COVERAGE OF SERVICES IN RELIGIOUS NONMEDICAL HEALTH CARE INSTITUTIONS UNDER THE MEDICARE AND MEDICAID PROGRAMS.

SEC. 4454. COVERAGE OF SERVICES IN RELIGIOUS NONMEDICAL HEALTH CARE INSTITUTIONS UNDER THE MEDICARE AND MEDICAID PROGRAMS. (a) Medicare Coverage.— (1) In general.—Section 1861 (42 U.S.C. 1395x) (as amended by sections 4103 and 4106) is amended— (A) in the sixth sentence of subsection (e)— (i) by striking “includes” and all that follows up to “but only” and inserting “includes a religious nonmedical health care institution (as defined in subsection (ss)(1)),”, and (ii) by inserting “consistent with section 1821” before the period; (B) in subsection (y)— (i) by amending the heading to read as follows: “Extended Care in Religious Nonmedical Health Care Institutions”, (ii) in paragraph (1), by striking “includes” and all that follows up to “but only” and inserting “includes 111 STAT. 427a religious nonmedical health care institution (as defined in subsection (ss)(11)),”, and (iii) by inserting “consistent with section 1821” before the period; and (C) by adding at the end the following: “Religious Nonmedical Health Care Institution “(ss)(1) The term ‘religious nonmedical health care institution’ means an institution that— “(A) is described in subsection (c)(3) of section 501 of the Internal Revenue Code of 1986 and is exempt from taxes under subsection (a) of such section; “(B) is lawfully operated under all applicable Federal, State, and local laws and regulations; “(C) provides only nonmedical nursing items and services exclusively to patients who choose to rely solely upon a religious method of healing and for whom the acceptance of medical health services would be inconsistent with their religious beliefs; “(D) provides such nonmedical items and services exclusively through nonmedical nursing personnel who are experienced in caring for the physical needs of such patients; “(E) provides such nonmedical items and services to inpatients on a 24-hour basis; “(F) on the basis of its religious beliefs, does not provide through its personnel or otherwise medical items and services (including any medical screening, examination, diagnosis, prognosis, treatment, or the administration of drugs) for its patients; “(G)(i) is not owed by, under common ownership with, or has an ownership interest in, a provider of medical treatment of services; “(ii) is not affiliated with— “(I) a provider of medical treatment or services, or “(II) an individual who has an ownership interest in a provider of medical treatment or services; “(H) has in effect a utilization review plan which— “(i) provides for the review of admissions to the institution, of the duration of stays therein, of cases of continuous extended duration, and of the items and services furnished by the institution, “(ii) requires that such reviews be made by an appropriate committee of the institution that includes the individuals responsible for overall administration and for supervision of nursing personnel at the institution, “(iii) provides that records be maintained of the meetings, decisions, and actions of such committee, and “(iv) meets such other requirements as the Secretary finds necessary to establish an effective utilization review plan; “(I) provides the Secretary with such information as the Secretary may require to implement section 1821, 111 STAT. 428including information relating to quality of care and coverage determinations; and “(J) meets such other requirements as the Secretary finds necessary in the interest of the health and safety of individuals who are furnished services in the institution. “(2) To the extent that the Secretary finds that the accreditation of an institution by a State, regional, or national agency or association provides reasonable assurances that any or all of the requirements of paragraph (1) are met or exceeded, the Secretary may treat such institution as meeting the condition or conditions with respect to which the Secretary made such finding. “(3)(A)(i) In administering this subsection and section 1821, the Secretary shall not require any patient of a religious nonmedical health care institution to undergo medical screening, examination, diagnosis, prognosis, or treatment or to accept any other medical health care service, if such patient (or legal representative of the patient) objects thereto on religious grounds. “(ii) Clause (i) shall not be construed as preventing the Secretary from requiring under section 1821(a)(2) the provision of sufficient information regarding an individual’s condition as a condition for receipt of benefits under part A for services provided in such an institution. “(B)(i) In administering this subsection and section 1821, the Secretary shall not subject a religious nonmedical health care institution or its personnel to any medical supervision, regulation, or control, insofar as such supervision, regulation, or control would be contrary to the religious beliefs observed by the institution or such personnel. “(ii) Clause (i) shall not be construed as preventing the Secretary from reviewing items and services billed by the institution to the extent the Secretary determines such review to be necessary to determine whether such items and services were not covered under part A, are excessive, or are fraudulent. “(4)(A) For purposes of paragraph (1)(G)(i), an ownership interest of less than 5 percent shall not be taken into account. “(B) For purposes of paragraph (1)(G)(ii), none of the following shall be considered to create an affiliation: “(i) An individual serving as an uncompensated director, trustee, officer, or other member of the governing body of a religious nonmedical health care institution. “(ii) An individual who is a director, trustee, officer, employee, or staff member of a religious nonmedical health care institution having a family relationship with an individual who is affiliated with (or has an ownership interest in) a provider of medical treatment or services. “(iii) An individual or entity furnishing goods or services as a vendor to both providers of medical treatment or services and religious nonmedical health care institutions.”. (2) Conditions of coverage.—Part A of title XVIII is amended by adding at the end the following new section: “conditions for coverage of religious nonmedical health care institutional services “Sec. 1821. (a) In General.—Subject to subsections (c) and (d), payment under this part may be made for inpatient hospital services or post-hospital extended care services furnished an individual in a religious nonmedical health care institution only if—111 STAT. 429 “(1) the individual has an election in effect for such benefits under subsection (b); and “(2) the individual has a condition such that the individual would qualify for benefits under this part for inpatient hospital services or extended care services, respectively, if the individual were an inpatient or resident in a hospital or skilled nursing facility that was not such an institution. “(b) Election.— “(1) In general.—An individual may make an election under this subsection in a form and manner specified by the Secretary consistent with this subsection. Unless otherwise provided, such an election shall take effect immediately upon its execution. Such an election, once made, shall continue in effect until revoked. “(2) Form.—The election form under this subsection shall include the following: “(A) A written statement, signed by the individual (or such individual’s legal representative), that— “(i) the individual is conscientiously opposed to acceptance of nonexcepted medical treatment; and “(ii) the individual’s acceptance of nonexcepted medical treatment would be inconsistent with the individual’s sincere religious beliefs. “(B) A statement that the receipt of nonexcepted medical services shall constitute a revocation of the election and may limit further receipt of services described in subsection (a). “(3) Revocation.—An election under this subsection by an individual may be revoked by voluntarily notifying the Secretary in writing of such revocation and shall be deemed to be revoked if the individual receives nonexcepted medical treatment for which reimbursement is made under this title. “(4) Limitation on subsequent elections.—Once an individual’s election under this subsection has been made and revoked twice— “(A) the next election may not become effective until the date that is 1 year after the date of most recent previous revocation, and “(B) any succeeding election may not become effective until the date that is 5 years after the date of the most recent previous revocation. “(5) Excepted medical treatment.—For purposes of this subsection: “(A) Excepted medical treatment.—The term ‘excepted medical treatment’ means medical care or treatment (including medical and other health services)— “(i) received involuntarily, or “(ii) required under Federal or State law or law of a political subdivision of a State. “(B) Nonexcepted medical treatment.—The term ‘nonexcepted medical treatment’ means medical care or treatment (including medical and other health services) other than excepted medical treatment. “(c) Monitoring and Safeguard Against Excessive Expenditures.— “(1) Estimate of expenditures.—Before the beginning of each fiscal year (beginning with fiscal year 2000), the Secretary 111 STAT. 430shall estimate the level of expenditures under this part for services described in subsection (a) for that fiscal year. “(2) Adjustment in payments.— “(A) Proportional adjustment.—If the Secretary determines that the level estimated under paragraph (1) for a fiscal year will exceed the trigger level (as defined in subparagraph (O) for that fiscal year, the Secretary shall, subject to subparagraph (B), provide for such a proportional reduction in payment amounts under this part for services described in subsection (a) for the fiscal year involved as will assure that such level (taking into account any adjustment under subparagraph (B)) does not exceed the trigger level for that fiscal year. “(B) Alternative adjustments.—The Secretary may, instead of making some or all of the reduction described in subparagraph (A), impose such other conditions or limitations with respect to the coverage of covered services (including limitations on new elections of coverage and new facilities) as may be appropriate to reduce the level of expenditures described in paragraph (1) to the trigger level. “(C) Trigger level.—For purposes of this subsection— “(i) In General.—Subject to adjustment under paragraph (3)(B), the ‘trigger level’ for a year is the unadjusted trigger level described in clause (ii). “(ii) Unadjusted trigger level.—The ‘unadjusted trigger level’ for— “(I) fiscal year 1998, is $20,000,000, or “(II) a succeeding fiscal year is the amount specified under this clause for the previous fiscal year increased by the percentage increase in the consumer price index for all urban consumers (all items; United States city average) for the 12-month period ending with July preceding the beginning of the fiscal year. “(D) Prohibition of administrative and judicial review.—There shall be no administrative or judicial review under section 1869, 1878, or otherwise of the estimation of expenditures under subparagraph (A) or the application of reduction amounts under subparagraph (B). “(E) Effect on billing.—Notwithstanding any other provision of this title, in the case of a reduction in payment provided under this subsection for services of a religious nonmedical health care institution provided to an individual, the amount that the institution is otherwise permitted to charge the individual for such services is increased by the amount of such reduction. “(3) Monitoring expenditure level.— “(A) In general.—The Secretary shall monitor the expenditure level described in paragraph (2)(A) for each fiscal year (beginning with fiscal year 1999). “(B) Adjustment in trigger level.— “(i) In general.—If the Secretary determines that such level for a fiscal year exceeded, or was less than, the trigger level for that fiscal year, then, subject to clause (ii), the trigger level for the succeeding fiscal 111 STAT. 431year shall be reduced, or increased, respectively, by the amount of such excess or deficit. “(ii) Limitation on carryforward.—In no case may the increase effected under clause (i) for a fiscal year exceed $50,000,000. “(d) Sunset.—If the Secretary determines that the level of expenditures described in subsection (c)(1) for 3 consecutive fiscal years (with the first such year being not earlier than fiscal year 2002) exceeds the trigger level for such expenditures for such years (as determined under subsection (c)(2)), benefits shall be paid under this part for services described in subsection (a) and furnished on or after the first January 1 that occurs after such 3 consecutive years only with respect to an individual who has an election in effect under subsection (b) as of such January 1 and only during the duration of such election. “(e) Annual Report.—At the beginning of each fiscal year (beginning with fiscal year 1999), the Secretary shall submit to the Committee on Ways and Means of the House of Representatives and the Committee on Finance of the Senate an annual report on coverage and expenditures for services described in subsection (a) under this part and under State plans under title XIX. Such report shall include— “(1) level of expenditures described in subsection (c)(1) for the previous fiscal year and estimated for the fiscal year involved; “(2) trends in such level; and “(3) facts and circumstances of any significant change in such level from the level in previous fiscal years.”. (b) Medicaid.— (1) The third sentence of section 1902(a) (42 U.S.C. 1396a(a)) is amended by striking all that follows “shall not apply” and inserting “to a religious nonmedical health care institution (as defined in section 1861(ss)(1)).”. (2) Section 1908(e)(1) (42 U.S.C. 1396g–1(e)(D) is amended by striking all that follows “does not include” and inserting “a religious nonmedical health care institution (as defined in section 1861(ss)(1)).”. (c) Conforming Amendments.— (1) Section 1122(h) (42 U.S.C. 1320a–1(h)) is amended by striking all that follows “shall not apply to” and inserting “a religious nonmedical health care institution (as defined in section 1861(ss)(1)).”. (2) Section 1162 (42 U.S.C. 1320c–11) is amended— (A) by amending the heading to read as follows: “exemptions for religious nonmedical health care institutions”; and (B) by striking all that follows “shall not apply with respect to a” and inserting “religious nonmedical health care institution (as defined in section 1861(ss)(1)).”. (d) Effective Date.—The amendments made by this section shall take effect on the date of the enactment of this Act and shall apply to items and services furnished on or after such date. By not later than July 1, 1998, the Secretary of Health and Human Services shall first issue regulations to carry out such amendments. Such regulations may be issued so they are effective on an interim 111 STAT. 432basis pending notice and opportunity for public comment. For periods before the effective date of such regulations, such regulations shall recognize elections entered into in good faith in order to comply with the requirements of section 1821(b) of the Social Security Act.