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Title of Law:Balanced Budget Act of 1997
Law #:Public Law 105- 33
Passed by Congress:105th Congress (1st Session)

The following are excerpts, highlighted in red, from the final legislation and/or conference report which contain National Academies’ studies. (Pound signs [##] between passages denote the deletion of unrelated text.)

HR2015 Kasich (R-OH) 08/01/97
Enrolled (finally passed both houses)

To provide for reconciliation pursuant to subsections (b)(1) and (c) of section 105 of the concurrent resolution on the budget for fiscal year 1998.
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SEC. 4108. STUDY ON PREVENTIVE AND ENHANCED BENEFITS.

(a) STUDY.--The Secretary of Health and Human Services shall request the National Academy of Sciences, and as appropriate in conjunction with the United States Preventive Services Task Force, to analyze the expansion or modification of preventive or other benefits provided to medicare beneficiaries under title XVIII of the Social Security Act. The analysis shall consider both the short term and long term benefits, and costs to the medicare program, of such expansion or modification.

(b) REPORT.--

(1) INITIAL REPORT.--Not later than 2 years after the date of the enactment of this Act, the Secretary shall submit a report on the findings of the analysis conducted under subsection (a) to the Committee on Ways and Means and the Committee on Commerce of the House of Representatives and the Committee on Finance of the Senate.

(2) CONTENTS.--Such report shall include specific findings with respect to coverage of at least the following benefits:

(A) Nutrition therapy services, including parenteral and enteral nutrition and including the provision of such services by a registered dietitian.

(B) Skin cancer screening.

(C) Medically necessary dental care.

(D) Routine patient care costs for beneficiaries enrolled in approved clinical trial programs.

(E) Elimination of time limitation for coverage of immunosuppressive drugs for transplant patients.

(3) FUNDING.--From funds appropriated to the Department of Health and Human Services for fiscal years 1998 and 1999, the Secretary shall provide for such funding as the Secretary determines necessary for the conduct of the study by the National Academy of Sciences under this section.

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SEC. 4553. REDUCTION IN UPDATES TO PAYMENT AMOUNTS FOR CLINICAL DIAGNOSTIC LABORATORY TESTS; STUDY ON LABORATORY TESTS.

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(c) STUDY AND REPORT ON CLINICAL LABORATORY TESTS.--

(1) IN GENERAL.--The Secretary shall request the Institute of Medicine of the National Academy of Sciences to conduct a study of payments under part B of title XVIII of the Social Security Act for clinical laboratory tests. The study shall include a review of the adequacy of the current methodology and recommendations regarding alternative payment systems. The study shall also analyze and discuss the relationship between such payment systems and access to high quality laboratory tests for medicare beneficiaries, including availability and access to new testing methodologies.

(2) REPORT TO CONGRESS.--The Secretary shall, not later than 2 years after the date of enactment of this section, report to the Committees on Ways and Means and Commerce of the House of Representatives and the Committee on Finance of the Senate the results of the study described in paragraph (1), including any recommendations for legislation.

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HRpt 105-217 CONFERENCE REPORT To accompany H.R. 2015 BALANCED BUDGET ACT OF 1997
Conference Committee
(07/30/97)

Special Typefaces Key:
[[ ]] Text to be omitted // \\ Italic text
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//SEC. 4108. STUDY ON PREVENTIVE AND ENHANCED BENEFITS.\\

// (a) STUDY.--The Secretary of Health and Human Services shall request the National Academy of Sciences, and as appropriate in conjunction with the United States Preventive Services Task Force, to analyze the expansion or modification of preventive or other benefits provided to medicare beneficiaries under title XVIII of the Social Security Act. The analysis shall consider both the short term and long term benefits, and costs to the medicare program, of such expansion or modification.\\

// (b) REPORT.--\\

// (1) INITIAL REPORT.--Not later than 2 years after the date of the enactment of this Act, the Secretary shall submit a report on the findings of the analysis conducted under subsection (a) to the Committee on Ways and Means and the Committee on Commerce of the House of Representatives and the Committee on Finance of the Senate. \\

// (2) CONTENTS.--Such report shall include specific findings with respect to coverage of at least the following benefits:\\

// (A) Nutrition therapy services, including parenteral and enteral nutrition and including the provision of such services by a registered dietitian.\\

// (B) Skin cancer screening.\\

// (C) Medically necessary dental care.\\

// (D) Routine patient care costs for beneficiaries enrolled in approved clinical trial programs.\\

// (E) Elimination of time limitation for coverage of immunosuppressive drugs for transplant patients.\\

// (3) FUNDING.--From funds appropriated to the Department of Health and Human Services for fiscal years 1998 and 1999, the Secretary shall provide for such funding as the Secretary determines necessary for the conduct of the study by the National Academy of Sciences under this section.\\

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//SEC. 4553. REDUCTION IN UPDATES TO PAYMENT AMOUNTS FOR CLINICAL DIAGNOSTIC LABORATORY TESTS; STUDY ON LABORATORY TESTS.\\

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// (c) STUDY AND REPORT ON CLINICAL LABORATORY TESTS.--\\

// (1) IN GENERAL.--The Secretary shall request the Institute of Medicine of the National Academy of Sciences to conduct a study of payments under part B of title XVIII of the Social Security Act for clinical laboratory tests. The study shall include a review of the adequacy of the current methodology and recommendations regarding alternative payment systems. The study shall also analyze and discuss the relationship between such payment systems and access to high quality laboratory tests for medicare beneficiaries, including availability and access to new testing methodologies.\\

// (2) REPORT TO CONGRESS.--The Secretary shall, not later than 2 years after the date of enactment of this section, report to the Committees on Ways and Means and Commerce of the House of Representatives and the Committee on Finance of the Senate the results of the study described in paragraph (1), including any recommendations for legislation.\\

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HOUSE BILL

Section 10108. Requires the Secretary to request the National Academy of Sciences, in conjunction with the U.S. Preventive Services Task Force, to analyze the expansion or modification of preventive services covered under Medicare. The study would consider both the short term and long term benefits and costs to Medicare. The study would have to include specific findings with respect to the following: (1) nutrition therapy, including parenteral and enteral nutrition; (2) medically necessary dental care; (3) routine patient care costs for beneficiaries enrolled in approved clinical trial programs; and (4) elimination of time limitation for coverage of immunosuppressive drugs for transplant patients. The Secretary would be required to provide such funding as may be necessary in FY 1998 and FY 1999

Effective Date. Enactment

Section 4108. Similar provision, except also includes study of coverage for bone mass measurement.

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SENATE AMENDMENT

Requires the Secretary to request the National Academy of Sciences, in conjunction with the U.S. Preventative Services Task Force, to analyze the expansion or modification of preventative benefits to include medical nutritional therapy services by a registered dietitian. The Secretary would be required to submit a report on the findings to the House Ways and Means and Commerce Committees and the Senate Finance Committee. The report would include specific findings regarding cost to Medicare, savings to Medicare, clinical outcomes, and short and long term benefits to Medicare. The Secretary would provide for such funds as may be necessary for FY 1998 and FY 1999.

Effective Date. Enactment.

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SENATE AMENDMENT

Requires the Secretary to request the Institute of Medicine to conduct a study of lab payments. The study would include a review of the adequacy of the current methodology and recommendations regarding alternative payment systems. It would also analyze and discuss the relationship between payment systems and access to high quality lab services for beneficiaries, including availability and access to new testing methodologies. The Secretary would be required to report to Congress within 2 years of enactment.

Effective Date. Enactment.

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SENATE AMENDMENT

Similar to House provision, except it requires primary care case managers and managed care organizations to obtain an annual external independent review of the quality outcomes and timeliness of, and access to the services included in the manager's or organization's contract with the state. The MCO's review shall include: (1) a review of the MCO's medical care and enrollee inpatient and ambulatory data for indications of quality of care, inappropriate utilization, and treatment; (2) notification of the entity and the state if inappropriate care, treatment, or utilization is found; and (3) other activities prescribed by the Secretary or the state. Requires the review to use protocols, developed and validated by the Secretary, that are at least as rigorous as those used by the National Committee on Quality Assurance as of the date of enactment. Requires the results of the reviews to be available to participating providers, enrollees and potential enrollees of the MCO. Requires the Secretary to review the external independent reviews each year, and monitor the effectiveness of the state's monitoring of managed care entities.

In addition, the Senate Amendment: requires Medicaid managed care organizations and primary care case managers to provide specified information to states; requires entities entering into contracts with the state to submit to the state information that demonstrates improvement in the care delivered to members and requires MCOs to provide enrollees with an annual report on non-health expenditures; and requires Medicaid MCOs to maintain sufficient patient encounter data to identify the health care provider furnishing services to Medicaid beneficiaries and to submit such data to the state or Secretary upon request.

Permits the Secretary and the State to establish an incentive program to reward high quality managed care entities.

Provides federal financial participation (FFP) for 75% of the amount expended with respect to costs incurred in a quarter (as found necessary by the Secretary for the proper and efficient administration of the state plan) as are attributable to the performance of independent external reviews of managed care entities.

Modifies the payment limit and actuarial soundness standards to require that capitated payment amounts be set at rates that have been determined to be sufficient and not excessive. Such determination would be made by an independent actuary meeting the standards of qualification and practice established to the Actuarial Standards Board.

Requires MCO's physician incentive plans to meet the requirements of section 1876(i)(8) and comparable requirements under part C of title XVIII.

Requires specified aspects of an MCOs provider participation agreements with rural health clinics, federally qualified health centers, and clinics providing Title X services to be no more restrictive than the MCOs agreements with other participating providers. Payments to federally qualified health centers and rural health clinics are required, at the election of such center or clinic, to be made on a cost basis.

Requires the Secretary, in consultation with specified others, to conduct a study and develop guidelines regarding managed care entities and individuals with special health care needs. The Secretary shall report such guidelines to Congress not later than 2 years after the date of enactment and make recommendations for implementing legislation. The guidelines shall relate to specified issues and will apply to primary care case management and capitated risk sharing arrangements.

Requires other specified studies and reports:

(1) By January 1, 1998, the Secretary must report to the Senate Finance and House Commerce Committees on the effect of managed care entities on the delivery of and payment for the services traditionally provided through FOHCs, RHCs, and DSH hospitals that have traditionally served Medicaid beneficiaries. The report must include specified information.

(2) The Secretary and Comptroller General must submit annually a report on the rates paid for hospital services under Medicaid managed care entities.

(3) Requires each state to report information on hospital rates submitted to such state under section 1947(b)(2).

(4) Requires the Institute of Medicine to analyze whether the quality assurance programs and accreditation standards applicable to managed care entities operating in the private sector or under contract under the Medicare program include consideration of the accessibility and quality of health care items and services such entities deliver to low-income individuals.

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SENATE AMENDMENT

In consultation with Governors, directors of state Medicaid and state maternal and child health programs, the Institute of Medicine, the American Academy of Pediatrics, and representatives of Medicaid beneficiaries, the Secretary would be required to conduct a study of EPSDT services. A report on the results of the study would be due to Congress not later than 12 months after the date of enactment.

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