use of District of Columbia appropriations for the medical treatment of persons (except in emergencies) who have not been residents of the District for 1 year. Neither section 226 of the Social Security Act, relating to entitlement for hospital insurance benefits, nor section 1836 of such Act, relating to eligibility for supplementary medical insurance benefits, imposes any durational residence requirement. The Commissioners allege that section 1902(b)(3) of such Act precludes approval by the Secretary of Health, Education, and Welfare of any plan for medical assistance which attempts to exclude any individual who "resides" in the District. However, that Act does not define "resides", nor who shall be considered to be a resident of the District. H.R. 3972 authorizes the Commissioners to provide, by regulation, medicare and medical assistance to any resident of the District of Columbia otherwise eligible for such services and benefits, without regard to the aforesaid 1-year residence requirement of the District of Columbia law. (2) Means Test-Under the 1947 D.C. Appropriations Act (60 Stat. 511; D.C. Code, Tit. 32, Sec. 322), there is a provision which prohibits, with certain exceptions, the use of D.C. appropriations for the Department of Public Health for the medical care of persons "who are not indigent". Section 1802 of the Social Security Act provides that any individual entitled to insurance benefits under title XVIII may obtain health services from any institution, agency, or person qualified to participate under such title if the institution, agency, or person undertakes to provide him such services. The term "medical assistance", as defined by section 1905 (a) of the Social Security Act, not only covers individuals who are recipients of public assistance, but also includes those persons who are medically needy; i.e., those whose income and resources are insufficient to meet all of the costs of hospital, physicians', and related medical services. (3) Per Diem Rates for Treatment-Under the 1967 Appropriations Act (80 Stat. 1180), the Congress established ceilings on the rates which the District might pay to various Federal and private hospitals for services rendered to indigent residents for inpatient or outpatient care or other treatment ($38-$40 per diem and $6-$6.75 per visit, except at St. Elizabeth's, at $12.18 per diem). Section 1902 (a) (13) (B) of the Social Security Act states that a plan submitted for approval under title XIX must provide for payment of the reasonable cost of inpatient hospital services provided under such plan. "Reasonable costs" are determined in accordance with standards approved by the Secretary of Health, Education, and Welfare. (4) Relatives' Financial Responsibility—Under the D.C. Code (Tit. 21, Sec. 551 & 586 (a)) a person ordered committed to a public hospital in D.C. must be a D.C. resident for more than 1 year, or be transferred back to his State, if the State will accept him. The expenses of the person committed must be borne by him, if able, or by his parents, spouse, or adult children. The Social Security Act authorizes the furnishing, under title XVIII, of limited inpatient psychiatric hospital services to persons 65 years of age or older, and, under title XIX, medical assistance in behalf of such individuals who are patients in mental hospitals. As heretofore indicated, the Commissioners are of the opinion that Federal aid or assistance in these medical programs will be withheld from any State, including the District of Columbia, which imposes any durational residence requirement upon recipients thereof. In addition, section 1902(a) (17) (D) of the Act provides that a State plan for medical assistance may not take into account the financial responsibility of an adult child for his parents, or the financial responsibility of a parent for his adult children, other than a child who is blind or permanently and totally disabled, with respect to any medical assistance furnished to such parent or child. (5) Public Assistance-Under the D.C. 1962 Public Assistance Act (76 Stat. 914; D.C .Code, Tit. 3, sec. 201), the term "public assistance" is defined as "payment in or by money, medical care, remedial care, goods or services to, or for the benefit of, needy persons". Should the bill be enacted into law, assistance in the form of medical care or remedial care furnished to needy persons by the District will no longer be subject to the provisions of the District of Columbia Public Assistance Act of 1962, but such care will be governed by regulations issued by the Commissioners in accordance with applicable requirements of title XIX of the Social Security Act. CONCLUSION Termination of Federal Benefits-The District of Columbia is faced with the loss of Federal medical and other assistance because of the termination of these programs on December 31, 1969. Federal sharing in medical aid or assistance under Title I (old-age assistance and medical assistance for the aged), Title IV (aid to families with dependent children), Title X (aid to the blind), Title XIV (aid to the permanently and totally disabled), and Title XVI (the combined adult program), will, pursuant to section 121 (b) of the Social Security Amendments of 1965, terminate with respect to any period after December 31, 1969. If the District does not secure authority to participate in title XIX on or before such date, it will be placed in the position of having to provide medical care to its indigent and medically needy residents without Federal assistance, the Commissioners allege. Mr. DoWDY. This legislation, we are advised, was requested by the Commissioners of the District to enable the District of Columbia to participate in the health and medical assistance benefits made available by the Social Security Amendments of 1965 (P.L. 89–97, approved July 30, 1965, 79 Stat. 286) and for other purposes. The report of the Commissioners on the proposed legislation, dated March 10, 1967, will be made a part of the record at this point. (The report of the Commissioners referred to is as follows): GOVERNMENT OF THE DISTRICT OF COLUMBIA, EXECUTIVE OFFICE, Washington, D.C., March 10, 1967. Hon. JOHN L. MCMILLAN, DEAR MR. MCMILLAN: The Commissioners of the District of Columbia have for report H.R. 3972, 90th Congress, a bill "To enable the District of Columbia to participate in the health and medical assistance benefits made available by the Social Security Amendments of 1965, and for other purposes." The purpose of the bill is to authorize the Commissioners to take such action and to promulgate such regulations as may be necessary or required to permit publicly-owned District of Columbia hospitals and other medical facilities to provide health and medical care and services to eligible aged individuals under the hospital insurance benefits program and the supplementary medical insurance benefits program established by title XVIII of the Social Security Act, and to furnish medical assistance to eligible residents of the District of Columbia under the program established by title XIX of such Act, as added by the Social Security Amendments of 1965 (79 Stat. 286; Public Law 89-97). Such programs would be conducted in the District pursuant to regulations issued, and policy and procedural guidelines established by the Secretary of Health, Education, and Welfare. The Social Security Amendments of 1965 contain health legislation which has a very significant impact on the District of Columbia government and particularly upon its Department of Public Health. The law makes it possible to greatly broaden the scope and to improve the quality of the health and medical services which are available to individuals in the District, particularly to those persons whose ability to obtain adequate medical care is impeded by the inadequacy of their finances. In further explanation of the purposes of the bill and in justification for its enactment, the Commissioners invite your attention to the attached justification. This justification refers to several provisions of existing District of Columbia laws which must be made inoperative if the District is to participate fully in programs under titles XVIII and XIX of the Social Security Act, and sets forth information concerning the budgetary implications of the bill and the financial impact its passage would likely have on both the Federal Government and the District Government. The Commissioners believe it highly advantageous to the District Government and its citizens that they realize the liberalized benefits of the expanded health and medical programs provided by titles XVIII and XIX of the Social Security Act, and they strongly recommend the enactment of this legislation during this session of the Congress. The Commissioners have been advised by the Bureau of the Budget that, from the standpoint of the Administration's program, there is no objection to the submission of this report to the Congress. Sincerely yours, (Attachment.) WALTER N. TOBRINER, President, Board of Commissioners, D.C. JUSTIFICATION FOR PROPOSED LEGISLATION TO ENABLE THE DISTRICT OF COLUMBIA TO PARTICIPATE IN THE HEALTH AND MEDICAL ASSISTANCE BENEFITS MADE AVAILABLE BY THE SOCIAL SECURITY AMENDMENTS OF 1965 In order for the District to meet various provisions of Federal law or conform to standards required under regulations issued by the Secretary of Health, Education, and Welfare, so as to enable its residents to receive the full measure of the benefits available, it is essential that several existing District legal requirements which are in basic conflict with titles XVIII and XIX of the Social Security Act be rendered inoperative. The proposed legislation accordingly authorizes the Commissioners to promulgate such rules and regulations as may be necessary to permit District participation in, and to secure for the District the health and medical assistance benefits made available by titles XVIII and XIX of the Act, notwithstanding any existing provision of law establishing (1) a durational residency requirement, (2) a means test, (3) per diem or other periodic rates for the inpatient or outpatient care or treatment of the medically needy, or (4) the financial responsibility of relatives of the medically needy, for persons provided health and medical care and treatment by or at the expense of the District of Columbia. Specifically, the Commissioners are authorized by the bill, notwithstanding existing provisions of law, to meet conditions imposed by applicable terms of the Social Security Act or administrative regulations in the following areas: 1. Permanent language appearing in the first proviso under the subheading "Operating Expenses, Gallinger Municipal Hospital" in section 1 of the District of Columbia Appropriation Act, 1946 (59 Stat. 282; D.C. Code, sec 32-321), prohibits the use of District of Columbia appropriations for the medical treatment of persons who have not been residents of the District for one year. The proviso reads as follows: "Provided, That hereafter no District of Columbia appropriations shall be available for the care of persons, except in emergency cases, where the person has been a resident of the District of Columbia for less than one year at the time of application for admission.” Neither section 226 of the Social Security Act, relating to entitlement for hospital insurance benefits, nor section 1836 of such Act, relating to eligibility for supplementary medical insurance benefits, impose any durational residence requirement, and section 1902(b) (3) of such Act precludes approval by the Secretary of Health, Education, and Welfare of any plan for medical assistance which attempts to exclude any individual who resides in the District. The bill authorizes the Commissioners to provide, by regulation, medicare and medical assistance to any resident of the District otherwise eligible for such services and benefits, without regard to the aforesaid durational residence requirement of District of Columbia law. 2. Section 1802 of the Social Security Act provides that any individual entitled to insurance benefits under title XVIII may obtain health services from any institution, agency, or person qualified to participate under such title if the institution, agency, or person undertakes to provide him such services. The term "medical assistance", as defined by section 1905 (a) of the Social Security Act, not only covers individuals who are recipients of public assistance, but also includes those persons who are medically needy; i.e., those whose income and resources are insufficient to meet all of the costs of hospital, physicians', and related medical services. A proviso to the District of Columbia Appropriation Act, 1947 (60 Stat. 511; D.C. Code, sec. 32-322), however, prohibits, with certain exceptions, the use of appropriations by the District of Columbia Department of Public Health for the medical care of persons who are not indigent. The proviso reads as follows: "Provided, That hereafter no part of any appropriation for Gallinger Municpal Hospital or the Health Department shall be used for furnishing, other than at rates prescribed by the Commissioners, clinical services, drugs, pharmaceutical preparations, or X-ray service, to persons who are not indigent, except in emergency cases or where the Commissioners determine it to be necessary in the public interest." Since there are no provisions in either title XVIII or title XIX which require that any person receiving services or benefits thereunder be indigent, it is necessary that the Commissioners have authority, through the issuance of appropriate regulations, to overcome the effect of the aforesaid proviso with respect to persons eligible for treatment under Federal aid programs of health insurance for the aged and medical assistance. 3. Under the subheading "Health and Welfare" in section 1 of the District of Columbia Appropriation Act, 1967 (80 Stat. 1170), the Congress has estab lished ceilings on the rates which the District may pay to Federal and private hospitals for services rendered to indigent residents. The proviso reads as follows: "Provided, That the inpatient rate and outpatient rate under such contracts [for the care and treatment of indigent patients in institutions, including those under sectarian control], with the exception of Children's Hospital, and for services rendered by Freedmen's Hospital shall not exceed $38 per diem and the outpatient rate shall not exceed $6 per visit; the inpatient rate and outpatient rate for Children's Hospital shall not exceed $40 per diem and $6.75 per visit; and the inpatient rate (excluding the proportionate share for repairs and construction) for services rendered by Saint Elizabeths Hospital for patient care shall be $12.18 per diem." (Brackets explanation added) Section 1902 (a) (13) (B) of the Social Security Act states that a plan submitted for approval under title XIX must provide for payment of the reasonable cost of inpatient hospital services provided under such plan. "Reasonable costs" are determined in accordance with standards approved by the Secretary of Health, Education, and Welfare. Presumably, similar maximums will be established under the 1968 Appropriation Act, which is yet to be approved by the Congress. Accordingly, it may become necessary, if District participation in title XIX is not to be jeopardized, that appropriate revisions be made in these rates to meet standards acceptable to the Secretary of Health, Education, and Welfare. It is quite possible, of course, that this problem can be solved by agreement with the respective Appropriation Committees of both Houses through the insertion of appropriate language in the pending District of Columbia appropriation bill, thereby making it unnecessary for the Commissioners to act further thereon. 4. The Social Security Act authorizes the furnishing, under title XVIII, of limited inpatient psychiatric hospital services to persons 65 years of age or older, and, under title XIX, medical assistance in behalf of such individuals who are patients in mental hospitals. As heretofore indicated, Federal aid or assistance in these medical programs will be withheld from any State which imposes any durational residence requirement upon recipients thereof. In addition, section 1902 (a) (17) (D) of the Act provides that a State plan for medical assistance may not take into account the financial responsibility of an adult child for his parents, or the financial responsibility of a parent for his adult children, other than a child who is blind or permanently and totally disabled, with respect to any medical assistance furnished to such parent or child. Moreover, section 1902 (a) (18) of such Act provides that no lien may be imposed against the property of any individual prior to his death on account of medical assistance paid or to be paid on his behalf, and that there shall be no adjustment or recovery from the estate of an individual who received medical assistance, except a person who was 65 years of age or older when he received such assistance, and then only after the death of his surviving spouse, if any, and only at a time when he has no surviving child who is under age 21 or is blind or permanently disabled. On the other hand, section 21-551 of the District of Columbia Code provides that "(a) If a person ordered committed to a public hospital by the court pursuant to section 21-545 is found by the Commission, subject to a review by the court, not to be a resident of the District of Columbia, and to be a resident of another place, he shall be transferred to the State of his residence, if an appropriate institution of that State is willing to accept him. If the person is an indigent, the expense of transferring him, including the traveling expenses of necessary attendants, shall be borne by the District of Columbia. |