103 STAT. 2158 PUBLIC LAW 101-239—DEC. 19, 1989 October 1, 1993 (and at least every 12 months thereafter)", and (B) by adding at the end the following new sentence: "Any adjustments or updates made under this subpara- graph for a fiscal year (beginning with fiscal year 1991) shall be made in a manner that assures that the aggregate payments under this subsection in the fiscal year are not greater or less than those that would have been made in the year without such adjustment.". 42 USC I395ww (7) EFFECTIVE DATE.—The amendments made by paragraphs °°*®- (3) and (4) shall apply to discharges occurring on or after April 1, 1990. Urbmi areas. (j) LEGISLATIVE PROPOSAL EUMINATING SEPARATE AVERAGE 42 USC 1395W STANDARDIZED AMOUNTS.- (1) IN GENERAL.—The Secretary of Health and Human Serv- ices (hereinafter referred to as the "Secretary") shall design a legislative proposal eliminating the system of determining sepa- rate average standardized amounts for subsection (d) hospitals (as defined in section 1886(d)(l)(B) of the Social Security Act) classified as being located in large urban, other urban, or rural areas under section 1886(d)(2)(D) of such Act, and shall include in such proposal the following: (A) A transition period beginning in fiscal year 1992 during which a single rate for determining payment to hospitals in all areas shall be phased in with such single rate to be completely in effect by fiscal year 1995. (B) Recommendations, where appropriate, for modifying or maintaining additional payments or adjustments made under title XVIII of the Social Security Act for teaching hospitals, rural referral centers, sole community hospitals, disproportionate share hospitals, and outlier cases, and for creating additional payments or adjustments where deemed appropriate by the Secretary. (C) Recommendations with respect to recalculating standardized amounts to reflect information from more recent cost reporting periods. (D) Recommendations, where appropriate, for modifying reimbursement for hospitals that are not subsection (d) hospitals under title XVIII of such Act. (E) A recommendation for a methodology to reflect the severity of illness of different patients within the same diagnosis-related group (as determined in section 1886(d)(4)(B) of such Act). (2) REPORT TO CONGRESS AND PROPAC.—(A) Not later than October 1, 1990, the Secretary shall submit the proposal de- scribed in paragraph (1) and an accompanying analysis of the impact of the proposed elimination of separate average standardized amounts on various categories of hospitals to Con- gress and the Prospective Payment Assessment Commission. (B) Not later than February 1, 1991, the Prospective Payment ^ Assessment Commission and the Director of the Congressional Budget Office shall each prepare and submit to Congress a report analyzing the legislative proposal submitted under subparagraph (A), and shall include in such report an analysis of the probable impact of such legislation on hospitals partici- pating in the medicare program.
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