S.Amdt. 1119

1. 1

   Change 1: Rewrites section 443

   Replaces

   In S. 1 · Reported to Senate

   Struck: SEC. 443. MEDICARE COMPLEX CLINICAL CARE MANAGEMENT PAYMENT DEMONSTRATION.

   Struck: (a) Establishment.--

   Struck: (1) In general.--The Secretary shall establish a demonstration program to make the medicare program more responsive to needs of eligible beneficiaries by promoting continuity of care, helping stabilize medical conditions, preventing or minimizing acute exacerbations of chronic conditions, and reducing adverse health outcomes, such as adverse drug interactions related to polypharmacy.

   Struck: (2) Sites.--The Secretary shall designate 6 sites at which to conduct the demonstration program under this section, of which at least 3 shall be in an urban area and at least 1 shall be in a rural area. One of the sites shall be located in the State of Arkansas.

   Show 31 more struck paragraphsShow less

   Struck: (3) Duration.--The Secretary shall conduct the demonstration program under this section for a 3-year period.

   Struck: (4) Implementation.--The Secretary shall not implement the demonstration program before October 1, 2004.

   Struck: (b) Participants.--Any eligible beneficiary who resides in an area designated by the Secretary as a demonstration site under subsection (a)(2) may participate in the demonstration program under this section if such beneficiary identifies a principal care physician who agrees to manage the complex clinical care of the eligible beneficiary under the demonstration program.

   Struck: (c) Principal Care Physician Responsibilities.--The Secretary shall enter into an agreement with each principal care physician who agrees to manage the complex clinical care of an eligible beneficiary under subsection (b) under which the principal care physician shall--

   Struck: (1) serve as the primary contact of the eligible beneficiary in accessing items and services for which payment may be made under the medicare program;

   Struck: (2) maintain medical information related to care provided by other health care providers who provide health care items and services to the eligible beneficiary, including clinical reports, medication and treatments prescribed by other physicians, hospital and hospital outpatient services, skilled nursing home care, home health care, and medical equipment services;

   Struck: (3) monitor and advocate for the continuity of care of the eligible beneficiary and the use of evidence-based guidelines;

   Struck: (4) promote self-care and family caregiver involvement where appropriate;

   Struck: (5) have appropriate staffing arrangements to conduct patient self-management and other care coordination activities as specified by the Secretary;

   Struck: (6) refer the eligible beneficiary to community services organizations and coordinate the services of such organizations with the care provided by health care providers; and

   Struck: (7) meet such other complex care management requirements as the Secretary may specify.

   Struck: (d) Complex Clinical Care Management Fee.--

   Struck: (1) Payment.--Under an agreement entered into under subsection (c), the Secretary shall pay to each principal care physician, on behalf of each eligible beneficiary under the care of that physician, the complex clinical care management fee developed by the Secretary under paragraph (2).

   Struck: (2) Development of fee.--The Secretary shall develop a complex care management fee under this paragraph that is paid on a monthly basis and which shall be payment in full for all the functions performed by the principal care physician under the demonstration program, including any functions performed by other qualified practitioners acting on behalf of the physician, appropriate staff under the supervision of the physician, and any other person under a contract with the physician, including any person who conducts patient self- management and caregiver education under subsection (c)(4).

   Struck: (e) Funding.--

   Struck: (1) In general.--The Secretary shall provide for the transfer from the Federal Supplementary Insurance Trust Fund established under section 1841 of the Social Security Act (42 U.S.C. 1395t) of such funds as are necessary for the costs of carrying out the demonstration program under this section.

   Struck: (2) Budget neutrality.--In conducting the demonstration program under this section, the Secretary shall ensure that the aggregate payments made by the Secretary do not exceed the amount which the Secretary would have paid if the demonstration program under this section was not implemented.

   Struck: (f) Waiver Authority.--The Secretary may waive such requirements of titles XI and XVIII of the Social Security Act (42 U.S.C. 1301 et seq.; 1395 et seq.) as may be necessary for the purpose of carrying out the demonstration program under this section.

   Struck: (g) Report.--Not later than 6 months after the completion of the demonstration program under this section, the Secretary shall submit to Congress a report on such program, together with recommendations for such legislation and administrative action as the Secretary determines to be appropriate.

   Struck: (h) Definitions.--In this section:

   Struck: (1) Activity of daily living.--The term "activity of daily living" means eating, toiling, transferring, bathing, dressing, and continence.

   Struck: (2) Chronic condition.--The term "chronic condition" means a biological, physical, or mental condition that is likely to last a year or more, for which there is no known cure, for which there is a need for ongoing medical care, and which may affect an individual's ability to carry out activities of daily living or instrumental activities of daily living, or both.

   Struck: (3) Eligible beneficiary.--The term "eligible beneficiary" means any individual who--

   Struck: (A) is enrolled for benefits under part B of the medicare program;

   Struck: (B) has at least 4 complex medical conditions (one of which may be cognitive impairment); and

   Struck: (C) has--

   Struck: (i) an inability to self-manage their care; or

   Struck: (ii) a functional limitation defined as an impairment in 1 or more activity of daily living or instrumental activity of daily living.

   Struck: (4) Instrumental activity of daily living.--The term "instrumental activity of daily living" means meal preparation, shopping, housekeeping, laundry, money management, telephone use, and transportation use.

   Struck: (5) Medicare program.--The term "medicare program" means the health care program under title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.).

   Struck: (6) Principal care physician.--The term "principal care physician" means the physician with primary responsibility for overall coordination of the care of an eligible beneficiary (as specified in a written plan of care) who may be a primary care physician or a specialist.

   Inserted: SEC. 443. MEDICARE COVERAGE OF CARE COORDINATION AND ASSESSMENT SERVICES.

   Inserted: (a) Part B Coverage of Care Coordination and Assessment Services.--Section 1861(s)(2) of the Social Security Act (42 U.S.C. 1395x(s)(2)) is amended--

   Inserted: (1) in subparagraph (U), by striking "and" at the end;

   Inserted: (2) in subparagraph (V)(iii), by adding "and" after the semicolon at the end; and

   Inserted: (3) by adding at the end the following new subparagraph:

   Inserted: "(W) care coordination and assessment services (as defined in subsection (ww)).".

   Inserted: (b) Care Coordination and Assessment Services Defined.--Section 1861 of the Social Security Act (42 U.S.C. 1395x) is amended by adding at the end the following new subsection:

   Inserted: "Care Coordination and Assessment Services

   Inserted: "(ww)(1) The term 'care coordination and assessment services' means services that are furnished to an eligible individual (as defined in paragraph (2)) by a care coordinator (as defined in paragraph (3)) under a plan of care prescribed by such care coordinator for the purpose of care coordination and assessment, which may include any of the following services:

   Inserted: "(A) an initial assessment of an individual's medical condition, functional and cognitive capacity and environmental and psychological needs and an annual assessment thereafter.

   Inserted: "(B) Management of transitions of care across practice settings and between providers.

   Inserted: "(C) Coordination of, and referral for, medical and other health-related services, including--

   Show 55 more inserted paragraphsShow less

   Inserted: "(i) multidisciplinary care conferences;

   Inserted: "(ii) coordination with other providers, including telephone consultations with physicians; and

   Inserted: "(iii) monitoring and management of medications, with special emphasis on clients using multiple prescriptions (including coordination with the entity managing benefits for the individual).

   Inserted: "(D) Patient and family care-giver education and counseling (through office visits or telephone consultation), including self-management services and risk appraisal to identify behavioral risk factors through self assessment.

   Inserted: "(E) Providing information about end of life care, including referral to hospice services, when appropriate, including patient and family caregiver education and counseling about hospice, and managing and facilitating transition to hospice when elected.

   Inserted: "(F) Referral to and coordination with community resources.

   Inserted: "(G) Such other services for which payment would not otherwise be made under this title as the Secretary shall determine to be appropriate including, but not limited to, activities to facilitate continuity of care and patient adherence to plans of care.

   Inserted: "(2) For purposes of this subsection, the term 'eligible individual' means an individual who a care coordinator annually certifies has multiple chronic conditions and meets eligibility criteria determined by the Secretary.

   Inserted: "(3)(A) For purposes of this subsection, the term 'care coordinator' means an individual or entity that--

   Inserted: "(i) is--

   Inserted: "(I) a physician who provides care to at least 50 eligible individuals; or

   Inserted: "(II) an independent nurse practitioner who provides care to at least 50 eligible individuals;

   Inserted: "(ii) has entered into a care coordination agreement with the Secretary; and

   Inserted: "(iii) has appropriate office staffing, operating under the direction of the eligible provider, which is sufficient in size and expertise to address the complex clinical care coordination needs of participating beneficiaries in the practice;

   Inserted: "(iv) has an ability and process to identify eligible beneficiaries;

   Inserted: "(v) has an ability to coordinate care for participating beneficiaries;

   Inserted: "(vi) has an ability to maintain and update patient records to ensure that care provided by other treating providers (including the instructions of other treating providers and any related lab results, prescription orders, and ancillary treatment services) is included in the record;

   Inserted: "(vii) has an ability to periodically review the medical record of participating beneficiaries to identify problems related to transitions, poly-pharmacy, and care continuity and to respond to resolve identified problems;

   Inserted: "(viii) is capable of referring to and coordinating with community-based supportive services;

   Inserted: "(ix) has an ability to communicate with participating beneficiaries or family caregivers as needed and appropriate, using telephonic and/or electronic communications; and

   Inserted: "(x) agrees to coordinate care for participating beneficiaries, consult with other treating providers (including but not limited to other treating physicians, other medical professionals involved in patient care, residential and inpatient facilities, and pharmacies), and community service providers;

   Inserted: "(xi) agrees to recognize patient treatment preferences; and

   Inserted: "(xii) is certified by the Secretary as meeting standards defined by the Secretary and being capable of coordinating clinical care for eligible beneficiaries.

   Inserted: "(B) For purposes of subparagraph (A)(ii), each care coordination agreement shall--

   Inserted: "(i) be entered into for a period of 1 year and may be renewed if the Secretary is satisfied that the care coordinator continues to meet the conditions of participation specified in subparagraph (A);

   Inserted: "(ii) contain such other terms and conditions as the Secretary may require.

   Inserted: "(4) For purposes of this subsection, the Secretary shall send quarterly reports to each eligible provider that inform, in aggregate, on the provider's participating beneficiary caseload, using measures determined by the Secretary that are derived from existing Medicare date sources. In preparing the reports under this paragraph, the Secretary shall consider--

   Inserted: "(A) the average number of emergency room and nursing home visits relative to geographic norms for all eligible beneficiaries; and

   Inserted: "(B) the average number of unique physician visits relative to geographic norms for all eligible beneficiaries.

   Inserted: "(5) For purposes of this subsection, the term 'functional limitations' means each of the following:

   Inserted: "(A) Eating.

   Inserted: "(B) Toileting.

   Inserted: "(C) Transferring.

   Inserted: "(D) Bathing.

   Inserted: "(E) Dressing.

   Inserted: "(F) Continence.

   Inserted: "(6) Rural health clinics and Federally qualified health centers shall be eligible sites at which care coordination and assessment services may be provided.

   Inserted: "(7) For purposes of this subsection, the term 'chronic condition' means an illness, functional limitation, or cognitive impairment that is expected to last at least 1 year and limits what a person can do, and requires ongoing care.

   Inserted: "(8) For purposes of this subsection, the Secretary shall establish eligibility criteria for the care management benefit that would target approximately 5 percent of elderly medicare fee-for-service enrollees. The eligibility criteria should identify enrollees who need care management because they have multiple chronic conditions that result in high use of Medicare services, high use of prescription medications, and high Medicare costs. Inability to manage one's own care due to cognitive impairment should be considered as an additional indicator of need for care management.

   Inserted: (c) Payment and Elimination of Coinsurance.--

   Inserted: (1) In general.--Section 1833(a)(1) of the Social Security Act (42 U.S.C. 1395l(a)(1)) is amended--

   Inserted: (A) by striking "and" before "(U)"; and

   Inserted: (B) by inserting before the semicolon at the end the following: ", and (V) with respect to assessment services described in section 1861(s)(2)(W), the amounts paid shall be 100 percent of the lesser of the actual charge for the service or the amount determined under the payment basis determined under section 1848 by the Secretary for such service and an administrative fee shall be developed for care coordination services".

   Inserted: (2) Payment under physician fee schedule.--Section 1848(j)(3) of the Social Security Act (42 U.S.C. 1395w-4(j)(3)) is amended by inserting "(2)(W)," after "(2)(S),".

   Inserted: (3) Elimination of coinsurance in outpatient hospital settings.--The third sentence of section 1866(a)(2)(A) of the Social Security Act (42 U.S.C. 1395cc(a)(2)(A)) is amended by inserting after "1861(s)(10)(A)" the following: ", with respect to care coordination and assessment services (as defined in section 1861(ww)(1)),".

   Inserted: (d) Application of Limits on Billing.--Section 1842(b)(18)(C) of the Social Security Act (42 U.S.C. 1395u(b)(18)(C)) is amended by adding at the end the following new clause:

   Inserted: "(vii) A care coordinator (as defined in section 1861(ww)(3)) that is not a physician.".

   Inserted: (e) Exception to Limits on Physician Referrals.--Section 1877(b) of the Social Security Act (42 U.S.C. 1395nn(b)) is amended--

   Inserted: (1) by redesignating paragraph (4) as paragraph (5); and

   Inserted: (2) by inserting after paragraph (3) the following new paragraph:

   Inserted: "(4) Private sector purchasing and quality improvement tools for original medicare.--In the case of a designated health service, if the designated health service is--

   Inserted: "(A) a care coordination and assessment service (as defined in section 1861(ww)(1)); and

   Inserted: "(B) provided by a care coordinator (as defined in paragraph (3) of such section).".

   Inserted: (f) Rulemaking.--The Secretary of Health and Human Services shall define such terms and establish such procedures as the Secretary determines necessary to implement the provisions of this section.

   Inserted: (g) Effective Date.--The amendments made by this section shall apply to care coordination and assessment services furnished on or after January 1, 2006, and before January 1, 2011.

   Original wording

   Strike section 443 and insert the following:

2. 2

   Change 2: Adds SEC. __. MEDICARE SECONDARY PAYOR (MSP) PROVISIONS at the end of subtitle B of title IV

   Adds a section

   In S. 1 · Reported to Senate

   (b) Report.--Not later than 1 year after the date of enactment of this Act, the Comptroller General of the United States shall submit to Congress a report on the study conducted under subsection (a). The report shall include recommendations regarding the use of more current data in computing geographic cost of practice indices as well as the use of data directly representative of physicians' costs (rather than proxy measures of such costs).

   Inserted: SEC. __. MEDICARE SECONDARY PAYOR (MSP) PROVISIONS.

   Inserted: (a) Technical Amendment Concerning Secretary's Authority to Make Conditional Payment When Certain Primary Plans Do Not Pay Promptly.--

   Inserted: (1) In general.--Section 1862(b)(2) (42 U.S.C. 1395y(b)(2)) is amended--

   Inserted: (A) in subparagraph (A)(ii), by striking "promptly (as determined in accordance with regulations)";

   Inserted: (B) in subparagraph (B)--

   Inserted: (i) by redesignating clauses (i) through (iii) as clauses (ii) through (iv), respectively; and

   Inserted: (ii) by inserting before clause (ii), as so redesignated, the following new clause:

   Inserted: "(i) Authority to make conditional payment.--The Secretary may make payment under this title with respect to an item or service if a primary plan described in subparagraph (A)(ii) has not made or cannot reasonably be expected to make payment with respect to such item or service promptly (as determined in accordance with regulations). Any such payment by the Secretary shall be conditioned on reimbursement to the appropriate Trust Fund in accordance with the succeeding provisions of this subsection.".

   Inserted: (2) Effective date.--The amendments made by paragraph (1) shall be effective as if included in the enactment of title III of the Medicare and Medicaid Budget Reconciliation Amendments of 1984 (Public Law 98-369).

   Inserted: (b) Clarifying Amendments to Conditional Payment Provisions.--Section 1862(b)(2) (42 U.S.C. 1395y(b)(2)) is further amended--

   Inserted: (1) in subparagraph (A), in the matter following clause (ii), by inserting the following sentence at the end: "An entity that engages in a business, trade, or profession shall be deemed to have a self-insured plan if it carries its own risk (whether by a failure to obtain insurance, or otherwise) in whole or in part.";

   Inserted: (2) in subparagraph (B)(ii), as redesignated by subsection (a)(2)(B)--

   Show 6 more inserted paragraphsShow less

   Inserted: (A) by striking the first sentence and inserting the following: "A primary plan, and an entity that receives payment from a primary plan, shall reimburse the appropriate Trust Fund for any payment made by the Secretary under this title with respect to an item or service if it is demonstrated that such primary plan has or had a responsibility to make payment with respect to such item or service. A primary plan's responsibility for such payment may be demonstrated by a judgment, a payment conditioned upon the recipient's compromise, waiver, or release (whether or not there is a determination or admission of liability) of payment for items or services included in a claim against the primary plan or the primary plan's insured, or by other means."; and

   Inserted: (B) in the final sentence, by striking "on the date such notice or other information is received" and inserting "on the date notice of, or information related to, a primary plan's responsibility for such payment or other information is received"; and

   Inserted: (3) in subparagraph (B)(iii), , as redesignated by subsection (a)(2)(B), by striking the first sentence and inserting the following: "In order to recover payment made under this title for an item or service, the United States may bring an action against any or all entities that are or were required or responsible (directly, as an insurer or self-insurer, as a third-party administrator, as an employer that sponsors or contributes to a group health plan, or large group health plan, or otherwise) to make payment with respect to the same item or service (or any portion thereof) under a primary plan. The United States may, in accordance with paragraph (3)(A) collect double damages against any such entity. In addition, the United States may recover under this clause from any entity that has received payment from a primary plan or from the proceeds of a primary plan's payment to any entity.".

   Inserted: (c) Clerical Amendments.--Section 1862(b) (42 U.S.C. 1395y(b)) is amended--

   Inserted: (1) in paragraph (1)(A), by moving the indentation of clauses (ii) through (v) 2 ems to the left; and

   Inserted: (2) in paragraph (3)(A), by striking "such" before "paragraphs".

   Original wording

   At the end of subtitle B of title IV, add the following:

Read automatically from the Congressional Record. Check the original before relying on it.

As printed