To strengthen protections for consumers against misleading direct-to-consumer drug advertising.

TEXT OF AMENDMENTS

SA 1044. Mr. BAYH submitted an amendment intended to be proposed by
him to the bill S. 1, to amend title XVIII of the Social Security Act
to make improvements in the medicare program, to provide prescription
drug coverage under the medicare program, and for other purposes; which
was ordered to lie on the table; as follows:

At the appropriate place, insert the following:

SEC. __. URBAN HEALTH PROVIDER ADJUSTMENT.

(a) In General.--Beginning with fiscal year 2004,
notwithstanding section 1923(f) of the Social Security Act
(42 U.S.C. 1396r-4(f)) and subject to subsection (c), with
respect to a State, payment adjustments made under title XIX
of the Social Security Act (42 U.S.C. 1396 et seq.) to a
hospital described in subsection (b) shall be made without
regard to the DSH allotment limitation for the State
determined under section 1923(f) of that Act (42 U.S.C.
1396r-4(f)).
(b) Hospital Described.--A hospital is described in this
subsection if the hospital--
(1) is owned or operated by a State (as defined for
purposes of title XIX of the Social Security Act), or by an
instrumentality or a municipal governmental unit within a
State (as so defined) as of January 1, 2003; and
(2) is located in Marion County, Indiana.
(c) Limitation.--The payment adjustment described in
subsection (a) for fiscal year 2004 and each fiscal year
thereafter shall not exceed 175 percent of the costs of
furnishing hospital services described in section
1923(g)(1)(A) of the Social Security Act (42 U.S.C. 1396r-
4(g)(1)(A)).
______

SA 1045. Mr. CHAMBLISS submitted an amendment intended to be proposed
by him to the bill S. 1, to amend title XVIII of the Social Security
Act to make improvements in the medicare program, to provide
prescription drug coverage under the medicare program, and for other
purposes; which was ordered to lie on the table; as follows:

At the end of subtitle B of title IV, add the following:

SEC. __. DEMONSTRATION PROJECT FOR EXCLUSION OF BRACHYTHERAPY
DEVICES FROM PROSPECTIVE PAYMENT SYSTEM FOR
OUTPATIENT HOSPITAL SERVICES.

(a) Demonstration Project.--The Secretary shall conduct a
demonstration project under part B of title XVIII of the
Social Security Act under which brachytherapy devices shall
be excluded from the prospective payment system for
outpatient hospital services under the medicare program and,
notwithstanding section 1833(t) of the Social Security Act
(42 U.S.C. 1395l(t)), the amount of payment for a device of
brachytherapy furnished under the demonstration project shall
be equal to the hospital's charges for each device furnished,
adjusted to cost.
(b) Specification of Groups for Brachytherapy Devices.--The
Secretary shall create additional groups of covered OPD
services that classify devices of brachytherapy furnished
under the demonstration project separately from the other
services (or group of services) paid for under section
1833(t) of the Social Security Act (42 U.S.C. 1395l(t)) in a
manner reflecting the number, isotope, and radioactive
intensity of such devices furnished, including separate
groups for palladium-103 and iodine-125 devices.
(c) Duration.--The Secretary shall conduct the
demonstration project under this section for the 3-year
period beginning on the date that is 90 days after the date
of enactment of this Act.
(d) Report.--Not later than January 1, 2007, the Secretary
shall submit to Congress a report on the demonstration
project conducted under this section. The report shall
include an evaluation of patient outcomes under the
demonstration project, as well as an analysis of the cost
effectiveness of the demonstration project.
(e) Waiver Authority.--The Secretary shall waive compliance
with the requirements of title XVIII of the Social Security
Act to such extent and for such period as the Secretary
determines is necessary to conduct the demonstration project
under this section.
(f) Funding.--
(1) In general.--The Secretary shall provide for the
transfer from the Federal Supplementary Insurance Trust Fund
established under section 1841 of the Social Security Act (42
U.S.C. 1395t) of such funds as are necessary for the costs of
carrying out the demonstration project under this section.
(2) Budget neutrality.--In conducting the demonstration
project under this section, the Secretary shall ensure that
the aggregate payments made by the Secretary do not exceed
the amount which the Secretary would have paid if the
demonstration project under this section was not implemented.
______

SA 1046. Mr. CHAMBLISS submitted an amendment intended to be proposed
by him to the bill S. 1, to amend title XVIII of the Social Security
Act to make improvements in the medicare program, to provide
prescription drug coverage under the medicare program, and for other
purposes; which was ordered to lie on the table; as follows:

At the end of subtile B of title IV, add the following:

SEC. __. DEMONSTRATION PROJECT FOR COVERAGE OF SURGICAL FIRST
ASSISTING SERVICES OF CERTIFIED REGISTERED
NURSE FIRST ASSISTANTS.

(a) Demonstration Project.--The Secretary shall conduct a
demonstration project under part B of title XVIII of the
Social Security Act under which payment is made for surgical
first assisting services furnished by a certified registered
nurse first assistant to medicare beneficiaries.
(b) Definitions.--In this section:
(1) Surgical First Assisting Services.--The term ``surgical
first assisting services'' means services consisting of first
assisting a physician with surgery and related preoperative,
intraoperative, and postoperative care (as determined by the
Secretary) furnished by a certified registered nurse first
assistant (as defined in paragraph (2)) which the certified
registered nurse first assistant is legally authorized to
perform by the State in which the services are performed.
(2) Certified Registered Nurse First Assistant.--The term
``certified registered nurse first assistant'' means an
individual who--
(A) is a registered nurse and is licensed to practice
nursing in the State in which the surgical first assisting
services are performed;
(B) has completed a minimum of 2,000 hours of first
assisting a physician with surgery and related preoperative,
intraoperative, and postoperative care; and
(C) is certified as a registered nurse first assistant by
an organization recognized by the Secretary.

[[Page S8579]]

(c) Payment Rates.--Payment under the demonstration project
for surgical first assisting services furnished by a
certified registered nurse first assistant shall be made at
the rate of 80 percent of the lesser of the actual charge for
the services or 85 percent of the amount determined under the
fee schedule established under section 1848(b) of the Social
Security Act (42 U.S.C. 1395w-4(b)) for the same services if
furnished by a physician.
(d) Demonstration Project Sites.--The project established
under this section shall be conducted in 5 States selected by
the Secretary.
(e) Duration.--The Secretary shall conduct the
demonstration project for the 3-year period beginning on the
date that is 90 days after the date of the enactment of this
Act.
(f) Report.--Not later than January 1, 2007, the Secretary
shall submit to Congress a report on the project. The report
shall include an evaluation of patient outcomes under the
project, as well as an analysis of the cost effectiveness of
the project.
(g) Funding.--
(1) In general.--The Secretary shall provide for the
transfer from the Federal Supplementary Insurance Trust Fund
established under section 1841 of the Social Security Act (42
U.S.C. 1395t) of such funds as are necessary for the costs of
carrying out the project under this section.
(2) Budget neutrality.--In conducting the project under
this section, the Secretary shall ensure that the aggregate
payments made by the Secretary do not exceed the amount which
the Secretary would have paid if the project under this
section was not implemented.
(i) Waiver Authority.--The Secretary shall waive compliance
with the requirements of title XVIII of the Social Security
Act to such extent and for such period as the Secretary
determines is necessary to conduct demonstration projects.
______

SA 1047. Mr. LEVIN submitted an amendment intended to be proposed by
him to the bill S. 1, to amend title XVIII of the Social Security Act
to make improvements in the medicare program, to provide prescription
drug coverage under the medicare program, and for other purposes; which
was ordered to lie on the table; as follows:

On page 78, line 15, insert before the period the
following: ``and all succeeding years. Once such a
determination is made with respect to an area, the
Administrator shall ensure that a contract of the type
entered into under the preceding sentence remains in effect
for such area for each such succeeding year and beneficiaries
receiving the standard prescription drug coverage under such
a contract may elect to remain enrolled in such coverage
under a such contract regardless of whether the access
required under subsection (d)(1) is going to be provided in
the area in the year''.
______

SA 1048. Mr. LEVIN submitted an amendment intended to be proposed by
him to the bill S. 1, to amend title XVIII of the Social Security Act
to make improvements in the medicare program, to provide prescription
drug coverage under the medicare program, and for other purposes; which
was ordered to lie on the table; as follows:

On page 79, between line 22 and 23, insert the following:
``(F) Permanent fallback in certain areas.--
``(i) In general.--Notwithstanding paragraph (1), in the
case of an applicable area, the Administrator shall enter
into a contract under paragraph (1)(B) with respect to the
area for each year after the year in which the area meets the
definition of an applicable area. Eligible beneficiaries
residing in such area may elect to receive standard
prescription drug coverage (including access to negotiated
prices for such beneficiaries pursuant to section 1860D-6(e))
under such contract in a year regardless of whether the
access required under subsection (d)(1) is going to be
provided in the area in that year.
``(ii) Applicable area.--For purposes of this subparagraph,
the term `applicable area' means an area--

``(I) that was designated under paragraph (1)(B) for a
year;
``(II) in which the access required under subsection (d)(1)
was met with respect to a year subsequent to the year
described in subclause (I); and
``(III) that was designated under paragraph (1)(B) for a
year subsequent to the year described in subclause (II).

______

SA 1049. Mr. LEVIN submitted an amendment intended to be proposed by
him to the bill S. 1, to amend title XVIII of the Social Security Act
to make improvements in the medicare program, to provide prescription
drug coverage under the medicare program, and for other purposes; which
was ordered to lie on the table; as follows:

Beginning on page 39, strike line 23 through page 40, line
2, and insert the following:
``(E) Restrictions on removing drugs from formulary.--An
eligible entity may not remove a drug from the formulary
under the plan--
``(i) during the 2-year contract for the plan; and
``(ii) unless the entity has provided appropriate notice to
beneficiaries, physicians, and pharmacists that the drug will
be removed at the beginning of the subsequent 2-year contract
for the plan.
______

SA 1050. Mr. LEVIN submitted an amendment intended to be proposed by
him to the bill S. 1, to amend title XVIII of the Social Security Act
to make improvements in the medicare program, to provide prescription
drug coverage under the medicare program, and for other purposes; which
was ordered to lie on the table; as follows:

On page 79, between line 22 and 23, insert the following:
``(F) Permanent fallback for certain beneficiaries.--
``(i) In general.--Notwithstanding paragraph (1), the
Administrator shall enter into a contract under paragraph
(1)(B) for each area for each year. Applicable eligible
beneficiaries residing in such area may elect to receive
standard prescription drug coverage (including access to
negotiated prices for such beneficiaries pursuant to section
1860D-6(e)) under such contract in a year regardless of
whether the access required under subsection (d)(1) is going
to be provided in the area in that year. Other eligible
beneficiaries residing in such area may elect to receive such
coverage under such contract only if the area has been
designated under paragraph (1)(B) for the year.
``(ii) Applicable eligible beneficiary.--For purposes of
this subparagraph, the term `applicable eligible beneficiary'
means an individual who--

``(I) is enrolled under this part;
``(II) was covered under a group health plan; and
``(III) involuntarily lost such coverage such that the
beneficiary was eligible for a special open enrollment period
under section 1860D-2(b)(3).

______

SA 1051. Mr. ENZI (for himself, Mrs. Lincoln, Mr. Pryor, and Ms.
Murkowski) proposed an amendment to the bill S. 1, to amend title XVIII
of the Social Security Act to make improvements in the medicare
program, to provide prescription drug coverage under the medicare
program, and for other purposes; as follows:
On page 37, between lines 20 and 21, insert the following:
``(C) Convenient access to pharmacies.--In this section,
the term `convenient access' means access that is no less
favorable to enrollees than the rules for convenient access
to pharmacies of the Secretary of Defense established as of
June 1, 2003, for purposes of the TriCare retail pharmacy
program. Such rules shall include adequate emergency access
for enrolled beneficiaries.
On page 48, between lines 4 and 5, insert the following:
``(4) Tying of contracts.--No eligible entity with a
contract under this part, or its agent, may require a
pharmacy to participate in a medicare prescription drug plan
as a condition of participating in nonmedicare programs or
networks, or require a pharmacy to participate in a
nonmedicare program or network as a condition of
participating in a medicare prescription drug plan.
______

SA 1052. Mr. EDWARDS (for himself and Mr. Harkin) proposed an
amendment to the bill S. 1, to amend title XVIII of the Social Security
Act to make improvements in the medicare program, to provide
prescription drug coverage under the medicar program, and for other
purposes; as follows:

At the end, add the following:

TITLE __--DIRECT-TO-CONSUMER PRESCRIPTION DRUG ADVERTISING

SEC.__01. DIRECT-TO-CONSUMER ADVERTISING.

Section 505 of the Federal Food, Drug, and Cosmetic Act (21
U.S.C. 355) is amended by inserting at the end the following:
Regulations.--
(1) In general.--Not later than 180 days after the date of
enactment of this Act, the Secretary of Health and Human
Services shall promulgate amended regulations governing
prescription drug advertisements.
(2) Contents.--In addition to any other requirements, the
regulations under paragraph (1) shall require that--
(A) any advertisement present a fair balance, comparable in
depth and detail, between--
(i) information relating to effectiveness of the drug
(including, if available, effectiveness in comparison to
other drugs for substantially the same condition or
conditions); and
(ii) information relating to side effects and
contraindications;
(B) any advertisement present a fair balance, comparable in
depth, between--
(i) aural and visual presentations relating to
effectiveness of the drug; and
(ii) aural and visual presentations relating to side
effects and contraindications, provided that, nothing in this
section shall require explicit images or sounds depicting
side effects and contraindications;
(C) prohibit false or misleading advertising that would
encourage a consumer to take the prescription drug for a use
other than a use for which the prescription drug is approved
under section 505 of the Federal Food, Drug, and Cosmetic Act
(21 U.S.C. 355); and

[[Page S8580]]

(D) require that any prescription drug that is the subject
of a direct-to-consumer advertisement include in the package
in which the prescription drug is sold to consumers a
medication guide explaining the benefits and risks of use of
the prescription drug in terms designed to be understandable
to the general public.

SEC. __02. CIVIL PENALTY.

Section 303 of the Federal Food, Drug, and Cosmetic Act (21
U.S.C. 333) is amended by adding at the end the following:
``(h) Direct-to-Consumer Prescription Drug Advertising.--
``(1) In general.--A person that commits a violation of
section 301 involving the misbranding of a prescription drug
(within the meaning of section 502(n)) in a direct-to-
consumer advertisement shall be assessed a civil penalty if--
``(A) the Secretary provides the person written notice of
the violation; and
``(B) the person fails to correct or cease the
advertisement so as to eliminate the violation not later than
180 days after the date of the notice.
``(2) Amount.--The amount of a civil penalty under
paragraph (1)--
``(A) shall not exceed $500,000 in the case of an
individual and $5,000,000 in the case of any other person;
and
``(B) shall not exceed $10,000,000 for all such violations
adjudicated in a single proceeding.
``(3) Procedure.--Paragraphs (3) through (5) of subsection
(g) apply with respect to a civil penalty under paragraph (1)
of this subsection to the same extent and in the same manner
as those paragraphs apply with respect to a civil penalty
under paragraph (1) or (2) of subsection (g).''.

SEC. __03. REPORTS.

The Secretary of Health and Human Services shall annually
submit to the Committee on Health, Education, Labor, and
Pensions of the Senate and the Committee on Energy and
Commerce of the House of Representatives a report that, for
the most recent 1-year period for which data are available--
(1) provides the total number of direct-to-consumer
prescription drug advertisements made by television, radio,
the Internet, written publication, or other media;
(2) identifies, for each such advertisement--
(A) the dates on which, the times at which, and the markets
in which the advertisement was made; and
(B) the type of advertisement (reminder, help-seeking, or
product-claim); and
(3)(A) identifies the advertisements that violated or
appeared to violate section 502(n) of the Federal Food, Drug,
and Cosmetic Act (21 U.S.C. 352(n)); and
(B) describes the actions taken by the Secretary in
response to the violations.

SEC. __04. REVIEW OF DIRECT-TO-CONSUMER DRUG ADVERTISEMENTS.

(a) In General.--The Secretary of Health and Human Services
shall expedite, to the maximum extent practicable, reviews of
the legality of direct-to-consumer drug advertisements.
(b) Policy.--The Secretary of Health and Human Services
shall not adopt or follow any policy that would have the
purpose or effect of delaying reviews of the legality of
direct-to-consumer drug advertisements except--
(1) as a result of notice-and-comment rulemaking; or
(2) as the Secretary determines to be necessary to protect
public health and safety.
______

SA 1053. Mr. AKAKA submitted an amendment intended to be proposed by
him to the bill S. 1, to amend title XVIII of the Social Security Act
to make improvements to the medicare program, to provide prescription
drug coverage under the medicare program, and for other purposes; which
was ordered to lie on the table; as follows:

On page 633, after line 21, add the following:
(3) Application to hawaii.--Section 1923(f) (42 U.S.C.
1396r-4(f)), as amended by paragraph (1), is amended--
(A) by redesignating paragraph (7) as paragraph (8); and
(B) by inserting after paragraph (6), the following:
``(7) Treatment of hawaii as a low-dsh state.--The
Secretary shall compute a DSH allotment for the State of
Hawaii for each of fiscal years 2004 and 2005 in the same
manner as DSH allotments are determined with respect to those
States to which paragraph (5) applies (but without regard to
the requirement under such paragraph that total expenditures
under the State plan for disproportionate share hospital
adjustments for any fiscal year exceeds 0).''.
______

SA 1054. Mr. FEINGOLD submitted an amendment intended to be proposed
by him to the bill S. 1, to amend title XVIII of the Social Security
Act to make improvements in the medicare program, to provide
prescription drug coverage under the medicare program, and for other
purposes; which was ordered to lie on the table; as follows:

At the end of subtitle D of title I, add the following:

SEC. 133. OFFICE OF THE MEDICARE BENEFICIARY ADVOCATE.

(a) Establishment.--Not later than 1 year after the date of
enactment of this Act, the Secretary shall establish within
the Department of Health and Human Services, an Office of the
Medicare Beneficiary Advocate (in this section referred to as
the ``Office'').
(b) Duties.--The Office shall carry out the following
activities:
(1) Establishing a toll-free telephone number for medicare
beneficiaries to use to obtain information on the medicare
program, and particularly with respect to the benefits
provided under part D of title XVIII of the Social Security
Act and the Medicare Prescription Drug plans and
MedicareAdvantage plans offering such benefits. The Office
shall ensure that the toll-free telephone number accommodates
beneficiaries with disabilities and limited-English
proficiency.
(2) Establishing an Internet website with easily accessible
information regarding Medicare Prescription Drug plans and
MedicareAdvantage plans and the benefits offered under such
plans. The website shall--
(A) be updated regularly to reflect changes in services and
benefits, including with respect to the plans offered in a
region and the associated monthly premiums, benefits offered,
formularies, and contact information for such plans, and to
ensure that there are no broken links or errors;
(B) have printer-friendly, downloadable fact sheets on the
medicare coverage options and benefits;
(C) be easy to navigate, with large print and easily
recognizable links; and
(D) provide links to the websites of the eligible entities
participating in part D of title XVIII.
(3) Providing regional publications to medicare
beneficiaries that include regional contacts for information,
and that inform the beneficiaries of the prescription drug
benefit options under title XVIII of the Social Security Act,
including with respect to--
(A) monthly premiums;
(B) formularies; and
(C) the scope of the benefits offered.
(4) Conducting outreach to medicare beneficiaries to inform
the beneficiaries of the medicare coverage options and
benefits under parts A, B, C, and D of title XVIII of the
Social Security Act.
(5) Working with local benefits administrators, ombudsmen,
local benefits specialists, and advocacy groups to ensure
that medicare beneficiaries are aware of the medicare
coverage options and benefits under parts A, B, C, and D of
title XVIII of the Social Security Act.
(c) Funding.--
(1) Establishment.--Of the amounts authorized to be
appropriated under the Secretary's discretion for
administrative expenditures, $2,000,000 may be used to
establish the Office in accordance with this section.
(2) Operation.--With respect to each fiscal year occurring
after the fiscal year in which the Office is established
under this section, the Secretary may use, out of amounts
authorized to be appropriated under the Secretary's
discretion for administrative expenditures for such fiscal
year, such sums as may be necessary to operate the Office in
that fiscal year.
______

SA 1055. Mrs. HUTCHISON (for herself, Mr. Kennedy, Mr. Durbin, Mr.
Kerry, and Mr. Lautenberg) submitted an amendment intended to be
proposed to amendment SA 1004 proposed by Mrs. Hutchison to the bill S.
1, to amend title XVIII of the Social Security Act to make improvements
in the medicare program, to provide prescription drug coverage under
the medicare program, and for other purposes; which was ordered to lie
on the table; as follows:

In lieu of the matter proposed to be added, add the
following:

SEC. __. REVISION OF THE INDIRECT MEDICAL EDUCATION (IME)
ADJUSTMENT PERCENTAGE.

(a) In General.--Section 1886(d)(5)(B)(ii) (42 U.S.C.
1395ww(d)(5)(B)(ii)) is amended--
(1) in subclause (VI), by striking ``and'' after the
semicolon at the end;
(2) in subclause (VII)--
(A) by striking ``on or after October 1, 2002'' and
inserting ``during fiscal year 2003''; and
(B) by striking the period at the end and inserting a
semicolon; and
(3) by adding at the end the following new subclause:
``(VIII) during fiscal year 2004, `c' is equal to 1.41; and
``(IX) on or after October 1, 2005, `c' is equal to
1.47.''.
(b) Conforming Amendment Relating to Determination of
Standardized Amount.--Section 1886(d)(2)(C)(i) (42 U.S.C.
1395ww(d)(2)(C)(i)) is amended--
(1) by striking ``1999 or'' and inserting ``1999,''; and
(2) by inserting ``, or the Prescription Drug and Medicare
Improvement Act of 2003'' after ``2000''.
(c) Effective Date.--The amendments made by this section
shall apply to discharges occurring on or after October 1,
2003.
At the end of subtitle B of title IV, add the following:

SEC. __. MEDICARE SECONDARY PAYOR (MSP) PROVISIONS.

(a) Technical Amendment Concerning Secretary's Authority to
Make Conditional Payment When Certain Primary Plans Do Not
Pay Promptly.--

[[Page S8581]]

(1) In general.--Section 1862(b)(2) (42 U.S.C. 1395y(b)(2))
is amended--
(A) in subparagraph (A)(ii), by striking ``promptly (as
determined in accordance with regulations)'';
(B) in subparagraph (B)--
(i) by redesignating clauses (i) through (iii) as clauses
(ii) through (iv), respectively; and
(ii) by inserting before clause (ii), as so redesignated,
the following new clause:
``(i) Authority to make conditional payment.--The Secretary
may make payment under this title with respect to an item or
service if a primary plan described in subparagraph (A)(ii)
has not made or cannot reasonably be expected to make payment
with respect to such item or service promptly (as determined
in accordance with regulations). Any such payment by the
Secretary shall be conditioned on reimbursement to the
appropriate Trust Fund in accordance with the succeeding
provisions of this subsection.''.
(2) Effective date.--The amendments made by paragraph (1)
shall be effective as if included in the enactment of title
III of the Medicare and Medicaid Budget Reconciliation
Amendments of 1984 (Public Law 98-369).
(b) Clarifying Amendments to Conditional Payment
Provisions.--Section 1862(b)(2) (42 U.S.C. 1395y(b)(2)) is
further amended--
(1) in subparagraph (A), in the matter following clause
(ii), by inserting the following sentence at the end: ``An
entity that engages in a business, trade, or profession shall
be deemed to have a self-insured plan if it carries its own
risk (whether by a failure to obtain insurance, or otherwise)
in whole or in part.'';
(2) in subparagraph (B)(ii), as redesignated by subsection
(a)(2)(B)--
(A) by striking the first sentence and inserting the
following: ``A primary plan, and an entity that receives
payment from a primary plan, shall reimburse the appropriate
Trust Fund for any payment made by the Secretary under this
title with respect to an item or service if it is
demonstrated that such primary plan has or had a
responsibility to make payment with respect to such item or
service. A primary plan's responsibility for such payment may
be demonstrated by a judgment, a payment conditioned upon the
recipient's compromise, waiver, or release (whether or not
there is a determination or admission of liability) of
payment for items or services included in a claim against the
primary plan or the primary plan's insured, or by other
means.''; and
(B) in the final sentence, by striking ``on the date such
notice or other information is received'' and inserting ``on
the date notice of, or information related to, a primary
plan's responsibility for such payment or other information
is received''; and
(3) in subparagraph (B)(iii), as redesignated by subsection
(a)(2)(B), by striking the first sentence and inserting the
following: ``In order to recover payment made under this
title for an item or service, the United States may bring an
action against any or all entities that are or were required
or responsible (directly, as an insurer or self-insurer, as a
third-party administrator, as an employer that sponsors or
contributes to a group health plan, or large group health
plan, or otherwise) to make payment with respect to the same
item or service (or any portion thereof) under a primary
plan. The United States may, in accordance with paragraph
(3)(A) collect double damages against any such entity. In
addition, the United States may recover under this clause
from any entity that has received payment from a primary plan
or from the proceeds of a primary plan's payment to any
entity.''.
(c) Clerical Amendments.--Section 1862(b) (42 U.S.C.
1395y(b)) is amended--
(1) in paragraph (1)(A), by moving the indentation of
clauses (ii) through (v) 2 ems to the left; and
(2) in paragraph (3)(A), by striking ``such'' before
``paragraphs''.
______

SA 1056. Mr. SHELBY (for himself, Ms. Stabenow, Mr. Sessions, Mr.
Cochran, Mr. Lott, and Mrs. Murray) submitted an amendment intended to
be proposed by him to the bill S. 1, to amend title XVIII of the Social
Security Act to make improvements in the medicare program, to provide
prescription drug coverage under the medicare program, and for other
purposes; which was ordered to lie on the table; as follows:

At the end of subtitle A of title IV, add the following:

SEC. __. TREATMENT OF GRANDFATHERED LONG-TERM CARE HOSPITALS.

(a) In General.--The last sentence of section 1886(d)(1)(B)
is amended by inserting ``, and the Secretary may not impose
any special conditions on the operation, size, number of
beds, or location of any hospital so classified for continued
participation under this title or title XIX or for continued
classification as a hospital described in clause (iv)''
before the period at the end.
(b) Treatment of Proposed Revision.--The Secretary shall
not adopt the proposed revision to section 412.22(f) of title
42, Code of Federal Regulations contained in 68 Federal
Register 27154 (May 19, 2003) or any revision reaching the
same or substantially the same result as such revision.
(c) Effective Date.--The amendment made by, and provisions
of, this section shall apply to cost reporting periods ending
on or after December 31, 2002.
______

SA 1057. Mrs. DOLE (for herself and Mr. Edwards) submitted an
amendment intended to be proposed by her to the bill S. 1, to amend
title XVIII of the Social Security Act to make improvements in the
medicare program, to provide prescription drug coverage under the
medicare program, and for other purposes; which was ordered to lie on
the table; as follows:

At the end of subtitle A of title IV, add the following:

SEC. __. TREATMENT OF CERTAIN ENTITIES FOR PURPOSES OF
PAYMENTS UNDER THE MEDICARE PROGRAM.

(a) Payments to Hospitals.--Notwithstanding any other
provision of law, effective for discharges occurring on or
after October 1, 2003, for purposes of making payments to
hospitals (as defined in section 1886(d) and 1833(t) of the
Social Security Act (42 U.S.C. 1395(d)) under the medicare
program under title XVIII of such Act (42 U.S.C. 1395 et
seq.), Iredell County, North Carolina, and Rowan County,
North Carolina, are deemed to be located in the Charlotte-
Gastonia-Rock Hill, North Carolina, South Carolina
Metropolitan Statistical Area.
(b) Budget Neutral.--The Secretary shall adjust the area
wage index referred to in subsection (a) in a manner which
assures that the appropriate payments made under section
1886(d) of the Social Security Act (42 U.S.C., 1395(ww)(d))
in a fiscal year for the operating cost of inpatient hospital
services are not greater or less than those which would have
be made in the year if this section did not apply.
(c) Payments to Skilled Nursing Facilities and Home Health
Agencies.--Notwithstanding any other provision of law,
effective beginning October 1, 2003, for purposes of making
payments to skilled nursing facilities (SNFs) and home health
agencies (as defined in sections 1861(j) and 1861(o) of the
Social Security Act (42 U.S.C. 1395(j)(o)) under the medicare
program under title XVIII of such Act (42 U.S.C 1395 et
seq.), Iredell County, North Carolina, and Rowan County,
North Carolina, are deemed to be located in the Charlotte-
Gastonia-Rock Hill, North Carolina, South Carolina
Metropolitan Statistical Area.
(d) Application.--Effective for fiscal year 2004, the
skilled nursing facility PPS and home health PPS rates for
Iredell County, North Carolina, and Rowan County, North
Carolina, will be updated by the prefloor, prereclassified
hospital wage index available for the Charlotte-Gastonia-Rock
Hill, North Carolina, South Carolina Metropolitan Statistical
Area. This provision must be implemented in a budget neutral
manner, using a methodology that maintains the current SNF
and home health expenditure levels.
______

SA 1058. Mr. CRAIG submitted an amendment intended to be proposed by
him to the bill S. 1, to amend title XVIII of the Social Security Act
to make improvements in the medicare program, to provide prescription
drug coverage under the medicare program, and for other purposes; which
was ordered to lie on the table; as follows:

At the appropriate place in title VI, insert the following:

SEC. __. RESTORATION OF FEDERAL HOSPITAL INSURANCE TRUST
FUND.

(a) Definitions.--In this section:
(1) Clerical error.--The term ``clerical error'' means the
failure that occurred on April 15, 2001, to have transferred
the correct amount from the general fund of the Treasury to
the Trust Fund.
(2) Trust fund.--The term ``Trust Fund'' means the Federal
Hospital Insurance Trust Fund established under section 1817
of the Social Security Act (42 U.S.C. 1395i).
(b) Correction of Trust Fund Holdings.--
(1) In general.--Not later than 120 days after the date of
enactment of this Act, the Secretary of the Treasury shall
take the actions described in paragraph (2) with respect to
the Trust Fund with the goal being that, after such actions
are taken, the holdings of the Trust Fund will replicate, to
the extent practicable in the judgment of the Secretary of
the Treasury, in consultation with the Secretary of Health
and Human Services, the holdings that would have been held by
the Trust Fund if the clerical error had not occurred.
(2) Obligations issued and redeemed.--The Secretary of the
Treasury shall--
(A) issue to the Trust Fund obligations under chapter 31 of
title 31, United States Code, that bear issue dates, interest
rates, and maturity dates that are the same as those for the
obligations that--
(i) would have been issued to the Trust Fund if the
clerical error had not occurred; or
(ii) were issued to the Trust Fund and were redeemed by
reason of the clerical error; and
(B) redeem from the Trust Fund obligations that would have
been redeemed from the Trust Fund if the clerical error had
not occurred.
(c) Appropriation.--Not later than 120 days after the date
of enactment of this Act, there is appropriated to the Trust
Fund, out of any money in the Treasury not otherwise
appropriated, an amount determined by the

[[Page S8582]]

Secretary of the Treasury, in consultation with the Secretary
of Health and Human Services, to be equal to the interest
income lost by the Trust Fund through the date on which the
appropriation is being made as a result of the clerical
error.
______

SA 1059. Mr. HATCH sumitted an amendment intended to be proposed by
him to the bill S. 1, to amend title XVIII of the Social Security Act
to make improvements in the medicare program, to provide prescription
drug coverage under the medicare program, and for other purposes; which
was ordered to lie on the table; as follows:
At the end of subtitle A of title I, add the following:

SEC. __. REVIEW AND REPORT ON CURRENT STANDARDS OF PRACTICE
FOR PHARMACY SERVICES PROVIDED TO PATIENTS IN
NURSING FACILITIES.

(a) Review.--
(1) In general.--The Secretary shall conduct a thorough
review of the current standards of practice for pharmacy
services provided to patients in nursing facilities.
(2) Specific matters reviewed.--In conducting the review
under paragraph (1), the Secretary shall--
(A) assess the current standards of practice, clinical
services, and other service requirements generally used for
pharmacy services in long-term care settings; and
(B) evaluate the impact of those standards with respect to
patient safety, reduction of medication errors and quality of
care.
(b) Report.--
(1) In general.--Not later than the date that is 18 months
after the date of enactment of this Act, the Secretary shall
submit a report to Congress on the study conducted under
subsection (a)(1), together with any recommendations for
legislation that the Administrator determines to be
appropriate as a result of such study.
(2) Contents.--The report submitted under paragraph (1)
shall contain--
(A) a detailed description of the plans of the Secretary to
implement the provisions of this Act in a manner consistent
with applicable State and Federal laws designed to protect
the safety and quality of care of nursing facility patients;
and
(B) recommendations regarding necessary actions and
appropriate reimbursement to ensure the provision of
prescription drugs to medicare beneficiaries residing in
nursing facilities in a manner consistent with existing
patient safety and quality of care standards under applicable
State and Federal laws.
______

SA 1060. Mr. BAUCUS (for Mrs. Feinstein (for herself, Mr. Nickles,
Mr. Chafee, and Mr. Graham of South Carolina) proposed an amendment to
the bill S. 1, to amend title XVIII of the Social Security Act to make
improvements in the medicare program, to provide prescription drug
coverage under the medicare program, and for other purposes; as
follows:
At the end of title IV, insert:

Subtitle D--Part B Premium

SEC. __. INCOME-RELATED INCREASE IN MEDICARE PART B PREMIUM.

(a) In General.--Section 1839 (42 U.S.C. 1395r) is amended
by adding at the end the following:
``(h) Increase in Premium for High-Income Beneficiaries.--
``(1) Amount of increase.--
``(A) In general.--Except as provided in paragraph (4), if
the modified adjusted gross income of an individual for a
taxable year ending with or within a calendar year (as
initially determined by the Secretary in accordance with
paragraph (2)) exceeds the threshold amount, the amount of
the premium under subsection (a) for the individual for the
calendar year shall, in lieu of the amount otherwise
determined under subsection (a), be equal to the applicable
percentage of an amount equal to 200 percent of the monthly
actuarial rate for enrollees age 65 and over as determined
under subsection (a)(1) for the calendar year.
``(B) Applicable percentage.--The term `applicable
percentage' means the percentage determined in accordance
with the following tables:
``(i) Individuals not filing joint returns.--

``If the modified adjusted gross income exceeds the threshold amount
by:                                     The applicable percentage is:
Not more than $25,000........................................50 percent
More than $25,000..........................................100 percent.
``(ii) Individuals filing joint returns.--

``If the modified adjusted gross income exceeds the threshold amount
by:                                     The applicable percentage is:
Not more than $50,000........................................50 percent
More than $50,000..........................................100 percent.
``(C) Definition of threshold amount.--For purposes of this
subsection, the term `threshold amount' means--
``(i) except as provided in clause (ii), $75,000; and
``(ii) $150,000 in the case of a taxpayer filing a joint
return.
``(D) Inflation adjustment for threshold amount.--
``(i) In general.--In the case of any calendar year
beginning after 2006, the dollar amount in clause (i) of
subparagraph (C) shall be increased by an amount equal to--

``(I) such dollar amount, multiplied by
``(II) the percentage (if any) by which the average of the
Consumer Price Index for all urban consumers (United States
city average) for the 12-month period ending with June of the
preceding calendar year exceeds such average for the 12-month
period ending with June 2005.

``(ii) Joint returns.--The dollar amount described in
clause (ii) of subparagraph (C) for any calendar year after
2006 shall be increased to an amount equal to twice the
amount in effect under clause (i) of subparagraph (C) (after
application of this subparagraph).
``(iii) Rounding.--If any dollar amount after being
increased under clause (i) is not a multiple of $1,000, such
dollar amount shall be rounded to the nearest multiple of
$1,000.
``(E) Definition of modified adjusted gross income.--For
purposes of this subsection, the term `modified adjusted
gross income' means adjusted gross income (as defined in
section 62 of the Internal Revenue Code of 1986)--
``(i) determined without regard to sections 135, 911, 931,
and 933 of such Code; and
``(ii) increased by the amount of interest received or
accrued by the taxpayer during the taxable year which is
exempt from tax under such Code.
``(F) Joint return.--For purposes of this subsection, the
term `joint return' has the meaning given such term by
section 7701(a)(38) of the Internal Revenue Code of 1986.
``(2) Determination of modified adjusted gross income.--The
Secretary shall make an initial determination of the amount
of an individual's modified adjusted gross income for a
taxable year ending with or within a calendar year for
purposes of this subsection as follows:
``(A) Notice.--Not later than September 1 of the year
preceding the year, the Secretary shall provide notice to
each individual whom the Secretary finds (on the basis of the
individual's actual modified adjusted gross income for the
most recent taxable year for which such information is
available or other information provided to the Secretary by
the Secretary of the Treasury) will be subject to an increase
under this subsection that the individual will be subject to
such an increase, and shall include in such notice the
Secretary's estimate of the individual's modified adjusted
gross income for the year. In providing such notice, the
Secretary shall use the most recent poverty line available as
of the date the notice is sent.
``(B) Calculation based on information provided by
beneficiary.--If, during the 60-day period beginning on the
date notice is provided to an individual under subparagraph
(A), the individual provides the Secretary with appropriate
information (as determined by the Secretary) on the
individual's anticipated modified adjusted gross income for
the year, the amount initially determined by the Secretary
under this paragraph with respect to the individual shall be
based on the information provided by the individual.
``(C) Calculation based on notice amount if no information
is provided by the beneficiary or if the secretary determines
that the provided information in not appropriate.--The amount
initially determined by the Secretary under this paragraph
with respect to an individual shall be the amount included in
the notice provided to the individual under subparagraph (A)
if--
``(i) the individual does not provide the Secretary with
information under subparagraph (B); or
``(ii) the Secretary determines that the information
provided by the individual to the Secretary under such
subparagraph in not appropriate.
``(3) Adjustments.--
``(A) In general.--If the Secretary determines (on the
basis of final information provided by the Secretary of the
Treasury) that the amount of an individual's actual modified
adjusted gross income for a taxable year ending with or
within a calendar year is less than or greater than the
amount initially determined by the Secretary under paragraph
(2), the Secretary shall increase or decrease the amount of
the individual's monthly premium under this part (as the case
may be) for months during the following calendar year by an
amount equal to \1/12\ of the difference between--
``(i) the total amount of all monthly premiums paid by the
individual under this part during the previous calendar year;
and
``(ii) the total amount of all such premiums which would
have been paid by the individual during the previous calendar
year if the amount of the individual's modified adjusted
gross income initially determined under paragraph (2) were
equal to the actual amount of the individual's modified
adjusted gross income determined under this paragraph.
``(B) Interest.--
``(i) Increase.--In the case of an individual for whom the
amount initially determined by the Secretary under paragraph
(2) is based on information provided by the individual under
subparagraph (B) of such paragraph, if the Secretary
determines under subparagraph (A) that the amount of the
individual's actual modified adjusted gross income for a
taxable year is greater than the amount initially determined
under paragraph (2), the Secretary shall increase the amount
otherwise determined for the year under subparagraph (A) by
an amount of interest equal to the sum of the amounts
determined under

[[Page S8583]]

clause (ii) for each of the months described in such clause.
``(ii) Computation.--Interest shall be computed for any
month in an amount determined by applying the underpayment
rate established under section 6621 of the Internal Revenue
Code of 1986 (compounded daily) to any portion of the
difference between the amount initially determined under
paragraph (2) and the amount determined under subparagraph
(A) for the period beginning on the first day of the month
beginning after the individual provided information to the
Secretary under subparagraph (B) of paragraph (2) and ending
30 days before the first month for which the individual's
monthly premium is increased under this paragraph.
``(iii) Exception.--Interest shall not be imposed under
this subparagraph if the amount of the individual's modified
adjusted gross income provided by the individual under
subparagraph (B) of paragraph (2) was not less than the
individual's modified adjusted gross income determined on the
basis of information shown on the return of tax imposed by
chapter 1 of the Internal Revenue Code of 1986 for the
taxable year involved.
``(C) Steps to recover amounts due from previously enrolled
beneficiaries.--In the case of an individual who is not
enrolled under this part for any calendar year for which the
individual's monthly premium under this part for months
during the year would be increased pursuant to subparagraph
(A) if the individual were enrolled under this part for the
year, the Secretary may take such steps as the Secretary
considers appropriate to recover from the individual the
total amount by which the individual's monthly premium under
this part for months during the year would have been
increased under subparagraph (A) if the individual were
enrolled under this part for the year.
``(D) Deceased beneficiary.--In the case of a deceased
individual for whom the amount of the monthly premium under
this part for months in a year would have been decreased
pursuant to subparagraph (A) if the individual were not
deceased, the Secretary shall make a payment to the
individual's surviving spouse (or, in the case of an
individual who does not have a surviving spouse, to the
individual's estate) in an amount equal to the difference
between--
``(i) the total amount by which the individual's premium
would have been decreased for all months during the year
pursuant to subparagraph (A); and
``(ii) the amount (if any) by which the individual's
premium was decreased for months during the year pursuant to
subparagraph (A).
``(4) Waiver by secretary.--The Secretary may waive the
imposition of all or part of the increase of the premium or
all or part of any interest due under this subsection for any
period if the Secretary determines that a gross injustice
would otherwise result without such waiver.
``(5) Transfer to part b trust fund.--
``(A) In general.--The Secretary shall transfer amounts
received pursuant to this subsection to the Federal
Supplementary Medical Insurance Trust Fund.
``(B) Disregard.--In applying section 1844(a), amounts
attributable to subparagraph (A) shall not be counted in
determining the dollar amount of the premium per enrollee
under paragraph (1)(A) or (1)(B) thereof.''
(b) Conforming Amendments.--(1) Section 1839 (42 U.S.C.
1395r) is amended--
(A) in subsection (a)(2), by inserting ``or section
subsection (h)'' after ``subsections (b) and (e)'';
(B) in subsection (a)(3) of section 1839(a), by inserting
``or subsection (h)'' after ``subsection (e)'';
(C) in subsection (b), inserting ``(and as increased under
subsection (h))'' after ``subsection (a) or (e)''; and
(D) in subsection (f), by striking ``if an individual'' and
inserting the following: ``if an individual (other than an
individual subject to an increase in the monthly premium
under this section pursuant to subsection (h))''.
(2) Section 1840(c) (42 U.S.C. 1395r(c)) is amended by
inserting ``or an individual determines that the estimate of
modified adjusted gross income used in determining whether
the individual is subject to an increase in the monthly
premium under section 1839 pursuant to subsection (h) of such
section (or in determining the amount of such increase) is
too low and results in a portion of the premium not being
deducted,'' before ``he may''.
(c) Reporting Requirements for Secretary of the Treasury.--
(1) In general.--Subsection (l) of section 6103 of the
Internal Revenue Code of 1986 (relating to confidentiality
and disclosure of returns and return information) is amended
by adding at the end the following new paragraph:
``(19) Disclosure of return information to carry out
income-related reduction in medicare part b premium.--
``(A) In general.--The Secretary may, upon written request
from the Secretary of Health and Human Services, disclose to
officers and employees of the Centers for Medicare & Medicaid
Services return information with respect to a taxpayer who is
required to pay a monthly premium under section 1839 of the
Social Security Act. Such return information shall be limited
to--
``(i) taxpayer identity information with respect to such
taxpayer,
``(ii) the filing status of such taxpayer,
``(iii) the adjusted gross income of such taxpayer,
``(iv) the amounts excluded from such taxpayer's gross
income under sections 135 and 911,
``(v) the interest received or accrued during the taxable
year which is exempt from the tax imposed by chapter 1 to the
extent such information is available, and
``(vi) the amounts excluded from such taxpayer's gross
income by sections 931 and 933 to the extent such information
is available.
``(B) Restriction on use of disclosed information.--Return
information disclosed under subparagraph (A) may be used by
officers and employees of the Centers for Medicare & Medicaid
Services only for the purposes of, and to the extent
necessary in, establishing the appropriate monthly premium
under section 1839 of the Social Security Act.''
(2) Conforming amendments.--
(A) Paragraph (3)(A) of section 6103(p) of such Code is
amended by striking ``or (18)'' each place it appears and
inserting ``(18), or (19)''.
(B) Paragraph (4) of section 6103(p) of such Code is
amended by striking ``or (16)'' and inserting ``(16), or
(19)''.
(d) Effective Date.--
(1) In general.--The amendments made by subsections (a) and
(b) shall apply to the monthly premium under section 1839 of
the Social Security Act for months beginning with January
2006.
(2) Information for prior years.--The Secretary of Health
and Human Services may request information under section
6013(l)(19) of the Social Security Act (as added by
subsection (c)) for taxable years beginning after December
31, 2002.
______

SA 1061. Mr. BAUCUS (for Mr. Akaka (for himself and Mr. Inouye))
proposed an amendment to the bill S. 1, to amend title XVIII of the
Social Security Act to make improvements in the medicare program, to
provide prescription drug coverage under the medicare program, and for
other purposes; as follows:

On page 633, after line 21, add the following:
(3) Application to hawaii.--Section 1923(f) (42 U.S.C.
1396r-4(f)), as amended by paragraph (1), is amended--
(A) by redesignating paragraph (7) as paragraph (8); and
(B) by inserting after paragraph (6), the following:
``(7) Treatment of hawaii as a low-dsh state.--The
Secretary shall compute a DSH allotment for the State of
Hawaii for each of fiscal years 2004 and 2005 in the same
manner as DSH allotments are determined with respect to those
States to which paragraph (5) applies (but without regard to
the requirement under such paragraph that total expenditures
under the State plan for disproportionate share hospital
adjustments for any fiscal year exceeds 0).''.
______

SA 1062. Mr. REID (for Mrs. Boxer) proposed an amendment to amendment
SA 974 proposed by Mr. Grassley (for himself, Mr. Leahy, Ms. Cantwell,
Mr. Durbin, and Mr. Kohl) the bill S. 1, to amend title XVIII of the
Social Security Act to make improvements in the medicare program, to
provide prescription drug coverage under the medicare program, and for
other purposes; as follows:

At the end of the amendment add the following:

``SEC.___. NO COVERAGE GAP FOR ELIGIBLE BENEFICIARIES WITH
CANCER.--

``(A) In general.--In the case of an eligible beneficiary
with cancer, the following rules shall apply:
``(i) Paragraph (2) shall be applied by substituting `up to
the annual out-of-pocket limit under paragraph (4)' for `up
to the initial coverage limit under paragraph (3)'.
``(ii) The Administrator shall not apply paragraph (3),
subsection (d)(1)(C), or paragraph (1)(D), (2)(D), or
(3)(A)(iv) of section 1860D-19(a).
``(B) Procedures.--The Administrator shall establish
procedures to carry out this paragraph. Such procedures shall
provide for the adjustment of payments to eligible entities
under section 1860D-16 that are necessary because of the
rules under subparagraph (A).
______

SA 1063. Ms. COLLINS submitted an amendment intended to be proposed
by her to the bill S. 1, to amend title XVIII of the Social Security
Act to make improvements in the medicare program, to provide
prescription drug coverage under the medicare program, and for other
purposes; which was ordered to lie on the table; as follows:

At the appropriate place in title IV, insert the following:

SEC. __. MEDICARE PANCREATIC ISLET CELL TRANSPLANT
DEMONSTRATION PROJECT.

(a) Establishment.--In order to test the appropriateness of
pancreatic islet cell transplantation, not later than 120
days after the date of the enactment of this Act, the
Secretary shall establish a demonstration project which the
Secretary, provides for

[[Page S8584]]

payment under the medicare program under title XVIII of the
Social Security Act for pancreatic islet cell transplantation
and related items and services in the case of medicare
beneficiaries who have type I (juvenile) diabetes and have
end stage renal disease.
(b) Duration of Project.--The authority of the Secretary to
conduct the demonstration project under this section shall
terminate on the date that is 5 years after the date of the
establishment of the project.
(c) Evaluation and Report.--The Secretary shall conduct an
evaluation of the outcomes of the demonstration project. Not
later than 120 days after the date of the termination of the
demonstration project under subsection (b), the Secretary
shall submit to Congress a report on the project, including
recommendations for such legislative and administrative
action as the Secretary deems appropriate.
(d) Payment Methodology.--The Secretary shall establish an
appropriate payment methodology for the provision of items
and services under the demonstration project, which may
include a payment methodology that bundles, to the maximum
extent feasible, payment for all such items and services.
______

SA 1064. Ms. SNOWE (for herself, Mr. Rockefeller, and Mr. Smith)
submitted an amendment intended to be proposed by her to the bill S. 1,
to amend title XVIII of the Social Security Act to make improvements in
the medicare program, to provide prescription drug coverage under the
medicare program, and for other purposes; which was ordered to lie on
the table; as follows:

At the end of title VI, insert the following:

SEC. __. MEDICARE COVERAGE OF ALL ANTICANCER ORAL DRUGS.

(a) In General.--Section 1861(s)(2)(Q) (42 U.S.C.
1395x(s)(2)(Q)) is amended by striking ``chemotherapeutic
agent for a given indication,'' and all that follows and
inserting ``agent for a medically accepted indication (as
defined in subsection (t)(2)(B));''.
(b) Conforming Amendment.--Section 1834(j)(5)(F)(iv) (42
U.S.C. 1395m(j)(5)(F)(iv)) is amended by striking
``therapeutic''.
(c) Effective Date.--The amendments made by this section
shall apply with respect to drugs furnished during the period
that begins on January 1, 2004 and ends on January 1, 2006.
After January 1, 2006, the Social Security Act shall be
applied and administered as if the amendments made by this
subsection had never been enacted.
______

SA 1065. Mr. BINGAMAN (for himself, Mr. Domenici, Ms. Mikulski, and
Mrs. Lincoln) proposed an amendment to the bill S. 1, to amend title
XVIII of the Social Security Act to make improvements in the medicare
program, to provide prescription drug coverage under the medicare
program, and for other purposes; as follows:

On page 120, between lines 16 and 17, insert the following:
``(I) Update of asset or resource test.--With respect to
eligibility determinations for premium and cost-sharing
subsidies under this section that are made on or after
January 1, 2009, such determinations shall be made (to the
extent a State, as of such date, has not already eliminated
the application of an asset or resource test under section
1905(p)(1)(C)) in accordance with the following:
``(i) Self-declaration of value.--

``(I) In general.--A State shall permit an individual
applying for such subsidies to declare and certify by
signature under penalty of perjury on the application form
that the value of the individual's assets or resources (or
the combined value of the individual's assets or resources
and the assets or resources of the individual's spouse), as
determined under section 1613 for purposes of the
supplemental security income program, does not exceed
$10,0000 ($20,000 in the case of the combined value of the
individual's assets or resources and the assets or resources
of the individual's spouse).
``(II) Annual adjustment.--Beginning on January 1, 2010,
and for each subsequent year, the dollar amounts specified in
subclause (I) for the preceding year shall be increased by
the percentage increase in the Consumer Price Index for all
urban consumers (U.S. urban average) for the 12-month period
ending with June of the previous year.

``(ii) Methodology flexibility.--Nothing in clause (i)
shall be construed as prohibiting a State in making
eligibility determinations for premium and cost-sharing
subsidies under this section from using asset or resource
methodologies that are less restrictive than the
methodologies used under 1613 for purposes of the
supplemental security income program.
``(J) Development of model declaration form.--The Secretary
shall--
``(i) develop a model, simplified application form for
individuals to use in making a self-declaration of assets or
resources in accordance with subparagraph (I)(i); and
``(ii) provide such form to States and, for purposes of
outreach under section 1144, the Commissioner of Social
Security.''.
______

SA 1066. Mr. BINGAMAN proposed an amendment to the bill S. 1, to
amend title XVIII of the Social Security Act to make improvements in
the medicare program, to provide prescription drug coverage under the
medicare program, and for other purposes; as follows:

On page 137, line 6, strike ``Notwithstanding'' and insert
``Except as provided in paragraph (4) and notwithstanding''.
On page 138, line 2, strike ``or `G' '' and insert `` `G',
or a policy described in paragraph (4)''.
On page 138, line 17, insert ``, who seeks to enroll with
the same issuer who was the issuer of the policy described in
clause (ii) of such subparagraph in which the individual was
enrolled (unless such issuer does not offer at least one of
the policies described in paragraph (4)),'' after ``section
1860D-2(b)(2)''.
On page 140, between lines 13 and 14, insert the following:
``(4) New standards.--In applying subsection (p)(1)(E)
(including permitting the NAIC to revise its model
regulations in response to changes in law) with respect to
the change in benefits resulting from title I of the
Prescription Drug and Medicare Improvement Act of 2003, with
respect to policies issued to individuals who are enrolled in
a Medicare Prescription Drug plan under part D or under a
contract under section 1860D-3(e), the changes in standards
shall only provide for substituting (for the benefit packages
described in paragraph (2)(B)(ii) that included coverage for
prescription drugs) two benefit packages that shall be
consistent with the following:
``(A) First new policy.--The policy described in this
subparagraph has the following benefits, notwithstanding any
other provision of this section relating to a core benefit
package:
``(i) The policy should provide coverage for benefits other
than prescription drugs similar to the coverage for benefits
other than prescription drugs provided under a medicare
supplemental policy which had a benefit package classified as
`H' before the date of enactment of the Prescription Drug and
Medicare Improvement Act of 2003.
``(ii) The policy should provide coverage for prescription
drugs that--

``(I) compliments, but does not duplicate, the benefits
available under part D; and
``(II) does not cover 100 percent of the deductible,
copayments, coinsurance (including any cost-sharing
applicable under the limitation on out-of-pocket
expenditures), or any other cost-sharing applicable under
part D.

``(B) Second new policy.--The policy described in this
subparagraph has the same benefits as the policy described in
subparagraph (A), except that the reference to the benefit
package classified as `H' in clause (i) of such subparagraph
is deemed to be a reference to the benefit package classified
as `J'.
(b) Report.--The Secretary shall enter into an arrangement
with the National Association of Insurance Commissioners (in
this section referred to as the ``NAIC'') under which, not
later than 18 months after the date of enactment of this Act,
the NAIC shall submit to Congress a report on the medicare
supplemental policies described in section 1882(v)(4) of the
Social Security Act, as added by subsection (a), that
assesses the viability of the policies described in such
section and, if viable, the details of those policies.
______

SA 1067. Mrs. LINCOLN submitted an amendment intended to be proposed
by her to the bill S. 1, to amend title XVIII of the Social Security
Act to make improvements in the medicare program, to provide
prescription drug coverage under the medicare program, and for other
purposes; which was ordered to lie on the table; as follows:

On page 510, after line 18, add the following:

SEC. __. MEDICARE COVERAGE OF KIDNEY DISEASE EDUCATION
SERVICES.

(a) Coverage of Kidney Disease Education Services.--
(1) In general.--Section 1861 of the Social Security Act
(42 U.S.C.1395x) is amended--
(A) in subsection (s)(2)--
(i) in subparagraph (U), by striking ``and'' at the end;
(ii) in subparagraph (V)(iii), by adding ``and'' at the
end; and
(iii) by adding at the end the following new subparagraph:
``(W) kidney disease education services (as defined in
subsection (ww));''; and
(B) by adding at the end the following new subsection:

``Kidney Disease Education Services

``(ww)(1) The term `kidney disease education services'
means educational services that are--
``(A) furnished to an individual with kidney disease who,
according to accepted clinical guidelines identified by the
Secretary, will require dialysis or a kidney transplant;
``(B) furnished, upon the referral of the physician
managing the individual's kidney condition, by a qualified
person (as defined in paragraph (2)); and
``(C) designed--
``(i) to provide comprehensive information regarding--
``(I) the management of comorbidities;
``(II) the prevention of uremic complications; and
``(III) each option for renal replacement therapy
(including peritoneal dialysis, hemodialysis (including
vascular access options), and transplantation); and
``(ii) to ensure that the individual has the opportunity to
actively participate in the choice of therapy.

[[Page S8585]]

``(2) The term `qualified person' means--
``(A) a physician (as described in subsection (r)(1));
``(B) an individual who--
``(i) is--
``(I) a registered nurse;
``(II) a registered dietitian or nutrition professional (as
defined in subsection (vv)(2));
``(III) a clinical social worker (as defined in subsection
(hh)(1));
``(IV) a physician assistant, nurse practitioner, or
clinical nurse specialist (as those terms are defined in
subsection (aa)(5)); or
``(V) a transplant coordinator; and
``(ii) meets such requirements related to experience and
other qualifications that the Secretary finds necessary and
appropriate for furnishing the services described in
paragraph (1); or
``(C) a renal dialysis facility subject to the requirements
of section 1881(b)(1) with personnel who--
``(i) provide the services described in paragraph (1); and
``(ii) meet the requirements of subparagraph (A) or (B).
``(3) The Secretary shall develop the requirements under
paragraph (2)(B)(ii) after consulting with physicians, health
educators, professional organizations, accrediting
organizations, kidney patient organizations, dialysis
facilities, transplant centers, network organizations
described in section 1881(c)(2), and other knowledgeable
persons.
``(4) In promulgating regulations to carry out this
subsection, the Secretary shall ensure that such regulations
ensure that each beneficiary who is entitled to kidney
disease education services under this title receives such
services in a timely manner that ensures that the beneficiary
receives the maximum benefit of those services.
``(5) The Secretary shall monitor the implementation of
this subsection to ensure that beneficiaries who are eligible
for kidney disease education services receive such services
in the manner described in paragraph (4).''.
(2) Payment under physician fee schedule.--Section
1848(j)(3) of such Act (42 U.S.C. 1395w-4(j)(3)) is amended
by inserting ``, (2)(W)'', after ``(2)(S)''.
(3) Payment to renal dialysis facilities.--Section 1881(b)
of such Act (42 U.S.C. 1395rr(b)), as amended by section
433(b)(5), is further amended by adding at the end the
following new paragraph:
``(13) For purposes of paragraph (7), the single composite
weighted formulas determined under such paragraph shall not
take into account the amount of payment for kidney disease
education services (as defined in section 1861(ww)). Instead,
payment for such services shall be made to the renal dialysis
facility on an assignment-related basis under section
1848.''.
(4) Annual report to congress.--Not later than April 1,
2004, and annually thereafter, the Secretary of Health and
Human Services shall submit to Congress a report on the
number of medicare beneficiaries who are entitled to kidney
disease education services (as defined in section 1861(ww) of
the Social Security Act, as added by paragraph (1)) under
title XVIII of such Act and who receive such services,
together with such recommendations for legislative and
administrative action as the Secretary determines to be
appropriate to fulfill the legislative intent that resulted
in the enactment of that subsection.
(b) Effective Date.--The amendments made by this section
shall apply to services furnished on or after the date that
is 6 months after the date of enactment of this Act.
______

SA 1068. Mrs. LINCOLN submitted an amendment intended to be proposed
by her to the bill S. 1, to amend title XVIII of the Social Security
Act to make improvements in the medicare program, to provide
prescription drug coverage under the medicare program, and for other
purposes; which was ordered to lie on the table; as follows:

On page 510, after line 18, add the following:

SEC. __. MEDICARE COVERAGE OF DIABETES LABORATORY DIAGNOSTIC
TESTS.

(a) Coverage.--Section 1861(s)(2) of the Social Security
Act (42 U.S.C. 1395x(s)(2)) is amended--
(1) in subparagraph (U), by striking ``and'' at the end;
(2) in subparagraph (V)(iii), by adding ``and'' at the end;
and
(3) by adding at the end the following new subparagraph:
``(W) diabetes screening tests and services (as defined in
subsection (ww));''.
(b) Services Described.--Section 1861 of the Social
Security Act (42 U.S.C. 1395x) is amended by adding at the
end the following new subsection:

``Diabetes Screening Tests and Services

``(ww)(1) The term `diabetes screening tests' means
diagnostic testing furnished to an individual at risk for
diabetes (as defined in paragraph (2)) for the purpose of
early detection of diabetes, including--
``(A) a fasting plasma glucose test; and
``(B) such other tests, and modifications to tests, as the
Secretary determines appropriate, in consultation with
appropriate organizations.
``(2) For purposes of paragraph (1), the term `individual
at risk for diabetes' means an individual who has any, a
combination of, or all of the following risk factors for
diabetes:
``(A) A family history of diabetes.
``(B) Overweight defined as a body mass index greater than
or equal to 25 kg/m\2\.
``(C) Habitual physical inactivity.
``(D) Belonging to a high-risk ethnic or racial group.
``(E) Previous identification of an elevated impaired
fasting glucose.
``(F) Identification of impaired glucose tolerance.
``(G) Hypertension.
``(H) Dyslipidemia.
``(I) History of gestational diabetes mellitus or delivery
of a baby weighing greater than 9 pounds.
``(J) Polycystic ovary syndrome.
``(3) The Secretary shall establish standards, in
consultation with appropriate organizations, regarding the
frequency of diabetes screening tests, except that such
frequency may not be more often than twice within the 12-
month period following the date of the most recent diabetes
screening test of that individual.''.
(c) Frequency.--Section 1862(a)(1) of the Social Security
Act (42 U.S.C. 1395y(a)(1)) is amended--
(1) in subparagraph (H), by striking ``and'' at the end;
(2) in subparagraph (I), by striking the semicolon at the
end and inserting ``, and''; and
(3) by adding at the end the following new subparagraph:
``(J) in the case of a diabetes screening test or service
(as defined in section 1861(ww)(1)), which is performed more
frequently than is covered under section 1861(ww)(3).''.
(d) Effective Date.--The amendments made by this section
shall apply to tests furnished on or after the date that is
90 days after the date of enactment of this Act.
______

SA 1069. Mrs. LINCOLN sumitted an amendment intended to be proposed
by her to the bill S. 1, to amend title XVIII of the Social Security
Act to make improvements in the medicare program, to provide
prescription drug coverage under the medicare program, and for other
purposes; which was ordered to lie on the table; as follows:

On page 499, after line 20, insert the following:

SEC. __. ELIMINATION OF COST-SHARING FOR BONE MASS
MEASUREMENTS.

(a) Elimination of Coinsurance.--
(1) In general.--Section 1833(a)(1)(N) of the Social
Security Act (42 U.S.C. 1395l(a)(1)(N)) is amended--
(A) by inserting ``other than bone mass measurement
described in section 1861(s)(15)'' after ``(as defined in
section 1848(j)(3))''; and
(B) by adding after the comma at the end the following:
``and in the case of such services consisting of such a bone
mass measurement, the amounts paid shall be 100 percent of
such payment basis,''.
(2) Elimination of coinsurance in outpatient hospital
settings.--The third sentence of section 1866(a)(2)(A) of the
Social Security Act (42 U.S.C. 1395cc(a)(2)(A)) is amended by
inserting after ``1861(s)(10)(A)'' the following: ``, with
respect to bone mass measurement (as defined in section
1861(rr)),''.
(b) Waiver of Deductible.--The first sentence of section
1833(b) of the Social Security Act (42 U.S.C. 1395l(b)), as
amended by section 432(b), is further amended--
(1) by striking ``and'' before ``(5)''; and
(2) by inserting before the period at the end the
following: ``, and (6) such deductible shall not apply with
respect to bone mass measurement (as defined in section
1861(rr))''.
(c) Effective Date.--The amendments made by this section
shall apply to items and services furnished on or after
January 1, 2004.
______

SA 1070. Mr. SCHUMER sumitted an amendment intended to be proposed by
him to the bill S. 1, to amend title XVIII of the Social Security Act
to make improvements in the medicare program, to provide prescription
drug coverage under the medicare program, and for other purposes; which
was ordered to lie on the table; as follows:

On page 120, strike lines 3 through 16, and insert the
following:
``(H) Nonapplication to dual eligible individuals.--In the
case of an individual who is a dual eligible individual--
``(i) the subsidies provided under this section shall not
apply; and
``(ii) such individuals may be provided with medical
assistance for covered outpatient drugs (as such term is
defined for purposes of section 1927) in accordance with the
State medicaid program under title XIX.
On page 122, line 1, strike ``and territorial residents''.
Beginning on page 149, strike line 22 and all that follows
through page 152, line 3, and insert the following:
``(e) Definitions.--For purposes of this section, the''.
On page 152, strike lines 8 through 11, and insert the
following:
(2) Exemption from funding limitation for the commonwealth
of puerto rico and the territories.--
(A) In general.--Section 1108(g) (42 U.S.C. 1308(g)) is
amended by adding at the end the following new paragraph:
``(3) Certain payments disregarded.--The limitations under
subsection (f) and the previous provisions of this subsection
shall be

[[Page S8586]]

applied without regard to any payments made for medical
assistance for covered drugs (as defined in section
1860D(a)(2)) under title XIX for dual eligible individuals
(as defined in section 1860D-19(a)(4)(E) or for any payments
made in carrying out section 1935.''.
(B) Conforming amendment.--Section 1108(f) (42 U.S.C.
1308(f)) is amended by inserting ``and section
1935(e)(1)(B)'' after ``Subject to subsection (g)''.
______

SA 1071. Mr. ROCKEFELLER (for himself and Mr. Smith) sumitted an
amendment intended to be proposed by him to the bill S. 1, to amend
title XVIII of the Social Security Act to make improvements in the
medicare program, to provide prescription drug coverage under the
medicare program, and for other purposes; which was ordered to lie on
the table; as follows:

At the end of title VI, insert the following:

SEC. __. MEDICARE COVERAGE OF ALL ANTINEOPLASTIC AND CERTAIN
OTHER DRUGS.

(a) In General.--Section 1861(s)(2)(Q) (42 U.S.C.
1395x(s)(2)(Q)) is amended by striking ``prescribed for use
as an anticancer chemotherapeutic agent'' and all that
follows and inserting ``prescribed for use as--
``(i) an antineoplastic agent for a medically accepted
anticancer indication (as defined in subsection (t)(2)(B)),
excluding (except as provided in subparagraph (T)) drugs for
chemotherapy-induced nausea; or
``(ii) an oral alternative to IV-administered medications,
but only if the Secretary determines such coverage does not
result, as estimated by the Secretary, in expenditures made
under this title during any 5-year period that are greater
than the expenditures that would have been made under this
title during such period if such coverage was not
provided.''.
(b) Conforming Amendment.--Section 1834(j)(5)(F)(iv) (42
U.S.C. 1395m(j)(5)(F)(iv)) is amended to read as follows:
``(iv) oral drugs described in section 1861(s)(2)(Q);
and''.
(c) Effective Date.--The amendments made by this section
shall apply only with respect to drugs furnished during the
period that begins on or after the date that is 90 days after
the date of the enactment of this Act and ends on January 1,
2006. After January 1, 2006, the Social Security Act shall be
applied and administered as if the amendments made by this
section had never been enacted.
______

SA 1072. Mr. ROCKEFELLER submitted an amendment intended to be
proposed by him to the bill S. 1, to amend title XVIII of the Social
Security Act to make improvements in the medicare program, to provide
prescription drug coverage under the medicare program, and for other
purposes; which was ordered to lie on the table; as follows:

At the end of title VI, insert the following:

SEC. __. MEDICARE COVERAGE OF ALL ANTINEOPLASTIC AND CERTAIN
OTHER DRUGS; PUBLIC DISCLOSURE OF MARKET-BASED
DRUG PRICING INFORMATION.

(a) Medicare Coverage of All Antineoplastic and Certain
Other Drugs.--
(1) In general.--Section 1861(s)(2)(Q) (42 U.S.C.
1395x(s)(2)(Q)) is amended by striking ``prescribed for use
as an anticancer chemotherapeutic agent'' and all that
follows and inserting ``prescribed for use as--
``(i) an antineoplastic agent for a medically accepted
anticancer indication (as defined in subsection (t)(2)(B)),
excluding (except as provided in subparagraph (T)) drugs for
chemotherapy-induced nausea; or
``(ii) an oral alternative to IV-administered medications,
but only if the Secretary determines such coverage does not
result, as estimated by the Secretary, in expenditures made
under this title during any 5-year period that are greater
than the expenditures that would have been made under this
title during such period if such coverage was not
provided.''.
(2) Conforming amendment.--Section 1834(j)(5)(F)(iv) (42
U.S.C. 1395m(j)(5)(F)(iv)) is amended to read as follows:
``(iv) oral drugs described in section 1861(s)(2)(Q);
and''.
(3) Effective date.--The amendments made by this subsection
shall apply only with respect to drugs furnished during the
period that begins on or after the date that is 90 days after
the date of the enactment of this Act and ends on January 1,
2006. After January 1, 2006, the Social Security Act shall be
applied and administered as if the amendments made by this
subsection had never been enacted.
(b) Public Disclosure of Market-Based Drug Pricing
Information.--
(1) In general.--Section 1927(b)(3)(D) (42 U.S.C. 1396r-
8(b)(3)(D)) is amended to read as follows:
``(D) Public availability of information.--
``(i) Timely availability of information.--Notwithstanding
any other provision of law, with respect to a manufacturer
with an agreement in effect under this section, not later
than 30 days after the date the Secretary receives from such
manufacturer the information required to be reported under
this paragraph (or verifies such information with a
wholesaler), the Secretary shall make the information
described in clause (ii), including the identity of the
manufacturer to which the information applies, publicly
available through the Internet or other means of
communication.
``(ii) Information described.--The information described in
this clause is the following:

``(I) Average manufacturer's price.--The average
manufacturer price (as defined in subsection (k)(1)) for each
of the manufacturer's covered outpatient drugs.
``(II) Best price.--With respect to single source drugs and
innovator multiple source drugs, the manufacturer's best
price (as defined in subsection (c)(1)(C)) for each of the
manufacturer's covered outpatient drugs.
``(III) Base average manufacturer price and initial average
manufacturer price for newly marketed drugs used to determine
an additional rebate for single source and innovator multiple
source drugs.--The average manufacturer price described in
subparagraphs (A)(ii)(II) (without regard to the percentage
increase determined under that subparagraph) and (B) of
subsection (c)(2) for each dosage form and strength of a
single source drug or an innovator multiple source drug used
to determine, with respect to a rebate period, an additional
rebate for such dosage form and strength for such a drug.

``(iii) Nondisclosure of certain information.--
Notwithstanding any other provision of law, information
disclosed by manufacturers (or verified with wholesalers)
under an agreement with the Secretary of Veterans Affairs
described in subsection (a)(6)(A) may not be disclosed
except--

``(I) as the Secretary determines to be necessary to carry
out this section;
``(II) to permit the Comptroller General to review the
information provided; or
``(III) to permit the Director of the Congressional Budget
Office to review the information provided.

``(iv) Rule of construction.--Nothing in this subparagraph
shall be construed as affecting any requirement applicable to
the Secretary of Veterans Affairs regarding the
confidentiality of information required to be disclosed to
the Secretary of Veterans Affairs by a manufacturer under
section 8126 of title 38, United States Code.''.
(2) Effective date; implementation.--
(A) Effective date.--The amendments made by paragraph (1)
take effect upon the date of enactment of this Act and apply
to the most recent reported price information under section
1927(b)(3) of the Social Security Act (42 U.S.C. 1396r-
8(b)(3)) as of such date, and all such information reported
under such section after such date.
(B) Additional period for implementation.--Notwithstanding
the 30-day requirement for the public availability of market-
based drug pricing information under section 1927(b)(3)(D)(i)
of the Social Security Act (42 U.S.C. 1396r-8(b)(3)(D)(i)),
with respect to the initial public availability of such
information, the Secretary of Health and Human Services shall
have up to 90 days from the date of the enactment of this Act
in which to make such information so available.
(3) Authorization of appropriations.--There are authorized
to be appropriated to carry out section 1927(b)(3)(D) of the
Social Security Act (42 U.S.C. 1396r-8(b)(3)(D)), as amended
by this subsection, such sums as may be necessary to carry
out such section. Amounts appropriated pursuant to this
subsection shall be in addition to amounts otherwise
appropriated to carry out title XIX of such Act (42 U.S.C.
1396 et seq.).
______

SA 1073. Mr. SMITH (for himself, Mr. Feingold, and Ms. Cantwell)
sumitted an amendment intended to be proposed by him to the bill S. 1,
to amend title XVIII of the Social Security Act to make improvements in
the medicare program, to provide prescription drug coverage under the
medicare program, and for other purposes; as follows:

On page 379, strike lines 9 through 13, and insert:
``(A) In General.--The term `specialized Medicare+Choice
plans for special needs beneficiaries' means a
Medicare+Choice plan that--
``(i) exclusively serves special needs beneficiaries (as
defined in subparagraph (B)), or
``(ii) to the extent provided in regulations prescribed by
the Secretary, disproportionately serves such special needs
beneficiaries, frail elderly medicare beneficiaries, or both.
______

SA 1074. Mr. COLEMAN sumitted an amendment intended to be proposed by
him to the bill S. 1, to amend title XVIII of the Social Security Act
to make improvements in the medicare program, to provide prescription
drug coverage under the medicare program, and for other purposes; which
was ordered to lie on the table; as follows:

At the end of subtitle C of title IV, add the following:

SEC. __. IMPROVEMENTS IN NATIONAL COVERAGE DETERMINATION
PROCESS TO RESPOND TO CHANGES IN TECHNOLOGY.

(a) In General.--Section 1862 (42 U.S.C. 1395y) is
amended--
(A) in the third sentence of subsection (a) by inserting
``consistent with subsection (j)'' after ``the Secretary
shall ensure''; and
(B) by adding at the end the following new subsection:

[[Page S8587]]

``(j) National Coverage Determination Process.--
``(1) Timeframe for decisions on requests for national
coverage determinations.--In the case of a request for a
national coverage determination that--
``(A) does not require a technology assessment from an
outside entity or deliberation from the Medicare Coverage
Advisory Committee, the decision on the request shall be made
not later than 6 months after the date of the request; or
``(B) requires such an assessment or deliberation and in
which a clinical trial is not requested, the decision on the
request shall be made not later than 9 months after the date
of the request.
``(2) Process for public comment in national coverage
determinations.--At the end of the 6-month period (with
respect to a request under paragraph (1)(A)) or 9-month
period (with respect to a request under paragraph (1)(B))
that begins on the date a request for a national coverage
determination is made, the Secretary shall--
``(A) make a draft of proposed decision on the request
available to the public through the Medicare Internet site of
the Department of Health and Human Services or other
appropriate means;
``(B) provide a 30-day period for public comment on such
draft;
``(C) make a final decision on the request within 60 days
of the conclusion of the 30-day period referred to under
subparagraph (B);
``(D) include in such final decision summaries of the
public comments received and responses thereto;
``(E) make available to the public the clinical evidence
and other data used in making such a decision when the
decision differs from the recommendations of the Medicare
Coverage Advisory Committee; and
``(F) in the case of a decision to grant the coverage
determination, assign a temporary or permanent code and
implement the coverage decision at the end of the 60-day
period referred to in subparagraph (C).
``(3) National coverage determination defined.--For
purposes of this subsection, the term `national coverage
determination' has the meaning given such term in section
1869(f)(1)(B).''.
(b) Effective date.--The amendments made by this section
shall apply to national coverage determinations as of January
1, 2004.
______

SA 1075. Ms. STABENOW (for herself and Mr. Levin) proposed an
amendment to the bill S. 1, to amend title XVIII of the Social Security
Act to make improvements in the medicare program, to provide
prescription drug coverage under the medicare program, and for other
purposes; as follows:

On page 676, after line 22, add the following:

SEC. __. EXTENSION OF MORATORIUM.

(a) In General.--Section 6408(a)(3) of the Omnibus Budget
Reconciliation Act of 1989, as amended by section 13642 of
the Omnibus Budget Reconciliation Act of 1993 and section
4758 of the Balanced Budget Act of 1997, is amended--
(1) by striking ``until December 31, 2002'', and
(2) by striking ``Kent Community Hospital Complex in
Michigan or.''
(b) Effective Dates.--
(1) Permanent extension.--The amendment made by subsection
(a)(1) shall take effect as if included in the amendment made
by section 4758 of the Balanced Budget Act of 1997.
(2) Modification.--The amendment made by subsection (a)(2)
shall take effect on the date of enactment of this Act.
______

SA 1076. Ms. STABENOW (for herself and Mr. Levin) proposed an
amendment to the bill S. 1, to amend title XVIII of the Social Security
Act to make improvements in the medicare program, to provide
prescription drug coverage under the medicare program, and for other
purposes; as follows:

On page 438, between lines 10 and 11, insert the following:

SEC. __. COMPREHENSIVE CANCER CENTERS.

(a) In General.--Section 1886(d)(1) of the Social Security
Act (42 U.S.C. 1395ww(d)(1)) is amended--
(1) in subparagraph (B)(v)--
(A) by striking ``or'' at the end of subclause (III);
(B) by striking the semicolon at the end of subclause (IV)
and inserting ``, or''; and
(C) by inserting after subclause (IV) the following:

``(IV) a hospital that is a nonprofit corporation, the sole
member of which was recognized as a comprehensive cancer
center by the National Cancer Institute of the National
Institutes of Health as of April 20, 1983, that specifies in
its articles of incorporation that at least 50 percent of its
total discharges must have a principal finding of neoplastic
disease, as defined in subparagraph (E), and that is a
freestanding facility licensed for less than 131 acute care
beds;''; and

(2) in subparagraph (E), by striking ``(II) and (III)'' and
inserting ``(II), (III), and (IV)''.
(b) Effective Date.--The amendments made by this section
shall apply to cost reporting periods beginning after the
date of enactment of this Act.
______

SA 1077. Ms. STABENOW (for herself and Mr. Levin) proposed an
amendment to the bill S. 1, to amend title XVIII of the Social Security
Act to make improvements in the medicare program, to provide
prescription drug coverage under the medicare program, and for other
purposes; as follows:

On page 438, between lines 10 and 11, insert the following:

SEC. __. REDISTRIBUTION OF UNUSED RESIDENT POSITIONS.

(a) In General.--Section 1886(h)(4) (42 U.S.C.
1395ww(h)(4)) is amended--
(1) in subparagraph (F)(i), by inserting ``subject to
subparagraph (I),'' after ``October 1, 1997,'';
(2) in subparagraph (H)(i), by inserting ``and subject to
subparagraph (I),'' after ``subparagraphs (F) and (G),''; and
(3) by adding at the end the following new subparagraph:
``(I) Redistribution of unused resident positions.--
``(i) Reduction in limit based on unused positions.--

``(I) In general.--If a hospital's resident level (as
defined in clause (iii)(I)) is less than the otherwise
applicable resident limit (as defined in clause (iii)(II))
for each of the reference periods (as defined in subclause
(II)), effective for cost reporting periods beginning on or
after January 1, 2003, the otherwise applicable resident
limit shall be reduced by 75 percent of the difference
between such limit and the reference resident level specified
in subclause (III) (or subclause (IV) if applicable).
``(II) Reference periods defined.--In this clause, the term
`reference periods' means, for a hospital, the 3 most recent
consecutive cost reporting periods of the hospital for which
cost reports have been settled (or, if not, submitted) on or
before September 30, 2001.
``(III) Reference resident level.--Subject to subclause
(IV), the reference resident level specified in this
subclause for a hospital is the highest resident level for
the hospital during any of the reference periods.
``(IV) Adjustment process.--Upon the timely request of a
hospital, the Secretary may adjust the reference resident
level for a hospital to be the resident level for the
hospital for the cost reporting period that includes July 1,
2002.

``(ii) Redistribution.--

``(I) In general.--The Secretary is authorized to increase
the otherwise applicable resident limits for hospitals by an
aggregate number estimated by the Secretary that does not
exceed the aggregate reduction in such limits attributable to
clause (i) (without taking into account any adjustment under
subclause (IV) of such clause).
``(II) Effective date.--No increase under subclause (I)
shall be permitted or taken into account for a hospital for
any portion of a cost reporting period that occurs before
July 1, 2003, or before the date of the hospital's
application for an increase under this clause. No such
increase shall be permitted for a hospital unless the
hospital has applied to the Secretary for such increase by
December 31, 2004.
``(III) Considerations in redistribution.--In determining
for which hospitals the increase in the otherwise applicable
resident limit is provided under subclause (I), the Secretary
shall take into account the need for such an increase by
specialty and location involved, consistent with subclause
(IV).
``(IV) Priority for rural and small urban areas.--In
determining for which hospitals and residency training
programs an increase in the otherwise applicable resident
limit is provided under subclause (I), the Secretary shall
first distribute the increase to programs of hospitals
located in rural areas or in urban areas that are not large
urban areas (as defined for purposes of subsection (d)) on a
first-come-first-served basis (as determined by the
Secretary) based on a demonstration that the hospital will
fill the positions made available under this clause and not
to exceed an increase of 25 full-time equivalent positions
with respect to any hospital.
``(V) Application of locality adjusted national average per
resident amount.--With respect to additional residency
positions in a hospital attributable to the increase provided
under this clause, notwithstanding any other provision of
this subsection, the approved FTE resident amount is deemed
to be equal to the locality adjusted national average per
resident amount computed under subparagraph (E) for that
hospital.
``(VI) Construction.--Nothing in this clause shall be
construed as permitting the redistribution of reductions in
residency positions attributable to voluntary reduction
programs under paragraph (6) or as affecting the ability of a
hospital to establish new medical residency training programs
under subparagraph (H).

``(iii) Resident level and limit defined.--In this
subparagraph:

``(I) Resident level.--The term `resident level' means,
with respect to a hospital, the total number of full-time
equivalent residents, before the application of weighting
factors (as determined under this paragraph), in the fields
of allopathic and osteopathic medicine for the hospital.
``(II) Otherwise applicable resident limit.--The term
`otherwise applicable resident limit' means, with respect to
a hospital,

[[Page S8588]]

the limit otherwise applicable under subparagraphs (F)(i) and
(H) on the resident level for the hospital determined without
regard to this subparagraph.''.

(b) No Application of Increase to IME.--Section
1886(d)(5)(B)(v) (42 U.S.C. 1395ww(d)(5)(B)(v)) is amended by
adding at the end the following: ``The provisions of
subsection (h)(4)(I) (determined without regard to clause
(ii) thereof) shall apply with respect to the first sentence
of this clause in the same manner as such provisions apply
with respect to subparagraph (F) of such subsection.''.
(c) Report on Extension of Applications Under
Redistribution Program.--Not later than July 1, 2004, the
Secretary of Health and Human Services shall submit to
Congress a report containing recommendations regarding
whether to extend the deadline for applications for an
increase in resident limits under section
1886(h)(4)(I)(i)(II) of the Social Security Act (as added by
subsection (a)).
______

SA 1076. Mr. LEVIN submitted an amendment intended to be proposed by
him to the bill S. 1, to amend title XVIII of the Social Security Act
to make improvements in the medicare program, to provide prescription
drug coverage under the medicare program, and for other purposes; which
was ordered to lie on the table; as follows:

At the end of subtitle A of title IV, add the following:

SEC. __. REVISION OF ALTERNATIVE GUIDELINES FOR GEOGRAPHIC
RECLASSIFICATION OF CERTAIN DISPROPORTIONATELY
LARGE HOSPITALS.

Section 4409(b) of the Balanced Budget Act of 1997 (42
U.S.C. 1395ww note) is amended--
(1) in paragraph (1)--
(A) by inserting ``(A)'' after ``(1)'';
(B) by adding ``or'' after the semicolon at the end; and
(C) by adding at the end the following new subparagraph:
``(B) beginning with fiscal year 2003, the hospital is the
only hospital located in such an Area'';
(2) in paragraph (2), by inserting ``in the case of a
hospital described in paragraph (1)(A),'' before ``not less
than 40 percent''; and
(3) in paragraph (3), by inserting ``for fiscal years
before 2003,'' before ``the hospital submitted an
application''.
______

SA 1079. Mr. LEVIN submitted an amendment intended to be proposed by
him to the bill S. 1, to amend title XVIII of the Social Security Act
to make improvements in the medicare program, to provide prescription
drug coverage under the medicare program, and for other purposes; which
was ordered to lie on the table; as follows:

At the end of subtitle A of title IV, add the following:

SEC. __. RECLASSIFICATION OF CERTAIN RURAL COUNTIES FOR
PURPOSES OF REIMBURSEMENT UNDER THE MEDICARE
PROGRAM.

(a) In General.--Notwithstanding any other provision of
law, effective for discharges occurring during fiscal years
2003, 2004, and 2005, for purposes of making payments under
section 1886(d) of the Social Security Act (42 U.S.C.
1395ww(d)), a hospital located in a rural county in a State
that is adjacent to 1 or more urban areas is deemed to be
located in the urban metropolitan statistical area from which
the greatest number of hospital employees commute, if--
(1) the rural county is surrounded by urban metropolitan
statistical areas; and
(2) the hospital would be reclassified as being located in
an adjacent urban metropolitan statistical area for purposes
of determining the wage index and the standardized amount
applicable to the hospital but for a requirement that the
hospital have a wage index that is 106 percent of its
applicable rural wage index.
(b) Treatment as Decision of Medicare Geographic
Classification review Board.--For purposes of section 1886(d)
of the Social Security Act (42 U.S.C 1395ww(d)), any
reclassification under subsection (a) shall be treated as a
decision of the Medicare Geographic Classification Review
Board under paragraph (10) of that section.
(c) Process for Applications To Ensure that Provisions
Apply Beginning October 1, 2003.--The Secretary of Health and
Human Services shall establish a process for the Medicare
Geographic Classification Review Board to accept, and make
determinations with respect to, applications that are filed
by applicable hospitals within 90 days of the date of
enactment of this section to reclassify based on the
provisions of this section in order to ensure that such
provisions shall apply to payments under such section 1886(d)
for discharges occurring on or after October 1, 2003.
(d) Adjustments To Ensure Budget Neutrality.--If 1 or more
applicable hospital's applications are approved pursuant to
the process under subsection (c), the Secretary of Health and
Human Services shall make a proportional adjustment in the
standardized amounts determined under paragraph (3) of such
section 1886(d) for payments for discharges occurring in
fiscal year 2004 to ensure that approval of such applications
does not result in aggregate payments under such section
1886(d) that are greater or less than those that would
otherwise be made if this section had not been enacted.
______

SA 1080. Mr. DeWINE (for himself and Mr. Durbin) submitted an
amendment intended to be proposed by him to the bill S. 1, to amend
title XVIII of the Social Security Act to make improvements to the
medicare program, to provide prescription drug coverage under the
medicare program, and for other purposes; which was ordered to lie on
the table; as follows:

At the end of title VI, insert the following:

SEC. __. COMPREHENSIVE IMMUNOSUPPRESSIVE DRUG COVERAGE FOR
TRANSPLANT PATIENTS.

(a) Comprehensive Coverage of Immunosuppressive Drugs Under
the Medicare Program.--
(1) In General.--Section 1861(s)(2)(J) (42 U.S.C.
1395x(s)(2)(J)) is amended by striking ``, to an individual
who receives'' and all that follows before the semicolon at
the end and inserting ``to an individual who has received an
organ transplant''.
(2) Effective Date.--The amendment made by this subsection
shall apply to drugs furnished on or after the date of
enactment of this Act.
(b) Provision of Appropriate Coverage of Immunosuppressive
Drugs under the Medicare Program for Organ Transplant
Recipients.--
(1) Continued entitlement to immunosuppressive drugs.--
(A) Kidney transplant recipients.--Section 226A(b)(2) (42
U.S.C. 426-1(b)(2)) is amended by inserting ``(except for
coverage of immunosuppressive drugs under section
1861(s)(2)(J))'' after ``shall end''.
(B) Other transplant recipients.--The flush matter
following paragraph (2)(C)(ii)(II) of section 226(b) (42
U.S.C. 426(b)) is amended by striking ``of this subsection)''
and inserting ``of this subsection and except for coverage of
immunosuppressive drugs under section 1861(s)(2)(J))''.
(C) Application.--Section 1836 (42 U.S.C. 1395o) is
amended--
(i) by striking ``Every individual who'' and inserting
``(a) In General.--Every individual who''; and
(ii) by adding at the end the following new subsection:
``(b) Special Rules Applicable to Individuals Only Eligible
for Coverage of Immunosuppressive Drugs.--
``(1) In general.--In the case of an individual whose
eligibility for benefits under this title has ended except
for the coverage of immunosuppressive drugs by reason of
section 226(b) or 226A(b)(2), the following rules shall
apply:
``(A) The individual shall be deemed to be enrolled under
this part for purposes of receiving coverage of such drugs.
``(B) The individual shall be responsible for the full
amount of the premium under section 1839 in order to receive
such coverage.
``(C) The provision of such drugs shall be subject to the
application of--
``(i) the deductible under section 1833(b); and
``(ii) the coinsurance amount applicable for such drugs (as
determined under this part).
``(D) If the individual is an inpatient of a hospital or
other entity, the individual is entitled to receive coverage
of such drugs under this part.
``(2) Establishment of procedures in order to implement
coverage.--The Secretary shall establish procedures for--
``(A) identifying beneficiaries that are entitled to
coverage of immunosuppressive drugs by reason of section
226(b) or 226A(b)(2); and
``(B) distinguishing such beneficiaries from beneficiaries
that are enrolled under this part for the complete package of
benefits under this part.''.
(D) Technical amendment.--Subsection (c) of section 226A
(42 U.S.C. 426-1), as added by section 201(a)(3)(D)(ii) of
the Social Security Independence and Program Improvements Act
of 1994 (Public Law 103-296; 108 Stat. 1497), is redesignated
as subsection (d).
(2) Extension of secondary payer requirements for esrd
beneficiaries.--Section 1862(b)(1)(C) (42 U.S.C.
1395y(b)(1)(C)) is amended by adding at the end the following
new sentence: ``With regard to immunosuppressive drugs
furnished on or after the date of enactment of the
Prescription Drug and Medicare Improvement Act of 2003, this
subparagraph shall be applied without regard to any time
limitation.''.
(3) Effective date.--The amendments made by this subsection
shall apply to drugs furnished on or after the date of
enactment of this Act.
(c) Plans Required to Maintain Coverage of
Immunosuppressive Drugs.--
(1) Application to certain health insurance coverage.--
(A) In general.--Subpart 2 of part A of title XXVII of the
Public Health Service Act (42 U.S.C. 300gg-4 et seq.) is
amended by adding at the end the following:

``SEC. 2707. COVERAGE OF IMMUNOSUPPRESSIVE DRUGS.

``A group health plan (and a health insurance issuer
offering health insurance coverage in connection with a group
health plan) shall provide coverage of immunosuppressive
drugs that is at least as comprehensive as the coverage
provided by such plan or issuer on the day before the date of
enactment of the Prescription Drug and Medicare Improvement
Act of 2003, and such

[[Page S8589]]

requirement shall be deemed to be incorporated into this
section.''.
(B) Conforming amendment.--Section 2721(b)(2)(A) of the
Public Health Service Act (42 U.S.C. 300gg-21(b)(2)(A)) is
amended by inserting ``(other than section 2707)'' after
``requirements of such subparts''.
(2) Application to group health plans and group health
insurance coverage under the employee retirement income
security act of 1974.--
(A) In general.--Subpart B of part 7 of subtitle B of title
I of the Employee Retirement Income Security Act of 1974 (29
U.S.C. 1185 et seq.) is amended by adding at the end the
following new section:

``SEC. 714. COVERAGE OF IMMUNOSUPPRESSIVE DRUGS.

``A group health plan (and a health insurance issuer
offering health insurance coverage in connection with a group
health plan) shall provide coverage of immunosuppressive
drugs that is at least as comprehensive as the coverage
provided by such plan or issuer on the day before the date of
enactment of the Prescription Drug and Medicare Improvement
Act of 2003, and such requirement shall be deemed to be
incorporated into this section.''.
(B) Conforming amendments.--
(i) Section 732(a) of the Employee Retirement Income
Security Act of 1974 (29 U.S.C. 1185(a)) is amended by
striking ``section 711'' and inserting ``sections 711 and
714''.
(ii) The table of contents in section 1 of the Employee
Retirement Income Security Act of 1974 is amended by
inserting after the item relating to section 713 the
following new item:

``Sec. 714. Coverage of immunosuppressive drugs.''.
(3) Application to group health plans under the internal
revenue code of 1986.--Subchapter B of chapter 100 of the
Internal Revenue Code of 1986 is amended--
(A) in the table of sections, by inserting after the item
relating to section 9812 the following new item:

``Sec. 9813. Coverage of immunosuppressive drugs.'';
and
(B) by inserting after section 9812 the following:

``SEC. 9813. COVERAGE OF IMMUNOSUPPRESSIVE DRUGS.

``A group health plan shall provide coverage of
immunosuppressive drugs that is at least as comprehensive as
the coverage provided by such plan on the day before the date
of enactment of the Prescription Drug and Medicare
Improvement Act of 2003, and such requirement shall be deemed
to be incorporated into this section.''.
(4) Effective Date.--The amendments made by this subsection
shall apply to plan years beginning on or after January 1,
2004.
______

SA 1081. Ms. LANDRIEU submitted an amendment intended to be proposed
by her to the bill S. 1, to amend title XVIII of the Social Security
Act to make improvements in the medicare program, to provide
prescription drug coverage under the medicare program, and for other
purposes; which was ordered to lie on the table; as follows:

On page 476, between lines 5 and 6, insert the following:
(10) Exemption for certain inhalation drugs and
biologicals.--Section 1842(o) (42 U.S.C. 1395u(o)), as
amended by subsection (a)(2) and paragraphs (4), (6) (7) and
(9), is amended by adding at the end the following new
paragraph:
``(10)(A) Notwithstanding the preceding provisions of this
subsection, in the case of existing inhalation drugs and
biologicals furnished on or after January 1, 2004, and before
January 1, 2011, the payment rate for such drugs and
biologicals shall be 95 percent of the average wholesale
price (as in effect on June 30, 2003).
``(B) During the period described in subparagraph (A), the
Secretary may not make any increased or separate payments
under paragraph (8) with respect to existing inhalation drugs
and biologicals.
``(C) For purposes of this paragraph, the term `existing
inhalation drugs and biologicals' means inhalation drugs and
biologicals furnished through durable medical equipment
covered under section 1861(n) that are first available for
payment under this part on or before June 30, 2003.''.
______

SA 1082. Mr. CONRAD submitted an amendment intended to be proposed by
him to the bill S. 1, to amend title XVIII of the Social Security Act
to make improvements in the medicare program, to provide prescription
drug coverage under the medicare program, and for other purposes; which
was ordered to lie on the table; as follows:

At the end of subtitle B of title IV, add the following:

SEC. __. ACCELERATING THE RATE OF REDUCTION OF BENEFICIARY
COPAYMENT LIABILITY UNDER THE MEDICARE HOSPITAL
OUTPATIENT DEPARTMENT PROSPECTIVE PAYMENT
SYSTEM.

Section 1833(t)(8)(C)(ii) (42 U.S.C. 1395l(t)(8)(C)(ii)) is
amended--
(1) in subclause (V), by striking ``and thereafter'' and
inserting ``through 2008''; and
(2) by adding at the end the following new subclauses:

``(VI) For procedures performed in 2009, 36 percent.
``(VII) For procedures performed in 2010 and 2011, 34
percent.
``(VIII) For procedures performed in 2012, 32 percent.
``(IX) For procedures performed in 2013 and thereafter, 30
percent.''.

SEC. __. MEDICARE SECONDARY PAYOR (MSP) PROVISIONS.

(a) Technical Amendment Concerning Secretary's Authority To
Make Conditional Payment When Certain Primary Plans Do Not
Pay Promptly.--
(1) In general.--Section 1862(b)(2) (42 U.S.C. 1395y(b)(2))
is amended--
(A) in subparagraph (A)(ii), by striking ``promptly (as
determined in accordance with regulations)'';
(B) in subparagraph (B)--
(i) by redesignating clauses (i) through (iii) as clauses
(ii) through (iv), respectively; and
(ii) by inserting before clause (ii), as so redesignated,
the following new clause:
``(i) Authority to make conditional payment.--The Secretary
may make payment under this title with respect to an item or
service if a primary plan described in subparagraph (A)(ii)
has not made or cannot reasonably be expected to make payment
with respect to such item or service promptly (as determined
in accordance with regulations). Any such payment by the
Secretary shall be conditioned on reimbursement to the
appropriate Trust Fund in accordance with the succeeding
provisions of this subsection.''.
(2) Effective date.--The amendments made by paragraph (1)
shall be effective as if included in the enactment of title
III of the Medicare and Medicaid Budget Reconciliation
Amendments of 1984 (Public Law 98-369).
(b) Clarifying Amendments to Conditional Payment
Provisions.--Section 1862(b)(2) (42 U.S.C. 1395y(b)(2)) is
further amended--
(1) in subparagraph (A), in the matter following clause
(ii), by inserting the following sentence at the end: ``An
entity that engages in a business, trade, or profession shall
be deemed to have a self-insured plan if it carries its own
risk (whether by a failure to obtain insurance, or otherwise)
in whole or in part.'';
(2) in subparagraph (B)(ii), as redesignated by subsection
(a)(2)(B)--
(A) by striking the first sentence and inserting the
following: ``A primary plan, and an entity that receives
payment from a primary plan, shall reimburse the appropriate
Trust Fund for any payment made by the Secretary under this
title with respect to an item or service if it is
demonstrated that such primary plan has or had a
responsibility to make payment with respect to such item or
service. A primary plan's responsibility for such payment may
be demonstrated by a judgment, a payment conditioned upon the
recipient's compromise, waiver, or release (whether or not
there is a determination or admission of liability) of
payment for items or services included in a claim against the
primary plan or the primary plan's insured, or by other
means.''; and
(B) in the final sentence, by striking ``on the date such
notice or other information is received'' and inserting ``on
the date notice of, or information related to, a primary
plan's responsibility for such payment or other information
is received''; and
(3) in subparagraph (B)(iii), , as redesignated by
subsection (a)(2)(B), by striking the first sentence and
inserting the following: ``In order to recover payment made
under this title for an item or service, the United States
may bring an action against any or all entities that are or
were required or responsible (directly, as an insurer or
self-insurer, as a third-party administrator, as an employer
that sponsors or contributes to a group health plan, or large
group health plan, or otherwise) to make payment with respect
to the same item or service (or any portion thereof) under a
primary plan. The United States may, in accordance with
paragraph (3)(A) collect double damages against any such
entity. In addition, the United States may recover under this
clause from any entity that has received payment from a
primary plan or from the proceeds of a primary plan's payment
to any entity.''.
(c) Clerical Amendments.--Section 1862(b) (42 U.S.C.
1395y(b)) is amended--
(1) in paragraph (1)(A), by moving the indentation of
clauses (ii) through (v) 2 ems to the left; and
(2) in paragraph (3)(A), by striking ``such'' before
``paragraphs''.
______

SA 1083. Mr. COLEMAN submitted an amendment intended to be proposed
by him to the bill S. 1, to amend title XVIII of the Social Security
Act to make improvements in the medicare program, to provide
prescription drug coverage under the medicare program, and for other
purposes; which was ordered to lie on the table; as follows:

At the end of subtitle A of title IV, add the following:

SEC. __. TREATMENT OF CERTAIN ENTITIES FOR PURPOSES OF
PAYMENTS UNDER THE MEDICARE PROGRAM.

(a) Payments to Hospitals.--Notwithstanding any other
provision of law, effective for discharges occurring on or
after October 1, 2003, for purposes of making payments to
hospitals (as defined in section 1886(d) and 1833(t) of the
Social Security Act (42 U.S.C.

[[Page S8590]]

1395(d)) under the medicare program under title XVIII of such
Act (42 U.S.C. 1395 et seq.), Stearns County, Minnesota, such
county is deemed to be located in the Minneapolis-St. Paul,
Minnesota-Wisconsin, Metropolitan Statistical Area.
(b) Budget Neutrality.--The Secretary shall adjust the area
wage index referred to in subsection (a) in a manner which
assures that the appropriate payments made under section
1886(d) of the Social Security Act (42 U.S.C., 1395(ww)(d))
in a fiscal year for the operating cost of inpatient hospital
services are not greater or less than those which would have
be made in the year if this section did not apply.
______

SA 1084. Mr. VOINOVICH submitted an amendment intended to be proposed
by him to the bill S. 1, to amend title XVIII of the Social Security
Act to make improvements in the medicare program, to provide
prescription drug coverage under the medicare program, and for other
purposes; which was ordered to lie on the table; as follows:

On page 152, between lines 7 and 8, and insert the
following:
``(g) State Option To Pay Medicare Part D Price for Covered
Outpatient Drugs for Dual Eligible Individuals.--
Notwithstanding any provision of title XVIII, or section
1927(c)(1)(C)(i), with respect to a State that provides
medical assistance for a covered drug (as such term is
defined in section 1860D(a)(2)) for a dual eligible
individual enrolled under the State plan under this title (or
under a waiver of such plan) that is also a covered
outpatient drug (as defined for purposes of in section 1927)
included on the State formulary established under section
1927, if the price the State would pay for the drug under
this title exceeds the price that an eligible entity offering
a Medicare Prescription Drug plan or a MedicareAdvantage
organization offering a MedicareAdvantage plan would pay for
the drug under title XVIII, the State may elect to pay the
price that applies under title XVIII. An election by a State
under the preceding sentence shall have no effect on the
terms of a rebate agreement entered into under section 1927
which would otherwise apply to the provision of medical
assistance for the covered outpatient drug.''.
______

SA 1085. Mr. SPECTER submitted an amendment intended to be proposed
by him to the bill S. 1, to amend title XVIII of the Social Security
Act to make improvements in the medicare program, to provide
prescription drug coverage under the medicare program, and for other
purposes; which was ordered to lie on the table; as follows:

At the end of title VI, insert the following:

SEC. __. SENSE OF THE SENATE ON PAYMENT REDUCTIONS UNDER
MEDICARE PHYSICIAN FEE SCHEDULE.

(a) Findings.--Congress finds that--
(1) the fees Medicare pays physicians were reduced by 5.4
percent across-the-board in 2002;
(2) recent action by Congress narrowly averted another
across-the-board reduction of 4.4 percent for 2003;
(3) based on current projections, the Centers for Medicare
& Medicaid Services (CMS) estimates that, absent legislative
or administrative action, fees will be reduced across-the-
board once again in 2004 by 4.2 percent;
(4) the prospect of continued payment reductions under the
Medicare physician fee schedule for the foreseeable future
threatens to destabilize an important element of the program,
namely physician participation and willingness to accept
Medicare patients;
(5) the primary source of this instability is the
sustainable growth rate (SGR), a system of annual spending
targets for physicians' services under Medicare;
(6) the SGR system has a number of defects that result in
unrealistically low spending targets, such as the use of the
increase in the gross domestic product (GDP) as a proxy for
increases in the volume and intensity of services provided by
physicians, no tolerance for variance between growth in
Medicare beneficiary health care costs and our Nation's GDP,
and a requirement for immediate recoupment of the difference;
(7) both administrative and legislative action are needed
to return stability to the physician payment system;
(8) using the discretion given to it by Medicare law, CMS
has included expenditures for prescription drugs and
biologicals administered incident to physicians' services
under the annual spending targets without making appropriate
adjustments to the targets to reflect price increases in
these drugs and biologicals or the growing reliance on such
therapies in the treatment of Medicare patients;
(9) between 1996 and 2002, annual Medicare spending on
these drugs grew from $1,800,000,000 to $6,200,000,000, or
from $55 per beneficiary to an estimated $187 per
beneficiary;
(10) although physicians are responsible for prescribing
these drugs and biologicals, neither the price of the drugs
and biologicals, nor the standards of care that encourage
their use, are within the control of physicians; and
(11) SGR target adjustments have not been made for cost
increases due to new coverage decisions and new rules and
regulations.
(b) Sense of the Senate.--It is the sense of the Senate
that--
(1) the Center for Medicare & Medicaid Services (CMS)
should use its discretion to exclude drugs and biologicals
administered incident to physician services from the
sustainable growth rate (SGR) system;
(2) CMS should use its discretion to make SGR target
adjustments for new coverage decisions and new rules and
regulations; and
(3) in order to provide ample time for Congress to consider
more fundamental changes to the SGR system, the conferees on
the Prescription Drug and Medicare Improvement Act of 2003
should include in the conference agreement a provision to
establish a minimum percentage update in physician fees for
the next 2 years and should consider adding provisions that
would mitigate the swings in payment, such as establishing
multi-year adjustments to recoup the variance and creating
``tolerance'' corridors for variations around the update
target trend.
______

SA 1086. Ms. MURKOWSKI submitted an amendment intended to be proposed
by her to the bill S. 1, to amend title XVIII of the Social Security
Act to make improvements in the medicare program, to provide
prescription drug coverage under the medicare program, and for other
purposes; which was ordered to lie on the table; as follows:

On page 37, strike lines 4 and 5 and insert ``reasonable
distances to pharmacy services in urban and rural areas and
access to pharmacy services of the Indian Health Service and
Indian tribes and tribal organizations.''.
On page 165, strike lines 4 and 5 and insert ``into account
reasonable distances to pharmacy services in urban and rural
areas and access to pharmacy services of the Indian Health
Service and Indian tribes and tribal organizations.''.
______

SA 1087. Mr. GRASSLEY (for Mr. Craig) proposed an amendment to the
bill S. 1, to amend title XVIII of the Social Security Act to make
improvements in the medicare program, to provide prescription drug
coverage under the medicare program, and for other purposes; as
follows:

At the end of subtitle A of title II, add the following:

SEC. __. ESTABLISHMENT OF MEDICAREADVANTAGE CONSUMER-DRIVEN
HEALTH PLAN OPTION.

(a) Program specifications.--Part C of title XVIII (42
U.S.C. 1395w-21 et seq.), amended by section 205, is amended
by inserting after section 1858A the following new section:

``consumer-driven health plan option

``Sec. 1858B. (a) Establishment of Program.--
``(1) In general.--Beginning on January 1, 2006, there is
established a consumer-driven health plan program under which
consumer-driven health plans offered by consumer-driven
health plan sponsors are offered to MedicareAdvantage
eligible individuals in preferred provider regions.
``(2) Definitions.--
``(A) Consumer-driven health plan sponsor.--The term
`consumer-driven health plan sponsor' means an entity with a
contract under section 1857 that meets the requirements of
this section applicable with respect to consumer-driven
health plan sponsors.
``(B) Consumer-driven health plan.--The term `consumer-
driven health plan' means a MedicareAdvantage plan that--
``(i) provides 100 percent coverage for preventive benefits
(as defined by the Secretary);
``(ii) includes a personal care account from which
enrollees must pay out-of-pocket costs until the deductible
is met; and
``(iii) has a high deductible (as determined by the
Secretary).
``(C) Preferred provider region.--The term `preferred
provider region' has the meaning given that term under
section 1858(a)(2)(C).
``(b) Eligibility, Election, and Enrollment; Benefits and
Beneficiary Protections.--
``(1) In general.--Except as provided in the succeeding
provisions of this subsection, the provisions of sections
1851 and 1852 that apply with respect to coordinated care
plans shall apply to consumer-driven health plans offered by
a consumer-driven health plan sponsor.
``(2) Service area.--The service area of a consumer-driven
health plan shall be a preferred provider region.
``(3) Availability.--Each preferred provider organization
plan must be offered to each MedicareAdvantage eligible
individual who resides in the service area of the plan.
``(4) Authority to prohibit risk selection.--The provisions
of section 1852(a)(6) shall apply to preferred provider
organization plans.
``(5) Assuring access to services in consumer-driven health
plans.--The requirements of section 1858(a)(5) shall apply to
consumer-driven health plans.
``(6) Personal care accounts.--
``(A) Establishment.--Each consumer-driven health plan
shall establish a personal care account on behalf of each
enrollee from which such enrollee shall be required to pay
out-of-pockets costs until the deductible described in
subsection (a)(2)(B)(iii) is met.
``(B) Rollover.--Subject to subparagraph (C), any amounts
remaining in a personal care account at the end of a year
shall be credited to such an account for the subsequent year.

[[Page S8591]]

``(C) Changes of election.--If, after electing a consumer-
driven health plan, a beneficiary elects a plan under this
part that is not a consumer-driven health plan during a
subsequent year or elects to receive benefits under the
original medicare fee-for-service program option (whether or
not as a result of circumstances described in section
1851(e)(4)), any amounts remaining in the account as of the
date of such election shall be credited to the Federal
Hospital Insurance Trust Fund under section 1817 and the
Federal Supplementary Medical Insurance Trust Fund under
section 1841 in such proportion as the Secretary determines
is appropriate.
``(c) Payments to Consumer-Driven Health Plan Sponsors.--
``(1) Payments to organizations.--
``(A) Monthly payments.--
``(i) In general.--Under a contract under section 1857 and
subject to paragraph (5), subsections (e) and (i), and
section 1859(e)(4), the Secretary shall make, to each
consumer-driven health plan sponsor, with respect to coverage
of an individual for a month under this part in a preferred
provider region, separate monthly payments with respect to--

``(I) benefits under the original medicare fee-for-service
program under parts A and B in accordance with paragraph (4);
and
``(II) benefits under the voluntary prescription drug
program under part D in accordance with section 1858A and the
other provisions of this part.

``(ii) Special rule for end-stage renal disease.--The
Secretary shall establish separate rates of payment
applicable with respect to classes of individuals determined
to have end-stage renal disease and enrolled in a consumer-
driven health plan under this clause that are similar to the
separate rates of payment described in section 1853(a)(1)(B).
``(B) Adjustment to reflect number of enrollees.--The
Secretary may retroactively adjust the amount of payment
under this paragraph in a manner that is similar to the
manner in which payment amounts may be retroactively adjusted
under section 1853(a)(2).
``(C) Comprehensive risk adjustment methodology.--The
Secretary shall apply the comprehensive risk adjustment
methodology described in section 1853(a)(3)(B) to 100 percent
of the amount of payments to plans under paragraph
(4)(D)(ii).
``(D) Adjustment for spending variations within a region.--
The Secretary shall establish a methodology for adjusting the
amount of payments to plans under paragraph (4)(D)(ii) that
achieves the same objective as the adjustment described in
paragraph 1853(a)(2)(C).
``(2) Application of preferred provider benchmarks.--The
benchmark amounts calculated under section 1858(c)(2) shall
apply with respect to consumer-driven health plans.
``(3) Application of preferred provider payment factors.--
The provisions of section 1858(c)(3) shall apply with respect
to consumer driven health plans.
``(4) Secretary's determination of payment amount for
benefits under the original medicare fee-for-service
program.--The Secretary shall determine the payment amount
for plans as follows:
``(A) Review of plan bids.--The Secretary shall review each
plan bid submitted under subsection (d)(1) for the coverage
of benefits under the original medicare fee-for-service
program option to ensure that such bids are consistent with
the requirements under this part and are based on the
assumptions described in section 1854(a)(2)(A)(iii).
``(B) Determination of preferred provider regional
benchmark amounts.--The preferred provider regional benchmark
calculated under section 1858(c)(4)(B) shall apply with
respect to consumer-drive health plans amount for that plan
for the benefits under the original medicare fee-for-service
program option for each plan equal to the regional benchmark
adjusted by using the assumptions described in section
1854(a)(2)(A)(iii).
``(C) Comparison to benchmark.--The Secretary shall
determine the difference between each plan bid (as adjusted
under subparagraph (A)) and the preferred provider regional
benchmark amount (as determined under subparagraph (B)) for
purposes of determining--
``(i) the payment amount under subparagraph (D); and
``(ii) the additional benefits required and
MedicareAdvantage monthly basic beneficiary premiums.
``(D) Determination of payment amount.--
``(i) In general.--Subject to clause (ii), the Secretary
shall determine the payment amount to a consumer-driven
health plan sponsor for a consumer-driven health plan as
follows:

``(I) Bids that equal or exceed the benchmark.--In the case
of a plan bid that equals or exceeds the preferred provider
regional benchmark amount, the amount of each monthly payment
to the organization with respect to each individual enrolled
in a plan shall be the preferred provider regional benchmark
amount.
``(II) Bids below the benchmark.--In the case of a plan bid
that is less than the preferred provider regional benchmark
amount, the amount of each monthly payment to the
organization with respect to each individual enrolled in a
plan shall be the preferred provider regional benchmark
amount reduced by the amount of any premium reduction elected
by the plan under section 1854(d)(1)(A)(i).

``(ii) Application of adjustment methodologies.--The
Secretary shall adjust the amounts determined under
subparagraph (A) using the factors described in section
1858(c)(3)(A)(ii).
``(E) Factors used in adjusting bids and benchmarks for
consumer-driven health plan sponsors and in determining
enrollee premiums.--Subject to subparagraph (F), in addition
to the factors used to adjust payments to plans described in
section 1853(d)(6), the Secretary shall use the adjustment
for geographic variation within the region established under
paragraph (1)(D).
``(F) Adjustment for national coverage determinations and
legislative changes in benefits.--The Secretary shall provide
for adjustments for national coverage determinations and
legislative changes in benefits applicable with respect to
consumer-driven health plan sponsors in the same manner as
the Secretary provides for adjustments under section
1853(d)(7).
``(5) Payments from trust fund.--The payment to a consumer-
driven health plan sponsor under this section shall be made
from the Federal Hospital Insurance Trust Fund and the
Federal Supplementary Medical Insurance Trust Fund in a
manner similar to the manner described in section 1853(g).
``(6) Special rule for certain inpatient hospital stays.--
Rules similar to the rules applicable under section 1853(h)
shall apply with respect consumer-driven health plan
sponsors.
``(7) Special rule for hospice care.--Rules similar to the
rules applicable under section 1853(i) shall apply with
respect to consumer-driven health plan sponsors.
``(d) Submission of Bids by Consumer-Driven Health Plans;
Premiums.--
``(1) Submission of bids by consumer-driven health plan
sponsors.--
``(A) In general.--For the requirements on submissions by
consumer-driven health plans, see section 1854(a)(1).
``(B) Uniform premiums.--Each bid amount submitted under
subparagraph (A) for a consumer-driven health plan in a
preferred provider region may not vary among
MedicareAdvantage eligible individuals residing in such
preferred provider region.
``(C) Application of fehbp standard; prohibition on price
gouging.--Each bid amount submitted under subparagraph (A)
for a consumer-driven health plan must reasonably and
equitably reflect the cost of benefits provided under that
plan.
``(D) Review.--The Secretary shall review the adjusted
community rates (as defined in section 1854(g)(3)), the
amounts of the MedicareAdvantage monthly basic premium and
the MedicareAdvantage monthly beneficiary premium for
enhanced medical benefits filed under this paragraph and
shall approve or disapprove such rates and amounts so
submitted. The Secretary shall review the actuarial
assumptions and data used by the consumer-driven health plan
sponsor with respect to such rates and amounts so submitted
to determine the appropriateness of such assumptions and
data.
``(E) No limit on number of plans in a region.--The
Secretary may not limit the number of consumer-driven health
plans offered in a preferred provider region.
``(2) Monthly premiums charged.--The amount of the monthly
premium charged to an individual enrolled in a consumer-
driven health plan offered by a consumer-driven health plan
sponsor shall be equal to the sum of the following:
``(A) The MedicareAdvantage monthly basic beneficiary
premium, as defined in section 1854(b)(2)(A) (if any).
``(B) The MedicareAdvantage monthly beneficiary premium for
enhanced medical benefits, as defined in section
1854(b)(2)(C) (if any).
``(C) The MedicareAdvantage monthly obligation for
qualified prescription drug coverage, as defined in section
1854(b)(2)(B) (if any).
``(3) Determination of premium reductions, reduced cost-
sharing, additional benefits, and beneficiary premiums.--The
rules for determining premium reductions, reduced cost-
sharing, additional benefits, and beneficiary premiums under
section 1854(d) shall apply with respect to consumer-driven
health plan sponsors.
``(4) Prohibition of segmenting preferred provider
regions.--The Secretary may not permit a consumer-driven
health plan sponsor to elect to apply the provisions of this
section uniformly to separate segments of a preferred
provider region (rather than uniformly to an entire preferred
provider region).
``(e) Portion of Total Payments to an Organization Subject
to Risk for 2 Years.--
``(1) Notification of spending under the plan.--
``(A) In general.--For 2007 and 2008, the consumer-driven
health plan sponsor offering a consumer-driven health plan
shall notify the Secretary of the total amount of costs that
the organization incurred in providing benefits covered under
parts A and B of the original medicare fee-for-service
program for all enrollees under the plan in the previous
year.
``(B) Certain expenses not included.--The total amount of
costs specified in subparagraph (A) may not include--
``(i) subject to subparagraph (C), administrative expenses
incurred in providing the benefits described in such
subparagraph; or

[[Page S8592]]

``(ii) amounts expended on providing enhanced medical
benefits under section 1852(a)(3)(D).
``(C) Establishment of allowable administrative expenses.--
For purposes of applying subparagraph (B)(i), the
administrative expenses incurred in providing benefits
described in subparagraph (A) under a consumer-driven health
plan may not exceed an amount determined appropriate by the
Administrator.
``(2) Adjustment of payment.--
``(A) No adjustment if costs within risk corridor.--If the
total amount of costs specified in paragraph (1)(A) for the
plan for the year are not more than the first threshold upper
limit of the risk corridor (specified in paragraph
(3)(A)(iii)) and are not less than the first threshold lower
limit of the risk corridor (specified in paragraph (3)(A)(i))
for the plan for the year, then no additional payments shall
be made by the Secretary and no reduced payments shall be
made to the consumer-driven health plan sponsor offering the
plan.
``(B) Increase in payment if costs above upper limit of
risk corridor.--
``(i) In general.--If the total amount of costs specified
in paragraph (1)(A) for the plan for the year are more than
the first threshold upper limit of the risk corridor for the
plan for the year, then the Secretary shall increase the
total of the monthly payments made to the consumer-driven
health plan sponsor offering the plan for the year under
subsection (c)(1)(A) by an amount equal to the sum of--

``(I) 50 percent of the amount of such total costs which
are more than such first threshold upper limit of the risk
corridor and not more than the second threshold upper limit
of the risk corridor for the plan for the year (as specified
under paragraph (3)(A)(iv)); and
``(II) 10 percent of the amount of such total costs which
are more than such second threshold upper limit of the risk
corridor.

``(C) Reduction in payment if costs below lower limit of
risk corridor.--If the total amount of costs specified in
paragraph (1)(A) for the plan for the year are less than the
first threshold lower limit of the risk corridor for the plan
for the year, then the Secretary shall reduce the total of
the monthly payments made to the consumer-driven health plan
sponsor offering the plan for the year under subsection
(c)(1)(A) by an amount (or otherwise recover from the plan an
amount) equal to--
``(i) 50 percent of the amount of such total costs which
are less than such first threshold lower limit of the risk
corridor and not less than the second threshold lower limit
of the risk corridor for the plan for the year (as specified
under paragraph (3)(A)(ii)); and
``(ii) 10 percent of the amount of such total costs which
are less than such second threshold lower limit of the risk
corridor.
``(3) Establishment of risk corridors.--
``(A) In general.--For 2006 and 2007, the Secretary shall
establish a risk corridor for each consumer-driven health
plan. The risk corridor for a plan for a year shall be equal
to a range as follows:
``(i) First threshold lower limit.--The first threshold
lower limit of such corridor shall be equal to--

``(I) the target amount described in subparagraph (B) for
the plan; minus
``(II) an amount equal to 5 percent of such target amount.

``(ii) Second threshold lower limit.--The second threshold
lower limit of such corridor shall be equal to--

``(I) the target amount described in subparagraph (B) for
the plan; minus
``(II) an amount equal to 10 percent of such target amount.

``(iii) First threshold upper limit.--The first threshold
upper limit of such corridor shall be equal to the sum of--

``(I) such target amount; and
``(II) the amount described in clause (i)(II).

``(iv) Second threshold upper limit.--The second threshold
upper limit of such corridor shall be equal to the sum of--

``(I) such target amount; and
``(II) the amount described in clause (ii)(II).

``(B) Target amount described.--The target amount described
in this paragraph is, with respect to a consumer-driven
health plan offered by a consumer-driven health plan sponsor
in a year, an amount equal to the sum of--
``(i) the total monthly payments made to the organization
for enrollees in the plan for the year under subsection
(c)(1)(A); and
``(ii) the total MedicareAdvantage basic beneficiary
premiums collected for such enrollees for the year under
subsection (d)(2)(A).
``(4) Plans at risk for entire amount of enhanced medical
benefits.--A consumer-driven health plan sponsor that offers
a consumer-driven health plan that provides enhanced medial
benefits under section 1852(a)(3)(D) shall be at full
financial risk for the provision of such benefits.
``(5) No effect on eligible beneficiaries.--No change in
payments made by reason of this subsection shall affect the
amount of the MedicareAdvantage basic beneficiary premium
that a beneficiary is otherwise required to pay under the
plan for the year under subsection (d)(2)(A).
``(6) Disclosure of information.--The provisions of section
1860D-16(b)(7), including subparagraph (B) of such section,
shall apply to a consumer-driven health plan sponsor and a
consumer-driven health plan in the same manner as such
provisions apply to an eligible entity and a Medicare
Prescription Drug plan under part D.
``(f) Organizational and Financial Requirements for
Consumer-Driven Health Plan Sponsors.--A consumer-driven
health plan sponsor shall be organized and licensed under
State law as a risk-bearing entity eligible to offer health
insurance or health benefits coverage in each State within
the preferred provider region in which it offers a consumer-
driven health plan.
``(g) Inapplicability of Provider-Sponsored Organization
Solvency Standards.--The requirements of section 1856 shall
not apply with respect to consumer-driven health plan
sponsors.
``(h) Contracts With Consumer-Driven Health Plan
Sponsors.--The provisions of section 1857 shall apply to a
consumer-driven health plan offered by a consumer-driven
health plan sponsor under this section.
``(i) Budget Neutrality.--Notwithstanding any other
provision of this section, in conducting the program under
this section, the Secretary shall ensure that the aggregate
payments made by the Secretary under this title do not exceed
the amount the Secretary would have paid if this section had
not been enacted.''.
(b) Consumer-Driven Health Plan Terminology Defined.--
Section 1859(a) (42 U.S.C. 1395w-29(a)), as amended by
section 211(b), is amended by adding at the end the following
new paragraph:
``(4) Consumer-driven health plan sponsor; consumer-driven
health plan.--The terms `consumer-driven health plan sponsor'
and `consumer-driven health plan' have the meaning given such
terms in section 1858B(a)(2).''.
______

SA 1088. Mr. BAUCUS (for Ms. Mikulski) proposed an amendment to the
bill S. 1, to amend title XVIII of the Social Security Act to make
improvements in the medicare program, to provide prescription drug
coverage under the medicare program, and for other purposes; as
follows:

At the end of subtitle B of title IV, add the following:

SEC. __. EQUITABLE TREATMENT FOR CHILDREN'S HOSPITALS.

(a) In General.--Section 1833(t)(7)(D)(ii) (42 U.S.C.
1395l(t)(7)(D)(ii)) is amended to read as follows:
``(ii) Permanent treatment for cancer hospitals and
children's hospitals.--

``(I) Cancer hospitals.--In the case of a hospital
described in section 1886(d)(1)(B)(v), for covered OPD
services for which the PPS amount is less than the pre-BBA
amount, the amount of payment under this subsection shall be
increased by the amount of such difference.
``(II) Children's hospitals.--In the case of a hospital
described in section 1886(d)(1)(B)(iii), for covered OPD
services furnished before October 1, 2003, and for which the
PPS amount is less than the pre-BBA amount the amount of
payment under this subsection shall be increased by the
amount of such difference. In the case of such a hospital,
for such services furnished on or after October 1, 2003, and
for which the PPS amount is less than the greater of the pre-
BBA amount or the reasonable operating and capital costs
without reductions incurred in furnishing such services, the
amount of payment under this subsection shall be increased by
the amount of such difference.''.

______

SA 1089. Mr. BAUCUS (for Ms. Mikulski) proposed an amendment to the
bill S. 1, to amend title XVIII of the Social Security Act to make
improvements in the medicare program, to provide prescription drug
coverage under the medicare program, and for other purposes; as
follows:

At the end of subtitle B of title IV, add the following:

SEC. __. EQUITABLE TREATMENT FOR CHILDREN'S HOSPITALS.

(a) In General.--Section 1833(t)(7)(D)(ii) (42 U.S.C.
1395l(t)(7)(D)(ii)) is amended to read as follows:
``(ii) Permanent treatment for cancer hospitals and
children's hospitals.--

``(I) In general.--Subject to subclause (II), in the case
of a hospital described in clause (iii) or (v) of section
1886(d)(1)(B), for covered OPD services for which the PPS
amount is less than the pre-BBA amount, the amount of payment
under this subsection shall be increased by the amount of
such difference.
``(II) Special rule for certain children's hospitals.--In
the case of a hospital described in section
1886(d)(1)(B)(iii) that is located in a State with a
reimbursement system under section 1814(b)(3), but that is
not reimbursed under such system, for covered OPD services
furnished on or after October 1, 2003, and for which the PPS
amount is less than the greater of the pre-BBA amount or the
reasonable operating and capital costs without reductions of
the hospital in providing such services, the amount of
payment under this subsection shall be increased by the
amount of such difference.''.

______

SA 1090. Mr. BAUCUS (for Ms. Mikulski) proposed an amendment to the
bill S. 1, to amend title XVIII of the Social Security Act to make
improvements in the medicare program, to provide prescription drug
coverage under the medicare program, and for other purposes; as
follows:

[[Page S8593]]

At the end of subtitle A of title IV, add the following:

SEC. __. PERMITTING DIRECT PAYMENT UNDER THE MEDICARE PROGRAM
FOR CLINICAL SOCIAL WORKER SERVICES PROVIDED TO
RESIDENTS OF SKILLED NURSING FACILITIES.

(a) In General.--Section 1888(e)(2)(A)(ii) (42 U.S.C.
1395yy(e)(2)(A)(ii)) is amended by inserting ``clinical
social worker services,'' after ``qualified psychologist
services,''.
(b) Conforming Amendment.--Section 1861(hh)(2) (42 U.S.C.
1395x(hh)(2)) is amended by striking ``and other than
services furnished to an inpatient of a skilled nursing
facility which the facility is required to provide as a
requirement for participation''.
(c) Effective Date.--The amendments made by this section
shall apply to items and services furnished on or after
October 1, 2003.
______

SA 1091. Mr. BAUCUS (for Ms. Mikulski) proposed an amendment to the
bill S. 1, to amend title XVIII of the Social Security Act to make
improvements in the medicare program, to provide prescription drug
coverage under the medicare program, and for other purposes; as
follows:

At the end of title VI, add the following:

SEC. __. EXTENSION OF MUNICIPAL HEALTH SERVICE DEMONSTRATION
PROJECTS.

The last sentence of section 9215(a) of the Consolidated
Omnibus Budget Reconciliation Act of 1985 (42 U.S.C. 1395b-1
note), as previously amended, is amended by striking
``December 31, 2004, but only with respect to'' and all that
follows and inserting ``December 31, 2009, but only with
respect to individuals who reside in the city in which the
project is operated and so long as the total number of
individuals participating in the project does not exceed the
number of such individuals participating as of January 1,
1996.''.
______

SA 1092. Mr. GRASSLEY (for himself and Mr. Baucus) proposed an
amendment to the bill S. 1, to amend title XVIII of the Social Security
Act to make improvements in the medicare program, to provide
prescription drug coverage under the medicare program, and for other
purposes; as follows:

At the end of subtitle C of title II, add the following:

Subtitle D--Evaluation of Alternative Payment and Delivery Systems

SEC. 231. ESTABLISHMENT OF ALTERNATIVE PAYMENT SYSTEM FOR
PREFERRED PROVIDER ORGANIZATIONS IN HIGHLY
COMPETITIVE REGIONS.

(a) Establishment of Alternative Payment System for
Preferred Provider Organizations in Highly Competitive
Regions.--Section 1858 (as added by section 211(b)) is
amended by adding at the end the following new subsection:
``(i) Alternative Payment Methodology for Highly
Competitive Regions.--
``(1) Annual determination and designation.--
``(A) In 2008.--In 2008, prior to the date on which the
Secretary expects to publish the risk adjusters under section
1860D-11, the Secretary shall designate a limited number (but
in no case fewer than 1) of preferred provider regions (other
than the region described in subsection (a)(2)(C)(ii)) as
highly competitive regions.
``(B) Subsequent years.--For each year (beginning with
2009) the Secretary may designate a limited number of
preferred provider regions (other than the region described
in subsection (a)(2)(C)(ii)) as highly competitive regions in
addition to any region designated as a highly competitive
region under subparagraph (A).
``(C) Considerations.--In determining which preferred
provider regions to designate as highly competitive regions
under subparagraph (A) or (B), the Secretary shall consider
the following:
``(i) Whether the application of this subsection to the
preferred provider region would enhance the participation of
preferred provider organization plans in that region.
``(ii) Whether the Secretary anticipates that there is
likely to be at least 3 bids submitted under subsection
(d)(1) with respect to the preferred provider region if the
Secretary designates such region as a highly competitive
region under subparagraph (A) or (B).
``(iii) Whether the Secretary expects that
MedicareAdvantage eligible individuals will elect preferred
provider organization plans in the preferred provider region
if the region is designated as a highly competitive region
under subparagraph (A) or (B).
``(iv) Whether the designation of the preferred provider
region as a highly competitive region will permit compliance
with the limitation described in paragraph (5).

In considering the matters described in clauses (i) through
(iv), the Secretary shall give special consideration to
preferred provider regions where no bids were submitted under
subsection (d)(1) for the previous year.
``(2) Effect of designation.--If a preferred provider
region is designated as a highly competitive region under
subparagraph (A) or (B) of paragraph (1)--
``(A) the provisions of this subsection shall apply to such
region and shall supersede the provisions of this part
relating to benchmarks for preferred provider regions; and
``(B) such region shall continue to be a highly competitive
region until such designation is rescinded pursuant to
paragraph (5)(B)(ii).
``(3) Submission of bids.--
``(A) In general.--Notwithstanding subsection (d)(1), for
purposes of applying section 1854(a)(2)(A)(i), the plan bid
for a highly competitive region shall consist of a dollar
amount that represents the total amount that the plan is
willing to accept (not taking into account the application of
the comprehensive risk adjustment methodology under section
1853(a)(3)) for providing coverage of only the benefits
described in section 1852(a)(1)(A) to an individual enrolled
in the plan that resides in the service area of the plan for
a month.
``(B) Construction.--Nothing in subparagraph (A) shall be
construed as permitting a preferred provider organization
plan not to provide coverage for the benefits described in
section 1852(a)(1)(C).
``(4) Payments to preferred provider organizations in
highly competitive areas.--With respect to highly competitive
regions, the following rules shall apply:
``(A) In general.--Notwithstanding subsection (c), of the
plans described in subsection (d)(1)(E), the Secretary shall
substitute the second lowest bid for the benchmark applicable
under subsection (c)(4).
``(B) If there are fewer than three bids.--Notwithstanding
subsection (c), if there are fewer than 3 bids in a highly
competitive region for a year, the Secretary shall substitute
the lowest bid for the benchmark applicable under subsection
(c)(4).
``(5) Funding limitation.--
``(A) In general.--
``(i) In general.--The total amount expended as a result of
the application of this subsection during the period or year,
as applicable, may not exceed the applicable amount (as
defined in clause (ii)).
``(ii) Applicable amount defined.--In this paragraph, the
term `applicable amount' means--

``(I) for the period beginning on January 1, 2009, and
ending on September 30, 2013, the total amount that would
have been expended under this title during the period if this
subsection had not been enacted plus $6,000,000,000; and
``(II) for fiscal year 2014 and any subsequent fiscal year,
the total amount that would have been expended under this
title during the year if this subsection had not been
enacted.

``(B) Application of limitation.--If the Secretary
determines that the application of this subsection will cause
expenditures to exceed the applicable amount, the Secretary
shall--
``(i) take appropriate steps to stay within the applicable
amount, including through providing limitations on
enrollment; or
``(ii) rescind the designation under subparagraph (A) or
(B) of paragraph (1) of 1 or more preferred provider regions
as highly competitive regions.
``(C) Transition.--If the Secretary rescinds a designation
under subparagraph (A) or (B) of paragraph (1) pursuant to
subparagraph (B)(ii) with respect to a preferred provider
region, the Secretary shall provide for an appropriate
transition from the payment system applicable under this
subsection to the payment system described in the other
provisions of this section in that region. Any amount
expended by reason of the preceding sentence shall be
considered to be part of the total amount expended as a
result of the application of this subsection for purposes of
applying the limitation under subparagraph (A).
``(D) Application.--Notwithstanding paragraph (1)(B), on or
after January 1 of the year in which the fiscal year
described in subparagraph (A)(ii)(II) begins, the Secretary
may designate appropriate regions under such paragraph.
``(6) Limitation of judicial review.--There shall be no
administrative or judicial review under section 1869, section
1878, or otherwise, of designations made under subparagraph
(A) or (B) of paragraph (1).
``(7) Secretary reports.--Not later than April 1 of each
year (beginning in 2010), the Secretary shall submit a report
to Congress and the Comptroller General of the United States
that includes--
``(A) a detailed description of--
``(i) the total amount expended as a result of the
application of this subsection in the previous year compared
to the total amount that would have been expended under this
title in the year if this subsection had not been enacted;
``(ii) the projections of the total amount that will be
expended as a result of the application of this subsection in
the year in which the report is submitted compared to the
total amount that would have been expended under this title
in the year if this subsection had not been enacted;
``(iii) amounts remaining within the funding limitation
specified in paragraph (5); and
``(iv) the steps that the Secretary will take under clauses
(i) and (ii) of paragraph (5)(B) to ensure that the
application of this subsection will not cause expenditures to
exceed the applicable amount described in paragraph (5)(A);
and
``(B) a certification from the Chief Actuary of the Centers
for Medicare & Medicaid Services that the descriptions under
clauses (i), (ii), (iii), and (iv) of subparagraph (A) are
reasonable, accurate, and based on generally accepted
actuarial principles and methodologies.

[[Page S8594]]

``(8) Biennial gao reports.--Not later than January 1,
2011, and biennially thereafter, the Comptroller General of
the United States shall submit to the Secretary and Congress
a report on the designation of highly competitive regions
under this subsection and the application of the payment
system under this subsection within such regions. Each report
shall include--
``(A) an evaluation of--
``(i) the quality of care provided to beneficiaries
enrolled in a MedicareAdvantage preferred provider plan in a
highly competitive region;
``(ii) the satisfaction of beneficiaries with benefits
under such a plan;
``(iii) the costs to the medicare program for payments made
to such plans; and
``(iv) any improvements in the delivery of health care
services under such a plan;
``(B) a comparative analysis of the benchmark system
applicable under the other provisions of this section and the
payment system applicable in highly competitive regions under
this subsection; and
``(C) recommendations for such legislation or
administrative action as the Comptroller General determines
to be appropriate.''.
(b) Conforming Amendment.--Section 1858(c)(3)(A)(i) (as
added by section 211(b)) is amended to read as follows:
``(i) Whether each preferred provider region has been
designated as a highly competitive region under subparagraph
(A) or (B) of subsection (i)(1) and the benchmark amount for
any preferred provider region (as calculated under paragraph
(2)(A)) for the year that has not been designated as a highly
competitive region.''.

SEC. 232. FEE-FOR-SERVICE MODERNIZATION PROJECTS.

(a) Establishment.--
(1) Review and report on results of existing
demonstrations.--
(A) Review.--The Secretary shall conduct an empirical
review of the results of the demonstrations under sections
442, 443, and 444.
(B) Report.--Not later than January 1, 2008, the Secretary
shall submit a report to Congress on the empirical review
conducted under subparagraph (A) which shall include
estimates of the total costs of the demonstrations, including
expenditures as a result of the provision of services
provided to beneficiaries under the demonstrations that are
incidental to the services provided under the demonstrations,
and all other expenditures under title XVIII of the Social
Security Act. The report shall also include a certification
from the Chief Actuary of the Centers for Medicare & Medicaid
Services that such estimates are reasonable, accurate, and
based on generally accepted actuarial principles and
methodologies.
(2) Projects.--Beginning in 2009, the Secretary, based on
the empirical review conducted under paragraph (1), shall
establish projects under which medicare beneficiaries
receiving benefits under the medicare fee-for-service program
under parts A and B of title XVIII of the Social Security Act
are provided with coverage of enhanced benefits or services
under such program. The purpose of such projects is to
evaluate whether the provision of such enhanced benefits or
services to such beneficiaries--
(A) improves the quality of care provided to such
beneficiaries under the medicare program;
(B) improves the health care delivery system under the
medicare program; and
(C) results in reduced expenditures under the medicare
program.
(2) Enhanced benefits or services.--For purposes of this
section, enhanced benefits or services shall include--
(A) preventive services not otherwise covered under title
XVIII of the Social Security Act;
(B) chronic care coordination services;
(C) disease management services; or
(D) other benefits or services that the Secretary
determines will improve preventive health care for medicare
beneficiaries, result in improved chronic disease management,
and management of complex, life-threatening, or high-cost
conditions and are consistent with the goals described in
subparagraphs (A), (B), and (C) of paragraph (1).
(b) Project Sites and Duration.--
(1) In general.--Subject to subsection (e)(2), the projects
under this section shall be conducted--
(A) in a region or regions that are comparable (as
determined by the Secretary) to the region or regions that
are designated as a highly competitive region under
subparagraph (A) or (B) of section 1858(i)(1) of the Social
Security Act, as added by section 231 of this Act; and
(B) during the years that the region or regions are
designated as such a highly competitive region.
(2) Rule of construction.--For purposes of paragraph (1), a
comparable region does not necessarily mean the identical
region.
(c) Waiver Authority.--The Secretary shall waive compliance
with the requirements of title XVIII of the Social Security
Act (42 U.S.C. 1395 et seq.) only to the extent and for such
period as the Secretary determines is necessary to provide
for enhanced benefits or services consistent with the
projects under this section.
(d) Biennial GAO Reports.--Not later than January 1, 2011,
and biennially thereafter for as long as the projects under
this section are being conducted, the Comptroller General of
the United States shall submit to the Secretary and Congress
a report that evaluates the projects. Each report shall
include--
(1) an evaluation of--
(A) the quality of care provided to beneficiaries receiving
benefits or services under the projects;
(B) the satisfaction of beneficiaries receiving benefits or
services under the projects;
(C) the costs to the medicare program under the projects;
and
(D) any improvements in the delivery of health care
services under the projects; and
(2) recommendations for such legislation or administrative
action as the Comptroller General determines to be
appropriate.
(e) Funding.--
(1) In general.--Payments for the costs of carrying out the
projects under this section shall be made from the Federal
Hospital Insurance Trust Fund under section 1817 of the
Social Security Act (42 U.S.C. 1395i) and the Federal
Supplementary Insurance Trust Fund under section 1841 of such
Act (42 U.S.C. 1395t), as determined appropriate by the
Secretary.
(2) Limitation.--The total amount expended under the
medicare fee-for-service program under parts A and B of title
XVIII of the Social Security Act (including all amounts
expended as a result of the projects under this section)
during the period or year, as applicable, may not exceed--
(A) for the period beginning on January 1, 2009, and ending
on September 30, 2013, an amount equal to the total amount
that would have been expended under the medicare fee-for-
service program under parts A and B of title XVIII of the
Social Security Act during the period if the projects had not
been conducted plus $6,000,000,000; and
(B) for fiscal year 2014 and any subsequent fiscal year, an
amount equal to the total amount that would have been
expended under the medicare fee-for-service program under
parts A and B of such title during the year if the projects
had not been conducted.
(3) Monitoring and reports.--
(A) Ongoing monitoring by the secretary to ensure funding
limitation is not violated.--The Secretary shall continually
monitor expenditures made under title XVIII of the Social
Security Act by reason of the projects under this section to
ensure that the limitations described in subparagraphs (A)
and (B) of paragraph (2) are not violated.
(B) Reports.--Not later than April 1 of each year
(beginning in 2010), the Secretary shall submit a report to
Congress and the Comptroller General of the United States
that includes--
(i) a detailed description of--

(I) the total amount expended under the medicare fee-for-
service program under parts A and B of title XVIII of the
Social Security Act (including all amounts expended as a
result of the projects under this section) during the
previous year compared to the total amount that would have
been expended under the original medicare fee-for-service
program in the year if the projects had not been conducted;
(II) the projections of the total amount expended under the
medicare fee-for-service program under parts A and B of title
XVIII of the Social Security Act (including all amounts
expended as a result of the projects under this section)
during the year in which the report is submitted compared to
the total amount that would have been expended under the
original medicare fee-for-service program in the year if the
projects had not been conducted;
(III) amounts remaining within the funding limitation
specified in paragraph (2); and
(IV) how the Secretary will change the scope, site, and
duration of the projects in subsequent years in order to
ensure that the limitations described in subparagraphs (A)
and (B) of paragraph (2) are not violated; and

(ii) a certification from the Chief Actuary of the Centers
for Medicare & Medicaid Services that the descriptions under
subclauses (I), (II), (III), and (IV) of clause (i) are
reasonable, accurate, and based on generally accepted
actuarial principles and methodologies.
(4) Application of Limitation.--If the Secretary determines
that the projects under this section will cause the
limitations described in subparagraphs (A) and (B) of
paragraph (2) to be violated, the Secretary shall take
appropriate steps to reduce spending under the projects,
including through reducing the scope, site, and duration of
the projects.
(5) Authority.--Beginning in 2014, the Secretary shall make
necessary spending adjustments (including pro rata reductions
in payments to health care providers under the medicare
program) to recoup amounts so that the limitations described
in subparagraphs (A) and (B) of paragraph (2) are not
violated.
______

SA 1093. Mr. KYL proposed an amendment to amendment SA 1092 proposed
by Mr. Grassley (for himself and Mr. Baucus) to the bill S. 1, to amend
title XVIII of the Social Security Act to make improvements in the
medicare program, to provide prescription drug coverage under the
medicare program, and for other purposes; as follows:

In lieu of the matter proposed to be inserted, insert the
following:

[[Page S8595]]

Subtitle D--Evaluation of Alternative Payment and Delivery Systems

SEC. 231. ESTABLISHMENT OF ALTERNATIVE PAYMENT SYSTEM FOR
PREFERRED PROVIDER ORGANIZATIONS IN HIGHLY
COMPETITIVE REGIONS.

(a) Establishment of Alternative Payment System for
Preferred Provider Organizations in Highly Competitive
Regions.--Section 1858 (as added by section 211(b)) is
amended by adding at the end the following new subsection:
``(i) Alternative Payment Methodology for Highly
Competitive Regions.--
``(1) Annual determination and designation.--
``(A) In 2008.--In 2008, prior to the date on which the
Secretary expects to publish the risk adjusters under section
1860D-11, the Secretary shall designate a limited number (but
in no case fewer than 1) of preferred provider regions (other
than the region described in subsection (a)(2)(C)(ii)) as
highly competitive regions.
``(B) Subsequent years.--For each year (beginning with
2009) the Secretary may designate a limited number of
preferred provider regions (other than the region described
in subsection (a)(2)(C)(ii)) as highly competitive regions in
addition to any region designated as a highly competitive
region under subparagraph (A).
``(C) Considerations.--In determining which preferred
provider regions to designate as highly competitive regions
under subparagraph (A) or (B), the Secretary shall consider
the following:
``(i) Whether the application of this subsection to the
preferred provider region would enhance the participation of
preferred provider organization plans in that region.
``(ii) Whether the Secretary anticipates that there is
likely to be at least 3 bids submitted under subsection
(d)(1) with respect to the preferred provider region if the
Secretary designates such region as a highly competitive
region under subparagraph (A) or (B).
``(iii) Whether the Secretary expects that
MedicareAdvantage eligible individuals will elect preferred
provider organization plans in the preferred provider region
if the region is designated as a highly competitive region
under subparagraph (A) or (B).
``(iv) Whether the designation of the preferred provider
region as a highly competitive region will permit compliance
with the limitation described in paragraph (5).

In considering the matters described in clauses (i) through
(iv), the Secretary shall give special consideration to
preferred provider regions where no bids were submitted under
subsection (d)(1) for the previous year.
``(2) Effect of designation.--If a preferred provider
region is designated as a highly competitive region under
subparagraph (A) or (B) of paragraph (1)--
``(A) the provisions of this subsection shall apply to such
region and shall supersede the provisions of this part
relating to benchmarks for preferred provider regions; and
``(B) such region shall continue to be a highly competitive
region until such designation is rescinded pursuant to
paragraph (5)(B)(ii).
``(3) Submission of bids.--
``(A) In general.--Notwithstanding subsection (d)(1), for
purposes of applying section 1854(a)(2)(A)(i), the plan bid
for a highly competitive region shall consist of a dollar
amount that represents the total amount that the plan is
willing to accept (not taking into account the application of
the comprehensive risk adjustment methodology under section
1853(a)(3)) for providing coverage of only the benefits
described in section 1852(a)(1)(A) to an individual enrolled
in the plan that resides in the service area of the plan for
a month.
``(B) Construction.--Nothing in subparagraph (A) shall be
construed as permitting a preferred provider organization
plan not to provide coverage for the benefits described in
section 1852(a)(1)(C).
``(4) Payments to preferred provider organizations in
highly competitive areas.--With respect to highly competitive
regions, the following rules shall apply:
``(A) In general.--Notwithstanding subsection (c), of the
plans described in subsection (d)(1)(E), the Secretary shall
substitute the second lowest bid for the benchmark applicable
under subsection (c)(4).
``(B) If there are fewer than three bids.--Notwithstanding
subsection (c), if there are fewer than 3 bids in a highly
competitive region for a year, the Secretary shall substitute
the lowest bid for the benchmark applicable under subsection
(c)(4).
``(5) Funding limitation.--
``(A) In general.--
``(i) In general.--The total amount expended as a result of
the application of this subsection during the period
beginning on January 1, 2009, and ending on September 30,
2013, may not exceed the applicable amount (as defined in
clause (ii)).
``(ii) Applicable amount defined.--In this paragraph, the
term `applicable amount' means the total amount that would
have been expended under this title during the period
described in clause (i) if this subsection had not been
enacted plus $6,000,000,000.
``(B) Application of limitation.--If the Secretary
determines that the application of this subsection will cause
expenditures to exceed the applicable amount, the Secretary
shall--
``(i) take appropriate steps to stay within the applicable
amount, including through providing limitations on
enrollment; or
``(ii) rescind the designation under subparagraph (A) or
(B) of paragraph (1) of 1 or more preferred provider regions
as highly competitive regions.
``(C) Transition.--If the Secretary rescinds a designation
under subparagraph (A) or (B) of paragraph (1) pursuant to
subparagraph (B)(ii) with respect to a preferred provider
region, the Secretary shall provide for an appropriate
transition from the payment system applicable under this
subsection to the payment system described in the other
provisions of this section in that region. Any amount
expended by reason of the preceding sentence shall be
considered to be part of the total amount expended as a
result of the application of this subsection for purposes of
applying the limitation under subparagraph (A).
``(D) Application.--Notwithstanding paragraph (1)(B), on or
after January 1 of the year in which the fiscal year
described in subparagraph (A)(ii)(II) begins, the Secretary
may designate appropriate regions under such paragraph.
``(6) Limitation of judicial review.--There shall be no
administrative or judicial review under section 1869, section
1878, or otherwise, of designations made under subparagraph
(A) or (B) of paragraph (1).
``(7) Secretary reports.--Not later than April 1 of each
year (beginning in 2010), the Secretary shall submit a report
to Congress and the Comptroller General of the United States
that includes--
``(A) a detailed description of--
``(i) the total amount expended as a result of the
application of this subsection in the previous year compared
to the total amount that would have been expended under this
title in the year if this subsection had not been enacted;
``(ii) the projections of the total amount that will be
expended as a result of the application of this subsection in
the year in which the report is submitted compared to the
total amount that would have been expended under this title
in the year if this subsection had not been enacted;
``(iii) amounts remaining within the funding limitation
specified in paragraph (5); and
``(iv) the steps that the Secretary will take under clauses
(i) and (ii) of paragraph (5)(B) to ensure that the
application of this subsection will not cause expenditures to
exceed the applicable amount described in paragraph (5)(A);
and
``(B) a certification from the Chief Actuary of the Centers
for Medicare & Medicaid Services that the descriptions under
clauses (i), (ii), (iii), and (iv) of subparagraph (A) are
reasonable, accurate, and based on generally accepted
actuarial principles and methodologies.
``(8) Biennial gao reports.--Not later than January 1,
2011, and biennially thereafter, the Comptroller General of
the United States shall submit to the Secretary and Congress
a report on the designation of highly competitive regions
under this subsection and the application of the payment
system under this subsection within such regions. Each report
shall include--
``(A) an evaluation of--
``(i) the quality of care provided to beneficiaries
enrolled in a MedicareAdvantage preferred provider plan in a
highly competitive region;
``(ii) the satisfaction of beneficiaries with benefits
under such a plan;
``(iii) the costs to the medicare program for payments made
to such plans; and
``(iv) any improvements in the delivery of health care
services under such a plan;
``(B) a comparative analysis of the benchmark system
applicable under the other provisions of this section and the
payment system applicable in highly competitive regions under
this subsection; and
``(C) recommendations for such legislation or
administrative action as the Comptroller General determines
to be appropriate.''.
(b) Conforming Amendment.--Section 1858(c)(3)(A)(i) (as
added by section 211(b)) is amended to read as follows:
``(i) Whether each preferred provider region has been
designated as a highly competitive region under subparagraph
(A) or (B) of subsection (i)(1) and the benchmark amount for
any preferred provider region (as calculated under paragraph
(2)(A)) for the year that has not been designated as a highly
competitive region.''.

SEC. 232. FEE-FOR-SERVICE MODERNIZATION PROJECTS.

(a) Establishment.--
(1) Review and report on results of existing
demonstrations.--
(A) Review.--The Secretary shall conduct an empirical
review of the results of the demonstrations under sections
442, 443, and 444.
(B) Report.--Not later than January 1, 2008, the Secretary
shall submit a report to Congress on the empirical review
conducted under subparagraph (A) which shall include
estimates of the total costs of the demonstrations, including
expenditures as a result of the provision of services
provided to beneficiaries under the demonstrations that are
incidental to the services provided under the demonstrations,
and all other expenditures under title XVIII of the Social
Security Act. The report shall also include a certification
from the Chief Actuary of the Centers for Medicare & Medicaid
Services that such estimates are reasonable, accurate, and
based on generally accepted actuarial principles and
methodologies.
(2) Projects.--Beginning in 2009, the Secretary, based on
the empirical review conducted under paragraph (1), shall
establish

[[Page S8596]]

projects under which medicare beneficiaries receiving
benefits under the medicare fee-for-service program under
parts A and B of title XVIII of the Social Security Act are
provided with coverage of enhanced benefits or services under
such program. The purpose of such projects is to evaluate
whether the provision of such enhanced benefits or services
to such beneficiaries--
(A) improves the quality of care provided to such
beneficiaries under the medicare program;
(B) improves the health care delivery system under the
medicare program; and
(C) results in reduced expenditures under the medicare
program.
(2) Enhanced benefits or services.--For purposes of this
section, enhanced benefits or services shall include--
(A) preventive services not otherwise covered under title
XVIII of the Social Security Act;
(B) chronic care coordination services;
(C) disease management services; or
(D) other benefits or services that the Secretary
determines will improve preventive health care for medicare
beneficiaries, result in improved chronic disease management,
and management of complex, life-threatening, or high-cost
conditions and are consistent with the goals described in
subparagraphs (A), (B), and (C) of paragraph (1).
(b) Project Sites and Duration.--
(1) In general.--Subject to subsection (e)(2), the projects
under this section shall be conducted--
(A) in a region or regions that are comparable (as
determined by the Secretary) to the region or regions that
are designated as a highly competitive region under
subparagraph (A) or (B) of section 1858(i)(1) of the Social
Security Act, as added by section 231 of this Act; and
(B) during the years that the region or regions are
designated as such a highly competitive region.
(2) Rule of construction.--For purposes of paragraph (1), a
comparable region does not necessarily mean the identical
region.
(c) Waiver Authority.--The Secretary shall waive compliance
with the requirements of title XVIII of the Social Security
Act (42 U.S.C. 1395 et seq.) only to the extent and for such
period as the Secretary determines is necessary to provide
for enhanced benefits or services consistent with the
projects under this section.
(d) Biennial GAO Reports.--Not later than January 1, 2011,
and biennially thereafter for as long as the projects under
this section are being conducted, the Comptroller General of
the United States shall submit to the Secretary and Congress
a report that evaluates the projects. Each report shall
include--
(1) an evaluation of--
(A) the quality of care provided to beneficiaries receiving
benefits or services under the projects;
(B) the satisfaction of beneficiaries receiving benefits or
services under the projects;
(C) the costs to the medicare program under the projects;
and
(D) any improvements in the delivery of health care
services under the projects; and
(2) recommendations for such legislation or administrative
action as the Comptroller General determines to be
appropriate.
(e) Funding.--
(1) In general.--Payments for the costs of carrying out the
projects under this section shall be made from the Federal
Hospital Insurance Trust Fund under section 1817 of the
Social Security Act (42 U.S.C. 1395i) and the Federal
Supplementary Insurance Trust Fund under section 1841 of such
Act (42 U.S.C. 1395t), as determined appropriate by the
Secretary.
(2) Limitation.--The total amount expended under the
medicare fee-for-service program under parts A and B of title
XVIII of the Social Security Act (including all amounts
expended as a result of the projects under this section)
during the period or year, as applicable, may not exceed--
(A) for the period beginning on January 1, 2009, and ending
on September 30, 2013, an amount equal to the total amount
that would have been expended under the medicare fee-for-
service program under parts A and B of title XVIII of the
Social Security Act during the period if the projects had not
been conducted plus $6,000,000,000; and
(B) for fiscal year 2014 and any subsequent fiscal year, an
amount equal to the total amount that would have been
expended under the medicare fee-for-service program under
parts A and B of such title during the year if the projects
had not been conducted.
(3) Monitoring and reports.--
(A) Ongoing monitoring by the secretary to ensure funding
limitation is not violated.--The Secretary shall continually
monitor expenditures made under title XVIII of the Social
Security Act by reason of the projects under this section to
ensure that the limitations described in subparagraphs (A)
and (B) of paragraph (2) are not violated.
(B) Reports.--Not later than April 1 of each year
(beginning in 2010), the Secretary shall submit a report to
Congress and the Comptroller General of the United States
that includes--
(i) a detailed description of--

(I) the total amount expended under the medicare fee-for-
service program under parts A and B of title XVIII of the
Social Security Act (including all amounts expended as a
result of the projects under this section) during the
previous year compared to the total amount that would have
been expended under the original medicare fee-for-service
program in the year if the projects had not been conducted;
(II) the projections of the total amount expended under the
medicare fee-for-service program under parts A and B of title
XVIII of the Social Security Act (including all amounts
expended as a result of the projects under this section)
during the year in which the report is submitted compared to
the total amount that would have been expended under the
original medicare fee-for-service program in the year if the
projects had not been conducted;
(III) amounts remaining within the funding limitation
specified in paragraph (2); and
(IV) how the Secretary will change the scope, site, and
duration of the projects in subsequent years in order to
ensure that the limitations described in subparagraphs (A)
and (B) of paragraph (2) are not violated; and

(ii) a certification from the Chief Actuary of the Centers
for Medicare & Medicaid Services that the descriptions under
subclauses (I), (II), (III), and (IV) of clause (i) are
reasonable, accurate, and based on generally accepted
actuarial principles and methodologies.
(4) Application of Limitation.--If the Secretary determines
that the projects under this section will cause the
limitations described in subparagraphs (A) and (B) of
paragraph (2) to be violated, the Secretary shall take
appropriate steps to reduce spending under the projects,
including through reducing the scope, site, and duration of
the projects.
(5) Authority.--Beginning in 2014, the Secretary shall make
necessary spending adjustments (including pro rata reductions
in payments to health care providers under the medicare
program) to recoup amounts so that the limitations described
in subparagraphs (A) and (B) of paragraph (2) are not
violated.

____________________