establishing a single coordinated process for the collection of overpayments established in an audit.
Requires, under the Medicare program, a skilled nursing facility to meet such provisions of such edition (as specified by the Secretary) of the Life Safety Code of the National Fire Protection Association as are applicable to nursing homes.
Provides that any institution which is in compliance with the Life Safety Code before the date of the enactment of this Act shall, so long as such compliance is maintained, be considered to be in compliance with this Act. Authorizes the Secretary under title XVIII and the State under title XIX, in lieu of decertifying a skilled nursing facility which is out of compliance with conditions of participation specified in the Act, to deny payment to such a facility for services furnished, if the health and safety of the patients is not immediately jeopardized.
Directs that the Secretary shall not make such a decision until such facility has had a reasonable opportunity to correct the deficiencies.
Authorizes the Secretary, under title XIX, to make an independent and binding determination concerning the extent to which an institution meets the conditions of participation.
Provides that criminal penalties for the solicitation of Medicare or Medicaid business shall apply only if such conduct is undertaken knowingly and willfully.
Sets limits, under the Medicare and Medicaid programs, on payments to a physician for laboratory tests reimbursable under those programs.
Directs the Secretary to report to Congress concerning such payments.
Directs the Secretary to conduct a study of the availability and need for skilled nursing facility services covered under Medicare and Medicaid and to report to Congress concerning such study.
Amends part B (Professional Standards Review) of title XI of the Social Security Act to permit an organization qualified for conditional designation as a Professional Standards Review Organization (PSRO) to include health care practitioners, other than physicians and osteopaths, who hold independent hospital admitting privileges, if invited to become members by the organization.
Includes as members of the advisory group for each statewide Professional Standards Review Council at least one registered professional nurse and doctor of dental surgery.
Includes one registered professional nurse, one doctor of dental surgery, and one health practitioner other than physicians and osteopaths on the National Professional Standards Review Council. Revises the duties of a conditionally designated PSRO. Directs the Secretary to establish a program for the evaluation of the cost-effectiveness of review of particular health care services by PSROs. Eliminates the requirement that a PSRO must, if capable, review ambulatory care services provided under the Act within two years of becoming a fully designated PSRO. Authorizes the Secretary to replace one PSRO with another PSRO if the PSRO initially designated is not conducting particular review activities.
Authorizes each PSRO to determine, in advance, the medical necessity and appropriateness of any routine diagnostic services furnished in connection with an elective admission to a hospital or other health care facility.
States that PSROs may be directed by the Secretary to exercise such authority.
Requires a PSRO to consult with representatives of health care practitioners, other than physicians, and representatives of institutional and noninstitutional providers of health care services in relation to the responsibility of a PSRO to review the professional activities of such practitioners and providers.
Permits a PSRO to withhold any records requested pursuant to a request under the Freedeom of Information Act until the later of:
(1) one year after the entry of a final court order ordering disclosure; or
(2) the last date of the Congress during which the court order was entered.
Directs the Secretary, in consultation with the National Professional Standards Review Council, to conduct a nationwide study of the differences in medical criteria and length-of-stay norms utilized by PSROs in the various regions of the country and to report to Congress the findings and conclusions.
Amends title XVIII (Medicare) of the Social Security Act with respect to home health care services to eliminate:
(1) the 100 visit limitation presently applicable to such services;
(2) prior hospitalization as a condition of eligibility for such services; and
(3) the $60 deductible.
Directs the Secretary of Health and Human Services to prescribe regulations which prohibit a physician who has a significant financial relationship with a home health agency from certifying that the services of such agency are required for any individual, and from establishing and reviewing a plan for furnishing such services to such individuals.
Includes occupational therapy as a home health service.
Requires home health aides to complete a training program approved by the Secretary. Repeals provisions of title XVIII which prohibit the classification as a home health agency of a private organization which is not a nonprofit organization unless licensed pursuant to State law.
Excludes certain costs related to bonding and escrow accounts from the determination of reasonable costs for home health agencies.
Amends title XVIII of such Act to authorize payments for alcohol detoxification facility services if such services are required on an inpatient basis.
Provides Medicare coverage for diagnostic services performed on an outpatient basis within seven days of a patient's admission to a hospital.
Directs the Secretary to report to Congress on this coverage.
Allows reimbursement under the Medicare program for services furnished in comprehensive outpatient rehabilitation centers.
Sets forth provisions specifying the scope of services provided in such centers and the conditions and limitations on payments for such services.
Authorizes payment under Medicare for certain surgical procedures specified by the Secretary which are performed in an ambulatory surgical center or in a physician's office in certain circumstances.
Requires such centers and physicians to agree to accept an amount determined under this Act as a fair fee.
Sets forth criteria for determining such fee.
Increases from $100 to $500 the payment limitation for certain outpatient physical therapy services under the Medicare program.
Provides Medicare coverage, effective July 1, 1981, for:
(1) all services performed by a dentist which would be covered if performed by a physician; and
(2) inpatient hospital services furnished because of the severity of the dental procedure.
Restricts payment for optometrists' services under Medicare to services related to the treatment of aphakia, effective July 1, 1981.
Directs the Secretary to make recommendations with respect to providing Medicare coverage for the treatment of cataracts and for other services which optometrists may perform.
Authorizes payment under the Medicare program for antigens prepared by a physician, after January 1, 1981.
Authorizes payment under the Medicare program for the cutting or removal of warts on the feet, effective July 1, 1981.
Repeals provisions of the Medicare program concerning the presumed coverage for extended care facilities and home health care in specified circumstances, effective January 1, 1981.
Repeals the existing provisions under part A (Hospital Insurance) of title XVIII under which payment to a provider of services shall be the lesser of the reasonable cost of such services or the customary charge with respect to such services, and provides that payment to a provider shall now be based upon the reasonable cost of such services.
Limits the 100 percent reimbursement for the impatient hospital services of radiologists and pathologists to those radiologists and pathologists who agree to accept assignment for all services furnished by such physicians under part B. Allows a speech pathologist, as well as a physician, to establish the plan of treatment for speech pathology services, after January 1, 1981.
Repeals the prohibition against enrolling more than twice in the Supplementary Medical Insurance Program (part B of title XVIII), effective April 1, 1981.
Repeals the present time limitation applicable for general enrollment under part B and permits an eligible individual to enroll at any time, effective April 1, 1981.
Permits States to enter into agreements with the Secretary during 1981 for Medicare Part B protection for individuals receiving other public assistance.
Sets forth criteria for determining reasonable charges for medical services.
Permits an individual whose coverage for part B of Medicare has ended to terminate such coverage effective with the month Medicare is notified that coverage is no longer wanted.
Includes, under Medicare, as inpatient hospital services the services of a physician in a teaching hospital only if:
(1) the hospital elects to receive any payment due under Medicare for reasonable costs of such services; and
(2) all physicians in the hospital agree not to bill charges for professional services rendered in such hospital to individuals covered by Medicare. Allows reimbursement on a charge basis under Medicare for services of a physician in a teaching hospital which does not meet such requriements if:
(1) such physician exercises full, personal control over the portion of the patient's case for which payment is sought;
(2) the services are the same as those such physician furnishes to non-Medicare patients; and
(3) at least 25 percent of such hospital's non-Medicare patients pay all or a substantial part of such services.
Sets forth criteria for determining the customary charge for such services in a hosptial.
Includes a rural health facility of 50 beds or less within the definition of the term "hospital" under title XVIII. Makes special provisions with respect to nursing services, health, fire, and safety requirements for such facilities.
Increases from 14 to 30 days the period within which a Medicare beneficiary must be admitted to a skilled nursing facility following inpatient hospital care in order to qualify for post hospital extended care benefits.
Recognizes podiatrists as physicians for purposes of physician certification and participation in utilization review where consistent with State law and policies of the health care institutions involved, effective January 1, 1981.
Prohibits Medicare reimbursement for amounts incurred by a provider with Medicare contracts for services valuing $10,000 or more annually unless such contracts permit the Secretary and the Comptroller General access to any books, records, and papers directly related to such contracts.
Prohibits Medicare payments where payment has been made or can reasonably be expected to be made under an automobile or liability insurance policy (including a self-insured plan) or under no fault insurance.
States that where services are provided for which payment may be made under the Medicare program to an individual who has died, and the persons who provided the services do not agree that the reasonable charge is the full charge for the services, payment shall be made on the basis of an itemized bill, effective January 1, 1981.
States that providers of services have the right to judicial review of any action of the fiscal intermediary involving a question of law or regulations relevant to the matters in controversy whenever the Provider Reimbursement Review Board determines, on its own motion or at the request of a provider, that it is without authority to decide the question.
Authorizes the Secretary to make payments of such benefits as are necessary to correct the effect of an unintentional or erroneous transfer of an individual from an approved hospital or skilled nursing facility, effective January 1, 1981.
Authorizes the Secretary to enter into agreements with nonprofit entities for the reimbursement of the reasonable cost of home dialysis equipment.
Directs the Secretary to conduct studies on the following:
(1) the circumstances and conditions under which services furnished by registered dietitians should be covered as a home health service under Medicare;
(2) the methods for providing Medicare coverage for orthopedic shoes for certain individuals;
(3) the circumstances and conditions under which services furnished with respect to respiratory therapy should be covered under Medicare as a home health benefit; and
(4) a comprehensive analysis of the cost effects of alternative approaches to improving Medicare coverage for the treatment of various types of foot conditions.
Directs the Secretary to carry out demonstration projects to determine:
(1) the extent to which nutritional therapy commenced in early renal failure, utilizing controlled protein substances, can retard or arrest the disease;
(2) the administrative, financial, and other aspects of making such nutritional therapy generally available as a Medicare benefit; and
(3) the administrative, financial, and other aspects of making the services of clinical social workers more generally available as a Medicare benefit.
Directs the Secretary to submit a report on each study and demonstration project.
Requires any study or demonstration project relating to payments for services furnished by independent practitioners to include an evaluation of the effect of such payments on coordination of care, cost, quality, and organization in the provision and utilization of such services.
Directs the Secretary to defer specified periodic interim payments to hospitals until fiscal year 1982.
Amends title XIX of the Social Security Act to authorize a State to retain Federal matching payments for all disputed Medicaid claims by such State until a final administrative determination with respect to such claims has been made, effective October 1, 1980.
Requires such State to return such Federal payments to the Secretary, with interest, if such determination upholds the Secretary's disallowance of such claims.
Requires the States to develop methods for determining reasonable rates for payment of skilled nursing and intermediate care facilities.
Extends funding for State Medicaid fraud control units.
Changes the calendar quarter for which satisfactory utilization review must be shown to receive waiver of Medicaid reduction.
Amends title XIX (Medicaid) of the Social Security Act to include coverage of services rendered by a nurse-midwife, whether or not he or she is supervised by or associated with a physician.
Defines the term "nurse-midwife" to mean a registered nurse who has successfully completed a prescribed course of study or who has been certified by a recognized organization, and who performs services in the management of the care of mothers and babies throughout the maternity cycle.
Authorizes the Secretary to enter into agreements with no more than 12 States for the purpose of conducting demonstration projects for the training and employment as homemakers or home health aides of individuals who have been certified by the appropriate State or local government agency as being eligible for financial assistance under a State plan of Aid to Families with Dependent Children approved under title IV of the Act. Directs the Secretary to submit annual reports to the Congress evaluating such demonstration projects.