[Congressional Bills 103th Congress]
[From the U.S. Government Publishing Office]
[S. 1098 Introduced in Senate (IS)]

103d CONGRESS
  1st Session
                                S. 1098

 To amend title XIX of the Social Security Act to provide for optional 
  coverage under State medicaid plans of case-management services for 
    individuals who sustain traumatic brain injuries, and for other 
                               purposes.


_______________________________________________________________________


                   IN THE SENATE OF THE UNITED STATES

                             June 15, 1993

   Mr. Rockefeller (for himself and Mr. Durenberger) introduced the 
 following bill; which was read twice and referred to the Committee on 
                                Finance

_______________________________________________________________________

                                 A BILL


 
 To amend title XIX of the Social Security Act to provide for optional 
  coverage under State medicaid plans of case-management services for 
    individuals who sustain traumatic brain injuries, and for other 
                               purposes.

    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Brain Injury Rehabilitation Quality 
Act of 1993''.

SEC. 2. MEDICAID COVERAGE OF CASE-MANAGEMENT SERVICES FOR INDIVIDUALS 
              WITH TRAUMATIC BRAIN INJURIES.

    (a) In General.--Section 1905(a) of the Social Security Act (42 
U.S.C. 1396d(a)) is amended--
            (1) by striking ``and'' at the end of paragraph (21);
            (2) by striking the period at the end of paragraph (24) and 
        inserting a semicolon;
            (3) by redesignating paragraphs (22), (23), and (24) as 
        paragraphs (25), (22), and (23), respectively, and by 
        transferring and inserting paragraph (25) after paragraph (23), 
        as so redesignated; and
            (4) by inserting after paragraph (23), as redesignated, the 
        following new paragraph:
            ``(24) case-management services provided (in accordance 
        with section 1931) for individuals who sustain traumatic brain 
        injuries; and''.
    (b) Case-Management Services Described.--Title XIX of the Social 
Security Act (42 U.S.C. 1396 et seq.) is amended by adding at the end 
the following new section:

    ``case-management services for individuals with traumatic brain 
                                injuries

    ``Sec. 1931. (a) In General.--For purposes of section 1905(a)(24), 
case-management services for individuals who sustain traumatic brain 
injuries are services provided to an eligible individual (as described 
in subsection (d)) through a State case-management program that meets 
the requirements of subsection (b).
    ``(b) Requirements for State Case-Management Programs.--
            ``(1) State coordinator.--A State case-management program 
        meets the requirements of this subsection if the State has 
        designated a State coordinator for traumatic brain injuries 
        who--
                    ``(A) establishes policies, standards, and 
                procedures for providing services under this section to 
                eligible individuals,
                    ``(B) contracts with qualified agencies or employs 
                staff to provide services under this section to 
                eligible individuals,
                    ``(C) supervises and coordinates services for 
                eligible individuals,
                    ``(D) makes necessary reports to the Secretary, and
                    ``(E) performs any other duties described in this 
                section.
            ``(2) Case-management services.--A State case-management 
        program meets the requirements of this subsection if the 
        program provides or arranges for the provision of the following 
        case-management services for eligible individuals:
                    ``(A) An initial assessment of--
                            ``(i) the individual's need for case-
                        management services, and
                            ``(ii) if the individual is an appropriate 
                        candidate for receiving case-management 
                        services, the individual's need for other 
                        services, with an emphasis on identifying 
                        community-based services required to prevent 
                        institutionalization or minimize the need for 
                        residential rehabilitation.
                    ``(B) Preparation of a treatment plan for each 
                individual requiring case-management services based on 
                consultation with the individual (other than an 
                individual who is comatose) and any person named by the 
                individual. Preparation of the plan shall be 
                completed--
                            ``(i) as soon as possible after the 
                        individual suffers the injury, but may be 
                        delayed (by one or more periods of no more than 
                        15 days each) based on a physician 
                        certification that contains a brief explanation 
                        of the reason for the delay and attests that 
                        such a delay is in the best interests of the 
                        individual, or
                            ``(ii) in the case of an individual who, at 
                        the time the individual sustains the traumatic 
                        brain injury, is not an eligible individual, 
                        within 60 days after such individual becomes an 
                        eligible individual.
                    ``(C) Presentation of a copy of the initial 
                treatment plan and any subsequent modifications to the 
                plan to the individual or the individual's legal 
                representative.
                    ``(D) Regular updates of each individual's 
                treatment plan (based on consultation with the care 
                provider, the individual, and any person named by the 
                individual) with data and information about treatments 
                and services provided, as well as specific outcome 
                measures of the individual's performance or activity 
                relative to goals previously established.
                    ``(E) Assistance in obtaining services necessary to 
                allow the individual to remain in the community, 
                including coordination of home care services with other 
                services.
                    ``(F) Advocacy services to assist the individual in 
                obtaining appropriate, accessible, and cost-effective 
                services.
                    ``(G) Assessment of the individual's need for and 
                level of home care services at appropriate intervals 
                during the course of the individual's treatment under 
                the program.
                    ``(H) Reassessment of each individual at regular 
                intervals of at least every 3 months to determine the 
                extent of each individual's progress and to ascertain 
                whether the individual--
                            ``(i) is being kept too long in a given 
                        setting,
                            ``(ii) is being provided services 
                        inappropriately, or
                            ``(iii) would be better served by other 
                        services or in another setting.
                    ``(I) In accordance with standards established by 
                the State coordinator, verification that any 
                residential setting or facility which provides services 
                to individuals under the program meets the requirements 
                applicable to nursing facilities under section 1919.
                    ``(J) A complaint procedure, overseen by the State 
                coordinator, regarding any treatment or service 
                provided to an individual which provides that--
                            ``(i) the individual or any person named by 
                        the individual may make an oral or written 
                        complaint;
                            ``(ii) the individual or any person named 
                        by the individual may receive the response to 
                        the complaint;
                            ``(iii) the confidentiality of any 
                        complainant is maintained;
                            ``(iv) an investigation of the complaint is 
                        completed within--
                                    ``(I) 30 days for a routine 
                                complaint,
                                    ``(II) 7 days for a complaint of 
                                abuse or neglect, and
                                    ``(III) 24 hours if the 
                                individual's life or safety is 
                                immediately threatened; and
                            ``(v) if the complaint is with respect to a 
                        publicly appointed case manager or case worker, 
                        substitution of such manager or worker is 
                        allowed.
            ``(3) Coordination and administration of benefits and 
        services.--A State case-management program meets the 
        requirements of this subsection if the program assists in 
        ensuring that an eligible individual is referred to and applies 
        for other benefits (through cooperative agreements with 
        agencies administering benefit programs) and services for which 
        the individual is eligible under other Federal, State, or local 
        programs, including--
                    ``(A) employment services, including vocational 
                assessment, training, and placement, sheltered 
                employment, and supported employment;
                    ``(B) education benefits, including primary, 
                secondary, and higher education programs;
                    ``(C) services available under the Older Americans 
                Act of 1965;
                    ``(D) disability insurance under title II; and
                    ``(E) independent living services under title VII 
                of the Rehabilitation Act of 1973.
    ``(c) Coordination of Services.--
            ``(1) In general.--An eligible individual who is receiving 
        case-management services described in subsection (b)(2) may 
        receive the following services under such individual's 
        treatment plan for which the individual is otherwise eligible 
        under a State plan:
                    ``(A) Acute rehabilitation services, focusing on 
                intensive physical and cognitive restorative services 
                in the early months following injury.
                    ``(B) Subacute rehabilitation in either inpatient 
                or outpatient settings.
                    ``(C) Transitional living services to train the 
                individual for more independent living, with an 
                emphasis on compensating for the loss of skills which 
                may not be restored.
                    ``(D) Lifelong living services for individuals 
                discharged from rehabilitation who require ongoing 
                lifetime support.
                    ``(E) Home care, including comprehensive training 
                for family or other informal caregivers.
                    ``(F) Day treatment and other outpatient programs 
                in nonresidential settings.
                    ``(G) Independent living services to allow the 
                individual to live at home with optimal personal 
                control over services.
                    ``(H) Behavior disorder treatment services to 
                address or resolve patterns of behavior which prevent 
                or hinder participation in active rehabilitation.
                    ``(I) Respite and recreation services to aid the 
                individual and members of the individual's family in 
                adapting psychologically and environmentally to 
                residual deficits resulting from brain injury.
                    ``(J) Treatment for conditions related to 
                alcoholism and drug dependency.
            ``(2) Waiver of certain limitations on the expenditure of 
        funds.--
                    ``(A) In general.--In accordance with standards 
                established by the State coordinator, a State case-
                management program may waive restrictions on the 
                amount, duration, and scope of services otherwise 
                applicable under the State plan for medical assistance 
                under this title to the extent necessary to carry out a 
                treatment plan for an individual.
                    ``(B) Home care services in excess of limitations 
                established by state coordinator.--In accordance with 
                standards established by the State coordinator, a State 
                case-management program may approve the use of funds 
                provided under the State plan for medical assistance 
                under this title to pay for home care services when 
                such home care services exceed limitations established 
                by the State coordinator.
                    ``(C) Out-of-state placements for residential 
                rehabilitation services.--In accordance with standards 
                established by the State coordinator, a State case 
                management program may approve the use of funds 
                provided under the State plan for medical assistance 
                under this title to pay for out-of-State placements for 
                residential rehabilitation services.
            ``(3) Special rule for providers of living services.--No 
        living services described in paragraph (1) may be provided to 
        or on behalf of any individual under this section unless the 
        State case-management program with which the individual is 
        enrolled has entered into an agreement with the entity 
        providing such services that specifies--
                    ``(A) the living services to be provided,
                    ``(B) the period of time over which such services 
                will be provided, and
                    ``(C) the charges to the patient for providing such 
                services.
    ``(d) Eligibility of Individuals To Receive Services.--
            ``(1) In general.--An individual is eligible to receive 
        case-management services under this section if the individual 
        resides in a State that has implemented a case-management 
        program that meets the requirements of this section, is 
        eligible to receive medical assistance under a State plan under 
        this title, has suffered a traumatic brain injury (as defined 
        in paragraph (2)), and is moderately or severely disabled (as 
        defined in paragraph (3)).
            ``(2) Traumatic brain injury defined.--For purposes of this 
        section, the term `traumatic brain injury' means a sudden 
        insult or damage to the brain or its coverings caused by an 
        external physical force which may produce a diminished or 
        altered state of consciousness, and which results in a 
        temporary or permanent impairment of cognitive or mental 
        abilities or physical functioning, or disturbance of behavioral 
        or emotional functioning. Such term does not include any 
        injuries of a degenerative or congenital nature.
            ``(3) Definitions relating to moderately or severely 
        disabled individuals.--
                    ``(A) In general.--For purposes of this section, 
                the term `moderately or severely disabled' means in the 
                case of an individual 6 years of age or older, an 
                individual who (without regard to income or employment 
                status) is certified under the case-management program 
                as--
                            ``(i) needing substantial assistance or 
                        supervision from another individual with at 
                        least 2 activities of daily living (as defined 
                        in subparagraph (C));
                            ``(ii) needing substantial supervision due 
                        to cognitive or other mental impairment and 
                        needing substantial assistance or supervision 
                        from another individual with at least 1 
                        activity of daily living or in complying with a 
                        daily drug regimen; or
                            ``(iii) needing substantial supervision 
                        from another individual due to behaviors that 
                        are dangerous (to the individual or others), 
                        disruptive, or difficult to manage.
                    ``(B) Moderately or severely disabled child.--
                            ``(i) In general.--For purposes of this 
                        section, the term `moderately or severely 
                        disabled' means, in the case of an individual 
                        under 6 years of age, an individual who is 
                        certified under the State case management 
                        program as suffering from comparable levels of 
                        disability which would entitle such individual 
                        to benefits under this title.
                            ``(ii) Comparable levels of disability.--
                        For purposes of clause (i), the term 
                        `comparable levels of disability' means 
                        physical, cognitive, or other mental 
                        impairments that limit the ability of an 
                        individual who is under 6 years of age to 
                        perform activities of daily living appropriate 
                        for the age of the individual that are 
                        comparable to the physical, cognitive, or other 
                        mental impairments that limit the ability of an 
                        individual 6 years of age or older such that 
                        the individual is described in clause (i), 
                        (ii), or (iii) of subparagraph (A).
                    ``(C) Activity of daily living defined.--The term 
                `activity of daily living' means any of the following 
                activities:
                            ``(i) Bathing.
                            ``(ii) Dressing.
                            ``(iii) Transferring.
                            ``(iv) Toileting.
                            ``(v) Eating.
            ``(4) Coverage of individuals under disability 
        protections.--Individuals receiving services through a State 
        case-management program under this section shall be considered 
        to be individuals with disabilities for purposes of the 
        Americans with Disabilities Act of 1990.
    ``(e) Additional Duties of State Coordinator.--
            ``(1) Prevention of traumatic brain injury.--The State 
        coordinator shall establish a program of activities related to 
        preventing and reducing the rate of traumatic brain injuries in 
        the State.
            ``(2) Traumatic brain injury registry.--
                    ``(A) In general.--The State coordinator shall 
                establish and maintain a central registry of 
                individuals who sustain traumatic brain injury using 
                standards established by the Secretary under subsection 
                (f) in order to--
                            ``(i) collect information to facilitate the 
                        development of injury prevention, treatment, 
                        and rehabilitation programs; and
                            ``(ii) ensure the provision to individuals 
                        with traumatic brain injury of information 
                        regarding appropriate public or private 
                        agencies that provide rehabilitative services 
                        so that injured individuals may obtain needed 
                        service to alleviate injuries and avoid 
                        secondary problems, such as mental illness and 
                        chemical dependency.
                    ``(B) Dissemination of data.--The State coordinator 
                shall provide summary registry data to public and 
                private entities to conduct studies using data 
                collected by the traumatic brain injury registry 
                established under subparagraph (A). The State 
                coordinator may charge a fee for all expenses 
                associated with the provision of data or data analysis.
            ``(3) Notification of injuries to job training programs.--
        Within a reasonable period of time after receiving a report 
        that an individual has sustained a traumatic brain injury or 
        spinal cord injury, the State coordinator shall notify any 
        State agency responsible for employment services and job 
        training and shall forward the individual's name and other 
        identifying information to such agency.
            ``(4) Standards for marketing of brain injury services.--
        The State coordinator, after consultation with the advisory 
        committee established under paragraph (6), shall--
                    ``(A) monitor standards established by the 
                Secretary regarding the marketing of services (by 
                hospitals and other providers) to any individual who 
                has sustained traumatic brain injury or family members 
                of such individual,
                    ``(B) disseminate such standards to State case-
                management programs, and
                    ``(C) furnish information about such standards to 
                such individual and such family members at the earliest 
                appropriate opportunity after such individual has 
                sustained the injury.
        Such standards shall include (at a minimum) a rule prohibiting 
        payments under a State case-management program under this 
        section for referring individuals to rehabilitation facilities.
            ``(5) Studies.--The State coordinator shall collect injury 
        incidence information (including the prevalence, prevention, 
        and treatment of traumatic brain injury), analyze the 
        information, and conduct special studies regarding traumatic 
        brain injury.
            ``(6) Establishment of advisory committee.--The State 
        coordinator shall establish an advisory committee (consisting 
        of representatives of professionals who provide community-based 
        services under this section and individuals with traumatic 
        brain injuries and family members of such individuals) to 
        provide recommendations regarding the needs of individuals with 
        traumatic brain injuries, provide advice on activities under 
        paragraph (1), and assist in the establishment of marketing 
        standards under paragraph (4).
            ``(7) Privacy.--Any data identifying specific individuals 
        which is collected by or provided to the State coordinator may 
        be used only for purposes of case-management and rehabilitation 
        and studies by the State coordinator, in accordance with rules 
        adopted by the State coordinator.
            ``(8) Adoption of standards for reporting data and 
        operation of registries.--The State coordinator shall adopt 
        such standards established under subsection (f) as are 
        necessary to carry out this subsection. At a minimum, the State 
        coordinator shall adopt the standards relating to the matters 
        identified in subparagraphs (A) through (E) of subsection 
        (f)(2).
            ``(9) Establishment of reporting system.--
                    ``(A) In general.--The State coordinator shall 
                design and establish a reporting system which requires 
                either the treating hospital, medical facility, or 
                physician to report to the State coordinator within a 
                reasonable period of time after the identification of 
                any individual with ICD diagnostic codes treated for a 
                traumatic brain injury in the State. The consent of the 
                injured individual is not required.
                    ``(B) Report.--A report under subparagraph (A) 
                shall include--
                            ``(i) the name, age, and residence of the 
                        injured individual;
                            ``(ii) the date and cause of the injury;
                            ``(iii) the initial diagnosis; and
                            ``(iv) other information required by the 
                        State coordinator.
                    ``(C) Liability protection.--The furnishing of 
                information pursuant to the system established under 
                subparagraph (A) shall not subject any individual or 
                facility to any action for damages or other relief, 
                provided that the individual or facility acted in good 
                faith in furnishing the information.
    ``(f) Standards for Reporting Data and Operation of Registries.--
            ``(1) In general.--Not later than January 1, 1995, the 
        Secretary of Health and Human Services, acting through the 
        Director of the Centers for Disease Control and Prevention, 
        shall establish standards for the reporting of data on 
        traumatic brain injuries and the operation of registries of 
        traumatic brain injuries for use by State coordinators under 
        this section.
            ``(2) Scope.--The standards established under paragraph (1) 
        shall at a minimum provide for--
                    ``(A) the specific International Classification of 
                Diseases, Ninth Revision, Clinical Modification, 
                diagnostic codes (hereafter referred to in this 
                subsection as `ICD diagnostic codes') included in the 
                definitions of traumatic brain injury;
                    ``(B) the type of data to be reported;
                    ``(C) standards for reporting specific types of 
                data;
                    ``(D) the individuals and facilities required to 
                report and the time period in which reports must be 
                submitted; and
                    ``(E) criteria relating to the use of registry data 
                by public and private entities engaged in research.''.
    (c) Budget Neutrality.--
            (1) In general.--During the first 12-month period a State 
        provides case-management services to which the amendments made 
        by this section apply, and each 12-month period thereafter, 
        Federal financial participation for all services under a State 
        plan approved under title XIX of the Social Security Act 
        provided to individuals with traumatic brain injuries shall not 
        exceed the base-year amount determined under paragraph (2).
            (2) Base-year amount.--
                    (A) First year.--The base-year amount for the first 
                12-month period to which paragraph (1) applies shall be 
                equal to the sum of--
                            (i) the amount of Federal financial 
                        participation attributable to all services 
                        provided to individuals with traumatic brain 
                        injuries under a State plan in the 12-month 
                        period prior to the inclusion of case-
                        management services in the State plan, as 
                        certified by the Secretary, plus
                            (ii) such amount multiplied by the 
                        estimated percentage increase in the Consumer 
                        Price Index for All-Urban Consumers for the 
                        preceding 12-month period, with appropriate 
                        adjustments to reflect previous 
                        underestimations or overestimations under this 
                        clause.
                    (B) Other years.--The base-year amount for any 
                other 12-month period shall be equal to the sum of--
                            (i) the base-year amount for the preceding 
                        12-month period, plus
                            (ii) such amount multiplied by the 
                        estimated percentage increase in the Consumer 
                        Price Index for All-Urban Consumers for the 
                        preceding 12-month period, with appropriate 
                        adjustments to reflect previous 
                        underestimations or overestimations under this 
                        clause.
    (d) Conforming Amendment.--Section 1915(g)(2) of the Social 
Security Act (42 U.S.C. 1396n(g)(2)) is amended by striking the period 
at the end and inserting the following: ``, but does not include any 
services provided under section 1931.''.
    (e) Authorization of Appropriations.--There are authorized to be 
appropriated $5,000,000 for each fiscal year beginning with fiscal year 
1995 to carry out paragraphs (1) and (2) of section 1931(e) of the 
Social Security Act (as added by subsection (b)).
    (f) Effective Date.--The amendments made by subsections (a), (b), 
and (d) shall apply to calendar quarters beginning on or after January 
1, 1995.

SEC. 3. STUDY OF EFFECTIVENESS OF TRAUMATIC BRAIN INJURY INTERVENTIONS.

    (a) Study.--The Administrator of the Agency for Health Care Policy 
and Research shall conduct a study to identify common therapeutic 
interventions which are used for the rehabilitation of traumatic brain 
injury patients, and shall include in the study an analysis of--
            (1) the effectiveness of each such intervention in 
        improving the functioning of traumatic brain injury patients; 
        and
            (2) the comparative effectiveness of interventions employed 
        in the course of rehabilitation of traumatic brain injury 
        patients to achieve the same or similar clinical outcome.
    (b) Report.--Not later than 3 years after the date of the enactment 
of this Act, the Administrator of the Agency for Health Care Policy and 
Research shall submit a report on the study conducted under subsection 
(a) to the Congress.
    (c) Authorization of Appropriations.--There are authorized to be 
appropriated $2,000,000 for each of fiscal years 1994 through 1997 to 
carry out the purposes of this section.

                                 <all>

S 1098 IS----2