[Congressional Record Volume 145, Number 114 (Thursday, August 5, 1999)]
[Senate]
[Pages S10391-S10392]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. MACK (for himself, Ms. Mikulski, Mr. Grams, Mr. Wellstone, 
        and Mr. Grassley):
  S. 1499. A bill to title XVIII of the Social Security Act to promote 
the coverage of frail elderly Medicare beneficiaries permanently 
residing in nursing facilities in specialized health insurance programs 
for the frail elderly; to the Committee on Finance.


 Medicare's Elderly Receiving Innovative Treatments (MERIT) Act of 1999

  Mr. MACK. Mr. President, today I am pleased to join my colleagues, 
Senator Mikulski, Senator Wellstone, and Senator Grams, in sponsoring 
the Medicare's Elderly Receiving Innovative Treatments (MERIT) Act of 
1999.
  This legislation ensures that frail elderly persons residing in 
nursing homes continue to have the opportunity for improved quality of 
care and better health outcomes provided by the EverCare program. This 
program is reimbursed by Medicare on a capitated fee basis to managed 
care organizations that deliver preventive and primary medical care 
geared to the special needs of this population. Care is given by nurse 
practitioner/physician primary care teams which also coordinate care 
when the patient is hospitalized. Ideally, as much care as possible is 
provided at the nursing home thus preventing the expense of 
hospitalization. A major goal is to maintain stability in the patients' 
life by caring for them in their place of residence. The typical 
patient is over 85, 82 percent are female, 75 percent are on Medicaid 
and 70 percent have dementia.
  The Balanced Budget Act of 1997 (BBA) requires the Health Care 
Financing Administration (HCFA) to establish a new risk-adjusted 
methodology for payments to health plans which is to go into effect on 
January 1, 2000. An interim risk adjusted payment will be based on 
inpatient hospital encounter data. However, an unintended consequence 
of this methodology may be a dramatic drop in EverCare payments by more 
than 40 percent, according to Long Term Care Data Institute study. This 
would jeopardize the program, which is currently comprised of 
demonstration and non-demonstration components, since providers could 
not afford to remain in business. HCFA recognized the possibly of this 
and did grant an exemption from the interim methodology for one year, 
2000-2001. HCFA, however, has not yet presented a methodology that 
would be fair and adequate to ensure the continuance of EverCare.
  This legislation exempts programs serving the frail elderly living in 
nursing homes from the phased in risk-adjustment payment methodology 
and continues payments using the current system. It directs HCFA to 
develop a distinct payment methodology which meets the needs of these 
patients and to establish performance measurement standards. It also 
allows the frail elderly to join EverCare on a continual basis without 
regard to enrollment periods.
  Mr. President, I ask unanimous consent that a copy of the legislation 
be printed in the Record.
  There being no objection, the bill was ordered to be printed in the 
Record, as follows:

                                S. 1499

       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 ``Medicare's Elderly Receiving 
     Innovative Treatments (MERIT) Act of 1999''.

     SEC. 2. MODIFICATION OF PAYMENT RULES.

       Section 1853 of the Social Security Act (42 U.S.C. 1395w-
     23) is amended--
       (1) in subsection (a)--
       (A) in paragraph (1)(A), by striking ``subsections (e) and 
     (f)'' and inserting ``subsections (e) through (i)'';
       (B) in paragraph (3)(D), by inserting ``and paragraph (4)'' 
     after ``section 1859(e)(4)''; and
       (C) by adding at the end the following:
       ``(4) Exemption from risk-adjustment system for frail 
     elderly beneficiaries enrolled in specialized programs for 
     the frail elderly.--
       ``(A) In general.--During the period described in 
     subparagraph (B), the risk-adjustment described in paragraph 
     (3) shall not apply to a frail elderly Medicare+Choice 
     beneficiary (as defined in subsection (i)(3)) who is enrolled 
     in a Medicare+Choice plan under a specialized program for the 
     frail elderly (as defined in subsection (i)(2)).
       ``(B) Period of application.--The period described in this 
     subparagraph begins with January 2000, and ends with the 
     first month for which the Secretary certifies to Congress 
     that a comprehensive risk adjustment methodology under 
     paragraph (3)(C) (that takes into account the types of 
     factors described in subsection (i)(1)) is being fully 
     implemented.''; and
       (2) by adding at the end the following:
       ``(i) Special Rules for Frail Elderly Enrolled in 
     Specialized Programs for the Frail Elderly.--
       ``(1) Development and implementation of new payment 
     system.--The Secretary shall develop and implement (as soon 
     as possible after the date of enactment of this subsection), 
     during the period described in subsection (a)(4)(B), a 
     payment methodology for frail elderly Medicare+Choice 
     beneficiaries enrolled in a Medicare+Choice plan under a 
     specialized program for the frail elderly (as defined in 
     paragraph (2)(A)). Such methodology shall account for the 
     prevalence, mix, and severity of chronic conditions among 
     such beneficiaries and shall include medical diagnostic 
     factors from all provider settings (including hospital and 
     nursing facility settings). It shall include functional 
     indicators of health status and such other factors as may be 
     necessary to achieve appropriate payments for plans serving 
     such beneficiaries.
       ``(2) Specialized program for the frail elderly 
     described.--
       ``(A) In general.--For purposes of this part, the term 
     `specialized program for the frail elderly' means a program 
     which the Secretary determines--
       ``(i) is offered under this part as a distinct part of a 
     Medicare+Choice plan;
       ``(ii) primarily enrolls frail elderly Medicare+Choice 
     beneficiaries; and
       ``(iii) has a clinical delivery system that is specifically 
     designed to serve the special needs of such beneficiaries and 
     to coordinate short-term and long-term care for such 
     beneficiaries through the use of a team described in 
     subparagraph (B) and through the provision of primary care 
     services to such beneficiaries by means of such a team at the 
     nursing facility involved.
       ``(B) Specialized team.--A team described in this 
     subparagraph--
       ``(i) includes--

       ``(I) a physician; and
       ``(II) a nurse practitioner or geriatric care manager, or 
     both; and

       ``(ii) has as members individuals who have special training 
     and specialize in the care and management of the frail 
     elderly beneficiaries.
       ``(3) Frail elderly medicare+choice beneficiary 
     described.--For purposes of this part, the term `frail 
     elderly Medicare+Choice beneficiary' means a Medicare+Choice 
     eligible individual who--
       ``(A) is residing in a skilled nursing facility or a 
     nursing facility (as defined for purposes of title XIX) for 
     an indefinite period and without any intention of residing 
     outside the facility; and
       ``(B) has a severity of condition that makes the individual 
     frail (as determined under guidelines approved by the 
     Secretary).''.

     SEC. 3. CONTINUOUS OPEN ENROLLMENT FOR QUALIFIED INDIVIDUALS.

       (a) In General.--Section 1851(e) of the Social Security Act 
     (42 U.S.C. 1395w-21(e)) is amended by adding at the end the 
     following:
       ``(7) Special rules for frail elderly medicare+choice 
     beneficiaries enrolling in specialized programs for the frail 
     elderly.--There shall be a continuous open enrollment period 
     for any frail elderly Medicare+Choice beneficiary (as defined 
     in section 1853(i)(3)) who is seeking to enroll in a 
     Medicare+Choice plan under a specialized program for the 
     frail elderly (as defined in section 1853(i)(2)).''.
       (b) Conforming Amendments.--
       (1) Open enrollment periods.--Section 1851(e)(6) of the 
     Social Security Act (42 U.S.C. 1395w-21(e)(6)) is amended--
       (A) in subparagraph (A), by striking ``and'' at the end;
       (B) by redesignating subparagraph (B) as subparagraph (C); 
     and
       (C) by inserting at the end of subparagraph (A) the 
     following:

[[Page S10392]]

       ``(B) that is offering a specialized program for the frail 
     elderly (as defined in section 1853(i)(2)), shall accept 
     elections at any time for purposes of enrolling frail elderly 
     Medicare+Choice beneficiaries (as defined in section 
     1853(i)(3)) in such program; and''.
       (2) Effectiveness of elections.--Section 1851(f)(4) of the 
     Social Security Act (42 U.S.C. 1395w-21(f)(4)) is amended by 
     striking ``subsection (e)(4)'' and inserting ``paragraph (4) 
     or (7) of subsection (e)''.
       (c) Effective Date.--The amendment made by this section 
     shall take effect on the date of enactment of this Act.

     SEC. 4. DEVELOPMENT OF QUALITY MEASUREMENT PROGRAM.

       (a) In General.--Section 1852(e) of the Social Security Act 
     (42 U.S.C. 1395w-22(e)) is amended by adding at the end the 
     following:
       ``(5) Quality measurement program for specialized programs 
     for the frail elderly as part of medicare+choice plans.--The 
     Secretary shall develop and implement a program to measure 
     the quality of care provided in specialized programs for the 
     frail elderly (as defined in section 1853(i)(2)) in order to 
     reflect the unique health aspects and needs of frail elderly 
     Medicare+Choice beneficiaries (as defined in section 
     1853(i)(3)). Such quality measurements may include indicators 
     of the prevalence of pressure sores, reduction of iatrogenic 
     disease, use of urinary catheters, use of anti-anxiety 
     medications, use of advance directives, incidence of 
     pneumonia, and incidence of congestive heart failure.''.
       (b) Effective Date.--The Secretary of Health and Human 
     Services shall first provide for the implementation of the 
     quality measurement program for specialized programs for the 
     frail elderly under the amendment made by subsection (a) by 
     not later than July 1, 2000.
                                 ______