PROPERTYOF NOV 16 REC'D HCFALIBRARY I 105thcongress H.R.4591 2dSession ToamendtitleXVIIIoftheSocialSecurityActtoprovideforhomehealth casemanagerservicesundertheMedicareProgram. IN THE HOUSE OF REPRESENTATIVES September17,1998 Mr.Stark(forhimselfandMr.Cardin)introducedthefollowingbill;which wasreferredtotheCommitteeonWaysandMeans,andinadditionto theCommitteeonCommerce,foraperiodtobesubsequentlydetermined bytheSpeaker,ineachcaseforconsiderationofsuchprovisionsasfall withinthejurisdictionofthecommitteeconcerned A BILL To amend title XVIH ofthe Social SecurityAct to provide for home health case manager services under the Medi- careProgram. 1 BeitenactedhytheSenateandHouseofRepresenta- 2 tivesoftheUnitedStatesofAmericainCongressassembled, 3 SECTION1.SHORTTITLE;FINDINGS. — 4 (a) Short Title. This Act may be cited as the 5 "MedicareHomeHealthCaseManagerActof1998". — 6 (b)Findings. TheCongressfindsasfollows: 7 (1) A Medicare beneficiary experiencing a se- 8 vere or chronic illness faces a bewildering array of 2 1 homehealth andpost-acute carehospital services at 2 atimeinhfewhenthe Medicarebeneficiaryis least 3 able to "manage" the choices, especially for bene- 4 ficiaries who do not have family members to help 5 themconsiderthechoices. 6 (2) Such a Medicare beneficiary may be un- 7 aware ofthe financial relationships between institu- 8 tions and agencies which may cause the patient to 9 bereferredforhomehealth servicesthatareunnec- 10 essaiyornotfurnishedinthemost appropriate set- 11 , ting. 12 (3) Medicare fee-for-service does not currently 13 have a system inwhich a physician or otherhealth 14 care provider is encouraged to guide the patient 15 through this maze ofservices and help ensure that 16 choices are madethatmaximizebenefitswhile mini- 17 mizingcosts. 18 (4) Chronically ill medicare patients need an 19 independent ombudsman to help develop a plan of 20 care andto periodically adjust the plan forthe sole 21 benefitofthepatientandthepatient'sfamily. •HR4591IH 3 1 SEC. 2. ESTABLISHMENT OF MEDICARE HOME HEALTH 2 CARE CASE MANAGERS FOR LONG TERM 3 HOMEHEALTHSPELLSOFILLNESS. 4 (a) Requireaient for Case Management Plan 5 FOR Beneficlvries Requiring Extended Home — 6 HealthServices. — 7 (1) In general. Section 1861(m) ofthe So- 8- cial SecurityAct (42 U.S.C. 1395x(m)) is amended, 9 inthe matterprecedingparagraph (1), byinserting 10 after ''under a plan (for furnishing such items and 11 services to such individual) established and periodi- t% caUy reviewed by a physician" the following: "and, 13 in the case of such services furnished (or likely to 14 be requiredto be furnished) for an extended period 15 (as defined by the Secretary in regulations), under 16 ahomehealth casemanagementplan (asdefined in 17 subsection (uu)(2)) established by a home health 18 case manager (as defined in subsection (uu)(l)) in 19 consultationwiththephysicianand, ifavailable, the 20 familyoftheindividual". r — 21 (2) Definitions. Section 1861 of such Act 22 (42 U.S.C. 1395x) is amendedbyaddingattheend 23 thefollowingnewsubsection: >HR4591IH — 4 1 ''HomeHealthCaseManager 2 "(uu)(l) The term 'home health case manager' 3 means apubUeagencyorprivate organization (ora sub- 4 divisionthereof)that 5 "(A) develops, coordinates, and monitors the 6 delivery of home health sendees by home health 7 agenciestoanindividual; 8 "(B) has experience and expertise in the fur- 9 nishingofhomehealthservices;and 10 "(C) meets such other standards as the Sec- 11 retaryfinds necessary forthe effective and efficient 12 developmentandoversightofhomehealthcaseman- 13 agement plans and to ensure the health and safety 14 ofindividuals furnished services under such a plan. 15 "(2) Theterm 'home healthcasemanagementplan' 16 means a structured plan forthe dehveiy ofhome health 17 servicesthatisdevelopedbyahomehealthcasemanager, 18 afterconsultationwiththephysicianand,ifavailable,the 19 familyoftheindividualinvolved. 20 "(3) The term 'home health case manager services' 21 means the development, coordination, and monitoring of 22 a home health case management plan for an individual 23 furnished (orhkelytobe requiredtobe furnished) home 24 health services foran extendedperiod (as definedbythe •HR4591IH 5 1 Secretarj^ in regulations under subsection (m)) and in- 2 eludestheperiodicreviewofsuchaplan.". 3 (3) Guidance on initiation of case man- — 4 AGER SERVICES. The Secretary of Health and 5 Human Services shallpro\dde guidance ontheproc- 6 ess orprocesses that maybeusedto identifyMedi- 7 carebeneficiaries requiringhome health services for 8 extended periods and to develop home health case 9 managementplansonatimelybasis. — 10 (4) Limitationonreferrals. Section 1877 11 ofthe Social SecurityAct (42 U.S.C. 1395nn) shall 12 applyto a referralby a home health case manager 13 to a home health agency in the same manner as 14 such section applies to a referral by a physician to 15 an entity described in section 1877(a)(2) of such 16 Act. 17 (b) Coverage of and Payment for Home — 18 HealthCaseManagerServices. 19 (1)Parta.— 20 (A) Coverage.—Section 1812(a)(3) of 21 such Act (42 U.S.C. 1395d(a)(3)) is amended 22 by insertingbefore the semicolon and home 23 healthcasemanagerservices (asdefinedinsec- 24 tion1861(uu)(3))". >HR4591IH — 6 1 (B) Eligibility.—Section 1814(a)(2)(C) 2 of such Act (42 U.S.C. 1395f(a)(2)(C)) is 3 amendedbyinserting"and, inthecaseofsuch 4 services furnished for an extended period (as 5 defined by the Secretary' under section 6 1861(m)), under a home health case manage- 7 ment plan that has been established and peri- 8 odically reviewed by a home health ease man- 9 ager" after"isperiodicallyreviewedbyaphysi- 10 cian". — 11 (C) Payment. Section 1812 ofsuchAct 12 (42 U.S.C. 1395d) isamendedbyaddingatthe ,13 endthefollovdngnewsubsection: 14 "(h)(1) Payment under this part for home health 15 casemanagerservices (asdefinedinsection1861(uu)(3)) 16 shallbemadepursuanttothefeescheduleestabhshedby 17 theSecretaryundersection1834(m). 18 "(2)(A) Payment may be made under this title for 19 homehealthcasemanagerservicesinthecaseofanindi- 20 vidualonly 21 "(i) for the initial development of the home 22 healthcasemanagementplanfortheindividual, and 23 "(ii) forthesubsequentreviewandmodification 24 ofsuchplan, asprovidedbytheSecretaryinregula- 25 tions.". •HR4591ra —— 1 1 (2)CO\^RAGEUNDERPARTB. 2 (A) In general.—Section 1832(a)(2)(A) 3 of such Act (42 U.S.C. 1395k(a)(2)(A)) is 4 amended by inserting before the semicolon 5 andhome health case manager services (as de- 6 finedinsection 1861(uu)(3))". 7 ' (B) Eligibility.—Section 1835(a)(2) of 8 such Act (42 U.S.C. 1395n(a)(2)) is amended 9 byinserting "and, in the case ofsuch services 10 furnishedforanextendedperiod (asdefinedby 11 the Secretaryunder section 1861(m)), under a 12 home health case management plan that has 13 been established and periodicallyreviewedbya 14 home health case manager" after "is periodi- 15 caUyreviewedbyaphysician". 16 (C) Payment.—Section 1833 ofsuchAct 17 (42U.S.C. 13951)isamended— 18 (i)insubsection(a)(2) 19 (I) by striking "and" at the end 20 ofsubparagraph(F); 21 (11) by adding "and" at the end 22 ofsubparagraph(G);and 23 (III) by adding after subpara- 24 graph (G) the foUov^ngnew subpara- 25 graph: •HR4591IH — 8 1 "(H) subject to subsection (u), with re- 2 spectto home healthcasemanager services (as 3 definedin section 1861(uu)(3), the amount de- 4 termined under the fee schedule established 5 undersection 1834(m);",and 6 (ii) byaddingattheendthefollowing 7 newsubsection: 8 "(u)(l) Payment may be made under this title for 9 homehealthcasemanagerservicesinthecaseofanindi- 10 vidua!only 11 "(A) for the initial development of the home 12 healthcasemanagementplanfortheindividual, and 13 "(B) for the subsequent review and modifica- 14 tion of such plan, as provided by the Secretary in 15 regulations.". — 16 (3) Establishment op Fee Schedule. 17 Section 1834 of such Act (42 U.S.C. 1395m) is 18 amendedbyaddingattheendthefollowingnewsec- 19 tion: 20 "(m) Establishment of Fee Schedule for — 21 HomeHealthCaseManagerServices. 22 "(1) In gen^eral.—The Secretaiy shall estab- 23 hshafeescheduleforpaymentforhomehealthcase 24 manager services. Such schedule may provide for 25 rates that differfor such servicesthat comprisethe m •HR4591 9 1 establishment of a home health ease management 2 plan and that comprise review and modification of 3 suchaplan. — 4 "(2) Considerations. In estabhshing such 5 fee schedule, the Secretary shall consider appro- 6 priate regional and operational differences and ad- 7 justments to payment rates to account for inflation 8 • andotherrelevantfactors. — 9 "(3) Consultation. In estabhshing the fee 10 schedule for home health case manager services 11 under this subsection, the Secretary shall consult 12 with appropriate organizations representing individ- 13 uals and entities who furnish referral services for 14 home health services and sharewith such organiza- 15 tionsrelevantdatainestablishingsuchschedule.". — 16 (c)EffectiveDates. 17 (1) Requirement of case management — 18 PLAN. The amendment made by subsection (a)(1) 19 applies with respect to home health services fur- 20 nishedonorafterOctober1,2000. — 21 (2) Paymentforcase managerservices. 22 The amendments made by subsection (b) apply to 23 home health case manager services furnished on or 24 after 6 monthsbefore the effective date specifiedin 25 paragraph(1). >HR4591IH CBSLIBRSRV 10 3 flOTS DDQLfl4fl4 E 1 SEC. 3.REPORTTO CONGRESS ONFEASIBILITYOF CASE 2 MANAGERSWITHRESPECTTOOTHERMEDI- 3 CARESERVICES. — 4 (a) Study. The Secretary of Health and Human 5 Servicesshallconductastudyofthetypesofservicescon- 6 sisting of post-acute hospital care furnished under the 7 MedicareprogramundertitleXVHIoftheSocialSecurity 8 Actto determinewhetheruse ofcasemanagers andcase 9 managementplans similartohomehealthcasemanagers 10 (asdefinedinsection 1861(uu)(l)) andhomehealthcase 11 managementplans (as definedinsection 1861(uu)(2)) is 12 feasible andappropriateforeachsuchtypeofservice. In 13 conductingthe study, the Secretar}^ shall also determine 14 v^hethersuchcasemanagers andcasemanagementplans 15 mayimprove qualityofcare andpatient outcomesunder 16 the medicare program, mayresult in cost savings to the 17 program, and may reduce incidents ofwaste, fraud and 18 abuseagainsttheprogram. — 19 (b) Report. Not later than January 1, 2001, the 20 SecretaryshallsubmittoCongressareportcontainingthe 21 determinations made pursuant to the study conducted 22 undersubsection(a)andanyrecommendationsforlegisla- 23 tiveandadministrativeactiontheSecretarydeemsappro- 24 priate. O m •HR4591