II 111th CONGRESS 1st Session S. 1640 IN THE SENATE OF THE UNITED STATES August 6, 2009 Mr. Wyden (for himself, Mr. Cornyn, and Mr. Harkin) introduced the following bill; which was read twice and referred to the Committee on Finance A BILL To amend title XVIII of the Social Security Act to provide coverage of intensive lifestyle treatment.

1.

Short title

This Act may be cited as the Take Back Your Health Act of 2009.

2.

Coverage of intensive lifestyle treatment

(a)

Intensive lifestyle treatment program

(1)

In general

Section 1861 of the Social Security Act (42 U.S.C. 1395x) is amended— (A)in subsection (s)(2)— (i)in subparagraph (DD) by striking and at the end; (ii)in subparagraph (EE) by inserting and at the end; and (iii)by adding at the end the following new subparagraph: (FF)items and services furnished under an intensive lifestyle treatment program (as defined in paragraph (hhh)(1)) to eligible beneficiaries (as defined in paragraph (hhh)(4)); ; and (B)by adding at the end the following new subsection: (hhh)

Intensive lifestyle treatment program

(1)The term intensive lifestyle treatment program means a physician-supervised program (as defined in paragraph (2)) that furnishes the items and services described in paragraph (3) intended to beneficially affect the progression of chronic diseases to eligible beneficiaries (as defined in paragraph (4)). (2)A program described in this paragraph is a program under which— (A)items and services under the program are delivered— (i)in a physician's office or clinic; (ii)in a hospital on an outpatient basis; or (iii)in other settings determined appropriate by the Secretary; (B)a physician (as defined in section 1861(r)(1)) is immediately available and accessible for medical consultation and medical emergencies at all times items and services are being furnished under the program, except that, in the case of items and services furnished under such a program in a hospital, such availability shall be presumed; (C)individualized treatment is furnished under a written plan established and designed by a physician (as so defined) in advance of the start of the program and reviewed and signed by a physician every 60 days that describes— (i)the individual's diagnosis; (ii)the type, amount, frequency, and duration of the items and services furnished under the plan; and (iii)the goals set for the individual under the plan; (D)items and services may be provided in a series of 72 one-hour sessions (as defined in section 1848(b)(6)), up to 6 sessions per day, over a period of 18 weeks, and may include group sessions with up to 15 other eligible beneficiaries; and (E)items and services may be provided— (i)by an intensive lifestyle team; (ii)under the direction of a physician (as so defined); and (iii)if determined appropriate by the Secretary, in the case of such items and services provided in underserved areas, by a physician assistant, nurse practitioner, or clinical nurse specialist as provided under State law. (3)The items and services described in this paragraph are— (A)exercise; (B)risk factor modification, including education, counseling, and behavioral intervention (to the extent such education, counseling, and behavioral intervention is closely related to the individual's care and treatment and is tailored to the individual's needs); (C)psychosocial assessment; (D)provider consultation; (E)care coordination; (F)medication management; (G)medical nutritional therapy; (H)tobacco cessation; (I)outcomes assessment; and (J)such other items and services as the Secretary determines appropriate, but only if such items and services are— (i)reasonable and necessary for the diagnosis or active treatment of the individual's condition; (ii)reasonably expected to improve or maintain the individual's condition and functional level; and (iii)furnished under such guidelines relating to the frequency and duration of such items and services as the Secretary shall establish, taking into account accepted norms of medical practice and the reasonable expectation of improvement of the individual. (4)The term eligible beneficiary means an individual who is entitled to, or enrolled for, benefits under part A and enrolled under this part and who has been diagnosed with 1 or more of the following conditions: (A)Coronary heart disease. (B)Type 2 diabetes. (C)Metabolic syndrome. (D)Prostate cancer. (E)Breast cancer. . (2)

Payment for intensive lifestyle treatment programs

(A)

Inclusion in physicians' services

Section 1848(j)(3) of the Social Security Act (42 U.S.C. 1395w–4(j)(3)) is amended by inserting (2)(FF), after (2)(EE).. (B)

Conforming amendment

Section 1848(b) of the Social Security Act (42 U.S.C. 1395w–4(b)) is amended by adding at the end the following new paragraph: (6)

Treatment of intensive lifestyle treatment program

(A)

In general

In the case of an intensive lifestyle treatment program described in section 1861(hhh)(2), the Secretary shall establish an aggregate payment for items and services furnished under such program (as described in section 1861(hhh)(3)) not to exceed the cost to the program under this title for a hospitalization for a similarly situated eligible beneficiary, subject to the limitation under subparagraph (C). (B)

Payment schedule

The Secretary shall— (i)make a payment to such a program in an amount that is equal to 50 percent of the amount established under subparagraph (A) upon completion of the initial consultation under the program; and (ii)subject to the limitation described in subparagraph (C), make a second payment to a program for the balance of the amount defined in subparagraph (A) upon completion of treatment under the program. (C)

Limitation

(i)

In general

Notwithstanding the provisions of subparagraph (B), an intensive lifestyle treatment program shall not receive the payment described in subparagraph (B)(ii) unless it documents, upon the completion of the program by an eligible beneficiary, that services provided to such beneficiary under the program are beneficially affecting the progression of chronic disease or diseases in the beneficiary, as measured under clause (ii) with respect to 2 or more of the following measures: (I)Measures described in subclauses (I) through (V) of section 1861(eee)(4)(A)(ii). (II)High density lipoprotein. (III)Hemoglobin A1C. (IV)C-reactive protein. (V)Waist size. (VI)Elimination of cotinine level as evidence that the eligible beneficiary no longer uses tobacco. (VII)Prostate specific antigen or other prognostic biomarkers of prostate cancer. (VIII)Prognostic biomarkers of breast cancer. (ii)

Measurement

The Secretary shall determine the beneficial progression of chronic disease or diseases under clause (i), using the level of 2 or more of the measures described in subclause (i) before receiving services under such program and such levels after completion of treatment under the program— (I)by normalization (as defined by the Secretary); and (II)in the case of— (aa)measures described in subclauses (I) through (V), (VII), and (VIII), by at least 10 percent reduction; or (bb)the measure described in subclause (VI), by elimination. (iii)

Refund of payments or costs in certain circumstances

In the case of an eligible beneficiary who, within 1 year of receiving an initial consultation under the program, receives any other treatment covered under part A or this part for any condition that relates to the initial diagnosis resulting in eligibility for the intensive lifestyle treatment program, except for a physician office visit for the purpose of making adjustments to medication prescribed to the eligible beneficiary, such program shall refund to the Secretary the lesser of— (I)any payments made under paragraph (B) for services provided to the eligible beneficiary under the program; or (II)the cost of such other treatment covered under part A or this part such condition. (D)

Coverage of sessions

(i)

In general

Items and services provided under the program in a series of 72 one-hour sessions (as defined in clause (ii)), up to 6 sessions per day, over a period of 18 weeks shall, subject to the limitation under subparagraph (C), be eligible for the aggregate payment established under subparagraph (A). (ii)

Definition of session

Each of the services described in subparagraphs (A) through (J) of section 1861(hhh)(3), when furnished for 1 hour, is a separate session under an intensive lifestyle treatment program. . (b)

Copayments for intensive lifestyle treatment items and services

Section 1833(a)(1) of the Social Security Act (42 U.S.C. 1395l(a)(1)) is amended— (1)by striking and before (W); (2)by inserting before the semicolon at the end the following: , and (X) with respect to items and services furnished under an intensive lifestyle treatment program (as defined in section 1861(hhh)(2)), the amount paid shall be 100 percent of the lesser of the actual charge for the services or the amount determined under section 1848(b)(6)(A). (c)

Lifestyle rewards program

Title XVIII of the Social Security Act is amended by adding at the end the following new section:

1899.

Lifestyle Rewards Programs

(a)

Establishment

The Secretary shall establish a Lifestyle Rewards Program (in this section referred to as the program) for eligible beneficiaries (as defined in section 1861(s)(2)(hhh)(4)) who have successfully completed an intensive lifestyle treatment program (as defined in section 1861(hhh)(2)) and meet the requirements described in subsection (b). (b)

Requirements

In order to receive an award under the program, an eligible beneficiary must— (1)demonstrate that the program has beneficially affected the progression of chronic disease or diseases in the beneficiary upon completion of the program, as measured under clause (ii) of section 1848(b)(6)(C) with respect to 2 or more of the measures described in clause (i) of such section; and (2)during the 1 year period beginning on the date of an initial consultation under the lifestyle treatment program, receive no other treatment under part A or this part for any condition that relates to the initial diagnosis resulting in eligibility for the intensive lifestyle treatment program, except for a physician office visit for the purpose of making adjustments to medication prescribed to the eligible beneficiary. (c)

Form of reward

The Secretary shall make such award to eligible beneficiaries described in subsection (a) in such form and manner as the Secretary, by regulation, shall prescribe. (d)

Amount of reward

The amount of such award for each such eligible beneficiary shall be $200.

. (d)

Effective date

The amendments made by this section shall apply to items and services furnished on or after January 1, 2010.

3.

Sense of the Congress

It is the sense of the Congress that the services provided under a intensive lifestyle treatment program (as defined in section 1861(hhh)(2) of the Social Security Act, as added by section 2(a))— (1)would benefit individuals with chronic diseases who are not enrolled in the Medicare Program under title XVIII of the Social Security Act; and (2)should be covered by all public and private payers.