[Congressional Bills 107th Congress]
[From the U.S. Government Publishing Office]
[H.R. 2953 Introduced in House (IH)]







107th CONGRESS
  1st Session
                                H. R. 2953

  To amend title XVIII of the Social Security Act to make the social 
     health maintenance organization a permanent option under the 
                        Medicare+Choice program.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                           September 25, 2001

   Mr. Horn introduced the following bill; which was referred to the 
Committee on Ways and Means, and in addition to the committee on Energy 
    and 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 make the social 
     health maintenance organization a permanent option under the 
                        Medicare+Choice program.

    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 Coordinated Community Care 
Act of 2001''.

SEC. 2. MAKING SOCIAL HEALTH MAINTENANCE ORGANIZATIONS (S/HMOS) A 
              PERMANENT OPTION AS COORDINATED COMMUNITY CARE PLANS 
              UNDER THE MEDICARE+CHOICE PROGRAM.

    (a) Inclusion of Coordinated Community Care Plans Into Grouping of 
Medicare+Choice Coordinated Care Plans.--Section 1851(a)(2)(A) of the 
Social Security Act (42 U.S.C. 1395w-21(a)(2)(A)) is amended by 
striking ``and preferred provider organization plans'' and inserting 
``preferred provider organization plans, and coordinated community care 
plans (as defined in section 1859(b)(4))''.
    (b) Definition of Coordinated Community Care Plan.--Section 1859(b) 
of such Act (42 U.S.C. 1395w-29(b)) is amended by adding at the end the 
following new paragraph:
            ``(4) Coordinated community care plan.--The term 
        `coordinated community care plan' means a Medicare+Choice plan 
        that (in addition to providing services and otherwise meeting 
        the requirements of this part) meets the following 
        requirements:
                    ``(A) The plan provides as benefits to all 
                enrollees chronic illness services and ancillary 
                services, as specified in section 1852(a)(6).
                    ``(B) The plan provides as benefits expanded care 
                services, as specified in section 1852(a)(7), to 
                enrollees who meet the criteria for at-risk enrollees 
                (as defined in paragraph (5)).
                    ``(C) The plan meets the quality assurance 
                requirements specified in section 1852(e)(2)(E).
                    ``(D) The plan submits to the Secretary reports on 
                the functional status of enrollees as well as on 
                expenditures and utilization of covered expanded care 
                services.
            ``(5) At-risk enrollee.--For purposes of determining an 
        enrollee's eligibility to receive expanded care services from a 
        coordinated community care plan, the term `at-risk enrollee' 
        means an enrollee of a coordinated community care plan who has 
        been determined by the coordinated community care plan, based 
        on a multidimensional, geriatric assessment, to meet at least 
        one of the following criteria:
                    ``(A) The individual needs personal supervision or 
                hands-on assistance with bathing, dressing, 
                transferring, toileting, eating, or daily mobility 
                assistance inside the home.
                    ``(B) The individual needs protection and 
                supervision on a constant basis due to cognitive 
                impairment.
                    ``(C) The individual needs daily personal 
                assistance to ensure proper administration and 
                management of prescribed medications or medical or 
                nursing procedures.
                    ``(D) The individual needs personal assistance (at 
                least 3 times a week) to manage incontinence problems 
                or ostomy equipment.
                    ``(E) The individual needs special ongoing 
                management because the enrollee is frequently 
                disruptive, aggressive, or agitated, or is a danger to 
                self or others.
                    ``(F) The individual needs help to prevent, delay, 
                or minimize functional decline.
                    ``(G) The individual meets such other criteria as 
                the Secretary may determine.''.
    (c) Information on Benefits.--Section 1851(a)(4)(A) of such Act (42 
U.S.C. 1395w-21(a)(4)(A)) is amended by adding at the end the following 
new clause:
                            ``(ix) In the case of a coordinated 
                        community care plan, differences in benefits, 
                        care coordination services, quality improvement 
                        programs, and other distinguishing factors 
                        compared to other Medicare+Choice plans.''.
    (d) Basic and Expanded Benefits.--Section 1852 of such Act (42 
U.S.C. 1395w-22) is amended--
            (1) by adding at the end of subsection (a) the following 
        new paragraphs:
            ``(6) Benefits offered by coordinated community care 
        plans.--
                    ``(A) In general.--In addition to the benefits 
                required under parts A and B, each coordinated 
                community care plan shall make available to each 
                enrollee--
                            ``(i) chronic illness care services 
                        (described in subparagraph (B)) to manage 
                        common geriatric conditions and chronic 
                        illness; and
                            ``(ii) ancillary services described in 
                        subparagraph (C).
                    ``(B) Chronic illness care services.--Chronic 
                illness care services under this subparagraph shall be 
                furnished in accordance with guidelines and protocols 
                adopted by the Secretary and by geriatricians, 
                geriatric nurse practitioners, and other providers 
                experienced in chronic illness care. Such services may 
include geriatric and chronic illness and disability training 
supplements, consultation with medical specialists, and other services 
deemed appropriate by the plans.
                    ``(C) Ancillary services.--Ancillary services under 
                this subparagraph--
                            ``(i) shall include prescription drugs, 
                        eyeglasses, and hearing aids, in an amount and 
                        duration specified under the plan; and
                            ``(ii) may also include, at the discretion 
                        of the plan, such preventive services and other 
                        items and services not otherwise covered under 
                        part A or B as the plan may specify.
            ``(7) Expanded care services for at-risk enrollees.--
                    ``(A) In general.--In addition to the benefits 
                required under parts A and B and paragraph (6), each 
                coordinated community care plan shall make available to 
                each at-risk enrollee (as defined in section 
                1859(b)(5)) through providers with appropriate 
                expertise in geriatric and chronic illness care 
                services and in accordance with an expanded care plan 
                under subsection (m)(3)--
                            ``(i) benefits for home and community-based 
                        services described in subparagraph (B);
                            ``(ii) benefits for supplemental non-acute 
                        institutional services described in 
                        subparagraph (C) but only in the case of an 
                        individual who does not reside in an 
                        institutional setting; and
                            ``(iii) end-of-life and palliative care 
                        services described in subparagraph (D).
                    ``(B) Home and community-based benefits.--
                            ``(i) In general.--The home and community-
                        based services under this subparagraph include, 
                        subject to clause (ii), personal care, 
                        homemakers, medical transportation, adult day 
                        health, and medication management. Such 
                        services may also include routine foot care in 
                        the home, home modifications, medical and 
                        adaptive equipment and supplies, expanded 
                        mental health services, personal emergency 
                        response systems, home-delivered meals, and 
                        nutritional assessments and services.
                            ``(ii) Scope.--The benefits under this 
                        subparagraph may be limited to a specified 
                        dollar amount of coverage per enrollee per year 
                        (exclusive of member copayments). Such dollar 
                        limit--
                                    ``(I) for benefits during 2002, 
                                shall not be less than $7,500; or
                                    ``(II) for benefits during a 
                                subsequent year, shall not be less than 
                                the dollar amount specified under this 
                                clause for the previous year increased 
                                by minimum percentage increase in 
                                Medicare+Choice capitation rates 
                                provided under section 1853(c)(1)(C) 
                                applicable to that subsequent year.
                            ``(iii) Limits on copayments.--With respect 
                        to the benefits under this subparagraph, a 
                        coordinated community care plan may not charge 
                        a deductible and may not charge copayments that 
                        exceed 25 percent.
                    ``(C) Supplemental non-acute institutional 
                services.--
                            ``(i) In general.--Benefits for 
                        supplemental non-acute institutional services 
                        under this subparagraph are benefits for 
                        institutional care (such as care in an 
                        institutional setting, as defined in clause 
                        (iv)) that is not otherwise covered under part 
                        A or part B and that is in aid of returning the 
                        enrollee to a community residence and that is 
                        provided to an individual who resides outside 
                        an institutional setting.
                            ``(ii) Duration.--
                                    ``(I) Initial period of 
                                eligibility.--The benefits under this 
                                subparagraph shall include at least 14 
                                days of supplemental non-acute 
                                institutional care.
                                    ``(II) Subsequent periods of 
                                eligibility.--After receipt of the 
                                benefits described in subclause (I), 
                                after the at-risk enrollee has resumed 
                                residing in a community residence for a 
                                continuous period of 60 days, subject 
                                to subclause (III), the benefits under 
                                this subparagraph shall include at 
                                least an additional 14 days of 
                                supplemental non-acute institutional 
                                care.
                                    ``(III) Annual limitation.--A plan 
                                is not required to provide supplemental 
                                non-acute institutional care for more 
                                than 30 days of supplemental non-acute 
                                institutional care for any enrollee in 
                                any calendar year.
                                    ``(IV) Community residence.--For 
                                purposes of this clause, the term 
                                `community residence' means a residence 
                                in a community-setting and does not 
                                include a residence in any 
                                institutional setting.
                            ``(iii) Limits on copayments.--With respect 
                        to the supplemental non-acute institutional 
                        services benefit under this subparagraph, the 
                        coordinated community care plan may not charge 
                        a deductible and may not charge copayments that 
                        exceed 25 percent.
                            ``(iv) Institutional setting.--For purposes 
                        of this paragraph, the term `institutional 
                        setting' includes a nursing facility, assisted 
                        living facility, adult foster home, or other 
                        licensed non-acute care facility.
                    ``(D) End-of-life care.--End-of-life and palliative 
                care services under this subparagraph shall not be 
                limited to the last 6 months of life, shall cover a 
                broader range of life-limiting conditions than 
                traditional hospice care, and shall include support of 
                family caregivers.''; and
            (2) by adding at the end the following new subsection:
    ``(m) Care Coordination.--Coordinated community care plans shall 
adopt a care coordination program for serving members. This program 
shall include geriatric-focused assessment and care planning that meet 
at least the following requirements:
            ``(1) Population screening.--The coordinated community care 
        plan shall screen each new enrollee upon enrollment and 
        annually thereafter through a self-report health status form 
        with a standardized set of core items designed to identify 
        enrollees who may be at risk due to medical, psychological, 
        behavioral, environmental, or functional conditions.
            ``(2) Clinical screening.--In the case of an enrollee who 
        is identified, under a screening under paragraph (1) or 
otherwise, as potentially being at risk due to conditions described in 
such paragraph or who otherwise self-identifies as potentially being so 
at risk, the coordinated community care plan shall provide for an 
appropriate clinical screening to determine if the enrollee is an at-
risk enrollee.
            ``(3) Comprehensive assessment and planning.--In the case 
        of an enrollee identified as an at-risk enrollee, a care 
        coordinator in the coordinated community care plan shall 
        contact the enrollee to determine the enrollee's need for a 
        comprehensive assessment to determine the enrollee's needs, 
        preferences, and eligibility for expanded care benefits. Such 
        an assessment shall be conducted in the enrollee's home and 
        other settings, as appropriate, using flexible, 
        multidimensional geriatric approaches that incorporate medical, 
        functional, psychological, and environmental dimensions. All 
        at-risk enrollees shall be assigned a care coordinator who will 
        develop an expanded care plan based on the multidimensional 
        assessment, information on medical status and care, and member 
        preferences. The coordinated community care plan shall assure 
        that at-risk enrollees be referred in a timely manner to the 
        appropriate provider or providers for appropriate services 
        under the expanded care plan.
            ``(4) Integration of care.--Procedures shall be established 
        among such care coordinators and acute and expanded care 
        providers in such plans to ensure timely sharing of clinical 
        information, assignment of responsibility, and coordination and 
        integration of services under the expanded care plan across all 
        providers and settings in a manner that meets the special needs 
        of geriatric and chronically ill or impaired individuals.''.
    (d) Quality Assurance.--Section 1852(e)(2) of such Act (42 U.S.C. 
1395w-22(e)(2)) is amended by adding at the end the following new 
subparagraph:
                    ``(E) Coordinated community care plans.--In 
                addition in the case of a coordinated community care 
                plan, the quality assurance program shall employ 
                systems to ensure the quality of covered expanded care 
                and chronic illness care services. The Secretary shall 
                establish appropriate outcome measures for assessing 
                the quality of care provided to frail elderly and at-
                risk enrollees with chronic conditions in such plans. 
                Such outcome indicators shall measure plans' and 
                providers' effectiveness in--
                            ``(i) integrating the delivery of acute 
                        care and expanded care;
                            ``(ii) meeting identified expanded care 
                        needs;
                            ``(iii) preventing, delaying, or minimizing 
                        disability progression; and
                            ``(iv) preventing or delaying 
                        institutionalization.''.
    (e) Payments.--Section 1853 of such Act (42 U.S.C. 1395w-23) is 
amended by adding at the end the following new subsection:
    ``(j) Coordinated Community Care Plans.--Notwithstanding the 
previous provisions of this section, each coordinated community care 
plans shall be paid under this section as follows:
            ``(1) In general.--Except as provided in paragraph (2)--
                    ``(A) Current social hmos.--In the case of a 
                coordinated community care plan that contracted with 
                the Secretary to furnish services as a social HMO 
                during 2001 and that continues to contract with the 
                Secretary following the effective date of this 
                subsection, payment shall be based on the same risk 
                adjustment factors and formula such plan was paid 
                during 2001.
                    ``(B) Other plans.--In the case of a coordinated 
                community care plan not described in subparagraph (A), 
                before the adoption and implementation of a new payment 
                methodology for coordinated community care plans under 
                paragraph (2), the Secretary shall have the discretion 
                to select one of the 2 methodologies for risk 
                adjustment factors and formula that may be applied 
                under subparagraph (A) to pay any Medicare+Choice 
                coordinated care plan that is certified as a 
                coordinated community care plan.
            ``(2) New payment methodology.--The Secretary shall develop 
        a new payment methodology to pay coordinated community care 
        plans. In developing this new payment methodology, the 
        Secretary shall be guided by the following 3 factors:
                    ``(A) Recognizing that impairment-related costs are 
                not adequately accounted for in the individual 
                diagnostic and demographic factors used to adjust 
                payments for other Medicare+Choice plans, a functional 
                status factor or factors or other factors equally 
                sensitive to costs associated with disability, frailty, 
                and comorbidities will be included in the coordinated 
community care plan payment system.
                    ``(B) There will be an enhancement of the 
                underlying base payment to coordinated community care 
                plans that reflects the increased risk of offering the 
                additional benefits required by paragraphs (6) and (7) 
                of section 1852(a). The Secretary shall make this 
                enhancement commensurate with the original intent of 
                the Deficit Reduction Act of 1984 to pay not less than 
                the actuarial equivalent of 100 percent of what would 
                have been paid under this title for the enrolled 
                members had they not enrolled in a plan under this part 
                but obtained benefits through the fee-for-service 
                system.
                    ``(C) The Secretary shall assure that the payment 
                methodology will not change because a coordinated 
                community care plan has a contract with a State under 
                title XIX to serve individuals dually eligible under 
                this title and that title.
            ``(3) Transition.--If the payment methodology developed by 
        the Secretary under paragraph (2) results in a reduction of 
        payment to a coordinated community care plan that is receiving 
        payment under a method described in paragraph (1), the 
        Secretary shall establish a 4-year transition period during 
        which the new payment methodology is phased in. During the 
        first year of the transition, payment will be based on a blend 
        weighted \1/4\ of the new payment methodology under paragraph 
        (2) and \3/4\ of the payment methodology under paragraph (1). 
        During each of the second and third years, payment will be 
        based on a blend weighted \1/2\ and \3/4\, respectively, of the 
        new payment methodology under paragraph (2) and \1/2\ and \1/
        4\, respectively, based on the payment methodology under 
        paragraph (1). The Secretary shall fully implement the new 
        payment methodology during the fourth year.
            ``(4) Comment.--The Secretary shall submit the new payment 
        methodology for coordinated community care plans to public 
        comment as part of the advance notice of methodological changes 
        under section 1853(b)(2).''.
    (f) Premiums.--Section 1854(f)(1) of such Act (42 U.S.C. 1395w-
24(f)(1)) is amended by adding at the end the following new 
subparagraph:
                    ``(F) Special rules for coordinated community care 
                plans.--
                            ``(i) Each coordinated community care plan 
                        shall include as additional benefits those 
                        services described in paragraphs (6) and (7) of 
                        section 1852(a) unless inclusion of the 
                        additional benefits results in the actuarial 
                        value of the benefits exceeding the average of 
                        the capitation payments made to the coordinated 
                        community care plan. If so, the coordinated 
                        community care plan may treat the excess as a 
                        supplemental benefit (as defined in section 
                        1852(a)(3)), and charge a premium for the 
                        actuarial value of the excess costs.
                            ``(ii) Nothing in this part shall be 
                        construed to preclude a coordinated community 
                        care plan from furnishing the services 
                        specified in section 1852(a)(7) only to at-risk 
                        enrollees (as defined in section 
                        1859(b)(5)).''.
    (g) Discretion to Waive Requirements.--Section 1856(b) of such Act 
(42 U.S.C. 1395w-26(b)) is amended by adding at the end the following 
new paragraph:
            ``(4) Adaptation to coordinated community care plans.--In 
        establishing standards under this section, the Secretary shall 
        adapt such standards as they apply to coordinated community 
        care plans to appropriately account for their unique 
        characteristics as reflected in the composition of enrollment 
        and the care coordination and expanded benefit requirements 
        under this part.''.
    (h) Effective Date; Transition.--
            (1) Effective date.--Except as otherwise provided in this 
        subsection, the amendments made by this section shall take 
        effect on January 1, 2002.
            (2) Transition.--
                    (A) In general.--Upon the enactment of this 
                section, the Secretary of Health and Human Services 
                shall proceed in an expedited manner to develop and 
                promulgate the necessary rules and the payment 
                methodology required by the amendments made by this 
                section.
                    (B) Application of requirements.--Except as 
                provided in paragraph (3), the Secretary of Health and 
                Human Services may not certify a Medicare+Choice 
                organization as meeting the requirements applicable to 
                coordinated community care plans under part C of title 
                XVIII of the Social Security Act until the adoption of 
final regulations implementing the statutory requirements applicable to 
coordinated community care plans under such part.
            (3) Deemed treatment.--
                    (A) Current s/hmos.--Any Medicare+Choice 
                organization that is operating as of the date of the 
                enactment of this Act under demonstration authority as 
                a Social HMO (S/HMO I or S/HMO II or a combination 
                thereof) shall be deemed to meet the requirements 
                applicable to coordinated community care plans under 
                part C of title XVIII of the Social Security Act from 
                the effective date specified in paragraph (1) through 
                24 months following the date the Secretary publishes 
                final regulations establishing standards for 
                coordinated community care plans under the amendments 
                made by this section.
                    (B) S/HMOs with planning grants.--In the case of an 
                entity that received a planning grant in 1998 under the 
                1997 Grants Program for Reforming Service Delivery for 
                Dual Eligible Beneficiaries to develop a Second 
                Generation Social HMO Demonstration program, if the 
                Secretary determines that the program developed under 
                such a grant would qualify to operate as a 
                demonstration authority as a Social HMO (S/HMO I or S/
                HMO II or a combination thereof), the Secretary may 
                treat the entity with respect to such program as a 
                Social HMO for purposes of applying subparagraph, 
                effective on a date specified by the Secretary.
            (4) Immediate removal of limitation on number of members 
        per site under demonstration project.--Section 13567(c) of the 
        Omnibus Budget Reconciliation Act of 1993, as amended by 
        sections 4014(b) of the Balanced Budget Act of 1997 and by 
        section 531(c) of the Medicare, Medicaid, and SCHIP Balanced 
        Budget Refinement Act of 1999 (113 1501A-388), is amended--
                    (A) in the heading, by striking ``Aggregate'' and 
                inserting ``No''; and
                    (B) by striking ``other than an aggregate limit of 
                not less than 324,000 for all sites''.
            (5) Limitation on initial expansion.--In the first 3 years 
        following the effective date of implementing regulations 
        described in paragraph (2)(A), the Secretary of Health and 
        Human Services shall not approve any more than the following 
        total number of coordinated community care plans under part C 
        of title XVIII of the Social Security Act (in addition to the 
        plans referred to in paragraph (3)):
                    (A) In the first such year, 5 coordinated community 
                care plans.
                    (B) In the second such year, 15 coordinated 
                community care plans.
                    (C) In the third such year, 30 coordinated 
                community care plans.
        For any succeeding year, there shall be no limit on the number 
        of such plans that may be approved.
    (i) Advisory Committee.--
            (1) Establishment.--The Secretary of Health and Human 
        Services shall establish a National Advisory Committee on 
        Social HMO Replication to assist Medicare+Choice plans, health 
        care providers, and other appropriate organizations in the 
        design, implementation, and ongoing evaluation of coordinated 
        community care plans under the amendments made by this section.
            (2) Membership.--Membership on the committee shall include 
        representation from the following:
                    (A) Existing Social HMO I and II sites.
                    (B) Social HMO II planning grant sites.
                    (C) Providers and professionals with expertise in 
                geriatric medicine, chronic illness care and home and 
                community-based service programs.
                    (D) Representatives from the Federal and State 
                governments with oversight responsibilities for 
                programs serving the elderly and disabled.
                    (E) Representatives from the Social HMO research 
                and development groups at Brandeis University, 
                University of Minnesota, and the University of 
                California at San Francisco.
                    (F) Such other representatives as the Secretary may 
                designate.
                                 <all>