[Congressional Bills 111th Congress]
[From the U.S. Government Publishing Office]
[H.R. 2390 Introduced in House (IH)]
111th CONGRESS
1st Session
H. R. 2390
To provide for a Medicare prescription drug outreach demonstration
program for individuals who are eligible for benefits under the
Medicare Program and for medical assistance under Medicaid and who have
mental disabilities.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
May 13, 2009
Ms. Roybal-Allard (for herself and Mr. Sessions) 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 provide for a Medicare prescription drug outreach demonstration
program for individuals who are eligible for benefits under the
Medicare Program and for medical assistance under Medicaid and who have
mental disabilities.
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 ``Guidance, Understanding, and
Information for Dual Eligibles (GUIDE) Act''.
SEC. 2. FINDINGS; PURPOSE.
(a) Findings.--The Congress finds the following:
(1) Nearly 8,800,000 Americans were eligible for benefits
under the Medicare program and for medical assistance under
Medicaid (dual eligible beneficiaries) in fiscal year 2005. Of
these ``dual eligible beneficiaries'', almost 40 percent have
cognitive impairments, including Alzheimer's disease, dementia,
serious mental illnesses, and intellectual disabilities. Until
December 31, 2005, dual eligible beneficiaries received
outpatient prescription drug benefits through medical
assistance under Medicaid. On January 1, 2006, drug coverage
for dual eligibles switched from Medicaid to Medicare.
(2) In 2008, 53 percent of dual eligible beneficiaries had
medication access problems and of those, 27 percent experienced
significant adverse clinical events.
(3) Individuals with medication access issues experience
significantly more adverse clinical events. Among dual eligible
beneficiaries with mental illness who had medication access
problems, 27 percent experienced significant adverse clinical
events, which included emergency room visits and
hospitalizations.
(4) In total, over 1,000,000 dual eligible beneficiaries
and low-income subsidy beneficiaries were automatically auto-
enrolled to new benchmark prescription drug plans under part D
of the Medicare program between 2006 and 2007.
(5) Community providers are at the front line of helping
the most vulnerable dual eligible beneficiaries obtain
prescription drug coverage under the Medicare program and
navigate complex enrollment and low-income subsidy eligibility
requirements under such program.
(b) Purpose.--It is the purpose of this bill to help low-income
persons with cognitive impairments to enroll in and navigate the
prescription drug benefit under the Medicare program by providing front
line community providers who serve the population daily with financial
assistance to conduct vigorous education and outreach and direct case
management.
SEC. 3. MEDICARE PRESCRIPTION DRUG OUTREACH DEMONSTRATION PROGRAM FOR
DUAL ELIGIBLE BENEFICIARIES WITH MENTAL DISABILITIES.
(a) In General.--The Secretary of Health and Human Services (in
this section referred to as the ``Secretary'') shall establish a 3-year
demonstration program (in this section referred to as ``the
demonstration program'') under which the Secretary awards grants and
contracts to appropriate, qualified community programs and clinics for
individuals with intellectual or developmental disabilities or such
programs that are described in subsection (b)(1) of section 1913 of the
Public Health Services Act, regardless of whether such program meets
the criteria described in subsection (c) of such section, to employ
qualified social workers and case managers to provide Medicare
prescription drug assistance described in subsection (c) to target
full-benefit dual eligible individuals. As a condition of receipt of a
grant or contract under this subsection, a program or clinic shall
collect and maintain data identified by the Centers for Medicare &
Medicaid Services as critical for the final evaluation and report to
Congress described in subsection (d).
(b) Target Full-Benefit Dual Eligible Individual Defined.--For
purposes of this section, the term ``target full-benefit dual eligible
individual'' means a part D eligible individual, as defined in section
1860D-1(a)(3)(A) of the Social Security Act (42 U.S.C. 1395w-
101(a)(3)(A)), who is a full-benefit dual eligible individual (as
defined in section 1935(c)(6) of the Social Security Act (42 U.S.C.
1396u-5(c)(6))) with one or more mental disabilities, including mental
retardation, dementia, mental illnesses, Alzheimer's disease, autism,
or any other related condition that produces serious cognitive
impairments.
(c) Types of Assistance.--For purposes of subsection (a), the
Medicare prescription drug assistance described in this subsection is
one-on-one counseling with respect to one or more of the following
areas of assistance:
(1) Assistance with initial enrollment in a prescription
drug plan under part D of title XVIII of the Social Security
Act or in an MA-PD plan under part C of such title.
(2) Assistance with switching from one such prescription
drug plan or MA-PD plan to another such prescription drug plan
or MA-PD plan.
(3) Assistance with filing for an exception to a formulary
used by such a plan.
(4) Assistance with filing a grievance, reconsideration, or
appeal under section 1860D-4 of the Social Security Act (42
U.S.C. 1395w-104), including assistance with collecting
relevant information to file such a grievance, reconsideration,
or appeal.
(5) Assistance with navigating utilization management
programs administered by a PDP sponsor offering a prescription
drug plan under part D of title XVIII of the Social Security
Act or a Medicare Advantage organization offering an MA-PD plan
under part C of such title.
(6) Assistance with obtaining prescription drugs from
pharmacies participating with such a plan.
(7) Assistance with facilitating contact with the Medicare
Beneficiary Ombudsman appointed under section 1808(c) of the
Social Security Act (42 U.S.C. 1395b-9).
(d) Evaluation and Report.--
(1) Evaluation.--The Secretary shall provide for an
evaluation of the demonstration program. Such evaluation may
include an analysis of--
(A) the utilization of the assistance provided
under the program;
(B) the satisfaction of target full-benefit dual
eligible individuals with such assistance; and
(C) the success of the program in--
(i) facilitating access by such individuals
to covered part D drugs (as defined in section
1860D-2(e) of the Social Security Act (42
U.S.C. 1395w-102(e)); and
(ii) medication compliance.
(2) Report.--Not later than 6 months after the date of the
completion of the demonstration program, the Secretary shall
submit to Congress a report on such evaluation and shall
include in such report recommendations regarding the
feasibility of permanently funding an education and outreach
program on the prescription drug benefit under the Medicare
program for target full-benefit dual eligible individuals.
(e) Authorization of Appropriations.--There is authorized to be
appropriated for each of the fiscal years 2011 through 2013--
(1) to carry out this section (other than subsection (d)),
$10,000,000; and
(2) such sums as may be necessary to carry out subsection
(d).
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