[Congressional Record Volume 144, Number 49 (Tuesday, April 28, 1998)]
[Senate]
[Pages S3720-S3721]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Ms. MIKULSKI (for herself and Mr. Faircloth):
  S. 1997. A bill to protect the right of a member of a health 
maintenance organization to receive continuing care at a facility 
selected by that member; to the Committee on Labor and Human Resources.


         THE ``SENIORS' ACCESS TO CONTINUING CARE ACT OF 1998''

  Ms. MIKULSKI. Mr. President, I rise today to introduce the ``Seniors' 
Access to Continuing Care Act of 1998'', a bill to protect seniors' 
access to treatment in the setting of their choice and to ensure that 
seniors who reside in continuing care communities, and nursing and 
other facilities have the right to return to that facility after a 
hospitalization.
  As our population ages, more and more elderly will become residents 
of various long term care facilities. These include independent living, 
assisted living and nursing facilities, as well as continuing care 
retirement communities, which provide the entire continuum of care. In 
Maryland alone, there are over 12,000 residents in 32 continuing care 
retirement communities and 24,000 residents in over 200 licenced 
nursing facilities.
  I have visited many of these facilities and have heard from both 
residents and operators. They have told me about a serious and 
unexpected problem encountered with returning to their facility after a 
hospitalization. Many individuals have little choice when entering a 
nursing facility. They do so because it is medically necessary, because 
they need a high level of care that they can no longer receive in their 
homes or in a more independent setting, such as assisted living. But 
residents are still able to form relationships with other residents and 
staff and consider the facility their ``home''.
  More and more individuals and couples are choosing to enter 
continuing care communities because of the community environment they 
provide. CCRC's provide independent living, assisted living and nursing 
care, usually on the same campus--the Continuum of Care. Residents find 
safety, security and peace of mind. They often prepay for the continuum 
of care. Couples can stay together, and if one spouse needs additional 
care, it can be provided right there, where the other spouse can remain 
close by.
  But hospitalization presents other challenges. Hospitalization is 
traumatic for anyone, but particularly for our vulnerable seniors. We 
know that having comfortable surroundings and familiar faces can aid 
dramatically in the recovery process. So, we should do everything we 
can to make sure that recovery process is not hindered.
  Today, more and more seniors are joining managed care plans. This 
trend is likely to accelerate given the expansion of managed care 
choices under the 1997 Balanced Budget Act. As more and more decisions 
are made based on financial considerations, choice often gets lost. 
Currently, a resident of a continuing care retirement community or a 
nursing facility who goes to the hospital has no guarantee that he or 
she will be allowed by the MCO to return to the CCRC or nursing 
facility for post acute follow up care.
  The MCO can dictate that the resident go to a different facility that 
is in the MCO network for that follow up care, even if the home 
facility is qualified and able to provide the needed care.
  Let me give you a few examples:
  In the fall of 1996, a resident of Applewood Estates in Freehold, New 
Jersey was admitted to the hospital. Upon discharge, her HMO would not 
permit her to return to Applewood and sent her to another facility in 
Jackson. The following year, the same thing happened, but after strong 
protest, the HMO finally relented and permitted her to return to 
Applewood. She should not have had to protest, and many seniors are 
unable to assert themselves.
  A Florida couple in their mid-80's were separated by a distance of 20 
miles after the wife was discharged from a hospital to an HMO-
participating nursing home located on the opposite side of the county. 
This was a hardship for the husband who had difficulty driving and for 
the wife who longed to return to her home, a CCRC. The CCRC had room in 
its skilled nursing facility on campus. Despite pleas from all those 
involved, the HMO would not allow the wife to recuperate in a familiar 
setting, close to her husband and friends. She later died at the HMO 
nursing facility, without the benefit of frequent visits by her husband 
and friends.
  An elderly couple in Riverside, California encountered the same 
problem when the husband was discharged from the hospital and retained 
against her will at the HMO skilled nursing facility instead of the 
couple's community. At 25 miles apart, it was impossible for his wife 
and friends to visit at a time when he needed the tenderness and 
compassion of loved ones.
  Another Florida woman, a resident of a CCRC fractured her hip. Her 
HMO wanted her to move into a nursing home for treatment. She refused 
to abandon her home and received the treatment at the CCRC. Her HMO 
refused to pay for the treatment, so she had to pay out of her pocket.
  Collington Episcopal Life Care Community, in my home state of 
Maryland, reports ongoing problems with its frail elderly having to 
obtain psychiatric services, including medication monitoring, off 
campus, even though the services are available at Collington--how 
disruptive to good patient care!
  On a brighter note, an Ohio woman's husband was in a nursing 
facility. When she was hospitalized, and then discharged, she was able 
to be admitted to the same nursing facility because of the Ohio law 
that protected that right.
  Seniors coming out of the hospital should not be passed around like a 
baton. Their care should be decided based on what is clinically 
appropriate, not what is financially mandated. Why is that important? 
What are the consequences?
  Residents consider their retirement community or long term care 
facility as their home. And being away from home for any reason can be 
very difficult. The trauma of being in unfamiliar surroundings can 
increase recovery time. The staff of the resident's ``home'' facility 
often knows best about the person's chronic care and service needs. 
Being away from ``home'' separates the resident from his or her 
emotional support system.
  Refusal to allow a resident to return to his or her home takes away 
the person's choice. All of this leads to greater recovery time and 
unnecessary trauma for the patient.
  And should a woman's husband have to hitch a ride or catch a cab in 
order to see his recovering spouse if the facility where they live can 
provide the care? No. Retirement communities and other long term care 
facilities are not just health care facilities. They provide an entire 
living environment for their residents, in other words, a home. We need 
to protect the choice of our seniors to return to their ``home'' after 
a hospitalization. And that is what my bill does.
  It protects residents of CCRC's and nursing facilities by: enabling 
them to return to their facility after a hospitalization; and requiring 
the resident's insurer or managed care organization (MCO) to cover the 
cost of the care, even if the insurer does not have a contract with the 
resident's facility.

[[Page S3721]]

  In order for the resident to return to the facility and have the 
services covered by the insurer or MCO: 1. The service to be provided 
must be a service that the insurer covers; 2. The resident must have 
resided at the facility before hospitalization, have a right to return, 
and choose to return; 3. The facility must have the capacity to provide 
the necessary service and meet applicable licensing and certification 
requirements of the state; 4. The facility must be willing to accept 
substantially similar payment as a facility under contract with the 
insurer or MCO.
  My bill also requires an insurer or MCO to pay for a service to one 
of its beneficiaries, without a prior hospital stay, if the service is 
necessary to prevent a hospitalization of the beneficiary and the 
service is provided as an additional benefit. Lastly, the bill requires 
an insurer or MCO to provide coverage to a beneficiary for services 
provided at a facility in which the beneficiary's spouse already 
resides, even if the facility is not under contract with the MCO, 
provided the other requirements are met.
  In conclusion, Mr. President, I am committed to providing a safety 
net for our seniors--this bill is part of that safety net. Seniors 
deserve quality, affordable health care and they deserve choice. This 
bill offers those residing in retirement communities and long term care 
facilities assurance to have their choices respected, to have where 
they reside recognized as their ``home'', and to be permitted to return 
to that ``home'' after a hospitalization. It ensures that spouses can 
be together as long as possible. And it ensures access to care in order 
to prevent a hospitalization. I urge my colleagues to join me in 
passing this important measure to protect the rights of seniors and 
their access to continuing care.
                                 ______