[Congressional Bills 103th Congress]
[From the U.S. Government Publishing Office]
[S. 484 Introduced in Senate (IS)]

103d CONGRESS
  1st Session
                                 S. 484

 To amend title XIX of the Social Security Act to provide for coverage 
 of alcoholism and drug dependency residential treatment services for 
 pregnant women and certain family members under the medicaid program, 
                        and for other purposes.


_______________________________________________________________________


                   IN THE SENATE OF THE UNITED STATES

                             March 3, 1993

  Mr. Daschle (for himself, Mr. Bradley, Mr. Kennedy, Mr. Chafee, Mr. 
Murkowski, Mr. Conrad, Mr. Simon, Ms. Kassebaum, Mr. DeConcini, and Mr. 
Akaka) 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 coverage 
 of alcoholism and drug dependency residential treatment services for 
 pregnant women and certain family members under the medicaid program, 
                        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 ``Medicaid Substance Abuse Treatment 
Act of 1993''.

SEC. 2. FINDINGS AND PURPOSE.

    (a) Findings.--The Congress finds that--
            (1) a woman's ability to bear healthy children is 
        threatened by the consequences of alcoholism and drug 
        addiction;
            (2) an estimated 375,000 infants each year are born drug-
        exposed, at least 5,000 infants are born each year with fetal 
        alcohol syndrome, and another 35,000 are born each year with 
        fetal alcohol effect, a less severe version of fetal alcohol 
        syndrome;
            (3) drug use during pregnancy can result in low 
        birthweight, physical deformities, mental retardation, learning 
        disabilities, and heightened nervousness and irritability in 
        newborns;
            (4) fetal alcohol syndrome is the leading identifiable 
        cause of mental retardation in the United States and the only 
        cause that is 100 percent preventable;
            (5) drug-impaired individuals pose extraordinary societal 
        costs in terms of medical, educational, foster care, 
        residential, and support services over the lifetimes of such 
        individuals;
            (6) women, in general, are underrepresented in drug and 
        alcohol treatment programs;
            (7) due to fears among service providers concerning the 
        risks pregnancies pose, pregnant women face more obstacles to 
        substance abuse treatment than do other addicts and many 
        substance abuse treatment programs, in fact, exclude pregnant 
        women or women with children;
            (8) alcohol and drug treatment is an important prevention 
        strategy to prevent low birthweight, transmission of AIDS, and 
        chronic physical, mental, and emotional disabilities associated 
        with prenatal exposure to alcohol and other drugs;
            (9) effective substance abuse treatment must address the 
        special needs of pregnant women who are alcohol or drug 
        dependent, including substance-abusing women who may often face 
        such problems as domestic violence, incest and other sexual 
        abuse, poor housing, poverty, unemployment, lack of education 
        and job skills, lack of access to health care, emotional 
        problems, chemical dependency in their family backgrounds, 
        single parenthood, and the need to ensure child care for 
        existing children while undergoing substance abuse treatment;
            (10) nonhospital residential treatment is an important 
        component of comprehensive and effective substance abuse 
        treatment for pregnant addicted women, many of whom need long-
        term, intensive habilitation outside of their communities to 
        recover from their addiction and take care of themselves and 
        their families; and
            (11) a gap exists under the medicaid program for the 
        financing of comprehensive residential care in the existing 
        continuum of medicaid-covered alcoholism and drug abuse 
        treatment services for low-income pregnant addicted women.
    (b) Purposes.--The purposes of this Act are--
            (1) to increase the ability of pregnant women who are 
        substance abusers to participate in alcohol and drug treatment;
            (2) to ensure the availability of comprehensive and 
        effective treatment programs for pregnant women, thus promoting 
        a woman's ability to bear healthy children;
            (3) to ensure that nonhospital residential treatment is 
        available to those low-income pregnant addicted women who need 
        long-term, intensive habilitation to recover from their 
        addiction;
            (4) to create a new optional medicaid residential treatment 
        service for alcoholism and drug dependency treatment; and
            (5) to define the core services that must be provided by 
        treatment providers to ensure that needed services will be 
        available and appropriate.

SEC. 3. MEDICAID COVERAGE OF ALCOHOLISM AND DRUG DEPENDENCY RESIDENTIAL 
              TREATMENT SERVICES FOR PREGNANT WOMEN, CARETAKER PARENTS, 
              AND THEIR CHILDREN.

    (a) Coverage of Alcoholism and Drug Dependency Residential 
Treatment Services.--
            (1) Optional coverage.--Section 1905 of the Social Security 
        Act (42 U.S.C. 1396d) is amended--
                    (A) in subsection (a)--
                            (i) by striking ``and'' at the end of 
                        paragraph (21);
                            (ii) in paragraph (24), by striking the 
                        period at the end and inserting a semicolon;
                            (iii) 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
                            (iv) by inserting after paragraph (23) the 
                        following new paragraph:
            ``(24) alcoholism and drug dependency residential treatment 
        services (to the extent allowed and as defined in section 
        1931); and''; and
                    (B) in the sentence following paragraph (25), as so 
                redesignated--
                            (i) in subdivision (A), by striking ``or'' 
                        at the end;
                            (ii) in subdivision (B), by inserting ``, 
                        who is not receiving alcoholism and drug 
                        dependency residential treatment services,'' 
                        after ``65 years of age''; and
                            (iii) by inserting after subdivision (B) 
                        the following:
            ``(C) any such payments with respect to alcoholism and drug 
        dependency residential treatment services under paragraph (24) 
        for individuals not described in section 1931(d).''.
            (2) Alcoholism and drug dependency residential treatment 
        services defined.--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:

    ``alcoholism and drug dependency residential treatment services

    ``Sec. 1931. (a) Alcoholism and Drug Dependency Residential 
Treatment Services.--The term `alcoholism and drug dependency 
residential treatment services' means all the required services 
described in subsection (b) which are provided--
            ``(1) in a coordinated manner by a residential treatment 
        facility that meets the requirements of subsection (c) either 
        directly or through arrangements with--
                    ``(A) public and nonprofit private entities;
                    ``(B) licensed practitioners or federally qualified 
                health centers with respect to medical services; or
                    ``(C) the Indian Health Service or a tribal or 
                Indian organization that has entered into a contract 
                with the Secretary under section 102 of the Indian 
                Self-Determination Act (25 U.S.C. 450f) or section 502 
                of the Indian Health Care Improvement Act (25 U.S.C. 
                1652) with respect to such services provided to women 
                eligible to receive services in Indian Health 
                Facilities; and
            ``(2) pursuant to a written individualized treatment plan 
        prepared for each individual, which plan--
                    ``(A) states specific objectives necessary to meet 
                the individual's needs;
                    ``(B) describes the services to be provided to the 
                individual to achieve those objectives;
                    ``(C) is established in consultation with the 
                individual;
                    ``(D) is periodically reviewed and (as appropriate) 
                revised by the staff of the facility in consultation 
                with the individual;
                    ``(E) reflects the preferences of the individual; 
                and
                    ``(F) is established in a manner which promotes the 
                active involvement of the individual in the development 
                of the plan and its objectives.
    ``(b) Required Services Defined.--
            ``(1) In general.--The required services described in this 
        subsection are as follows:
                    ``(A) Counseling, addiction education, and 
                treatment provided on an individual, group, and family 
                basis and provided pursuant to individualized treatment 
                plans, including the opportunity for involvement in 
                Alcoholics Anonymous and Narcotics Anonymous.
                    ``(B) Parenting skills training.
                    ``(C) Education concerning prevention of HIV 
                infection.
                    ``(D) Assessment of each individual's need for 
                domestic violence counseling and sexual abuse 
                counseling and provision of such counseling where 
                needed.
                    ``(E) Room and board in a structured environment 
                with on-site supervision 24 hours-a-day.
                    ``(F) Therapeutic child care or counseling for 
                children of individuals in treatment.
                    ``(G) Assisting parents in obtaining access to--
                            ``(i) developmental services (to the extent 
                        available) for their preschool children;
                            ``(ii) public education for their school-
                        age children, including assistance in enrolling 
                        them in school; and
                            ``(iii) public education for parents who 
                        have not completed high school.
                    ``(H) Facilitating access to prenatal and 
                postpartum health care for women, to pediatric health 
                care for infants and children, and to other health and 
                social services where appropriate and to the extent 
                available, including services under title V, services 
                and nutritional supplements provided under the special 
                supplemental food program for women, infants, and 
                children (WIC) under section 17 of the Child Nutrition 
                Act of 1966, services provided by federally qualified 
                health centers, outpatient pediatric services, well-
                baby care, and early and periodic screening, 
                diagnostic, and treatment services (as defined in 
                section 1905(r)).
                    ``(I) Ensuring supervision of children during times 
                their mother is in therapy or engaged in other 
                necessary health or rehabilitative activities, 
                including facilitating access to child care services 
                under title IV and title XX.
                    ``(J) Planning for and counseling to assist reentry 
                into society, including appropriate outpatient 
                treatment and counseling after discharge (which may be 
                provided by the same program, if available and 
                appropriate) to assist in preventing relapses, 
                assistance in obtaining suitable affordable housing and 
                employment upon discharge, and referrals to appropriate 
                educational, vocational, and other employment-related 
                programs (to the extent available).
                    ``(K) Continuing specialized training for staff in 
                the special needs of residents and their children, 
                designed to enable such staff to stay abreast of the 
                latest and most effective treatment techniques.
            ``(2) Requirement for certain services.--Services under 
        subparagraphs (A), (B), (C), and (D), of paragraph (1) shall be 
        provided in a cultural context that is appropriate to the 
        individuals and in a manner that ensures that the individuals 
        can communicate effectively, either directly or through 
        interpreters, with persons providing services.
            ``(3) Limitations on coverage.--
                    ``(A) In general.--Subject to subparagraph (B), 
                services described in paragraph (1) shall be covered in 
                the amount, duration, and scope therapeutically 
                required for each eligible individual in need of such 
                services.
                    ``(B) Restrictions on limiting coverage.--A State 
                plan shall not limit coverage of alcoholism and drug 
                dependency residential treatment services for any 
                period of less than 12 months per individual, except in 
                those instances where a finding is made that such 
                services are no longer therapeutically necessary for an 
                individual.
    ``(c) Facility Requirements.--The requirements of this subsection 
with respect to a facility are as follows:
            ``(1) The agency designated by the chief executive officer 
        of the State to administer the State's alcohol and drug abuse 
        prevention and treatment activities and programs has certified 
        to the single State agency under section 1902(a)(5) that the 
        facility--
                    ``(A) is able to provide all the services described 
                in subsection (b) either directly or through 
                arrangements with--
                            ``(i) public and nonprofit private 
                        entities;
                            ``(ii) licensed practitioners or federally 
                        qualified health centers with respect to 
                        medical services; or
                            ``(iii) the Indian Health Service or with a 
                        tribal or Indian organization that has entered 
                        into a contract with the Secretary under 
                        section 102 of the Indian Self-Determination 
                        Act (25 U.S.C. 450f) or section 502 of the 
                        Indian Health Care Improvement Act (25 U.S.C. 
                        1652) with respect to such services provided to 
                        women eligible to receive services in Indian 
                        Health Facilities; and
                    ``(B) except for Indian Health Facilities, meets 
                all applicable State licensure or certification 
                requirements for a facility of that type.
            ``(2)(A) The facility or a distinct part of the facility 
        provides room and board, except that--
                    ``(i) subject to subparagraph (B), the facility 
                shall have no more than 40 beds; and
                    ``(ii) subject to subparagraph (C), the facility 
                shall not be licensed as a hospital.
            ``(B) The single State agency may waive the bed limit under 
        subparagraph (A)(i) for one or more facilities subject to 
        review by the Secretary. Waivers, where granted, must be made 
        pursuant to standards and procedures set out in the State plan 
        and must require the facility seeking a waiver to demonstrate 
        that--
                    ``(i) the facility will be able to maintain a 
                therapeutic, family-like environment;
                    ``(ii) the facility can provide quality care in the 
                delivery of each of the services identified in 
                subsection (b);
                    ``(iii) the size of the facility will be 
                appropriate to the surrounding community; and
                    ``(iv) the development of smaller facilities is not 
                feasible in that geographic area.
            ``(C) The Secretary may waive the requirement under 
        subparagraph (A)(ii) that a facility not be a hospital, if the 
        Secretary finds that such facility is located in an Indian 
        Health Service area and that such facility is the only or one 
        of the only facilities available in such area to provide 
        services under this section.
            ``(3) With respect to a facility providing the services 
        described in subsection (b) to an individual eligible to 
        receive services in Indian Health Facilities, such a facility 
        demonstrates (as required by the Secretary) an ability to meet 
        the special needs of Indian and Native Alaskan women.
    ``(d) Eligible Individuals.--
            ``(1) In general.--A State plan shall limit coverage of 
        alcoholism and drug dependency residential treatment services 
        under section 1905(a)(24) to the following individuals 
        otherwise eligible for medical assistance under this title:
                    ``(A) Women during pregnancy, and until the end of 
                the 12th month following the termination of the 
                pregnancy.
                    ``(B) Children of a woman described in subparagraph 
                (A).
                    ``(C) At the option of a State, a caretaker parent 
                or parents and children of such a parent.
            ``(2) Initial assessment of eligible individuals.--An 
        initial assessment of eligible individuals specified in 
        paragraph (1) seeking alcoholism and drug dependency 
        residential treatment services shall be performed by the agency 
        designated by the chief executive officer of the State to 
        administer the State's alcohol and drug abuse treatment 
        activities (or its designee). Such assessment shall determine 
        whether such individuals are in need of alcoholism or drug 
        dependency treatment services and, if so, the treatment setting 
        (such as inpatient hospital, nonhospital residential, or 
        outpatient) that is most appropriate in meeting such 
        individual's health and therapeutic needs and the needs of such 
        individual's dependent children, if any.
    ``(e) Overall Cap on Medical Assistance and Allocation of Beds.--
            ``(1) Total amount of services as medical assistance.--
                    ``(A) In general.--The total amount of services 
                provided under this section as medical assistance for 
                which payment may be made available under section 1903 
                shall be limited to the total number of beds allowed to 
                be allocated for such services in any given year as 
                specified under subparagraph (B).
                    ``(B) Total number of beds.--The total number of 
                beds allowed to be allocated under this subparagraph 
                (subject to paragraph (2)(C)) for the furnishing of 
                services under this section and for which Federal 
                medical assistance may be made available under section 
                1903 is for calendar year--
                            ``(i) 1994, 1,080 beds;
                            ``(ii) 1995, 2,000 beds;
                            ``(iii) 1996, 3,500 beds;
                            ``(iv) 1997, 5,000 beds;
                            ``(v) 1998, 6,000 beds; and
                            ``(vi) 1999 and for calendar years 
                        thereafter, a number of beds determined 
                        appropriate by the Secretary.
            ``(2) Allocation of beds.--
                    ``(A) Initial allocation formula.--For each 
                calendar year, a State exercising the option to provide 
                the services described in this section shall be 
                allocated from the total number of beds available under 
                paragraph (1)(B)--
                            ``(i) in calendar years 1994 and 1995, 20 
                        beds;
                            ``(ii) in calendar years 1996, 1997, and 
                        1998, 40 beds; and
                            ``(iii) in calendar year 1999 and for each 
                        calendar year thereafter, a number of beds 
                        determined based on a formula (as provided by 
                        the Secretary) distributing beds to States on 
                        the basis of the relative percentage of women 
                        of childbearing age in a State.
                    ``(B) Reallocation of beds.--The Secretary shall 
                provide that in allocating the number of beds made 
                available to a State for the furnishing of services 
                under this section that, to the extent not all States 
                are exercising the option of providing services under 
                this section and there are beds available that have not 
                been allocated in a year as provided in paragraph 
                (1)(B), that such beds shall be reallocated among 
                States which are furnishing services under this section 
                based on a formula (as provided by the Secretary) 
                distributing beds to States on the basis of the 
                relative percentage of women of childbearing age in a 
                State.
                    ``(C) Indian health service areas.--In addition to 
                the beds allowed to be allocated under paragraph (1)(B) 
                there shall be an additional 20 beds allocated in any 
                calendar year to States for each Indian Health Service 
                area within the State to be utilized by Indian Health 
                Facilities within such an area and, to the extent such 
                beds are not utilized by a State, the beds shall be 
                reapportioned to Indian Health Service areas in other 
                States.''.
            (3) Maintenance of state financial effort and 100 percent 
        federal matching for services for indian and native alaskan 
        women in indian health services areas.--Section 1903 of the 
        Social Security Act (42 U.S.C. 1396b) is amended by adding at 
        the end the following new subsections:
    ``(x) No payment shall be made to a State under this section in a 
State fiscal year for alcoholism and drug dependency residential 
treatment services (described in section 1931) unless the State 
provides assurances satisfactory to the Secretary that the State is 
maintaining State expenditures for such services at a level that is not 
less than the average annual level maintained by the State for such 
services for the 2-year period preceding such fiscal year.
    ``(y) Notwithstanding the preceding provisions of this section, the 
Federal medical assistance percentage for purposes of payment under 
this section for services described in section 1931 provided to 
individuals residing on or receiving services in an Indian Health 
Service area shall be 100 percent.''.
    (b) Payment on a Cost-Related Basis.--Section 1902(a)(13) of the 
Social Security Act (42 U.S.C. 1396a(a)(13)) is amended--
            (1) by striking ``and'' at the end of subparagraph (E);
            (2) by adding ``and'' at the end of subparagraph (F); and
            (3) by adding at the end the following new subparagraph:
                    ``(G) for payment for alcoholism and drug 
                dependency residential treatment services which the 
                State finds, and makes assurances satisfactory to the 
                Secretary, are reasonable and adequate to meet the 
                costs which must be incurred by efficiently and 
                economically operated facilities in order to provide 
                all the services listed in section 1931(b) in 
                conformity with applicable Federal and State laws, 
                regulations, and quality and safety standards and to 
                assure that individuals eligible for such services have 
                reasonable access to such services;''.
    (c) Conforming Amendments.--
            (1) Clarification of optional coverage for specified 
        individuals.--Section 1902(a)(10) of the Social Security Act 
        (42 U.S.C. 1396a(a)(10)) is amended, in the matter following 
        subparagraph (F)--
                    (A) by striking ``; and (XI)'' and inserting ``, 
                (XI)'';
                    (B) by striking ``, and (XI)'' and inserting ``, 
                and (XII)''; and
                    (C) by inserting before the semicolon at the end 
                the following: ``, and (XIII) the making available of 
                alcoholism and drug dependency residential treatment 
                services to individuals described in section 1931(d) 
                shall not, by reason of this paragraph, require the 
                making of such services available to other 
                individuals''.
            (2) Continuation of eligibility for alcoholism and drug 
        dependency treatment for pregnant women for 12 months following 
        end of pregnancy.--Section 1902 of the Social Security Act (42 
        U.S.C. 1396a) is amended in subsection (e)(5) by striking 
        ``under the plan,'' and all through the period at the end and 
        inserting ``under the plan--
            ``(A) as though she were pregnant, for all pregnancy-
        related and postpartum medical assistance under the plan, 
        through the end of the month in which the 60-day period 
        (beginning on the last day of her pregnancy) ends; and
            ``(B) for alcoholism and drug dependency residential 
        treatment services under section 1931 through the end of the 1-
        year period beginning on the last day of her pregnancy.''.
            (3) Redesignations.--Section 1902 of the Social Security 
        Act (42 U.S.C. 1396a) is further amended--
                    (A) in subsection (a)(10)(C)(iv), by striking 
                ``(21)'' and inserting ``(24)''; and
                    (B) in subsection (j), by striking ``(22)'' and 
                inserting ``(25)''.
    (d) Annual Education and Training in Indian Health Service Areas.--
The Secretary of Health and Human Services in cooperation with the 
Indian Health Service shall conduct on at least an annual basis 
training and education in each of the 12 Indian Health Service areas 
for tribes, Indian organizations, residential treatment providers, and 
State health care workers regarding the availability and nature of 
residential treatment services available in such areas under the 
provisions of this Act.
    (e) Effective Date; Transition.--(1) The amendments made by this 
section apply to alcoholism and drug dependency residential treatment 
services furnished on or after July 1, 1994, without regard to whether 
or not final regulations to carry out such amendments have been 
promulgated by such date.
    (2) The Secretary of Health and Human Services shall not take any 
compliance, disallowance, penalty, or other regulatory action against a 
State under title XIX of the Social Security Act with regard to 
alcoholism and drug dependency residential treatment services (as 
defined in section 1931(a) of such Act) made available under such title 
on or after July 1, 1994, before the date the Secretary issues final 
regulations to carry out the amendments made by this section, if the 
services are provided under its plan in good faith compliance with such 
amendments.

                                 <all>

S 484 IS----2