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BALANCED BUDGET ACT OF 1997

The Balanced Budget Act (BBA) of 1997 (Public Law 105-33) was signed into law by President Clinton in August 1997. This legislation enacts the most significant changes to the Medicare and Medicaid Programs since their inception 30 years ago. Additionally, it expands the services provided by HCFA through the new Child Health Insurance Program (Title XXI).

MEDICARE AND MEDICAID PROVISIONS
 
Table of Contents on this page (below)
 
 Originally Posted circa 2002; Most Recent Revision 1/11/2005:
[http://www.doctordeluca.com/Library/PublicHealth//MedicareMedicaidProvisionsBBA97.htm]

MEDICARE AND MEDICAID PROVISIONS
 
Full Text of this document
 

Establishment of Medicare+Choice Program (Section 4001)

"Section 1851--Eligibility, Election, and Enrollment"

"Section 1852--Benefits and Beneficiary Protections"

"Section 1853--Payments to Medicare+Choice Organizations"

"Section 1854--Premiums"

"Section 1855--Organizational and Financial Requirements for Medicare+Choice Organizations; Provider Sponsored Organizations"

"Section 1856--Establishment of Solvency Standards"

"Section 1857--Contracts with Medicare+Choice Organizations"

"Section 1859--Definitions; Miscellaneous Provisions"

Transitional Rules for Current Medicare HMO Program
Conforming Changes in Medigap Program
Special Rules for Medicare+Choice Medical Savings Accounts

Medicare Prepaid Competitive Pricing Demonstration Project

Advisory Committees

Social Health Maintenance Organizations (SHMOs)

Medicare Subvention Project for Military Retirees

Medicare Coordinated Care Demonstration Project

Orderly Transition of Municipal Health Service Demonstration Projects

Medicare Enrollment Demonstration Project

Extension of Certain Medicare Community Nursing Organizations Demonstration Project

National Bipartisan Commission on the Future of Medicare

Medicare Payment Advisory Commission

Medigap Protections

Addition of High Deductible Medigap Policies

Tax Treatment of Hospital Which Participate in Provider Sponsored-Organizations

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SUBTITLE B--PREVENTION INITIATIVES

Screening Mammography

Screening Pap Smear and Pelvic Exams

Prostate Cancer Screening Tests

Coverage of Colorectal Screening

Diabetes Self-Management Benefits

Standardization of Medicare Coverage of Bone Mass Measurements

Vaccines Outreach Expansion

Study on Preventive and Enhanced Benefits

Medicare Rural Hospital Flexibility Program

Prohibiting Denial of Request by Rural Referral Centers for Reclassification on Basis of Comparability of Wages

Hospital Geographic Reclassification Permitted for Purposes of Disproportionate Share Adjustments

Medicare-Dependent, Small Rural Hospital Payment Extension

Rural Health Clinic Services

Medicare Reimbursement for Telehealth Services

Informatics, Telemedicine, and Education Demonstration Project

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SUBTITLE D--ANTI-FRAUD AND ABUSE PROVISIONS AND IMPROVEMENTS IN PROTECTING PROGRAM INTEGRITY

Permanent Exclusion for Those Convicted of 3 Health Care Related Crimes

Authority to Refuse to Enter into Medicare Agreements with Individuals or Entities Convicted of Felons

Exclusion of Entity Controlled by Family Member of a Sanctioned Individual

Imposition of Civil Monetary Penalties

Anti-Fraud Message in Medicare Handbook and Required Information on EOMBs

Disclosure of Information and Surety Bonds

Certain Identification Numbers

Advisory Opinions Regarding Certain Physician Self-Referral Provisions

Replacement of Reasonable Charge Methodology by Fee Schedules

Application of Inherent Reasonableness to All Part B Services Other Than Physicians' Services

Requirement to Furnish Diagnostic Information

Report by GAO on Operation of Fraud and Abuse Control Program

Competitive Bidding Demonstration Projects

Prohibiting Unnecessary and Wasteful Medicare Payments for Certain Items

Non-discrimination in Post-Hospital Referral to Home Health Agencies and Other Entities

Other Fraud and Abuse Related Provisions

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PPS Hospital Payment Update

Maintaining Savings from Temporary Reduction in Capital Payments for PPS Hospitals

Disproportionate Share

Medicare Capital Asset Sales Price Equal to Book Value

Elimination of IME and DSH Payments Attributable to Outlier Payments

Increase Base Payment Rate to Puerto Rico Hospitals

Certain Hospital Discharges to Post Acute Care

Program

Geographic Reclassification for Certain Disproportionately Large Hospitals

Floor on Area Wage Index

Payment Update

Reductions to Capital Payments for Certain PPS-Exempt Hospitals and Units

Rebasing

Cap on TEFRA Limits

Bonus and Relief Payments

Change in Payment and Target Amount for New Providers

Treatment of Certain Long Term Care Hospitals

Treatment of Certain Cancer Hospitals

Elimination of Exemptions for Certain Hospitals

Prospective Payment for Inpatient Rehabilitation Hospital Services

Development of Proposal on Payments for Long-Term Care Hospitals

Extension of Cost Limits

Prospective Payment for SNF Services

Payments for Hospice Services

Payment for Home Hospice Care Based on Location of Service

Hospice Care Benefits Period

Other Items and Services included in Hospice Care

Contracting with Independent Physicians or Physician Groups for Hospice Services

Waiver of Certain Staffing Requirements for Hospice Care Programs in Nonurbanized Areas

Limitation on Liability of Beneficiaries for Certain Hospice Coverage Denials

Extending the Period for Physician Certification of an Individual’s Terminal Illness

Reductions in Payments for Enrollee Bad Debt

Permanent Extension of Hemophilia Pass-Through Payments

Reduction in Part A Medicare Premium for Certain Public Retirees

Coverage of Services in Religious Nonmedical Health Care Institutions
 

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Establishment of Single Conversion Factor for 1998

Establishing Update for Conversion Factor to Match Spending Under Sustainable Growth Rate

Replacement of Volume Performance Standard with Sustainable Growth Rate

Payment Rules for Anesthesia Services

Implementation of Resource-Based Methodologies

Dissemination of Information on High Per Discharge Relative Values for In-Hospital Physicians' Services

Use of Private Contracts by Medicare Beneficiaries

Increased Medicare Reimbursement for Nurse Practitioners and Clinical Nurse Specialists

Increased Medicare Reimbursement for Physician Assistants

No X-Ray Required for Chiropractic Services

Elimination of Formula-Driven Overpayment (FDO) for Certain Outpatient Hospital Services

Extension of Reductions in Payments for Costs of Hospital Outpatient Services

Prospective Payment System for Hospital Outpatient Department Services

Payments for Ambulance Services

Demonstration of Coverage of Ambulance Services Under Medicare Through Contracts With Units of Local Government

Prospective Payment for Outpatient Rehabilitation Services

Payments for Durable Medical Equipment

Oxygen and Oxygen Equipment

Reduction in Updates to Payment Amounts for Clinical Diagnostic Laboratory Tests; Study on Laboratory Tests

Improvements in Administration of Laboratory Tests Benefit

Updates for Ambulatory Surgical Services

Reimbursement for Drugs and Biologicals

Coverage of Oral Anti-Nausea Drugs Under Chemotherapeutic Regimen

Renal Dialysis-Related Services

Temporary Coverage Restoration for Portable Electrocardiogram Transportation

Part B Premium

Protections Under the Medicare Program for Disabled Workers Who Lose Benefits Under a Group Health Plan

Governmental Entities Eligible to Elect to Pay Part B Premiums for Eligible Individuals

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Recapturing Savings from the OBRA 1993 Freeze on Payment Increases for Home Health Services

Interim Payments for Home Health Services

Establish a Prospective Payment System

Payment Based on Location of Service

Creation of Separate Part A and Part B Home Health Benefits

Clarification of Part-Time or Intermittent Nursing Care

Study on the Definition of Homebound

Authority to Make Payment Denials Based on Normative Standards

No Home Health Benefits Based Solely on Drawing Blood

Reports to Congress on Home Health Cost Containment

Payment to Hospitals of Indirect Medical Education Costs for Medicare Choice Enrollees

Limit on Number of Residents and Rolling Average FTE Count

Payments to Hospitals for Direct Cost of Graduate Medical Education of Medicare Choice Enrollees

Permitting Payment to Nonhospital Providers

Incentive Payments Under Plans for Voluntary Reduction in Number of Residents

Medicare Special Reimbursement Rule for Primary Care Combined Residency Programs

GME Consortia Demonstration

Recommendations on Long-Term Policies Regarding Teaching Hospitals and Graduate Medical Education

Study of Hospital Overhead and Supervisory Physician Components of Direct Medical Education Costs

Permanent Extension and Revisions of Certain Secondary Payer Provisions

Clarification of Time and Filing Limitations

Permitting Recovery Against Third Party Administrator

Placement of Advance Directive in Medical Record

Increased Certification Period for Certain Organ Procurement Organizations

Office of the Chief Actuary in the Health Care Financing Administration

Conforming Amendments to Comply with Congressional Review of Agency Rulemaking

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State Option of Using Managed Care; Change in Terminology

"Section 1932(a)(1)(2)(3)--State Option to Use Managed Care"

"Section 1932(a)(3)(C)--Treatment of Certain County-Operated Health Insuring Organizations"

"Section 1932(a)(4)--Process for Enrollment and Termination"

"Section 1932(a)(4)(D)--Default Enrollment Process"

"Section 1932(a)(5)--Provision of Information"

Primary Care Case Management Services as State Option Without Need for Waiver

Elimination of 75:25 Restriction on Risk Contracts

Protections

"Section 1932(b)(2)--Assuring Coverage to Emergency Services"

"Section 1932(b)(3)--Protection of Enrollee-Provider Communications"

"Section 1932(b)(4)--Grievance Procedures"

"Section 1932(b)(5)--Demonstration of Adequate Capacity and Services"

"Section 1932(b)(6)--Protecting Enrollees Against Liability for Payment"

"Section 1932(b)(7) Antidiscrimination"

Quality Assurance Standards

"Section 1932(c)(1)--Quality Assessment and Improvement Strategy"

"Section 1932(c)(2)--External Independent Review of Managed Care Activities"

Studies and Reports

Solvency Standards

Protections Against Fraud and Abuse

"Section 1932(d)(1)--Prohibiting Affiliations with Individuals Debarred by Federal Agencies"

"Section 1932(d)(2)--Restrictions on Marketing"

"Section 1932(d)(3)--State Conflict-of-Interest Safeguards in Medicaid Risk Contracting"

"Section 1932(d)(4)--Use of Unique Physician Identifier for Participating Physicians"

"Section 1932(e)--Sanctions for Noncompliance"

"Section 1903(b)--Limitation on Availability of FFP For Use of Enrollment Brokers"

Improved Administration

Change in Threshold Amount for Contracts Requiring Secretary’s Prior Approval

Permitting Same Copayments in Health Maintenance Organizations as in Fee-For-Service

Assuring Timeliness of Provider Payments

6-Month Guaranteed Eligibility for All Individuals Enrolled in Managed Care

Flexibility in Payment Methods for Hospital, Nursing Facility, ICF/MR, and Home Health Services

Payment for Center and Clinic Services

Elimination of Obstetrical and Pediatric Payment Rate Requirements

Medicaid Payment Rates for Certain Medicare Cost-Sharing

Treatment of Veterans’ Pensions Under Medicaid

Reforming Disproportionate Share Payments Under State Medicaid Programs

Treatment of State Taxes Imposed on Certain Hospitals

Additional Funding for State Emergency Health Services Furnished to Undocumented Aliens

Elimination of Waste, Fraud, and Abuse

Increased FMAPs

Increase in Payment Limitation for Territories

State Option of Continuous Eligibility for 12 Months; Clarification of State Option to Cover Children

Payment of Part B Premiums

State Option to Permit Workers with Disabilities to Buy into Medicaid

Penalty for Fraudulent Eligibility

Treatment of Certain Settlement Payments

Elimination of Requirement to Pay for Private Insurance

Physician Qualification Requirements

Elimination of Requirement of Prior Institutionalization with Respect to Habilitation Services Furnished Under a Waiver for Home or Community-Based Services

Study and Report on EPSDT Benefit

Elimination of Duplicative Inspection of Care Requirements for ICFs/MR and Mental Hospitals

Alternative Sanctions for Noncompliant ICFs/MR

Modification of MMIS Requirements

Facilitating Imposition of State Alternative Remedies on Noncompliant Nursing Facilities

Removal of Name from Nurse Aide Registry

Medically Accepted Indication

Continuation of State-Wide Section 1115 Medicaid Waivers

Extension of Moratorium

Extension of Effective Date for State Law Amendment

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Coverage of PACE Under the Medicare Program

Receipt of Benefits Through Enrollment in PACE Program; Definitions for PACE Program Related Terms

Scope of Benefits; Beneficiary Safeguards

Eligibility Determinations

Payments to PACE Providers on a Capitated Basis

PACE Program Agreement

Regulations

Waivers of Requirements

Demonstration for For-Profit Entities

Program of All-Inclusive Care For the Elderly (PACE)

Scope of Benefits; Beneficiary Safeguards

Eligibility Determinations

Payments to PACE Providers on a Capitated Basis

PACE Program Agreement

Regulations

Waivers of Requirements

Demonstration Project for For-Profit Entities

Post-Eligibility Treatment of Income

Miscellaneous Provisions

Effective Date; Transition

Study and Report

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Establishment of Program (Section 4901)

"Section 2101--Purpose; State Child Health Plans"

"Section 2102--General Contents of State Child Health Plan; Eligibility; Outreach"

"Section 2103--Coverage Requirements for Children’s Health Insurance"

"Section 2104--Allotments"

"Section 2105--Payment to States"

"Section 2106--Process for Submission, Approval and Amendment of State Child Health Plans"

"Section 2107--Strategic Objectives and Performance Goals; Plan Administration"

"Section 2108--Annual Reports; Evaluations"

"Section 2109--Miscellaneous Provisions"

"Section 2110--Definitions"

Optional Use of State Child Health Assistance Funds for Enhanced Medicaid Match for Expanded Medicaid Eligibility

Medicaid Presumptive Eligibility for Low-Income Children

Continuation of Medicaid Eligibility for Disabled Children Who Lose SSI Benefits

Special Diabetes Programs for Type I Diabetes

Special Diabetes Programs for Indians

Report on Diabetes Grant Programs

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SSI Eligibility for Aliens Receiving SSI on August 22, 1996 and Disabled Aliens Lawfully Residing in the United States on August 22, 1996

Extension of Eligibility Period for Refugees and Certain Other Qualified Aliens from 5 to 7 Years for SSI and Medicaid; Status of Cuban and Haitian Entrants

Exemption for Certain Indians from Limitation on Eligibility for Supplemental Security Income and Medicaid Benefits

Exemption from Restriction on Supplemental Security Income Program Participation by Certain Recipients Eligible on the Basis of Very Old Applications

Reinstatement of Eligibility for Medicaid Benefits

Treatment of Certain Amerasian Immigrants as Refugees

Verification of Eligibility for State and Local Public Benefits (Section 5572)

Coordinated Acute and Long-Term Care Benefits Under a Medicare+Choice Plan (Section 4001) (New Medicare provision, Section 1859(d))

Coverage of Services in Religious Non-Medical Health Care Institutions Under the Medicare and Medicaid Programs (Section 4454)

Limitation on Pension for Certain Recipients of Medicaid-Covered Nursing Home Care (Section 8015)

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