[Congressional Bills 106th Congress]
[From the U.S. Government Publishing Office]
[H.R. 5449 Introduced in House (IH)]







106th CONGRESS
  2d Session
                                H. R. 5449

  To amend title XVIII of the Social Security Act to combat fraud and 
       abuse under the Medicare Program with respect to partial 
                       hospitalization services.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                            October 11, 2000

  Mr. Stark introduced the following bill; which was referred to the 
   Committee on Ways and Means, and in addition to the Committee on 
Commerce, for a period to be subsequently determined by the Speaker, in 
   each case for consideration of such provisions as fall within the 
                jurisdiction of the committee concerned

_______________________________________________________________________

                                 A BILL


 
  To amend title XVIII of the Social Security Act to combat fraud and 
       abuse under the Medicare Program with respect to partial 
                       hospitalization services.

    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 ``Medicare Partial Hospitalization 
Services Restoration and Integrity Act of 2000''.

SEC. 2. MENTAL HEALTH PARTIAL HOSPITALIZATION SERVICES.

    (a) Improvement of Mental Health Partial Hospitalization Services 
Program.--Section 1861(ff) of the Social Security Act (42 U.S.C. 
1395x(ff)) is amended to read as follows:

                   ``Partial Hospitalization Services

    ``(ff)(1) The term ``partial hospitalization services'' means the 
items and services described in paragraph (2) prescribed by a physician 
after a direct patient-physician encounter and provided under a 
distinct and organized intensive treatment program of mental health 
services offering less than 24-hour-daily care and furnished by a 
facility described in paragraph (3) under the supervision of a 
physician pursuant to an individual written plan of care established 
and periodically reviewed by a physician (in consultation with 
appropriate staff participating in such program), which plan sets forth 
the physician's diagnosis, the type, amount, frequency, and duration of 
the items and services provided under the plan, and the goals for 
treatment under the plan.
    ``(2) The items and services described in this paragraph are the 
following items and services that are reasonable and necessary for the 
diagnosis or treatment of the individual's condition (which may be 
acute or chronic), reasonably expected to improve or maintain the 
individual's condition and functional level and to prevent relapse or 
hospitalization, and furnished pursuant to standards relating to 
frequency and duration of services and quality of care as the Secretary 
establishes by regulation under paragraph (5) (taking into account 
accepted norms of medical practice):
            ``(A) Individual and group therapy with physicians or 
        psychologists (or other mental health professionals to the 
        extent authorized under State law).
            ``(B) Occupational therapy requiring the skills of a 
        qualified occupational therapist.
            ``(C) Services of social workers, trained psychiatric 
        nurses, and other staff trained to work with psychiatric 
        patients.
            ``(D) Drugs and biologicals furnished for therapeutic 
        purposes (which cannot, as determined in accordance with 
        regulations, be self-administered).
            ``(E) Individual activity therapies to the extent that such 
        therapies are closely and clearly related to the individual's 
        care and treatment, and are not primarily recreational or 
        diversionary.
            ``(F) Family counseling (the primary purpose of which is 
        treatment of the individual's condition).
            ``(G) Patient training and education to the extent that 
        such training and educational activities are closely and 
        clearly related to the individual's care and treatment.
            ``(H) Diagnostic services.
            ``(I) Individual case management services.
            ``(J) Such other items and services as the Secretary may 
        provide (but in no event to include meals and transportation).
    ``(3)(A)(i) Subject to clause (ii), a facility described in this 
paragraph is a hospital or a community mental health center (as defined 
in subparagraph (B)) that furnishes partial hospitalization services 
and that provides the Secretary with such information on the sites at 
which the services described in paragraph (2) are furnished as the 
Secretary may require to monitor and survey services furnished at such 
sites for compliance with applicable requirements.
    ``(ii) In no case may a facility described in this paragraph 
furnish partial hospitalization services in a skilled nursing facility, 
residential treatment facility or other residential setting (as 
determined by the Secretary).
    ``(B) For purposes of subparagraph (A), the term ``community mental 
health center'' means an entity that--
            ``(i)(I) provides the mental health services described in 
        subparagraphs (A) through (D) of section 1913(c)(1) of the 
        Public Health Service Act and also determines the clinical 
        appropriateness of admissions to inpatient psychiatric 
        hospitals by engaging a full-time mental health professional 
        who is licensed or certified to make such a determination by 
        the State involved; or
            ``(II) in the case of an entity operating in a State that 
        by law precludes the entity from providing a service described 
        in such section itself, provides for such service by contract 
        with an approved organization or entity (as determined by the 
        Secretary);
            ``(ii) meets applicable licensing or certification 
        requirements for community mental health centers in the State 
        in which it is located or, in the case of a center which is 
        located in a State that does not have any applicable licensing 
        or certification requirements, meets certification requirements 
        established by the Secretary; and
            ``(iii) meets such additional conditions as the Secretary 
        shall specify to ensure (I) the health and safety of 
        individuals being furnished such services, (II) the effective 
        and efficient furnishing of such services, (III) the quality of 
        such services, and (IV) the compliance of such entity with the 
        criteria establishes by regulation under paragraph (5)(E).
With respect to each community mental health center that furnishes 
partial hospitalization services for which payment is made under this 
title, the Secretary shall provide for periodic recertification to 
ensure that the provision of such services complies with applicable 
requirements of this title. The first recertification under this 
subparagraph shall be completed not later than one year after the date 
of the enactment of this subparagraph.
    ``(4) The Secretary shall provide, through peer review 
organizations under section 1154(a)(12) and otherwise, for the 
monitoring of the quality of partial hospitalization services furnished 
using an appropriate patient assessment instrument established by the 
Secretary.
    ``(5) Not later than one year after the date of the enactment of 
this paragraph, the Secretary shall promulgate revised regulations to 
carry out this subsection and section 1835(a)(2)(F) using a negotiated 
rulemaking process under subchapter III of chapter 5 of title 5, United 
States Code. Such regulations shall take into account the following 
matters:
            ``(A) Eligibility for benefits for partial hospitalization 
        services, including certification and recertification of the 
        need for such services under section 1835(a)(2)(F).
            ``(B) The type and level of partial hospitalization 
        services covered under this title, including the frequency and 
        duration of services based on an individual's condition and 
        functional level.
            ``(C) Quality of care standards to be applied under this 
        paragraph.
            ``(D) Review standards to be applied by carriers (including 
        through manual instructions) in making payment for partial 
        hospitalization services.
            ``(E) Certification and recertification requirements 
        referred to in paragraph (3)(B).''.
    (b) Designation of Carriers for Partial Hospitalization Services.--
Section 1842(b)(2) of the Social Security Act (42 U.S.C. 1395u(b)(2)) 
is amended by adding at the end the following new subparagraph:
    ``(F) The Secretary shall designate under this section not more 
than 5 carriers to process all claims for partial hospitalization 
services under this part.''.
    (c) Conforming Amendments.--
            (1) Role of peer review organizations.--Section 1154(a) of 
        the Social Security Act (42 U.S.C. 1320c-3(a)) is amended by 
        inserting after paragraph (11) the following new paragraph:
            ``(12) The organization shall review data on the quality of 
        partial hospitalization services furnished under title XVIII, 
        using patient assessment instruments described in section 
        1861(ff)(4) applied with respect to such services.''.
            (2) Conforming standard for physician certification for 
        coverage.--Section 1835(a)(2)(F)(i) of such Act (42 U.S.C. 
        1395n(a)(2)(F)(i)) is amended by striking ``the individual 
        would require inpatient psychiatric care in the absence of such 
        services'' and all that follows and inserting ``that those 
        services are reasonably expected to improve or maintain the 
        individual's condition and functional level and to prevent 
        relapse or hospitalization.''.
    (d) Effective Date.--Except as otherwise provided in this section, 
the amendments made by this section apply with respect to partial 
hospitalization services furnished on or after the first day of the 
third month beginning after the date of the enactment of this Act.
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