TITLE I-HOSPITAL INSURANCE BENEFITS FOR THE AGED BENEFITS SEC. 101. The Social Security Act is amended by adding after title XVI the following new title: "TITLE XVII-HOSPITAL INSURANCE BENEFITS FOR THE AGED "PROHIBITION AGAINST ANY FEDERAL INTERFERENCE "SEC. 1701. Nothing in this title shall be construed to authorize any Federal officer or employee to exercise any supervision or control over the practice of medicine or the manner in which medical services are provided, or over the selection, tenure, or compensation of any officer or employee of any hospital, skilled nursing facility, or home health agency; or to exercise any supervision or control over the administration or operation of any such hospital, facility, or agency. "FREE CHOICE BY PATIENT GUARANTEED "SEC. 1702. Any individual entitled to have payment made under this title for services furnished him may obtain inpatient hospital services, skilled nursing facility services, home health services, or outpatient hospital diagnostic services from any provided of services with which an agreement is in effect under this title and which undertakes to provide him such services. "DESCRIPTION OF SERVICES "SEC. 1703. For purposes of this title "Inpatient Hospital Services "(a) The term 'inpatient hospital services' means the following items and services furnished to an inpatient in a hospital and (except as provided in paragraph (3)) by the hospital "(1) bed and board, "(2) such nursing services and other related services, such use of hospital facilities, and such medical social services as are customarily furnished by the hospital for the care and treatment of inpatients, and such drugs, biologicals, supplies, appliances, and equipment, for use in the hospital, as are customarily furnished by such hospital for the care and treatment of inpatients, and "(3) such other diagnostic or therapeutic items or services, furnished by the hospital or by others under arrangements with them made by the hospital, as are customarily furnished to inpatients either by such hospital or by others under such arrangements; excluding, however— "(4) medical or surgical services provided by a physician, resident, or intern, except services provided in the field of pathology, radiology, physiatry or anesthesiology, and except services provided in the hospital by an intern or a resident-in-training under a teaching program approved by the Council on Medical Education and Hospitals of the American Medical Association (or, in the case of an osteopathic hospital, approved by a recognized body approved for the purpose by the Secretary), and (5) the services of a private-duty nurse. "Skilled Nursing Facility Services "(b) The term 'skilled nursing facility services' means the following items and services furnished to an inpatient in a skilled nursing facility, after transfer from a hospital in which he was an inpatient, and (except as provided in paragraph (3)) by such skilled nursing facility "(1) nursing care provided by or under the supervision of a registered professional nurse, "(2) bed and board in connection with the furnishing of such nursing care, "(3) physical, occupational, or speech therapy furnished by the skilled nursing facility or by others under arrangements with them made by the facility, "(4) medical social services, "(5) such drugs, biologicals, supplies, appliances, and equipment, furnished for use in the skilled nursing facility, as are customarily furnished by such facility for the care and treatment of inpatients, "(6) medical services provided by an intern or resident-in-training of the hospital, with which the facility is affiliated or under common control, under a teaching program of such hospital approved as provided in subsection (a) (4), and "(7) such other services necessary to the health of the patient as are generally provided by skilled nursing facilities; excluding, however, any item or service if it would not be included under subsection (a) if furnished to an inpatient in a hospital. "Home Health Services "(c) The term 'home health services' means the following items and services furnished to an individual, who is under the care of a physician, by a home health agency or by others under arrangements with them made by such agency, under a plan (for furnishing such items and services to such individual) established and periodically reviewed by a physician, which items and services are provided in a place of residence used as such individual's home “(1) part-time or intermittent nursing care provided by or under the supervision of a registered professional nurse, "(2) physical, occupational, or speech therapy, "(3) medical social services, "(4) to the extent permitted in regulations, part-time or intermittent services of a home health aid, “(5) medical supplies (other than drugs and biologicals), and the use of medical appliances, while under such a plan, and "(6) in the case of a home health agency which is affiliated or under common control with a hospital, medical services provided by an intern or resident-in-training of such hospital, under a teaching program of such hospital approved as provided in subsection (a) (4); excluding, however, any item or service if it would not be included under subsection (a) if furnished to an inpatient in a hospital. "Outpatient Hospital Diagnostic Services "(d) The term 'outpatient hospital diagnostic services' means diagnostic services “(1) which are furnished to an individual as an outpatient by a hospital or by others under arrangements with them made by a hospital, or by a clinic and "(2) which are customarily furnished by such hospital (or by others under such arrangements) to its outpatients or by such clinic to its patients for the purpose of diagnostic study; excluding, however "(3) any item or service if it would not be included under subsection (a) if furnished to an inpatient in a hospital; and "(4) any service furnished under such arrangements unless (A) furnished in the hospital or in other facilities operated by or under the supervision of the hospital, and (B) in the case of professional services, furnished by or under the responsibility of members of the hospital medical staff acting as such members. "Drugs and Biologicals "(e) (1) The term 'expensive and life-saving' drug or biological means any drug or biological which is listed as an expensive and life-saving drug or biological in the regulations, which is prescribed by a physician, and which is furnished to an individual, excluding, however, any such drug or biological furnished by a hospital or skilled nursing facility pursuant to subsections (a) (2) and (b)(5) of this section. “(e)(2) The term 'drugs' and the term 'biologicals', except for purposes of subsection (c) (5) of this section, include only such drugs and biologicals, respectively, as are included in the United States Pharmacopoeia, National Formulary, New and Non-Official Drugs, or Accepted Dental Remedies, or are approved by the pharmacy and drug therapeutics committee (or equivalent committee) of the medical staff of the hospital or clinic furnishing such drugs or biologicals (or of the hospital with which the skilled nursing facility furnishing such drugs or biologicals is affiliated or is under common control). "Arrangements for Certain Services "(f) As used in this section, the term 'arrangements' is limited to arrangements under which receipt of payment by the hospital, skilled nursing facility, or home health agency (whether in its own right or as agent), as the case may be, with respect to services for which an individual is entitled to have payment made under this title, discharges the liability of such individual or any other person to pay for the services. "DEDUCTIBLE; DURATION OF SERVICES; BENEFIT PERIOD "Deductible "SEC. 1704.(a)(1) Except as provided in subsection (e), payment for inpatient hospital services furnished an individual during any benefit period shall be reduced by a deduction equal to $20, or if greater, $10 multiplied by the number of days, not exceeding nine, for which he received such services in such period. "(2) Payment for outpatient hospital diagnostic services furnished an individual during any thirty-day period shall be reduced by a deduction equal to $20. For purposes of the preceding sentence, a thirty-day period for any individuat is a period of thirty consecutive days beginning with the first day (not included in a previous such period) on which he is entitled to benefits under this title and on which outpatient hospital diagnostic services are furnished him. · "Duration of Services (b) "(a) Payment under this title for services furnished any individual during a benefit period may not be made for "(1) inpatient hospital services furnished to him during such period after such services have been furnished to him for 90 45 days during such period, except as provided in subsection (c); or "(2) skilled nursing facility services furnished to him during such period after such services have been furnished to him for 180 days during such period. For purposes of the preceding provisions of this subsection, inpatient hospital services or skilled nursing facility services shall be counted only if payment is or would, except for this subsection and except for the failure to comply with the procedural and other requirements of or under section 1709(a)(1), be made with respect to such services under this title. Payment under this title for home health services furnished an individual during a calendar year may not be made for any such services after such services have been furnished him during 240 visits in such year. "Payment under this title for expensive and life-saving drugs and biologicals furnished an individual may not be made when the cost of one such item is less than a minimum fixed in the regulations and when the cost of all such items furnished the individual during any calendar year is greater than a maximum fixed in the regulations. Election as te Duration of Inpatient Hospital Services and Deductible "(e)(1) An individual may eleet, instead of the number of days in a benefit period for which payment may be made for inpatient hospital services furnished to him specified in subsection (b)(1) (A) to have such number of days for each benefit period increased to 180, and, in such ease; the payment under this title for inpatient hospital services furnished him during any benefit period shall, instead of being reduced by the deduction specified in subsection (a)(1), be reduced by a deduction equal to either (i) 21⁄2 times the average per diem rate for such services, determined under paragraph (4), or (ii) if less, the charges eustomarily made for such services by the hospital which furnished them, or (B) to have such number of days reduced to 45 for each benefit period and, in such ease, the reduction, provided in subsection (a) (1), in the payment under this title for inpatient hospital services furnished during any benefit period shall not apply to him: "(2) An individual may make an election under paragraph (1) only on such form or forms and in such manner as the Secretary may prescribe: Any such election shall be valid only if made before the month preceding, and after the fourth month preceding, the first month in which he both has attained the age of 65 and is eligible for the benefits referred to in section 1705(a)(2); except that if such first month occurs before January 1965, such election shall be valid only if made after May 1964 and before December 1964. For purposes of the preceding sentence, (A) an individual shall be regarded as eligible for benefits for a month if he is or, upon filing application for such benefits in such month, would be entitled to such benefits, and (B) an individual to whom section 103 of the Hospital Insurance Act of 1963 applies shall be deemed eligible for the benefits referred to in such section 1705(a)(2) for and after the month in which he attains the age of 65: "(3) An individual shall be permitted only one election under this subsection and such election shall be irrevocable. "(4) The Secretary shall, between July 1 and October 1 of the calendar year 1966 and of each ealendar year thereafter, promulgate the average per diem rate for inpatient hospital services which shall be applicable in the ease of benefit periods beginning during the succeeding year. Such promulgation shall be based on the best information available to the Secretary (at the time the determination is made) as to the amounts paid under this title on aecount of inpatient hospital services furnished, during the calendar year preceding such determination, by hospitals, with which agreements under section 1710 are in effect, to individuals who are entitled to have such payments made with respect to such services; and the amount so determined shall be rounded to the nearest $1, or, if it is a multiple of $0.50 but not of $1, to the next higher $1. For benefit periods beginning prior to the calendar year 1967, such average per diem rate shall be $37: "Benefit Period "(b) For the purposes of this section, a 'benefit period' with respect to any individual means a period of consecutive days— "(1) beginning with the first day (not included in a previous benefit period) (A) on which such individual is furnished inpatient hospital services or skilled nursing facility services and (B) which occurs in a month for which he is entitled to insurance benefits under this title, and "(2) ending with the ninetieth day thereafter on each of which he is neither an inpatient in a hospital nor an inpatient in a skilled nursing facility (whether or not such 90 days are consecutive), but only if such 90 days occur within a period of not more than 180 consecutive days. "ENTITLEMENT TO BENEFITS "SEC. 1705. (a) Every individual who "(1) has attained the age of 65, and "(2) is entitled to monthly insurance benefits under section 202, shall be entitled to insurance benefits under this title for each month for which he is entitled to such benefits under section 202, beginning with the first month after December 1964 with respect to which he meets the conditions specified in paragraphs (1) and (2). "(b) For the purposes of this section "(1) entitlement of an individual to insurance benefits under this title for a month shall consist of entitlement to have payment made under, and subject to the limitations in, this title on his behalf for inpatient hospital services, skilled nursing facility services, home health services, and outpatient hospital diagnostic services furnished him in the United States during such month; and "(2) an individual shall be deemed entitled to monthly insurance benefits under section 202 for the month in which he died if he would have been entitled to such benefits for such month had he died in the next month. "(c) Notwithstanding the preceding provisions of this section, no payments may be made under this title for inpatient hospital services, outpatient hospital diagnostic services, or home health services furnished an individual prior to January 1, 1965, or for skilled nursing facility services furnished him prior to July 1, 1965. DEFINITIONS OF PROVIDERS OF SERVICES "Sec. 1796. For purposes of this title "Hospital "(a) The term 'hospital' (except for purposes of section 1704(d) (2), section 1709 (f), paragraph (6) of this subsection, and so much of section 1703(b) as precedes paragraph (1) thereof) means an institution which "(1) is primarily engaged in providing, by or under the supervision of physicians or surgeons, to inpatients (A) diagnostic services and therapeutic services for medical diagnosis, treatment, and care of injured, disabled, or sick persons, or (B) rehabilitation facilities and services for the rehabilitation of injured, disabled, or sick persons, "(2) maintains clinical records on all patients, "(3) has bylaws in effect with respect to its staff pf physicians, "(4) continuously provides twenty-four-hour nursing service rendered or supervised by a registered professional nurse, "(5) has in effect a hospital utilization review plan which meets the requirements of subsection (e), "(6) in the case of an institution in any State in which State or applicable local law provides for the licensing of hospitals, (A) is licensed pursuant to such law or (B) is approved, by the agency of such State responsible for licensing hospitals, as meeting the standards established for such licensing, and "(7) meets such other of the requirements prescribed for the accreditation of hospitals by the Joint Commission of the Accreditation of Hospitals, as the Secretary finds necessary in the interest of the health and safety of individuals who are furnished services by or in the institution. For purposes of section 1704(d) (2), such term includes any institution which meets the requirements of paragraph (1) of this subsection. For purposes of section 1709 (f) (including determination of whether an individual received inpatient hospital services for purposes of such section 1709 (f)), and so much of section 1703(b) as precedes paragraph (1) thereof, such term includes any institution which meets the requirements of paragraphs (1), (2), (4), and (6) of this subsection. Notwithstanding the preceding provisions of this subsection, such term shall not, except for purposes of section 1704(d) (2), include any institution which is primarily for the care and treatment of tuberculosis or mentally ill patients. "Skilled Nursing Facility "(b) The term 'skilled nursing facility' means (except for purposes of section 1704(d) (2)) an institution (or a distinct part of an institution) which is affiliated or under common control with a hospital having an agreement in effect under section 1710 and which "(1) is primarily engaged in providing to inpatients (A) skilled nursing care and related services for patients who require planned medical or nursing care or (B) rehabilitation services, "(2) has policies, which are established by a group of professional personnel (associated with the facility), including 1 or more physicians and 1 or more registered professional nurses, to govern the skilled nursing care and related medical or other services it provides and which include a requirement that every patient must be under the care of a physician, "(3) has a physician, a registered professional nurse, or a medical staff responsible for the execution of such policies, (4) maintains clinical records on all patients, "(5) continuously provides twenty-four-hour nursing service rendered or supervised by a registered professional nurse, "(6) operates under a utilization review plan, which has been made applicable to it under subsection (g), of the hospital with which it is affiliated or under common control, "(7) in the case of an institution in any State in which State or applicable local law provides for the licensing of institutions of this nature, (A) is licensed pursuant to such law, or (B) is approved, by the agency of such State responsible for licensing institutions of this nature, as meeting standards established for such licensing; and |