I 111th CONGRESS 1st Session H. R. 2390 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.

1.

Short title

This Act may be cited as the Guidance, Understanding, and Information for Dual Eligibles (GUIDE) Act.

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.

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).