[Congressional Bills 108th Congress]
[From the U.S. Government Publishing Office]
[H.R. 2342 Introduced in House (IH)]
108th CONGRESS
1st Session
H. R. 2342
To amend title XVIII of the Social Security Act to expand Medicare
benefits to prevent, delay, and minimize the progression of chronic
conditions, and develop national policies on effective chronic
condition care, and for other purposes.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
June 4, 2003
Mr. Stark (for himself, Mr. Rangel, Mr. Matsui, Mr. McDermott, Mr.
Sandlin, and Mrs. Jones of Ohio) 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 amend title XVIII of the Social Security Act to expand Medicare
benefits to prevent, delay, and minimize the progression of chronic
conditions, and develop national policies on effective chronic
condition care, and for other purposes.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE; TABLE OF CONTENTS.
(a) Short Title.--This Act may be cited as the ``Medicare Chronic
Care Improvement Act of 2003''.
(b) Table of Contents.--The table of contents of this Act is as
follows:
Sec. 1. Short title; table of contents.
TITLE I--BENEFITS TO PREVENT, DELAY, AND MINIMIZE THE PROGRESSION OF
CHRONIC CONDITIONS
Subtitle A--Improving Access to Preventive Services
Sec. 101. Elimination of deductibles and coinsurance for existing
preventive health benefits.
Sec. 102. Institute of Medicine medicare prevention benefit study and
report.
Sec. 103. Authority to administratively provide for coverage of
additional preventive benefits.
Sec. 104. Coverage of an initial preventive physical examination.
Subtitle B--Medicare Coverage for Care Coordination and Assessment
Services
Sec. 111. Care coordination and assessment services.
Sec. 112. Care coordination and assessment services and quality
improvement program in Medicare+Choice
plans.
Sec. 113. Improving chronic care coordination through information
technology.
Subtitle C--Additional Provisions
Sec. 121. Review of coverage standards.
TITLE II--INSTITUTE OF MEDICINE STUDY ON EFFECTIVE CHRONIC CONDITION
CARE
Sec. 201. Institute of Medicine medicare chronic condition care
improvement study and report.
TITLE I--BENEFITS TO PREVENT, DELAY, AND MINIMIZE THE PROGRESSION OF
CHRONIC CONDITIONS
Subtitle A--Improving Access to Preventive Services
SEC. 101. ELIMINATION OF DEDUCTIBLES AND COINSURANCE FOR EXISTING
PREVENTIVE HEALTH BENEFITS.
(a) In General.--Section 1833 of the Social Security Act (42 U.S.C.
1395l) is amended by inserting after subsection (o) the following new
subsection:
``(p) Deductibles and Coinsurance Waived for Preventive Health
Items and Services.--The Secretary shall not require the payment of any
deductible or coinsurance under subsection (a) or (b), respectively, of
any individual enrolled for coverage under this part for any of the
following preventive health items and services:
``(1) Blood-testing strips, lancets, and blood glucose
monitors for individuals with diabetes described in section
1861(n).
``(2) Diabetes outpatient self-management training services
(as defined in section 1861(qq)(1)).
``(3) Pneumococcal, influenza, and hepatitis B vaccines and
administration described in section 1861(s)(10).
``(4) Screening mammography (as defined in section
1861(jj)).
``(5) Screening pap smear and screening pelvic exam (as
defined in paragraphs (1) and (2) of section 1861(nn),
respectively).
``(6) Bone mass measurement (as defined in section
1861(rr)(1)).
``(7) Prostate cancer screening test (as defined in section
1861(oo)(1)).
``(8) Colorectal cancer screening test (as defined in
section 1861(pp)(1)).
``(9) Screening for glaucoma (as defined in section
1861(uu)).
``(10) Medical nutrition therapy services (as defined in
section 1861(vv)(1)).''.
(b) Waiver of Coinsurance.--
(1) In general.--Section 1833(a)(1)(B) of the Social
Security Act (42 U.S.C. 1395l(a)(1)(B)) is amended to read as
follows: ``(B) with respect to preventive health items and
services described in subsection (p), the amounts paid shall be
100 percent of the fee schedule or other basis of payment under
this title for the particular item or service,''.
(2) 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: ``,
preventive health items and services described in section
1833(p),''.
(c) Waiver of Application of Deductible.--Section 1833(b)(1) of the
Social Security Act (42 U.S.C. 1395l(b)(1)) is amended to read as
follows: ``(1) such deductible shall not apply with respect to
preventive health items and services described in subsection (p),''.
(d) Adding ``Lancet'' to Definition of DME.--Section 1861(n) of the
Social Security Act (42 U.S.C. 1395x(n)) is amended by striking
``blood-testing strips and blood glucose monitors'' and inserting
``blood-testing strips, lancets, and blood glucose monitors''.
(e) Conforming Amendments.--
(1) Elimination of coinsurance for clinical diagnostic
laboratory tests.--Paragraphs (1)(D)(i) and (2)(D)(i) of
section 1833(a) of the Social Security Act (42 U.S.C. 1395l(a))
are each amended by inserting ``or which are described in
subsection (p)'' after ``assignment-related basis''.
(2) Elimination of coinsurance for certain dme.--Section
1834(a)(1)(A) of the Social Security Act (42 U.S.C.
1395m(a)(1)(A)) is amended by inserting ``(or 100 percent, in
the case of such an item described in section 1833(p))'' after
``80 percent''.
(3) Elimination of deductibles and coinsurance for
colorectal cancer screening tests.--Section 1834(d) of the
Social Security Act (42 U.S.C. 1395m(d)) is amended--
(A) in paragraph (2)(C)--
(i) by striking ``(C) Facility payment
limit.--'' and all that follows through
``Notwithstanding subsections'' and inserting
the following:
``(C) Facility payment limit.--Notwithstanding
subsections'';
(ii) by striking ``(I) in accordance'' and
inserting the following:
``(i) in accordance'';
(iii) by striking ``(II) are performed''
and all that follows through ``payment under''
and inserting the following:
``(ii) are performed in an ambulatory
surgical center or hospital outpatient
department,
payment under''; and
(iv) by striking clause (ii); and
(B) in paragraph (3)(C)--
(i) by striking ``(C) Facility payment
limit.--'' and all that follows through
``Notwithstanding subsections'' and inserting
the following:
``(C) Facility payment limit.--Notwithstanding
subsections''; and
(ii) by striking clause (ii).
(f) Effective Date.--The amendments made by this section shall
apply to services furnished on or after January 1, 2004.
SEC. 102. INSTITUTE OF MEDICINE MEDICARE PREVENTION BENEFIT STUDY AND
REPORT.
(a) Study.--
(1) In general.--The Secretary of Health and Human Services
shall contract with the Institute of Medicine of the National
Academy of Sciences to--
(A) conduct a comprehensive study of current
literature and best practices in the field of health
promotion and disease prevention among medicare
beneficiaries, including the issues described in
paragraph (2); and
(B) submit the report described in subsection (b).
(2) Issues studied.--The study required under paragraph (1)
shall include an assessment of--
(A) whether each health promotion and disease
prevention benefit covered under the medicare program
is medically effective (as defined in subsection
(d)(3));
(B) utilization by medicare beneficiaries of such
benefits (including any barriers to or incentives to
increase utilization);
(C) quality of life issues associated with such
benefits; and
(D) whether health promotion and disease prevention
benefits that are not covered under the medicare
program that would affect all medicare beneficiaries
are likely to be medically effective (as so defined).
(b) Reports.--
(1) Three-year report.--On the date that is 3 years after
the date of enactment of this Act, and each successive 3-year
anniversary thereafter, the Institute of Medicine of the
National Academy of Sciences shall submit to the President a
report that contains--
(A) a detailed statement of the findings and
conclusions of the study conducted under subsection
(a); and
(B) the recommendations for legislation described
in paragraph (3).
(2) Interim report based on new guidelines.--If the United
States Preventive Services Task Force or the Task Force on
Community Preventive Services establishes new guidelines
regarding preventive health benefits for medicare beneficiaries
more than 1 year prior to the date that a report described in
paragraph (1) is due to be submitted to the President, then not
later than 6 months after the date such new guidelines are
established, the Institute of Medicine of the National Academy
of Sciences shall submit to the President a report that
contains a detailed description of such new guidelines. Such
report may also contain recommendations for legislation
described in paragraph (3).
(3) Recommendations for legislation.--The Institute of
Medicine of the National Academy of Sciences, in consultation
with the United States Preventive Services Task Force and the
Task Force on Community Preventive Services, shall develop
recommendations in legislative form that--
(A) prioritize the preventive health benefits under
the medicare program; and
(B) modify such benefits, including adding new
benefits under such program, based on the study
conducted under subsection (a).
(c) Transmission to Congress.--
(1) In general.--Subject to paragraph (2), on the day that
is 6 months after the date on which the report described in
paragraph (1) of subsection (b) (or paragraph (2) of such
subsection if the report contains recommendations in
legislative form described in subsection (b)(3)) is submitted
to the President, the President shall transmit the report and
recommendations to Congress.
(2) Regulatory action by the secretary of health and human
services.--If the Secretary of Health and Human Services has
exercised the authority under section 103(a) to adopt by
regulation one or more of the recommendations under subsection
(b)(3), the President shall only submit to Congress those
recommendations under subsection (b)(3) that have not been
adopted by the Secretary.
(3) Delivery.--Copies of the report and recommendations in
legislative form required to be transmitted to Congress under
paragraph (1) shall be delivered--
(A) to both Houses of Congress on the same day;
(B) to the Clerk of the House of Representatives if
the House is not in session; and
(C) to the Secretary of the Senate if the Senate is
not in session.
(d) Definition of Medically Effective.--In this section, the term
``medically effective'' means, with respect to a benefit or technique,
that the benefit or technique has been--
(1) subject to peer review;
(2) described in scientific journals; and
(3) determined to achieve an intended goal under normal
programmatic conditions.
SEC. 103. AUTHORITY TO ADMINISTRATIVELY PROVIDE FOR COVERAGE OF
ADDITIONAL PREVENTIVE BENEFITS.
(a) In General.--The Secretary of Health and Human Services may by
regulation adopt any or all of the legislative recommendations
developed by the Institute of Medicine of the National Academy of
Sciences, in consultation with the United States Preventive Services
Task Force and the Task Force on Community Preventive Services in a
report under section 102(b)(3) (relating to prioritizing and modifying
preventive health benefits under the medicare program and the addition
of new preventive benefits), consistent with subsection (b).
(b) Elimination of Cost-Sharing.--With respect to items and
services furnished under the medicare program that the Secretary has
incorporated by regulation under subsection (a), the provisions of
section 1833(p) of the Social Security Act (relating to elimination of
cost-sharing for preventive benefits), as added by section 101(a),
shall apply to those items and services in the same manner as such
section applies to the items and services described in paragraphs (1)
through (10) of such section.
SEC. 104. COVERAGE OF AN INITIAL PREVENTIVE PHYSICAL EXAMINATION.
(a) Coverage.--Section 1861(s)(2) of the Social Security Act (42
U.S.C. 1395x(s)(2)) is amended--
(1) in subparagraph (U), by striking ``and'' at the end;
(2) in subparagraph (V), by inserting ``and'' at the end;
and
(3) by adding at the end the following new subparagraph:
``(W) an initial preventive physical examination (as
defined in subsection (ww));''.
(b) Services Described.--Section 1861 of such Act (42 U.S.C. 1395x)
is amended by adding at the end the following new subsection:
``Initial Preventive Physical Examination
``(ww) The term `initial preventive physical examination' means
physicians' services consisting of a physical examination with the goal
of health promotion and disease detection and includes a history and
physical exam, a health risk appraisal, and health risk counseling, and
laboratory tests or other items and services as determined by the
Secretary in consultation with the United States Preventive Services
Task Force.''.
(c) Waiver of Deductible and Coinsurance.--
(1) Deductible.--The first sentence of section 1833(b) of
such Act (42 U.S.C. 1395l(b)) is amended--
(A) by striking ``and'' before ``(6)'', and
(B) by inserting before the period at the end the
following: ``, and (7) such deductible shall not apply
with respect to an initial preventive physical
examination (as defined in section 1861(ww))''.
(2) Coinsurance.--Section 1833(a)(1) of such Act (42 U.S.C.
1395l(a)(1)) is amended--
(A) in clause (N), by inserting ``(or 100 percent
in the case of an initial preventive physical
examination, as defined in section 1861(ww))'' after
``80 percent''; and
(B) in clause (O), by inserting ``(or 100 percent
in the case of an initial preventive physical
examination, as defined in section 1861(ww))'' after
``80 percent''.
(d) Payment as Physicians' Services.--Section 1848(j)(3) of such
Act (42 U.S.C. 1395w-4(j)(3)) is amended by inserting ``(2)(W),'' after
``(2)(S),''.
(e) Other Conforming Amendments.--Section 1862(a) of such Act (42
U.S.C. 1395y(a)) is amended--
(1) in paragraph (1)--
(A) by striking ``and'' at the end of subparagraph
(H);
(B) by striking the semicolon at the end of
subparagraph (I) and inserting ``, and''; and
(C) by adding at the end the following new
subparagraph:
``(J) in the case of an initial preventive physical
examination (as defined in section 1861(ww)), which is
performed not later than 6 months after the date the
individual's first coverage period begins under part B;''; and
(2) in paragraph (7), by striking ``or (H)'' and inserting
``(H), or (J)''.
(f) Effective Date.--The amendments made by this section shall
apply to services furnished on or after January 1, 2004, but only for
individuals whose coverage period begins on or after such date.
Subtitle B--Medicare Coverage for Care Coordination and Assessment
Services
SEC. 111. CARE COORDINATION AND ASSESSMENT SERVICES.
(a) Services Authorized.--Title XVIII of the Social Security Act
(42 U.S.C. 1395 et seq.) is amended by adding at the end the following
new section:
``care coordination and assessment services
``Sec. 1897. (a) Purpose.--
``(1) In general.--The purpose of this section is to
provide the appropriate level and mix of follow-up care to an
individual with a chronic condition who qualifies as an
eligible beneficiary (as defined in paragraph (2)).
``(2) Eligible beneficiary defined.--In this section, the
term `eligible beneficiary' means a beneficiary who--
``(A) has a serious and disabling chronic condition
(as defined in subsection(f)(1)); or
``(B) has four or more chronic conditions (as
defined in subsection (f)(4)).
``(b) Election of Care Coordination and Assessment Services.--
``(1) In general.--On or after January 1, 2005, an eligible
beneficiary may elect to receive care coordination services in
accordance with the provisions of this section under which, in
appropriate circumstances, the eligible beneficiary has health
care services covered under this title managed and coordinated
by a care coordinator who is qualified under subsection (e) to
furnish care coordination services under this section.
``(2) Revocation of election.--An eligible beneficiary who
has made an election under paragraph (1) may revoke that
election at any time.
``(c) Outreach.--The Secretary shall provide for the wide
dissemination of information to beneficiaries and providers of
services, physicians, practitioners, and suppliers with respect to the
availability of and requirements for care coordination services under
this section.
``(d) Care Coordination and Assessment Services Described.--Care
coordination services under this section shall include the following:
``(1) Basic care coordination and assessment services.--
Except as otherwise provided in this section, eligible
beneficiaries who have made an election under this section
shall receive the following services:
``(A)(i) An initial assessment of an individual's
medical condition, functional and cognitive capacity,
and environmental and psychosocial needs.
``(ii) Annual assessments after the initial
assessment performed under clause (i), unless the
physician or care coordinator of the individual
determines that additional assessments are required due
to sentinel health events or changes in the health
status of the individual that may require changes in
the plan of care developed for the individual.
``(B) The development of an initial plan of care,
and subsequent appropriate revisions to that plan of
care.
``(C) The management of, and referral for, medical
and other health services, including multidisciplinary
care conferences and coordination with other providers.
``(D) The monitoring and management of medications.
``(E) Patient education and counseling services.
``(F) Family caregiver education and counseling
services.
``(G) Self-management services, including health
education and risk appraisal to identify behavioral
risk factors through self-assessment.
``(H) Consultations by telephone with physicians
and other appropriate health care professionals,
including 24-hour access to a care coordinator.
``(I) Coordination with the principal caregiver in
the home.
``(J) The managing and facilitating of transitions
among health care professionals and across settings of
care, including the following:
``(i) The pursuit the treatment option
elected by the individual.
``(ii) The inclusion of any advance
directive executed by the individual in the
medical file of the individual.
``(K) Activities that facilitate continuity of care
and patient adherence to plans of care.
``(L) Information about, and referral to,
community-based services, including patient and family
caregiver education and counseling about such services,
and facilitating access to such services when elected.
``(M) Information about, and referral to, hospice
services and palliative care, including patient and
family caregiver education and counseling about hospice
services and palliative care, and facilitating
transition to hospice when elected.
``(N) Such other medical and health care services
for which payment would not otherwise be made under
this title as the Secretary determines to be
appropriate for effective care coordination, including
the additional items and services as described in
paragraph (2).
``(2) Additional benefits.--The Secretary may specify
additional benefits for which payment would not otherwise be
made under this title that may be available to eligible
beneficiaries who have made an election under this section
(subject to an assessment by the care coordinator of an
individual beneficiary's circumstances and need for such
benefits) in order to encourage the receipt of, or to improve
the effectiveness of, care coordination services.
``(e) Care Coordinators.--
``(1) Requirement for certification.--
``(A) In general.--In order to be qualified to
furnish care coordination and assessment services under
this section, an individual or entity shall be a health
care professional or entity (which may include
physicians, physician group practices, or other health
care professionals or entities the Secretary may find
appropriate) who has been certified for a period (as
provided in subparagraph (B)) by the Secretary, or by
an organization recognized by the Secretary, as having
met such criteria as the Secretary may establish for
the furnishing of care coordination under this section
(which may include experience in the provision of care
coordination or primary care physician's services).
``(B) Period of certification.--The period of
certification for an individual referred to in
subparagraph (A) is as follows:
``(i) A one-year period for each of the
first three years of participation under this
section.
``(ii) A three-year period thereafter.
``(2) Additional requirements.--
``(A) Submission of data.--A care coordinator shall
comply with such data collection and reporting
requirements as the Secretary determines necessary to
assess the effect of care coordination on health
outcomes.
``(B) Participation in quality improvement
program.--A care coordinator shall participate in the
quality improvement program under paragraph (3).
``(C) Additional terms.--A care coordinator shall
comply with such other terms and conditions as the
Secretary may specify.
``(3) Quality improvement program.--
``(A) In general.--The Secretary shall establish a
chronic care quality assurance program to monitor and
improve clinical outcomes for beneficiaries with
chronic conditions.
``(B) Elements of program.--Under the program, the
Secretary shall--
``(i) establish standards to measure--
``(I) quality and performance of
the care of chronic conditions;
``(II) the continuity and
coordination of care that eligible
beneficiaries under this section
receive; and
``(III) both underutilization and
overutilization of services;
``(ii) provide to care coordinators
periodic reports on their performance on such
measures; and
``(iii) make available information on
quality and outcomes measures to facilitate
beneficiary comparison and choice of care
coordination options (in such form and on such
quality and outcomes measures as the Secretary
determines to be appropriate).
``(C) Review of claims.--
``(i) In general.--Subject to clause (ii),
under the program the Secretary shall make
available to care coordinators claims data
relating to a beneficiary for whom the
coordinator coordinates care under this section
for the coordinator's review and subsequent
appropriate follow-up action.
``(ii) Authorization.--Data may only be
provided to a care coordinator under clause (i)
if the eligible beneficiary involved has given
written authorization for such information to
be so provided.
``(4) Limitation on number of care coordinators.--Payment
may only be made under this section for care coordination
services furnished during a period to one care coordinator with
respect to an eligible beneficiary.
``(5) Payment for services.--
``(A) In general.--The Secretary shall establish
payment terms and conditions and payment rates for
basic care coordination and assessment services
described in subsection (d).
``(B) Payment methodology.--Payment under this
section shall be made in a manner that bundles payment
for all care coordination and assessment services
furnished during a period, as specified by the
Secretary.
``(C) Codes.--The Secretary may establish new
billing codes to carry out the provisions of this
paragraph.
``(f) Definitions.--In this section:
``(1) Serious and disabling chronic condition.--The term
`serious and disabling chronic condition' means, with respect
to an individual, that the individual has at least one chronic
condition and a licensed health care practitioner has certified
within the preceding 12-month period that--
``(A) the individual has a level of disability such
that the individual is unable to perform (without
substantial assistance from another individual) for a
period of at least 90 days due to a loss of functional
capacity--
``(i) at least 2 activities of daily
living; or
``(ii) such number of instrumental
activities of daily living that is equivalent
(as determined by the Secretary) to the level
of disability described in clause (i);
``(B) the individual has a level of disability
equivalent (as determined by the Secretary) to the
level of disability described in subparagraph (A); or
``(C) the individual requires substantial
supervision to protect the individual from threats to
health and safety due to severe cognitive impairment.
``(2) Activities of daily living.--The term `activities of
daily living' means each of the following:
``(A) Eating.
``(B) Toileting.
``(C) Transferring.
``(D) Bathing.
``(E) Dressing.
``(F) Continence.
``(3) Instrumental activities of daily living.--The term
`instrumental activities of daily living' means each of the
following:
``(A) Medication management.
``(B) Meal preparation.
``(C) Shopping.
``(D) Housekeeping.
``(E) Laundry.
``(F) Money management.
``(G) Telephone use.
``(H) Transportation use.
``(4) Chronic condition.--The term `chronic condition'
means an illness, functional limitation, or cognitive
impairment that--
``(A) lasts, or is expected to last, at least one
year;
``(B) limits what a person can do; and
``(C) requires on-going medical care.
``(5) Beneficiary.--The term `beneficiary' means an
individual entitled to benefits under part A and enrolled under
part B, including an individual enrolled under the
Medicare+Choice program under part C.''.
(b) Coverage of Care Coordination and Assessment Services as a Part
B Medical Service.--
(1) In general.--Section 1861(s) of the Social Security Act
(42 U.S.C. 1395x(s)) is amended--
(A) in the second sentence, by redesignating
paragraphs (16) and (17) as clauses (i) and (ii); and
(B) in the first sentence--
(i) by striking ``and'' at the end of
paragraph (14);
(ii) by striking the period at the end of
paragraph (15) and inserting ``; and''; and
(iii) by adding after paragraph (15) the
following new paragraph:
``(16) care coordination and assessment services furnished
by a care coordinator in accordance with section 1897.''.
(2) Conforming amendments.--Sections 1864(a),
1902(a)(9)(C), and 1915(a)(1)(B)(ii)(I) of such Act (42 U.S.C.
1395aa(a), 1396a(a)(9)(C), and 1396n(a)(1)(B)(ii)(I)) are each
amended by striking ``paragraphs (16) and (17)'' each place it
appears and inserting ``clauses (i) and (ii) of the second
sentence''.
(3) Part b coinsurance and deductible not applicable to
care coordination and assessment services.--
(A) Coinsurance.--Section 1833(a)(1) of the Social
Security Act (42 U.S.C. 1395l(a)(1)) is amended--
(i) by striking ``and'' at the end of
subparagraph (T); and
(ii) by inserting before the final
semicolon ``, and (V) with respect to care
coordination and assessment services described
in section 1861(s)(16) that are furnished by,
or coordinated through, a care coordinator, the
amounts paid shall be 100 percent of the
payment amount established under section
1897''.
(B) Deductible.--Section 1833(b) of such Act (42
U.S.C. 1395l(b)) is amended--
(i) by striking ``and'' at the end of
paragraph (5); and
(ii) by inserting before the final period
``, and (7) such deductible shall not apply
with respect to care coordination and
assessment services (as described in section
1861(s)(16))''.
(C) Elimination of coinsurance in outpatient
hospital settings.--The third sentence of section
1866(a)(2)(A) of such Act (42 U.S.C. 1395cc(a)(2)(A)),
as amended by section 101(b)(2), is further amended by
inserting after ``section 1833(p),'' the following:
``with respect to care coordination and assessment
services (as described in section 1861(s)(16)),''.
SEC. 112. CARE COORDINATION AND ASSESSMENT SERVICES AND QUALITY
IMPROVEMENT PROGRAM IN MEDICARE+CHOICE PLANS.
Section 1852(e)(1) of the Social Security Act (42 U.S.C. 1395w-
22(e)(1)) is amended by inserting before the period at the end the
following: ``, including a quality improvement program for coordinated
care services referred to in section 1897(e)(3)''.
SEC. 113. IMPROVING CHRONIC CARE COORDINATION THROUGH INFORMATION
TECHNOLOGY.
(a) Technology Improvement Grants.--
(1) In general.--The Secretary of Health and Human Services
(hereinafter in this section referred to as the ``Secretary'')
shall make grants to eligible entities to enable such entities
to develop, implement, or train personnel in the use of
standardized clinical information technology systems designed
to--
(A) improve the coordination and quality of care
furnished to medicare beneficiaries with chronic
conditions; and
(B) increase administrative efficiencies of such
entities.
(2) Care coordinators as eligible entities.--In this
section, an eligible entity is a care coordinator who furnishes
care coordination services to medicare beneficiaries under
section 1897 of the Social Security Act.
(b) Eligibility.--To be eligible to receive a grant under
subsection (a), a care coordinator shall--
(1) prepare and submit to the Secretary an application at
such time, in such manner, and containing such information as
the Secretary may require, including a description of the
clinical information technology system that the care
coordinator intends to implement using amounts received under
the grant;
(2) provide assurances that are satisfactory to the
Secretary that such system, for which amounts are to be
expended under the grant, conforms to the standards established
by the Secretary under part C of title XI of the Social
Security Act, and such other standards as the Secretary may
specify; and
(3) furnish the Secretary with such information as the
Secretary may require to--
(A) evaluate the project for which the grant is
made; and
(B) ensure that funding provided under the grant is
expended for the purposes for which it is made.
(c) Matching Requirement.--The Secretary may not make a grant to a
care coordinator under subsection (a) unless that care coordinator
agrees that, with respect to the costs to be incurred by the care
coordinator in carrying out the activities for which the grant is being
awarded, the care coordinator will make available (directly or through
donations from public or private entities) non-Federal contributions
toward such costs in an amount equal to $1 for each $1 of Federal funds
provided under the grant.
(d) Reports to Congress.--
(1) Initial report.--Not later than 18 months after the
first grant has been made under this section, the Secretary
shall submit an initial report to Congress containing the
information referred to in paragraph (3) as well as any
recommendations with respect to grants under this section.
(2) Final report.--Not later than 6 months after the last
grant has been awarded (as determined by the Secretary) under
this section, the Secretary shall submit a final report to
Congress containing the information referred to in paragraph
(2) as well as any recommendations with respect to grants under
this section.
(3) Contents of report.--The reports under this subsection
shall include the following:
(A) A description of the number and nature of
grants made under this section.
(B) An evaluation of--
(i) improvements in the coordination and
quality of care furnished to beneficiaries with
chronic conditions; and
(ii) increases in administrative
efficiencies of care coordinators.
(e) Authorization of Appropriations.--For each of fiscal years
2005, 2006, and 2007, there are authorized to be appropriated to the
Secretary $10,000,000 to carry out the program under this section.
Subtitle C--Additional Provisions
SEC. 121. REVIEW OF COVERAGE STANDARDS.
(a) Review.--With respect to determinations under section
1862(a)(1) of such Act (42 U.S.C. 1395y(a)(1)) (relating to whether an
item or service is reasonable and necessary for the diagnosis or
treatment of illness or injury for purposes of payment under title
XVIII of such Act), the Secretary of Health and Human Services shall
conduct a review of--
(1) regulations, policies, procedures, and instructions of
the Centers for Medicare & Medicaid Services for making those
determinations; and
(2) policies, procedures, local medical review policies,
manual instructions, interpretative rules, statements of
policy, and guidelines of general applicability of fiscal
intermediaries (under section 1816 of the Social Security Act
(42 U.S.C. 1395h)) and carriers under section 1842 of such Act
(42 U.S.C. 1395u) for making those determinations.
(b) Modification.--Insofar as the Secretary determines that the
Centers for Medicare & Medicaid Services, a fiscal intermediary, or a
carrier has misapplied such standard by requiring that the item or
service improve the condition of the patient with respect to such
illness or injury, the Secretary shall take such corrective measures as
are appropriate to ensure the Centers, intermediary, or carrier (as the
case may be) applies the proper standard for making such
determinations.
(c) Report.--On the date that is 18 months after the date of
enactment of this Act, the Secretary shall submit to Congress a report
that contains--
(1) a detailed statement of the findings and conclusions of
the review conducted under subsection (a);
(2) a detailed statement of the modifications made under
subsection (b); and
(3) recommendations to avoid misapplication of the standard
in the future.
TITLE II--INSTITUTE OF MEDICINE STUDY ON EFFECTIVE CHRONIC CONDITION
CARE
SEC. 201. INSTITUTE OF MEDICINE MEDICARE CHRONIC CONDITION CARE
IMPROVEMENT STUDY AND REPORT.
(a) Study.--
(1) In general.--The Secretary of Health and Human Services
shall contract with the Institute of Medicine of the National
Academy of Sciences to--
(A) conduct a comprehensive study of the medicare
program to identify--
(i) factors that facilitate provision of
effective care (including, where appropriate,
hospice care) for medicare beneficiaries with
chronic conditions; and
(ii) factors that impede provision of such
care for such beneficiaries,
including the issues studied under paragraph (2); and
(B) submit the report described in subsection (b).
(2) Issues studied.--The study required under paragraph (1)
shall--
(A) identify inconsistent clinical, financial, or
administrative requirements across provider and
supplier settings or professional services with respect
to medicare beneficiaries;
(B) identify requirements under the program imposed
by law or regulation that--
(i) promote costshifting across providers
and suppliers;
(ii) impede provision of effective,
seamless transitions across health care
settings, such as between hospitals, skilled
nursing facilities, home health services,
hospice care, and care in the home;
(iii) impose unnecessary burdens on such
beneficiaries and their family caregivers;
(iv) impede the establishment of
administrative information systems to track
health status, utilization, cost, and quality
data across providers and suppliers and
provider settings;
(v) impede the establishment of clinical
information systems that support continuity of
care across settings and over time; or
(vi) impede the alignment of financial
incentives among the medicare program, the
medicaid program, and group health plans and
providers and suppliers that furnish services
to the same beneficiary.
(b) Report.--On the date that is 18 months after the date of
enactment of this Act, the Institute of Medicine of the National
Academy of Sciences shall submit to Congress and the Secretary of
Health and Human Services a report that contains--
(1) a detailed statement of the findings and conclusions of
the study conducted under subsection (a); and
(2) recommendations to improve provision of effective care
for medicare beneficiaries with chronic conditions.
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