[Congressional Bills 109th Congress]
[From the U.S. Government Publishing Office]
[H.R. 467 Introduced in House (IH)]






109th CONGRESS
  1st Session
                                H. R. 467

  To amend title XVIII of the Social Security Act to provide Medicare 
  beneficiaries with access to geriatric assessments and chronic care 
                  management, and for other purposes.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                            February 1, 2005

   Mr. Gene Green of Texas 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 provide Medicare 
  beneficiaries with access to geriatric assessments and chronic care 
                  management, 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 ``Geriatric and 
Chronic Care Management Act of 2005''.
    (b) Table of Contents.--The table of contents of this Act is as 
follows:

Sec. 1. Short title; table of contents.
Sec. 2. Findings.
Sec. 3. Medicare coverage of geriatric assessments.
Sec. 4. Medicare coverage of chronic care management services.
Sec. 5. Study and report on best practices for medicare chronic care 
                            management.

SEC. 2. FINDINGS.

    Congress makes the following findings:
            (1) We must redesign the medicare system to provide high-
        quality, cost-effective care to a growing population: elderly 
        individuals with multiple chronic conditions.
            (2) According to the Congressional Budget Office, 50 
        percent of medicare costs can be attributed to 5 percent of 
        medicare's most costly beneficiaries.
            (3) Currently, 82 percent of the medicare population has at 
        least 1 chronic condition, and \2/3\ have more than 1 chronic 
        condition. The 20 percent of beneficiaries with 5 or more 
        chronic conditions account for \2/3\ of all medicare spending. 
        In addition, the large Baby Boomer generation is moving toward 
        retirement and medicare eligibility.
            (4) In general, the prevalence of chronic conditions 
        increases with age: 74 percent of the 65- to 69-year-old group 
        have a least 1 chronic condition, while 86 percent of the 85 
        years and older group have at least 1 chronic condition. 
        Similarly, just 14 percent of the 65- to 69-year-olds have 5 or 
        more chronic conditions, but 28 percent of the 85 years and 
        older group have 5 or more chronic conditions.
            (5) There is a strong pattern of increasing utilization as 
        the number of conditions increase. Fifty-five percent of 
        medicare beneficiaries with 5 or more conditions experienced an 
        inpatient hospital stay compared to 5 percent for those with 1 
        condition or 9 percent for those with 2 conditions.
            (6) In terms of physician visits, the average medicare 
        beneficiary has over 15 physician visits annually and sees 6 
        different physicians annually.
            (7) There is almost a 4-fold increase in visits by people 
        with 5 chronic conditions compared to visits by people with 1 
        chronic condition. The number of specific physicians seen 
        increases almost 2\1/2\ times for people with 5 or more chronic 
        conditions relative to those with just 1 chronic condition.
            (8) When Alzheimer's disease and dementia are present along 
        with 1 or more other chronic conditions, utilization also 
        increases. For example, in 2000, total average per person 
        medicare expenditures for those with congestive heart failure 
        and Alzheimer's or dementia were 47 percent higher than for 
        those with congestive heart failure and no dementia.
            (9) Based on numerous studies in the United States and 
        internationally, we know that the delivery of higher quality 
        health care, increased efficiency and cost-effectiveness are 
        the result of systems in which patients are linked with a 
        physician or other qualified health professional who 
        coordinates their care.
            (10) The current medicare program penalizes physicians for 
        integrating and coordinating health care because these services 
        are not explicitly recognized and distinctly paid for. Instead, 
        physicians are incentivized to provide episodic care and to 
        generate more individual patient visits to the doctor's office 
        and hospital for separately reimbursed tests and procedures.
            (11) The chronic care model established by this Act 
        includes several elements that are effective in managing 
        chronic disease--
                    (A) linkages with community resources;
                    (B) health care system changes that reward quality 
                chronic care;
                    (C) support for patient self-management of chronic 
                disease;
                    (D) practice redesign;
                    (E) evidence-based clinical practice guidelines; 
                and
                    (F) clinical information systems, such as 
                electronic medical records and continuity of care 
                records.
            (12) We must realign the financial incentives within 
        medicare as part of a comprehensive system change. Medicare 
        should be restructured to reimburse physicians and other 
        qualified health professionals for the cost of coordinating 
        care.

SEC. 3. MEDICARE COVERAGE OF GERIATRIC ASSESSMENTS.

    (a) Part B Coverage of Geriatric Assessments.--
            (1) In general.--Section 1861(s)(2) of the Social Security 
        Act (42 U.S.C. 1395x(s)(2)), as amended by section 642(a) of 
        the Medicare Prescription Drug, Improvement, and Modernization 
        Act of 2003 (Public Law 108-173; 117 Stat. 2322), is amended--
                    (A) in subparagraph (Y), by striking ``and'' after 
                the semicolon at the end;
                    (B) in subparagraph (Z), by adding ``and'' after 
                the semicolon at the end; and
                    (C) by adding at the end the following new 
                subparagraph:
            ``(AA) geriatric assessments (as defined in subsection 
        (bbb)(1)).''.
            (2) Conforming amendments.--(A) Section 1862(a)(7) of the 
        Social Security Act (42 U.S.C. 1395y(a)(7)), as amended by 
        section 611(d)(1)(B) of the Medicare Prescription Drug, 
        Improvement, and Modernization Act of 2003 (Public Law 108-173; 
        117 Stat. 2304), is amended by striking ``or (K)'' and 
        inserting ``(K), or (AA)''.
            (B) Clauses (i) and (ii) of section 1861(s)(2)(K) of the 
        Social Security Act (42 U.S.C. 1395x(s)(2)(K)), as amended by 
        section 611(d)(2) of the Medicare Prescription Drug, 
        Improvement, and Modernization Act of 2003 (Public Law 108-173; 
        117 Stat. 2304), are each amended by striking ``subsection 
        (ww)(1)'' and inserting ``subsections (ww)(1) and (bbb)(1)''.
    (b) Geriatric Assessments Defined.--Section 1861 of the Social 
Security Act (42 U.S.C. 1395x), as amended by section 706(b) of the 
Medicare Prescription Drug, Improvement, and Modernization Act of 2003 
(Public Law 108-173; 117 Stat. 2339), is amended by adding at the end 
the following new subsection:

              ``Geriatric Assessment; Eligible Individual

    ``(bbb)(1) The term `geriatric assessment' means--
            ``(A) an initial assessment of an eligible individual's 
        medical condition, functional and cognitive capacity, primary 
        caregiver needs, and environmental and psychosocial needs that 
        is conducted by a physician or an entity that meets such 
        conditions as the Secretary may specify (which may include 
        physicians, physician group practices, or other health care 
        professionals or entities the Secretary may find appropriate) 
        working in collaboration with a physician; and
            ``(B) subsequent assessments, which may not be conducted 
        more frequently than annually, unless a physician or chronic 
        care manager of the eligible individual determines that such 
        assessments are required due to sentinel health events or 
        changes in the health status of the individual that may require 
        changes in plans of care developed for the individual.
    ``(2)(A) For purposes of this subsection, the term `eligible 
individual' means an individual who has--
            ``(i) at least 5 chronic conditions and an inability to 
        manage care (as defined by the Secretary); or
            ``(ii) a mental or cognitive impairment, including 
        dementia, and at least 1 other chronic condition.
    ``(B) For purposes of this paragraph, the term `chronic condition' 
means an illness, functional limitation, or cognitive impairment that 
is expected to last at least 1 year, limits the activities of an 
individual, and requires ongoing care.''.
    (c) Payment and Elimination of Cost-sharing.--
            (1) Payment and elimination of coinsurance.--Section 
        1833(a)(1) of the Social Security Act (42 U.S.C. 1395l(a)(1)), 
        as amended by section 302(b)(2) of the Medicare Prescription 
        Drug, Improvement, and Modernization Act of 2003 (Public Law 
        108-173; 117 Stat. 2229), is amended--
                    (A) in subparagraph (N), by inserting ``other than 
                geriatric assessments (as defined in section 
                1861(bbb)(1))'' after ``(as defined in section 
                1848(j)(3))'';
                    (B) by striking ``and'' before ``(V)''; and
                    (C) by inserting before the semicolon at the end 
                the following: ``, and (W) with respect to geriatric 
                assessments (as defined in section 1861(bbb)(1)), the 
                amount paid shall be 100 percent of the lesser of the 
                actual charge for the services or the amount determined 
                under the payment basis determined under section 
                1848''.
            (2) Payment under physician fee schedule.--Section 
        1848(j)(3) of the Social Security Act (42 U.S.C. 1395w-
        4(j)(3)), as amended by section 611(c) of the Medicare 
        Prescription Drug, Improvement, and Modernization Act of 2003 
        (Public Law 108-173; 117 Stat. 2304), is amended by inserting 
        ``(2)(AA),'' after ``(2)(W),''.
            (3) Elimination of coinsurance in outpatient hospital 
        settings.--
                    (A) Exclusion from opd fee schedule.--Section 
                1833(t)(1)(B)(iv) of the Social Security Act (42 U.S.C. 
                1395l(t)(1)(B)(iv)), as amended by section 614 of the 
                Medicare Prescription Drug, Improvement, and 
                Modernization Act of 2003 (Public Law 108-173; 117 
                Stat. 2306), is amended by striking ``and diagnostic 
                mammography'' and inserting ``, diagnostic mammography, 
                or geriatric assessments (as defined in section 
                1861(bbb)(1))''.
                    (B) Conforming amendments.--Section 1833(a)(2) of 
                the Social Security Act (42 U.S.C. 1395l(a)(2)) is 
                amended--
                            (i) in subparagraph (F), by striking 
                        ``and'' after the semicolon at the end;
                            (ii) in subparagraph (G)(ii), by striking 
                        the comma at the end and inserting ``; and''; 
                        and
                            (iii) by inserting after subparagraph 
                        (G)(ii) the following new subparagraph:
                    ``(H) with respect to geriatric assessments (as 
                defined in section 1861(bbb)(1)) furnished by an 
                outpatient department of a hospital, the amount 
                determined under paragraph (1)(W),''.
            (4) Elimination of deductible.--The first sentence of 
        section 1833(b) of the Social Security Act (42 U.S.C. 1395l(b)) 
        is amended--
                    (A) by striking ``and'' before ``(6)''; and
                    (B) by inserting before the period the following: 
                ``, and (7) such deductible shall not apply with 
                respect to geriatric assessments (as defined in section 
                1861(bbb)(1))''.
    (d) Frequency Limitation.--Section 1862(a)(1) of the Social 
Security Act (42 U.S.C. 1395y(a)(1)), as amended by section 613(c) of 
the Medicare Prescription Drug, Improvement, and Modernization Act of 
2003 (Public Law 108-173; 117 Stat. 2306), is amended--
            (1) by striking ``and'' at the end of subparagraph (L);
            (2) by striking the semicolon at the end of subparagraph 
        (M) and inserting ``, and''; and
            (3) by adding at the end the following new subparagraph:
            ``(N) in the case of geriatric assessments (as defined in 
        section 1861(bbb)(1)), which are performed more frequently than 
        is covered under such section;''.
    (e) Exception to Limits on Physician Referrals.--Section 1877(b) of 
the Social Security Act (42 U.S.C. 1395nn(b)), as amended by section 
101(e)(8)(B) of the Medicare Prescription Drug, Improvement, and 
Modernization Act of 2003 (Public Law 108-173; 117 Stat. 2306), is 
amended by adding at the end the following new paragraph:
            ``(6) Geriatric assessments.--In the case of a designated 
        health service, if the designated health service is a geriatric 
        assessment (as defined in section 1861(bbb)(1)) and furnished 
        by a physician.''.
    (f) Rulemaking.--The Secretary of Health and Human Services shall 
define such terms and establish such procedures as the Secretary 
determines necessary to implement the provisions of this section.
    (g) Effective Date.--The amendments made by this section shall 
apply to assessments and chronic care management services furnished on 
or after January 1, 2006.

SEC. 4. MEDICARE COVERAGE OF CHRONIC CARE MANAGEMENT SERVICES.

    (a) Part B Coverage of Chronic Care Management Services.--
            (1) In general.--Section 1861(s)(2) of the Social Security 
        Act (42 U.S.C. 1395x(s)(2)), as amended by section 3(a)(1), is 
        amended--
                    (A) in subparagraph (Z), by striking ``and'' after 
                the semicolon at the end;
                    (B) in subparagraph (AA), by adding ``and'' after 
                the semicolon at the end; and
                    (C) by adding at the end the following new 
                subparagraph:
            ``(BB) chronic care management services (as defined in 
        subsection (ccc));''.
            (2) Conforming amendments.--(A) Section 1862(a)(7) of the 
        Social Security Act (42 U.S.C. 1395y(a)(7)), as amended section 
        3(a)(2)(A), is amended by striking ``or (AA)'' and inserting 
        ``(AA), or (BB)''.
            (B) Clauses (i) and (ii) of section 1861(s)(2)(K) of the 
        Social Security Act (42 U.S.C. 1395x(s)(2)(K)), as amended by 
        section 3(a)(2)(B), are each amended by striking ``subsections 
        (ww)(1) and (bbb)'' and inserting ``subsections (ww)(1), (bbb), 
        and (ccc)''.
    (b) Services Described.--Section 1861 of the Social Security Act 
(42 U.S.C. 1395x), as amended by section 3(b), is amended by adding at 
the end the following new subsection:

  ``Chronic Care Management Services; Chronic Care Manager; Eligible 
                               Individual

    ``(ccc)(1) The term `chronic care management services' means 
services that are furnished to an eligible individual (as defined in 
paragraph (3)) by a chronic care manager (as defined in paragraph (2)) 
under a plan of care prescribed by such chronic care manager for the 
purpose of chronic care management, which may include any of the 
following services:
            ``(A) The development of an initial plan of care, and 
        subsequent appropriate revisions to that plan of care.
            ``(B) The management of, and referral for, medical and 
        other health services, including interdisciplinary care 
        conferences and management with other providers.
            ``(C) The monitoring and management of medications.
            ``(D) Patient education and counseling services.
            ``(E) Family caregiver education and counseling services.
            ``(F) Self-management services, including health education 
        and risk appraisal to identify behavioral risk factors through 
        self-assessment.
            ``(G) Providing access for consultations by telephone with 
        physicians and other appropriate health care professionals, 
        including 24-hour availability of such professionals for 
        emergency consultations.
            ``(H) Management with the principal nonprofessional 
        caregiver in the home.
            ``(I) Managing and facilitating transitions among health 
        care professionals and across settings of care, including the 
        following:
                    ``(i) Pursuing the treatment option elected by the 
                individual.
                    ``(ii) Including any advance directive executed by 
                the individual in the medical file of the individual.
            ``(J) Information about, and referral to, hospice services, 
        including patient and family caregiver education and counseling 
        about hospice, and facilitating transition to hospice when 
        elected.
            ``(K) Information about, referral to, and management with, 
        community services.
            ``(L) Such additional services for which payment would not 
        otherwise be made under this title that the Secretary may 
        specify that encourage the receipt of, or to improve the 
        effectiveness of, the services described in the preceding 
        subparagraphs.
    ``(2)(A) For purposes of this subsection, the term `chronic care 
manager' means an individual or entity that--
            ``(i) is--
                    ``(I) a physician (as defined in subsection 
                (r)(1)); or
                    ``(II) a practitioner described in section 
                1842(b)(18)(C) or an entity that meets such conditions 
                as the Secretary may specify (which may include 
                physicians, physician group practices, or other health 
                care professionals or entities the Secretary may find 
                appropriate) working in collaboration with a physician;
            ``(ii) has entered into a chronic care management agreement 
        with the Secretary; and
            ``(iii) meets such other criteria as the Secretary may 
        establish (which may include experience in the provision of 
        chronic care management or primary care physicians' services).
    ``(B) For purposes of subparagraph (A)(ii), each chronic care 
management agreement shall--
            ``(i) be entered into for a period of 1 year and may be 
        renewed if the Secretary is satisfied that the chronic care 
        manager continues to meet the conditions of participation 
        specified in subparagraph (A);
            ``(ii) ensure that the chronic care manager will submit 
        reports to the Secretary on the functional and medical status 
        of eligible individuals who receive chronic care management 
        services, expenditures relating to such services, and health 
        outcomes relating to such services, except that the Secretary 
        may not require a chronic care manager to submit more than one 
        such report during a year; and
            ``(iii) contain such other terms and conditions as the 
        Secretary may require.
    ``(3) For purposes of this subsection, the term `eligible 
individual' means an eligible individual (as defined in subsection 
(bbb)(2)) who has undergone a geriatric assessment (as defined in 
subsection (bbb)(1)) and who a physician has determined would benefit 
from chronic care management.''.
    (c) Payment and Elimination of Cost-sharing.--
            (1) Payment and elimination of coinsurance.--Section 
        1833(a)(1) of the Social Security Act (42 U.S.C. 1395l(a)(1)), 
        as amended by section 3(c)(1), is amended--
                    (A) in subparagraph (N), by inserting ``or chronic 
                care management services (as defined in section 
                1861(ccc))'' after ``other than geriatric assessments 
                (as defined in section 1861(bbb)(1))'';
                    (B) by striking ``and'' before ``(W)''; and
                    (C) by inserting before the semicolon at the end 
                the following: ``, and (X) with respect to chronic care 
                management services (as defined in section 1861(ccc)), 
                the amount paid shall be 100 percent of the amount 
                determined under section 1834(n)''.
            (2) Payment.--Section 1834 of the Social Security Act (42 
        U.S.C. 1395m) is amended by adding at the end the following new 
        subsection:
    ``(n) Payment for Chronic Care Management Services.--
            ``(1) In general.--The Secretary shall pay for chronic care 
        management services (as defined in section 1861(ccc)(1)) 
        furnished to an eligible individual (as defined in section 
        1861(ccc)(3)) by a chronic care manager (as defined in section 
        1861(ccc)(2))--
                    ``(A) separately from geriatric assessments (as 
                defined in section 1861(bbb)(1)) and other services for 
                which payment is made under this title; and
                    ``(B) based on the methodology selected by the 
                chronic care manager (as so defined) from among the 
                methodologies developed and implemented by the 
                Secretary under paragraph (2).
            ``(2) Development and implementation of payment 
        methodologies.--The Secretary, in consultation with national 
        membership associations representing physicians, qualified 
        health professionals, and patients, shall develop and implement 
        payment methodologies applicable with respect to chronic care 
        management services (as defined in section 1861(ccc)(1)) as 
        follows:
                    ``(A) Unadjusted monthly capitated payment 
                amount.--A per patient per month chronic care 
                management fee separate from evaluation and management 
                services for which payment is made under the physician 
                fee schedule under section 1848 that does not take into 
                account the severity of the eligible individual's 
                condition.
                    ``(B) Adjusted monthly capitated payment amount.--A 
                per patient per month chronic care management fee 
                separate from evaluation and management services for 
                which payment is made under the physician fee schedule 
                under section 1848 that provides for an adjustment to 
                the payment amount based on the severity of the 
                eligible individual's condition.
                    ``(C) Unadjusted fee schedule amount.--A chronic 
                care management fee for care coordination that includes 
                payment for related evaluation and management services 
                for which payment would otherwise be made under the 
                physician fee schedule under section 1848 that does not 
                take into account the severity of the eligible 
                individual's condition.
                    ``(D) Adjusted fee schedule amount.--A chronic care 
                management fee for care coordination that includes 
                payment for related evaluation and management services 
                for which payment would otherwise be made under the 
                physician fee schedule under section 1848 that provides 
                for an adjustment to the payment amount based on the 
                severity of the eligible individual's condition.
                    ``(E) Other payment methodologies.--Any other 
                payment methodology that the Secretary determines 
                effective in creating incentives for physicians and 
                other chronic care managers to make practice-based 
                improvements to improve the quality and cost-
                effectiveness of care provided to eligible 
                individuals.''.
            (3) Elimination of coinsurance in outpatient hospital 
        settings.--
                    (A) Exclusion from opd fee schedule.--Section 
                1833(t)(1)(B)(iv) of the Social Security Act (42 U.S.C. 
                1395l(t)(1)(B)(iv)), as amended by section 3(c)(3)(A), 
                is amended by striking ``or geriatric assessments (as 
                defined in section 1861(bbb)(1))'' and inserting 
                ``geriatric assessments (as defined in section 
                1861(bbb)(1)), or chronic care management services (as 
                defined in section 1861(ccc)(1))''.
                    (B) Conforming amendments.--Section 1833(a)(2) of 
                the Social Security Act (42 U.S.C. 1395l(a)(2)) is 
                amended--
                            (i) in subparagraph (G)(ii), by striking 
                        ``and'' after the semicolon at the end;
                            (ii) in subparagraph (H), by striking the 
                        comma at the end and inserting ``; and''; and
                            (iii) by inserting after subparagraph (H) 
                        the following new subparagraph:
                    ``(I) with respect to chronic care management 
                services (as defined in section 1861(ccc)(1)) furnished 
                by an outpatient department of a hospital, the amount 
                determined under section 1834(n),''.
            (4) Elimination of deductible.--Section 1833(b)(7) of the 
        Social Security Act (42 U.S.C. 1395l(b)(7)), as added by 
        section 3(c)(4), is amended by inserting ``or chronic care 
        management services (as defined in section 1861(ccc)(1))'' 
        after ``geriatric assessments (as defined in section 
        1861(bbb)(1))''.
    (d) Application of Limits on Billing.--Section 1842(b)(18)(C) of 
the Social Security Act (42 U.S.C. 1395u(b)(18)(C)) is amended by 
adding at the end the following new clause:
            ``(vii) A chronic care manager (as defined in section 
        1861(ccc)(2)) that is not a physician.''.
    (e) Exception to Limits on Physician Referrals.--Section 1877(b)(6) 
of the Social Security Act (42 U.S.C. 1395nn(b)(6)), as amended by 
section 3(e), is amended to read as follows:
            ``(6) Geriatric assessments and chronic care management 
        services.--In the case of a designated health service, if the 
        designated health service is--
                    ``(A) a geriatric assessment or a chronic care 
                management service (as defined in subsections (bbb)(1) 
                or (ccc)(1) of section 1861, respectively); and
                    ``(B) provided by a physician or a chronic care 
                manager (as defined in section 1861(ccc)(2)).''.
    (f) Rulemaking.--The Secretary of Health and Human Services shall 
define such terms and establish such procedures as the Secretary 
determines necessary to implement the provisions of this section.
    (g) Effective Date.--The amendments made by this section shall 
apply to assessments and chronic care management services furnished on 
or after January 1, 2006.

SEC. 5. STUDY AND REPORT ON BEST PRACTICES FOR MEDICARE CHRONIC CARE 
              MANAGEMENT.

    (a) Study.--The Secretary, in consultation with the Medicare 
Payment Advisory Commission, shall conduct a thorough study of the 
following issues:
            (1) The effectiveness of the different payment 
        methodologies applicable with respect to chronic care 
        management services developed and implemented under section 
        1834(n)(2) of the Social Security Act (as added by section 
        4(c)(2)).
            (2) The effectiveness of pay-for-performance programs to 
        serve medicare beneficiaries with multiple chronic conditions, 
        including dementia.
            (3) Process measures and outcomes for medicare 
        beneficiaries with multiple chronic illnesses, including 
        dementia.
            (4) The cost-effectiveness and quality associated with 
        chronic care management under the medicare program.
            (5) The feasibility of broadening and incorporating the 
        findings of the Assessing Care of Vulnerable Elders (ACOVE) 
        study into the medicare program.
    (b) Report.--Not later than the date that is 1 year after the date 
of enactment of this Act, the Secretary of Health and Human Services 
shall submit to Congress a report on the study conducted under 
subsection (a) that contains--
            (1) recommendations on the best practices for chronic care 
        management of the conditions of medicare beneficiaries with 
        multiple chronic conditions, including dementia; and
            (2) such other recommendations for legislation or 
        administrative action as the Secretary determines appropriate.
                                 <all>