[Congressional Bills 108th Congress]
[From the U.S. Government Publishing Office]
[H.R. 2342 Introduced in House (IH)]







108th CONGRESS
  1st Session
                                H. R. 2342

  To amend title XVIII of the Social Security Act to expand Medicare 
  benefits to prevent, delay, and minimize the progression of chronic 
    conditions, and develop national policies on effective chronic 
                condition care, and for other purposes.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                              June 4, 2003

  Mr. Stark (for himself, Mr. Rangel, Mr. Matsui, Mr. McDermott, Mr. 
 Sandlin, and Mrs. Jones of Ohio) introduced the following bill; which 
 was referred to the Committee on Energy and Commerce, and in addition 
  to the Committee on Ways and Means, 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 expand Medicare 
  benefits to prevent, delay, and minimize the progression of chronic 
    conditions, and develop national policies on effective chronic 
                condition care, 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; TABLE OF CONTENTS.

    (a) Short Title.--This Act may be cited as the ``Medicare Chronic 
Care Improvement Act of 2003''.
    (b) Table of Contents.--The table of contents of this Act is as 
follows:

Sec. 1. Short title; table of contents.
 TITLE I--BENEFITS TO PREVENT, DELAY, AND MINIMIZE THE PROGRESSION OF 
                           CHRONIC CONDITIONS

          Subtitle A--Improving Access to Preventive Services

Sec. 101. Elimination of deductibles and coinsurance for existing 
                            preventive health benefits.
Sec. 102. Institute of Medicine medicare prevention benefit study and 
                            report.
Sec. 103. Authority to administratively provide for coverage of 
                            additional preventive benefits.
Sec. 104. Coverage of an initial preventive physical examination.
  Subtitle B--Medicare Coverage for Care Coordination and Assessment 
                                Services

Sec. 111. Care coordination and assessment services.
Sec. 112. Care coordination and assessment services and quality 
                            improvement program in Medicare+Choice 
                            plans.
Sec. 113. Improving chronic care coordination through information 
                            technology.
                   Subtitle C--Additional Provisions

Sec. 121. Review of coverage standards.
 TITLE II--INSTITUTE OF MEDICINE STUDY ON EFFECTIVE CHRONIC CONDITION 
                                  CARE

Sec. 201. Institute of Medicine medicare chronic condition care 
                            improvement study and report.

 TITLE I--BENEFITS TO PREVENT, DELAY, AND MINIMIZE THE PROGRESSION OF 
                           CHRONIC CONDITIONS

          Subtitle A--Improving Access to Preventive Services

SEC. 101. ELIMINATION OF DEDUCTIBLES AND COINSURANCE FOR EXISTING 
              PREVENTIVE HEALTH BENEFITS.

    (a) In General.--Section 1833 of the Social Security Act (42 U.S.C. 
1395l) is amended by inserting after subsection (o) the following new 
subsection:
    ``(p) Deductibles and Coinsurance Waived for Preventive Health 
Items and Services.--The Secretary shall not require the payment of any 
deductible or coinsurance under subsection (a) or (b), respectively, of 
any individual enrolled for coverage under this part for any of the 
following preventive health items and services:
            ``(1) Blood-testing strips, lancets, and blood glucose 
        monitors for individuals with diabetes described in section 
        1861(n).
            ``(2) Diabetes outpatient self-management training services 
        (as defined in section 1861(qq)(1)).
            ``(3) Pneumococcal, influenza, and hepatitis B vaccines and 
        administration described in section 1861(s)(10).
            ``(4) Screening mammography (as defined in section 
        1861(jj)).
            ``(5) Screening pap smear and screening pelvic exam (as 
        defined in paragraphs (1) and (2) of section 1861(nn), 
        respectively).
            ``(6) Bone mass measurement (as defined in section 
        1861(rr)(1)).
            ``(7) Prostate cancer screening test (as defined in section 
        1861(oo)(1)).
            ``(8) Colorectal cancer screening test (as defined in 
        section 1861(pp)(1)).
            ``(9) Screening for glaucoma (as defined in section 
        1861(uu)).
            ``(10) Medical nutrition therapy services (as defined in 
        section 1861(vv)(1)).''.
    (b) Waiver of Coinsurance.--
            (1) In general.--Section 1833(a)(1)(B) of the Social 
        Security Act (42 U.S.C. 1395l(a)(1)(B)) is amended to read as 
        follows: ``(B) with respect to preventive health items and 
        services described in subsection (p), the amounts paid shall be 
        100 percent of the fee schedule or other basis of payment under 
        this title for the particular item or service,''.
            (2) Elimination of coinsurance in outpatient hospital 
        settings.--The third sentence of section 1866(a)(2)(A) of the 
        Social Security Act (42 U.S.C. 1395cc(a)(2)(A)) is amended by 
        inserting after ``1861(s)(10)(A)'' the following: ``, 
        preventive health items and services described in section 
        1833(p),''.
    (c) Waiver of Application of Deductible.--Section 1833(b)(1) of the 
Social Security Act (42 U.S.C. 1395l(b)(1)) is amended to read as 
follows: ``(1) such deductible shall not apply with respect to 
preventive health items and services described in subsection (p),''.
    (d) Adding ``Lancet'' to Definition of DME.--Section 1861(n) of the 
Social Security Act (42 U.S.C. 1395x(n)) is amended by striking 
``blood-testing strips and blood glucose monitors'' and inserting 
``blood-testing strips, lancets, and blood glucose monitors''.
    (e) Conforming Amendments.--
            (1) Elimination of coinsurance for clinical diagnostic 
        laboratory tests.--Paragraphs (1)(D)(i) and (2)(D)(i) of 
        section 1833(a) of the Social Security Act (42 U.S.C. 1395l(a)) 
        are each amended by inserting ``or which are described in 
subsection (p)'' after ``assignment-related basis''.
            (2) Elimination of coinsurance for certain dme.--Section 
        1834(a)(1)(A) of the Social Security Act (42 U.S.C. 
        1395m(a)(1)(A)) is amended by inserting ``(or 100 percent, in 
        the case of such an item described in section 1833(p))'' after 
        ``80 percent''.
            (3) Elimination of deductibles and coinsurance for 
        colorectal cancer screening tests.--Section 1834(d) of the 
        Social Security Act (42 U.S.C. 1395m(d)) is amended--
                    (A) in paragraph (2)(C)--
                            (i) by striking ``(C) Facility payment 
                        limit.--'' and all that follows through 
                        ``Notwithstanding subsections'' and inserting 
                        the following:
                    ``(C) Facility payment limit.--Notwithstanding 
                subsections'';
                            (ii) by striking ``(I) in accordance'' and 
                        inserting the following:
                            ``(i) in accordance'';
                            (iii) by striking ``(II) are performed'' 
                        and all that follows through ``payment under'' 
                        and inserting the following:
                            ``(ii) are performed in an ambulatory 
                        surgical center or hospital outpatient 
                        department,
                payment under''; and
                            (iv) by striking clause (ii); and
                    (B) in paragraph (3)(C)--
                            (i) by striking ``(C) Facility payment 
                        limit.--'' and all that follows through 
                        ``Notwithstanding subsections'' and inserting 
                        the following:
                    ``(C) Facility payment limit.--Notwithstanding 
                subsections''; and
                            (ii) by striking clause (ii).
    (f) Effective Date.--The amendments made by this section shall 
apply to services furnished on or after January 1, 2004.

SEC. 102. INSTITUTE OF MEDICINE MEDICARE PREVENTION BENEFIT STUDY AND 
              REPORT.

    (a) Study.--
            (1) In general.--The Secretary of Health and Human Services 
        shall contract with the Institute of Medicine of the National 
        Academy of Sciences to--
                    (A) conduct a comprehensive study of current 
                literature and best practices in the field of health 
                promotion and disease prevention among medicare 
                beneficiaries, including the issues described in 
                paragraph (2); and
                    (B) submit the report described in subsection (b).
            (2) Issues studied.--The study required under paragraph (1) 
        shall include an assessment of--
                    (A) whether each health promotion and disease 
                prevention benefit covered under the medicare program 
                is medically effective (as defined in subsection 
                (d)(3));
                    (B) utilization by medicare beneficiaries of such 
                benefits (including any barriers to or incentives to 
                increase utilization);
                    (C) quality of life issues associated with such 
                benefits; and
                    (D) whether health promotion and disease prevention 
                benefits that are not covered under the medicare 
                program that would affect all medicare beneficiaries 
                are likely to be medically effective (as so defined).
    (b) Reports.--
            (1) Three-year report.--On the date that is 3 years after 
        the date of enactment of this Act, and each successive 3-year 
        anniversary thereafter, the Institute of Medicine of the 
        National Academy of Sciences shall submit to the President a 
        report that contains--
                    (A) a detailed statement of the findings and 
                conclusions of the study conducted under subsection 
                (a); and
                    (B) the recommendations for legislation described 
                in paragraph (3).
            (2) Interim report based on new guidelines.--If the United 
        States Preventive Services Task Force or the Task Force on 
        Community Preventive Services establishes new guidelines 
        regarding preventive health benefits for medicare beneficiaries 
        more than 1 year prior to the date that a report described in 
        paragraph (1) is due to be submitted to the President, then not 
        later than 6 months after the date such new guidelines are 
        established, the Institute of Medicine of the National Academy 
        of Sciences shall submit to the President a report that 
        contains a detailed description of such new guidelines. Such 
        report may also contain recommendations for legislation 
        described in paragraph (3).
            (3) Recommendations for legislation.--The Institute of 
        Medicine of the National Academy of Sciences, in consultation 
        with the United States Preventive Services Task Force and the 
        Task Force on Community Preventive Services, shall develop 
        recommendations in legislative form that--
                    (A) prioritize the preventive health benefits under 
                the medicare program; and
                    (B) modify such benefits, including adding new 
                benefits under such program, based on the study 
                conducted under subsection (a).
    (c) Transmission to Congress.--
            (1) In general.--Subject to paragraph (2), on the day that 
        is 6 months after the date on which the report described in 
        paragraph (1) of subsection (b) (or paragraph (2) of such 
        subsection if the report contains recommendations in 
        legislative form described in subsection (b)(3)) is submitted 
        to the President, the President shall transmit the report and 
        recommendations to Congress.
            (2) Regulatory action by the secretary of health and human 
        services.--If the Secretary of Health and Human Services has 
        exercised the authority under section 103(a) to adopt by 
        regulation one or more of the recommendations under subsection 
        (b)(3), the President shall only submit to Congress those 
        recommendations under subsection (b)(3) that have not been 
        adopted by the Secretary.
            (3) Delivery.--Copies of the report and recommendations in 
        legislative form required to be transmitted to Congress under 
        paragraph (1) shall be delivered--
                    (A) to both Houses of Congress on the same day;
                    (B) to the Clerk of the House of Representatives if 
                the House is not in session; and
                    (C) to the Secretary of the Senate if the Senate is 
                not in session.
    (d) Definition of Medically Effective.--In this section, the term 
``medically effective'' means, with respect to a benefit or technique, 
that the benefit or technique has been--
            (1) subject to peer review;
            (2) described in scientific journals; and
            (3) determined to achieve an intended goal under normal 
        programmatic conditions.

SEC. 103. AUTHORITY TO ADMINISTRATIVELY PROVIDE FOR COVERAGE OF 
              ADDITIONAL PREVENTIVE BENEFITS.

    (a) In General.--The Secretary of Health and Human Services may by 
regulation adopt any or all of the legislative recommendations 
developed by the Institute of Medicine of the National Academy of 
Sciences, in consultation with the United States Preventive Services 
Task Force and the Task Force on Community Preventive Services in a 
report under section 102(b)(3) (relating to prioritizing and modifying 
preventive health benefits under the medicare program and the addition 
of new preventive benefits), consistent with subsection (b).
    (b) Elimination of Cost-Sharing.--With respect to items and 
services furnished under the medicare program that the Secretary has 
incorporated by regulation under subsection (a), the provisions of 
section 1833(p) of the Social Security Act (relating to elimination of 
cost-sharing for preventive benefits), as added by section 101(a), 
shall apply to those items and services in the same manner as such 
section applies to the items and services described in paragraphs (1) 
through (10) of such section.

SEC. 104. COVERAGE OF AN INITIAL PREVENTIVE PHYSICAL EXAMINATION.

    (a) Coverage.--Section 1861(s)(2) of the Social Security Act (42 
U.S.C. 1395x(s)(2)) is amended--
            (1) in subparagraph (U), by striking ``and'' at the end;
            (2) in subparagraph (V), by inserting ``and'' at the end; 
        and
            (3) by adding at the end the following new subparagraph:
            ``(W) an initial preventive physical examination (as 
        defined in subsection (ww));''.
    (b) Services Described.--Section 1861 of such Act (42 U.S.C. 1395x) 
is amended by adding at the end the following new subsection:

               ``Initial Preventive Physical Examination

    ``(ww) The term `initial preventive physical examination' means 
physicians' services consisting of a physical examination with the goal 
of health promotion and disease detection and includes a history and 
physical exam, a health risk appraisal, and health risk counseling, and 
laboratory tests or other items and services as determined by the 
Secretary in consultation with the United States Preventive Services 
Task Force.''.
    (c) Waiver of Deductible and Coinsurance.--
            (1) Deductible.--The first sentence of section 1833(b) of 
        such Act (42 U.S.C. 1395l(b)) is amended--
                    (A) by striking ``and'' before ``(6)'', and
                    (B) by inserting before the period at the end the 
                following: ``, and (7) such deductible shall not apply 
                with respect to an initial preventive physical 
                examination (as defined in section 1861(ww))''.
            (2) Coinsurance.--Section 1833(a)(1) of such Act (42 U.S.C. 
        1395l(a)(1)) is amended--
                    (A) in clause (N), by inserting ``(or 100 percent 
                in the case of an initial preventive physical 
                examination, as defined in section 1861(ww))'' after 
                ``80 percent''; and
                    (B) in clause (O), by inserting ``(or 100 percent 
                in the case of an initial preventive physical 
                examination, as defined in section 1861(ww))'' after 
                ``80 percent''.
    (d) Payment as Physicians' Services.--Section 1848(j)(3) of such 
Act (42 U.S.C. 1395w-4(j)(3)) is amended by inserting ``(2)(W),'' after 
``(2)(S),''.
    (e) Other Conforming Amendments.--Section 1862(a) of such Act (42 
U.S.C. 1395y(a)) is amended--
            (1) in paragraph (1)--
                    (A) by striking ``and'' at the end of subparagraph 
                (H);
                    (B) by striking the semicolon at the end of 
                subparagraph (I) and inserting ``, and''; and
                    (C) by adding at the end the following new 
                subparagraph:
            ``(J) in the case of an initial preventive physical 
        examination (as defined in section 1861(ww)), which is 
        performed not later than 6 months after the date the 
        individual's first coverage period begins under part B;''; and
            (2) in paragraph (7), by striking ``or (H)'' and inserting 
        ``(H), or (J)''.
    (f) Effective Date.--The amendments made by this section shall 
apply to services furnished on or after January 1, 2004, but only for 
individuals whose coverage period begins on or after such date.

  Subtitle B--Medicare Coverage for Care Coordination and Assessment 
                                Services

SEC. 111. CARE COORDINATION AND ASSESSMENT SERVICES.

    (a) Services Authorized.--Title XVIII of the Social Security Act 
(42 U.S.C. 1395 et seq.) is amended by adding at the end the following 
new section:

              ``care coordination and assessment services

    ``Sec. 1897. (a) Purpose.--
            ``(1) In general.--The purpose of this section is to 
        provide the appropriate level and mix of follow-up care to an 
        individual with a chronic condition who qualifies as an 
        eligible beneficiary (as defined in paragraph (2)).
            ``(2) Eligible beneficiary defined.--In this section, the 
        term `eligible beneficiary' means a beneficiary who--
                    ``(A) has a serious and disabling chronic condition 
                (as defined in subsection(f)(1)); or
                    ``(B) has four or more chronic conditions (as 
                defined in subsection (f)(4)).
    ``(b) Election of Care Coordination and Assessment Services.--
            ``(1) In general.--On or after January 1, 2005, an eligible 
        beneficiary may elect to receive care coordination services in 
        accordance with the provisions of this section under which, in 
        appropriate circumstances, the eligible beneficiary has health 
        care services covered under this title managed and coordinated 
        by a care coordinator who is qualified under subsection (e) to 
        furnish care coordination services under this section.
            ``(2) Revocation of election.--An eligible beneficiary who 
        has made an election under paragraph (1) may revoke that 
        election at any time.
    ``(c) Outreach.--The Secretary shall provide for the wide 
dissemination of information to beneficiaries and providers of 
services, physicians, practitioners, and suppliers with respect to the 
availability of and requirements for care coordination services under 
this section.
    ``(d) Care Coordination and Assessment Services Described.--Care 
coordination services under this section shall include the following:
            ``(1) Basic care coordination and assessment services.--
        Except as otherwise provided in this section, eligible 
        beneficiaries who have made an election under this section 
        shall receive the following services:
                    ``(A)(i) An initial assessment of an individual's 
                medical condition, functional and cognitive capacity, 
                and environmental and psychosocial needs.
                    ``(ii) Annual assessments after the initial 
                assessment performed under clause (i), unless the 
                physician or care coordinator of the individual 
                determines that additional assessments are required due 
                to sentinel health events or changes in the health 
                status of the individual that may require changes in 
                the plan of care developed for the individual.
                    ``(B) The development of an initial plan of care, 
                and subsequent appropriate revisions to that plan of 
                care.
                    ``(C) The management of, and referral for, medical 
                and other health services, including multidisciplinary 
                care conferences and coordination with other providers.
                    ``(D) The monitoring and management of medications.
                    ``(E) Patient education and counseling services.
                    ``(F) Family caregiver education and counseling 
                services.
                    ``(G) Self-management services, including health 
                education and risk appraisal to identify behavioral 
                risk factors through self-assessment.
                    ``(H) Consultations by telephone with physicians 
                and other appropriate health care professionals, 
                including 24-hour access to a care coordinator.
                    ``(I) Coordination with the principal caregiver in 
                the home.
                    ``(J) The managing and facilitating of transitions 
                among health care professionals and across settings of 
                care, including the following:
                            ``(i) The pursuit the treatment option 
                        elected by the individual.
                            ``(ii) The inclusion of any advance 
                        directive executed by the individual in the 
                        medical file of the individual.
                    ``(K) Activities that facilitate continuity of care 
                and patient adherence to plans of care.
                    ``(L) Information about, and referral to, 
                community-based services, including patient and family 
                caregiver education and counseling about such services, 
                and facilitating access to such services when elected.
                    ``(M) Information about, and referral to, hospice 
                services and palliative care, including patient and 
                family caregiver education and counseling about hospice 
                services and palliative care, and facilitating 
                transition to hospice when elected.
                    ``(N) Such other medical and health care services 
                for which payment would not otherwise be made under 
                this title as the Secretary determines to be 
                appropriate for effective care coordination, including 
                the additional items and services as described in 
                paragraph (2).
            ``(2) Additional benefits.--The Secretary may specify 
        additional benefits for which payment would not otherwise be 
        made under this title that may be available to eligible 
        beneficiaries who have made an election under this section 
        (subject to an assessment by the care coordinator of an 
        individual beneficiary's circumstances and need for such 
        benefits) in order to encourage the receipt of, or to improve 
        the effectiveness of, care coordination services.
    ``(e) Care Coordinators.--
            ``(1) Requirement for certification.--
                    ``(A) In general.--In order to be qualified to 
                furnish care coordination and assessment services under 
                this section, an individual or entity shall be a health 
                care professional or entity (which may include 
                physicians, physician group practices, or other health 
                care professionals or entities the Secretary may find 
                appropriate) who has been certified for a period (as 
                provided in subparagraph (B)) by the Secretary, or by 
                an organization recognized by the Secretary, as having 
                met such criteria as the Secretary may establish for 
                the furnishing of care coordination under this section 
                (which may include experience in the provision of care 
                coordination or primary care physician's services).
                    ``(B) Period of certification.--The period of 
                certification for an individual referred to in 
                subparagraph (A) is as follows:
                            ``(i) A one-year period for each of the 
                        first three years of participation under this 
                        section.
                            ``(ii) A three-year period thereafter.
            ``(2) Additional requirements.--
                    ``(A) Submission of data.--A care coordinator shall 
                comply with such data collection and reporting 
                requirements as the Secretary determines necessary to 
                assess the effect of care coordination on health 
                outcomes.
                    ``(B) Participation in quality improvement 
                program.--A care coordinator shall participate in the 
                quality improvement program under paragraph (3).
                    ``(C) Additional terms.--A care coordinator shall 
                comply with such other terms and conditions as the 
                Secretary may specify.
            ``(3) Quality improvement program.--
                    ``(A) In general.--The Secretary shall establish a 
                chronic care quality assurance program to monitor and 
                improve clinical outcomes for beneficiaries with 
                chronic conditions.
                    ``(B) Elements of program.--Under the program, the 
                Secretary shall--
                            ``(i) establish standards to measure--
                                    ``(I) quality and performance of 
                                the care of chronic conditions;
                                    ``(II) the continuity and 
                                coordination of care that eligible 
                                beneficiaries under this section 
                                receive; and
                                    ``(III) both underutilization and 
                                overutilization of services;
                            ``(ii) provide to care coordinators 
                        periodic reports on their performance on such 
                        measures; and
                            ``(iii) make available information on 
                        quality and outcomes measures to facilitate 
                        beneficiary comparison and choice of care 
                        coordination options (in such form and on such 
                        quality and outcomes measures as the Secretary 
                        determines to be appropriate).
                    ``(C) Review of claims.--
                            ``(i) In general.--Subject to clause (ii), 
                        under the program the Secretary shall make 
                        available to care coordinators claims data 
                        relating to a beneficiary for whom the 
                        coordinator coordinates care under this section 
                        for the coordinator's review and subsequent 
                        appropriate follow-up action.
                            ``(ii) Authorization.--Data may only be 
                        provided to a care coordinator under clause (i) 
                        if the eligible beneficiary involved has given 
                        written authorization for such information to 
                        be so provided.
            ``(4) Limitation on number of care coordinators.--Payment 
        may only be made under this section for care coordination 
        services furnished during a period to one care coordinator with 
        respect to an eligible beneficiary.
            ``(5) Payment for services.--
                    ``(A) In general.--The Secretary shall establish 
                payment terms and conditions and payment rates for 
                basic care coordination and assessment services 
                described in subsection (d).
                    ``(B) Payment methodology.--Payment under this 
                section shall be made in a manner that bundles payment 
                for all care coordination and assessment services 
                furnished during a period, as specified by the 
                Secretary.
                    ``(C) Codes.--The Secretary may establish new 
                billing codes to carry out the provisions of this 
                paragraph.
    ``(f) Definitions.--In this section:
            ``(1) Serious and disabling chronic condition.--The term 
        `serious and disabling chronic condition' means, with respect 
        to an individual, that the individual has at least one chronic 
        condition and a licensed health care practitioner has certified 
        within the preceding 12-month period that--
                    ``(A) the individual has a level of disability such 
                that the individual is unable to perform (without 
                substantial assistance from another individual) for a 
                period of at least 90 days due to a loss of functional 
                capacity--
                            ``(i) at least 2 activities of daily 
                        living; or
                            ``(ii) such number of instrumental 
                        activities of daily living that is equivalent 
                        (as determined by the Secretary) to the level 
                        of disability described in clause (i);
                    ``(B) the individual has a level of disability 
                equivalent (as determined by the Secretary) to the 
                level of disability described in subparagraph (A); or
                    ``(C) the individual requires substantial 
                supervision to protect the individual from threats to 
                health and safety due to severe cognitive impairment.
            ``(2) Activities of daily living.--The term `activities of 
        daily living' means each of the following:
                    ``(A) Eating.
                    ``(B) Toileting.
                    ``(C) Transferring.
                    ``(D) Bathing.
                    ``(E) Dressing.
                    ``(F) Continence.
            ``(3) Instrumental activities of daily living.--The term 
        `instrumental activities of daily living' means each of the 
        following:
                    ``(A) Medication management.
                    ``(B) Meal preparation.
                    ``(C) Shopping.
                    ``(D) Housekeeping.
                    ``(E) Laundry.
                    ``(F) Money management.
                    ``(G) Telephone use.
                    ``(H) Transportation use.
            ``(4) Chronic condition.--The term `chronic condition' 
        means an illness, functional limitation, or cognitive 
        impairment that--
                    ``(A) lasts, or is expected to last, at least one 
                year;
                    ``(B) limits what a person can do; and
                    ``(C) requires on-going medical care.
            ``(5) Beneficiary.--The term `beneficiary' means an 
        individual entitled to benefits under part A and enrolled under 
        part B, including an individual enrolled under the 
        Medicare+Choice program under part C.''.
    (b) Coverage of Care Coordination and Assessment Services as a Part 
B Medical Service.--
            (1) In general.--Section 1861(s) of the Social Security Act 
        (42 U.S.C. 1395x(s)) is amended--
                    (A) in the second sentence, by redesignating 
                paragraphs (16) and (17) as clauses (i) and (ii); and
                    (B) in the first sentence--
                            (i) by striking ``and'' at the end of 
                        paragraph (14);
                            (ii) by striking the period at the end of 
                        paragraph (15) and inserting ``; and''; and
                            (iii) by adding after paragraph (15) the 
                        following new paragraph:
            ``(16) care coordination and assessment services furnished 
        by a care coordinator in accordance with section 1897.''.
            (2) Conforming amendments.--Sections 1864(a), 
        1902(a)(9)(C), and 1915(a)(1)(B)(ii)(I) of such Act (42 U.S.C. 
        1395aa(a), 1396a(a)(9)(C), and 1396n(a)(1)(B)(ii)(I)) are each 
        amended by striking ``paragraphs (16) and (17)'' each place it 
        appears and inserting ``clauses (i) and (ii) of the second 
        sentence''.
            (3) Part b coinsurance and deductible not applicable to 
        care coordination and assessment services.--
                    (A) Coinsurance.--Section 1833(a)(1) of the Social 
                Security Act (42 U.S.C. 1395l(a)(1)) is amended--
                            (i) by striking ``and'' at the end of 
                        subparagraph (T); and
                            (ii) by inserting before the final 
                        semicolon ``, and (V) with respect to care 
                        coordination and assessment services described 
                        in section 1861(s)(16) that are furnished by, 
                        or coordinated through, a care coordinator, the 
                        amounts paid shall be 100 percent of the 
                        payment amount established under section 
                        1897''.
                    (B) Deductible.--Section 1833(b) of such Act (42 
                U.S.C. 1395l(b)) is amended--
                            (i) by striking ``and'' at the end of 
                        paragraph (5); and
                            (ii) by inserting before the final period 
                        ``, and (7) such deductible shall not apply 
                        with respect to care coordination and 
                        assessment services (as described in section 
                        1861(s)(16))''.
                    (C) Elimination of coinsurance in outpatient 
                hospital settings.--The third sentence of section 
                1866(a)(2)(A) of such Act (42 U.S.C. 1395cc(a)(2)(A)), 
                as amended by section 101(b)(2), is further amended by 
                inserting after ``section 1833(p),'' the following: 
                ``with respect to care coordination and assessment 
                services (as described in section 1861(s)(16)),''.

SEC. 112. CARE COORDINATION AND ASSESSMENT SERVICES AND QUALITY 
              IMPROVEMENT PROGRAM IN MEDICARE+CHOICE PLANS.

    Section 1852(e)(1) of the Social Security Act (42 U.S.C. 1395w-
22(e)(1)) is amended by inserting before the period at the end the 
following: ``, including a quality improvement program for coordinated 
care services referred to in section 1897(e)(3)''.

SEC. 113. IMPROVING CHRONIC CARE COORDINATION THROUGH INFORMATION 
              TECHNOLOGY.

    (a) Technology Improvement Grants.--
            (1) In general.--The Secretary of Health and Human Services 
        (hereinafter in this section referred to as the ``Secretary'') 
        shall make grants to eligible entities to enable such entities 
        to develop, implement, or train personnel in the use of 
        standardized clinical information technology systems designed 
        to--
                    (A) improve the coordination and quality of care 
                furnished to medicare beneficiaries with chronic 
                conditions; and
                    (B) increase administrative efficiencies of such 
                entities.
            (2) Care coordinators as eligible entities.--In this 
        section, an eligible entity is a care coordinator who furnishes 
        care coordination services to medicare beneficiaries under 
        section 1897 of the Social Security Act.
    (b) Eligibility.--To be eligible to receive a grant under 
subsection (a), a care coordinator shall--
            (1) prepare and submit to the Secretary an application at 
        such time, in such manner, and containing such information as 
        the Secretary may require, including a description of the 
        clinical information technology system that the care 
        coordinator intends to implement using amounts received under 
        the grant;
            (2) provide assurances that are satisfactory to the 
        Secretary that such system, for which amounts are to be 
        expended under the grant, conforms to the standards established 
        by the Secretary under part C of title XI of the Social 
        Security Act, and such other standards as the Secretary may 
        specify; and
            (3) furnish the Secretary with such information as the 
        Secretary may require to--
                    (A) evaluate the project for which the grant is 
                made; and
                    (B) ensure that funding provided under the grant is 
                expended for the purposes for which it is made.
    (c) Matching Requirement.--The Secretary may not make a grant to a 
care coordinator under subsection (a) unless that care coordinator 
agrees that, with respect to the costs to be incurred by the care 
coordinator in carrying out the activities for which the grant is being 
awarded, the care coordinator will make available (directly or through 
donations from public or private entities) non-Federal contributions 
toward such costs in an amount equal to $1 for each $1 of Federal funds 
provided under the grant.
    (d) Reports to Congress.--
            (1) Initial report.--Not later than 18 months after the 
        first grant has been made under this section, the Secretary 
        shall submit an initial report to Congress containing the 
        information referred to in paragraph (3) as well as any 
        recommendations with respect to grants under this section.
            (2) Final report.--Not later than 6 months after the last 
        grant has been awarded (as determined by the Secretary) under 
        this section, the Secretary shall submit a final report to 
        Congress containing the information referred to in paragraph 
        (2) as well as any recommendations with respect to grants under 
        this section.
            (3) Contents of report.--The reports under this subsection 
        shall include the following:
                    (A) A description of the number and nature of 
                grants made under this section.
                    (B) An evaluation of--
                            (i) improvements in the coordination and 
                        quality of care furnished to beneficiaries with 
                        chronic conditions; and
                            (ii) increases in administrative 
                        efficiencies of care coordinators.
    (e) Authorization of Appropriations.--For each of fiscal years 
2005, 2006, and 2007, there are authorized to be appropriated to the 
Secretary $10,000,000 to carry out the program under this section.

                   Subtitle C--Additional Provisions

SEC. 121. REVIEW OF COVERAGE STANDARDS.

    (a) Review.--With respect to determinations under section 
1862(a)(1) of such Act (42 U.S.C. 1395y(a)(1)) (relating to whether an 
item or service is reasonable and necessary for the diagnosis or 
treatment of illness or injury for purposes of payment under title 
XVIII of such Act), the Secretary of Health and Human Services shall 
conduct a review of--
            (1) regulations, policies, procedures, and instructions of 
        the Centers for Medicare & Medicaid Services for making those 
        determinations; and
            (2) policies, procedures, local medical review policies, 
        manual instructions, interpretative rules, statements of 
        policy, and guidelines of general applicability of fiscal 
        intermediaries (under section 1816 of the Social Security Act 
        (42 U.S.C. 1395h)) and carriers under section 1842 of such Act 
        (42 U.S.C. 1395u) for making those determinations.
    (b) Modification.--Insofar as the Secretary determines that the 
Centers for Medicare & Medicaid Services, a fiscal intermediary, or a 
carrier has misapplied such standard by requiring that the item or 
service improve the condition of the patient with respect to such 
illness or injury, the Secretary shall take such corrective measures as 
are appropriate to ensure the Centers, intermediary, or carrier (as the 
case may be) applies the proper standard for making such 
determinations.
    (c) Report.--On the date that is 18 months after the date of 
enactment of this Act, the Secretary shall submit to Congress a report 
that contains--
            (1) a detailed statement of the findings and conclusions of 
        the review conducted under subsection (a);
            (2) a detailed statement of the modifications made under 
        subsection (b); and
            (3) recommendations to avoid misapplication of the standard 
        in the future.

 TITLE II--INSTITUTE OF MEDICINE STUDY ON EFFECTIVE CHRONIC CONDITION 
                                  CARE

SEC. 201. INSTITUTE OF MEDICINE MEDICARE CHRONIC CONDITION CARE 
              IMPROVEMENT STUDY AND REPORT.

    (a) Study.--
            (1) In general.--The Secretary of Health and Human Services 
        shall contract with the Institute of Medicine of the National 
        Academy of Sciences to--
                    (A) conduct a comprehensive study of the medicare 
                program to identify--
                            (i) factors that facilitate provision of 
                        effective care (including, where appropriate, 
                        hospice care) for medicare beneficiaries with 
                        chronic conditions; and
                            (ii) factors that impede provision of such 
                        care for such beneficiaries,
                including the issues studied under paragraph (2); and
                    (B) submit the report described in subsection (b).
            (2) Issues studied.--The study required under paragraph (1) 
        shall--
                    (A) identify inconsistent clinical, financial, or 
                administrative requirements across provider and 
                supplier settings or professional services with respect 
                to medicare beneficiaries;
                    (B) identify requirements under the program imposed 
                by law or regulation that--
                            (i) promote costshifting across providers 
                        and suppliers;
                            (ii) impede provision of effective, 
                        seamless transitions across health care 
                        settings, such as between hospitals, skilled 
                        nursing facilities, home health services, 
                        hospice care, and care in the home;
                            (iii) impose unnecessary burdens on such 
                        beneficiaries and their family caregivers;
                            (iv) impede the establishment of 
                        administrative information systems to track 
                        health status, utilization, cost, and quality 
                        data across providers and suppliers and 
                        provider settings;
                            (v) impede the establishment of clinical 
                        information systems that support continuity of 
                        care across settings and over time; or
                            (vi) impede the alignment of financial 
                        incentives among the medicare program, the 
                        medicaid program, and group health plans and 
                        providers and suppliers that furnish services 
                        to the same beneficiary.
    (b) Report.--On the date that is 18 months after the date of 
enactment of this Act, the Institute of Medicine of the National 
Academy of Sciences shall submit to Congress and the Secretary of 
Health and Human Services a report that contains--
            (1) a detailed statement of the findings and conclusions of 
        the study conducted under subsection (a); and
            (2) recommendations to improve provision of effective care 
        for medicare beneficiaries with chronic conditions.
                                 <all>