PROPERTY OF NOV 2 0 REC'D ii HCFA LIBRARY 105th CONGRESS 720 S. 1st Session To amend titles XVIII and XIX of the Social Security Act to expand and make permanent the availability of cost-effective, comprehensive acute and long-term care services to frail elderly persons through Programs of All-inclusive Care for the Elderly (PACE) under the medicare and medicaid programs. IN THE SENATE OF THE UNITED STATES May 8, 1997 Mr. Grassley (for himself, Mr. Inouye, Mr. Frist, and Mr. Graham) intro- duced the following bill; which was read twice and referred to the Com- mittee on Finance A BILL To amend titles XVIII and XEX of the Social Security Act to expand and make permanent the availability of cost- effective, comprehensive acute and long-term care serv- ices to frail elderly persons through Programs of All- inclusive Care for the Elderly (PACE) under the medi- care and medicaid programs. 1 Be it enacted by the Senate and House ofRepresenta- 2 tives ofthe United States ofAmerica in Congress assembled, 3 SECTION 1. SHORT TITLE. 4 This Act may be cited as the "Programs of All-inclu- 5 sive Care for the Elderly (PACE) Coverage Act of 1997". — — 2 1 SEC. 2. COVERAGE OF PACE UNDER THE MEDICARE PRO- 2 GRAM. 3 (a) In General.—Title XVIII of the Social Security 4 Act (42 U.S.C. 1395 et seq.) is amended by adding at 5 the end the following new section: 6 "PAYMENTS TO, AND COVERAGE OP BENEFITS UNDER, 7 PROGRAMS OF ALL-INCLUSP7E CARE FOR THE EL- 8 DERLY (PACE) 9 "Sec. 1894. (a) Receipt of Benefits Through 10 Enrollment in PACE Program; Definitions for — PACE Program Related Terms. 1 1 12 "(1) Benefits through enrollment in a — 13 pace program. In accordance with this section, in 14 the case of an individual who is entitled to benefits 15 under part A or enrolled under part B and who is 16 a PACE program eligible individual (as defined in 17 paragraph (5)) with respect to a PACE program of- 18 fered by a PACE provider under a PACE program 19 agreement 20 "(A) the individual may enroll in the pro- 21 gram under this section; and 22 "(B) so long as the individual is so en- 23 rolled and in accordance with regulations 24 "(i) the individual shall receive bene- 25 fits under this title solely through such 26 program, and •S 720 is t*MicLa*S I6»'lls I Se*«Ve| (Of-Hv Coheres; j (s-f feh j I ft 3 PACE 1 "(ii) the provider is entitled to 2 payment under and in accordance with this 3 section and such agreement for provision 4 of such benefits. — 5 "(2) PACE PROGRAM defined. For purposes 6 of this section and section 1932, the term 'PACE 7 program' means a program of all-inclusive care for 8 the elderly that meets the following requirements: — 9 "(A) Operation. The entity operating 10 the program is a PACE provider (as defined in 11 paragraph (3)). — 12 "(B) Comprehensive benefits. The 13 program provides comprehensive health care 14 services to PACE program eligible individuals 15 in accordance with the PACE program agree- 16 ment and regulations under this section. — 17 "(C) Transition. In the case of an indi- 18 vidual who is enrolled under the program under 19 this section and whose enrollment ceases for 20 any reason (including the individual no longer 21 qualifies as a PACE program eligible individual, 22 the termination of a PACE program agreement, 23 or otherwise), the program provides assistance 24 to the individual in obtaining necessary transi- 25 tional care through appropriate referrals and >S 720 IS — — — 4 1 making the individual's medical records avail- 2 able to new providers. 3 "(3) PACE PROVIDER DEFINED. — 4 "(A) In GENERAL. For purposes of this 5 section, the term 'PACE provider' means an en- 6 tity that 7 "(i) subject to subparagraph (B), is 8 (or is a distinct part of) a public entity or 9 a private, nonprofit entity organized for 10 charitable purposes under section 11 501(c)(3) of the Internal Revenue Code of 12 1986, and PACE 13 "(ii) has entered into a pro- 14 gram agreement with respect to its oper- PACE 15 ation of a program. 16 "(B) Treatment of private, for-prof- — 17 it providers. Clause (i) of subparagraph (A) 18 shall not apply 19 "(i) to entities subject to a dem- 20 onstration project waiver under subsection 21 (h); and 22 "(ii) after the date the report under 23 section 5(b) of the Programs of All-inclu- 24 sive Care for the Elderly (PACE) Coverage 25 Act of 1997 is submitted, unless the Sec- S 720 is — — 5 retary determines that any of the findings 1 2 described in subparagraph (A), (B), (C) or 3 (D) of paragraph (2) of such section are 4 true. 5 "(4) PACE PROGRAM AGREEMENT DEFINED. 6 For purposes of this section, the term 'PACE pro- 7 gram agreement' means, with respect to a PACE 8 provider, an agreement, consistent with this section, 9 section 1932 (if applicable), and regulations promul- PACE 10 gated to carry out such sections, between the 1 1 provider and the Secretary, or an agreement between 12 the PACE provider and a State administering agen- 13 cy for the operation of a PACE program by the pro- 14 vider under such sections. 15 "(5) PACE PROGRAM ELIGIBLE INDIVIDUAL — 16 defined. For purposes of this section, the term 17 'PACE program eligible individual' means, with re- 18 spect to a PACE program, an individual who 19 "(A) is 55 years of age or older; 20 "(B) subject to subsection (c)(4), is deter- 21 mined under subsection (c) to require the level 22 of care required under the State medicaid plan 23 for coverage of nursing facility services; 24 "(C) resides in the service area of the 25 PACE program; and •S 720 is 6 1 "(D) meets such other eligibility conditions 2 as may be imposed under the PACE program 3 agreement for the program under subsection 4 (e)(2)(A)(ii). — 5 "(6) PACE PROTOCOL. For purposes of this 6 section, the term 'PACE protocol' means the Proto- 7 col for the Program of All-inclusive Care for the El- 8 derly (PACE), as published by On Lok, Inc., as of 9 April 14, 1995. 10 "(7) PACE DEMONSTRATION WAIVER PROGRAM — 11 defined. For purposes of this section, the term 12 'PACE demonstration waiver program' means a 13 demonstration program under either of the following 14 sections (as in effect before the date of their repeal): 15 "(A) Section 603(c) of the Social Security 16 Amendments of 1983 (Public Law 98-21), as 17 extended by section 9220 of the Consolidated 18 Omnibus Budget Reconciliation Act of 1985 19 (Public Law 99-272). 20 "(B) Section 9412(b) of the Omnibus 21 Budget Reconciliation Act of 1986 (Public Law 22 99-509). 23 "(8) State administering agency de- — 24 FINED. For purposes of this section, the term 25 'State administering agency' means, with respect to •S 720 is 7 1 the operation of a PACE program in a State, the 2 agency of that State (which may be the single agen- 3 cy responsible for administration of the State plan 4 under title XLX in the State) responsible for admin- 5 istering PACE program agreements under this sec- 6 tion and section 1932 in the State. — 7 "(9) Trial period defined. — 8 "(A) In general. For purposes of this 9 section, the term 'trial period' means, with re- 10 spect to a PACE program operated by a PACE 11 provider under a PACE program agreement, 12 the first 3 contract years under such agreement 13 with respect to such program. 14 "(B) Treatment of entities pre- 15 VIOUSLY OPERATING PACE DEMONSTRATION — 16 waiver PROGRAMS. Each contract year (in- 17 eluding a year occurring before the effective 18 date of this section) during which an entity has PACE 19 operated a demonstration waiver pro- 20 gram shall be counted under subparagraph (A) 21 as a contract year during which the entity oper- 22 ated a PACE program as a PACE provider 23 under a PACE program agreement. — 24 "(10) Regulations. For purposes of this 25 section, the term 'regulations' refers to interim final •S 720 IS — — 8 1 or final regulations promulgated under subsection (f) 2 to carry out this section and section 1932. 3 "(b) Scope of Benefits; Beneficiary Safe- — 4 guards. — 5 "(1) In general. Under a PACE program PACE 6 agreement, a provider shall 7 "(A) provide to PACE program eligible in- 8 dividuals, regardless of source of payment and 9 directly or under contracts with other entities, 10 at a minimum 11 "(i) all items and services covered 12 under this title (for individuals enrolled 13 under this section) and all items and serv- 14 ices covered under title XLX, but without 15 any limitation or condition as to amount, 16 duration, or scope and without application 17 of deductibles, copayments, coinsurance, or 18 other cost-sharing that would otherwise 19 apply under this title or such title, respec- 20 tively; and 21 "(ii) all additional items and services 22 specified in regulations, based upon those 23 required under the PACE protocol; >S 720 is — 9 1 "(B) provide such enrollees access to nec- 2 essary covered items and services 24 hours per 3 day, every day of the year; 4 "(C) provide services to such enrollees 5 through a comprehensive, multidisciplinary 6 health and social services delivery system which 7 integrates acute and long-term care services 8 pursuant to regulations; and 9 "(D) specify the covered items and services 10 that will not be provided directly by the entity, 11 and to arrange for delivery of those items and 12 services through contracts meeting the require- 13 ments of regulations. 14 "(2) Quality assurance; patient safe- — 15 GUARDS. The PACE program agreement shall re- PACE 16 quire the provider to have in effect at a mini- mum 17 18 "(A) a written plan of quality assurance 19 and improvement, and procedures implementing 20 such plan, in accordance with regulations, and 21 "(B) written safeguards of the rights of 22 enrolled participants (including a patient bill of 23 rights and procedures for grievances and ap- 24 peals) in accordance with regulations and with 25 other requirements of this title and Federal and S 720 IS -- 2 — 10 1 State law designed for the protection of pa- 2 tients. — 3 "(c) Eligibility Determinations. — 4 "(1) In general. The determination of 5 whether an individual is a PACE program eligible 6 individual 7 "(A) shall be made under and in accord- 8 ance with the PACE program agreement, and 9 "(B) who is entitled to medical assistance 10 under title XLX, shall be made (or who is not 11 so entitled, may be made) by the State admin- 12 istering agency. — 13 "(2) Condition. An individual is not a PACE 14 program eligible individual (with respect to payment 15 under this section) unless the individual's health sta- 16 tus has been determined, in accordance with regula- 17 tions, to be comparable to the health status of indi- 18 viduals who have participated in the PACE dem- 19 onstration waiver programs. Such determination 20 shall be based upon information on health status 21 and related indicators (such as medical diagnoses 22 and measures of activities of daily living, instrumen- 23 tal activities of daily living, and cognitive impair- 24 ment) that are part of a uniform minimum data set •S 720 is