II
109th CONGRESS
1st Session
S. 927
IN THE SENATE OF THE UNITED STATES
April 27, 2005
Mr. Corzine (for himself, Mr. Lautenberg, Mr. Sarbanes, Mr. Johnson, Ms. Landrieu, and Mr. Kennedy) 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 expand and improve coverage of mental health services under the medicare program.
Short title; table of contents
In general
This Act may be cited
as the Medicare Mental Health Modernization Act of 2005
.
Table of contents
The table of contents of this Act is as follows:
Sec. 1. Short title; table of contents.
Sec. 2. Findings.
TITLE I—Establishing parity for mental health services
Sec. 101. Elimination of lifetime limit on inpatient mental health services.
Sec. 102. Parity in treatment for outpatient mental health services.
TITLE II—Expanding coverage of community-based mental health services
Sec. 201. Coverage of intensive residential services.
Sec. 202. Coverage of intensive outpatient services.
TITLE III—Improving beneficiary access to medicare-covered services
Sec. 301. Excluding clinical social worker services from coverage under the medicare skilled nursing facility prospective payment system and consolidated payment.
Sec. 302. Coverage of marriage and family therapist services.
Sec. 303. Coverage of mental health counselor services.
Sec. 304. Study of coverage criteria for alzheimer’s disease and related mental illnesses.
Findings
Congress finds the following:
Older people have the highest rate of suicide of any population in the United States, and the suicide rate of that population increases with age, with individuals 65 and older accounting for 20 percent of all suicide deaths in the United States, while comprising only 13 percent of the population of the United States.
Disability due to mental illness in individuals over 65 years old will become a major public health problem in the near future because of demographic changes. In particular, anxiety, dementia, depression, schizophrenia, among other conditions, will all present special problems for this age group.
Major depression is strikingly prevalent among older people, with between 8 and 20 percent of older people in community studies and up to 37 percent of those seen in primary care settings experiencing symptoms of depression.
Anxiety disorders rival depression in their prevalence among older people with a rate of 11.4 percent in persons aged 55 and older.
Almost 20 percent of the population of individuals age 55 and older, experience specific mental disorders that are not part of normal aging.
Unrecognized and untreated depression, Alzheimer’s disease, anxiety, late-life schizophrenia, and other mental conditions can be severely impairing and may even be fatal.
Substance abuse, particularly the abuse of alcohol and prescription drugs, among adults 65 and older is one of the fastest growing health problems in the United States, with 17 percent of this age group suffering from addiction or substance abuse. While addiction often goes undetected and untreated among older adults, aging and disability makes the body more vulnerable to the effects of alcohol and drugs, further exacerbating other age-related health problems. Medicare coverage for addiction treatment of the elderly needs to recognize these special vulnerabilities.
The disabled are another population receiving inadequate mental health care through medicare. According to the Centers for Medicare & Medicaid Services, medicare is the primary health care coverage for the 5,000,000 nonelderly, disabled people on Social Security Disability Insurance. Up to 40 percent of these individuals have a diagnosis of mental illness.
The current medicare benefit structure discriminates against the millions of Americans who suffer from mental illness and maintains an outdated bias toward institutionally based service delivery. According to the report of the Surgeon General on mental health for 1999, intensive outpatient services, such as psychiatric rehabilitation and assertive community treatment, represent state-of-the-art mental health services. These evidence-based community support services help people with psychiatric disabilities improve their ability to function in the community and reduce hospitalization rates by 30 to 60 percent, even for people with the most severe mental illnesses.
Establishing parity for mental health services
Elimination of lifetime limit on inpatient mental health services
In general
Section 1812 of the Social Security Act (42 U.S.C. 1395d) is amended—
in subsection (b)—
in paragraph (1), by adding
or
at the end;
in paragraph (2), by striking ;
or
at the end and inserting a period; and
by striking paragraph (3); and
by striking subsection (c).
Effective date
The amendments made by subsection (a) shall apply to items and services furnished on or after January 1, 2006.
Parity in treatment for outpatient mental health services
In general
Section 1833 of the Social Security Act (42 U.S.C. 1395l) is amended by striking subsection (c).
Effective date
The amendment made by subsection (a) shall apply to items and services furnished on or after January 1, 2006.
Expanding coverage of community-based mental health services
Coverage of intensive residential services
Coverage under part A
Section 1812(a) of the Social Security Act (42 U.S.C. 1395d(a)) is amended—
in paragraph (4), by striking
and
at the end;
in paragraph (5), by striking the period at
the end and inserting ; and
; and
by adding at the end the following new paragraph:
intensive residential services (as defined in section 1861(bbb)) furnished to an individual for up to 120 days during any calendar year, except that such services may be furnished to the individual for additional days (not to exceed 20 days) during the year if necessary for the individual to complete a course of treatment.
.
Services described
Section 1861 of the Social Security Act (42 U.S.C. 1395x) is amended by adding at the end the following new subsection:
Intensive residential services
Subject to paragraphs (3) and (4), the term intensive residential services means a program of residential services (described in paragraph (2)) that is—
prescribed by a physician for an individual entitled to, or enrolled for, benefits under part A who is under the care of the physician; and
furnished under the supervision of a physician pursuant to an individualized, written plan of treatment established and periodically reviewed by a physician (in consultation with appropriate staff participating in such services), which plan sets forth—
the individual’s diagnosis,
the type, amount, frequency, and duration of the items and services provided under the plan, and
the goals for treatment under the plan.
The program of residential services described in this paragraph is a nonhospital-based community residential program that furnishes acute mental health services or substance abuse services, or both, on a 24-hour basis. Such services shall include treatment planning and development, medication management, case management, crisis intervention, individual therapy, group therapy, and detoxification services. Such services shall be furnished in any of the following facilities:
Crisis residential programs or mental illness residential treatment programs.
Therapeutic family or group treatment homes.
Residential detoxification centers.
Residential centers for substance abuse treatment.
No service may be treated as an intensive residential service under paragraph (1) unless the facility at which the service is provided—
is legally authorized to provide such service under the law of the State (or under a State regulatory mechanism provided by State law) in which the facility is located or meets such certification requirements that the Secretary may impose; and
meets such other requirements as the Secretary may impose to assure the quality of the intensive residential services provided.
No service may be treated as an intensive residential service under paragraph (1) unless the service is furnished in accordance with standards established by the Secretary for the management of such services.
.
Amount of payment
Section 1814 of the Social Security Act (42 U.S.C. 1395f) is amended—
in subsection (b), in the matter preceding
paragraph (1), by inserting other than intensive residential
services,
after hospice care,
; and
by adding at the end the following new subsection:
Payment for intensive residential services
The amount of payment under this part for intensive residential services under section 1812(a)(6) shall be equal to an amount specified under a prospective payment system established by the Secretary, taking into account the prospective payment system established for psychiatric hospitals pursuant to section 124 of the Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999 (113 Stat. 1501A–332), as enacted into law by section 1000(a)(6) of Public Law 106–113.
Prior to the date on which the Secretary implements the prospective payment system established under paragraph (1), the amount of payment under this part for such intensive residential services is the reasonable costs of providing such services.
.
Effective date
The amendments made by this section shall apply to items and services furnished on or after January 1, 2006.
Coverage of intensive outpatient services
Coverage
Section 1832(a)(2) of the Social Security Act (42 U.S.C. 1395k(a)(2)) is amended—
in subparagraph (I), by striking
and
at the end;
in subparagraph (J), by striking the period
at the end and inserting ; and
; and
by adding at the end the following new subparagraph:
intensive outpatient services (as described in section 1861(ccc)).
.
Services described
Section 1861 of the Social Security Act (42 U.S.C. 1395x), as amended by section 201(b), is amended by adding at the end the following new subsection:
Intensive outpatient services
The term intensive outpatient services means the items and services described in paragraph (2) prescribed by a physician and provided within the context described in paragraph (3) under the supervision of a physician (or, to the extent permitted under the law of the State in which the services are furnished, a non-physician mental health professional) pursuant to an individualized, written plan of treatment that is established by a physician and periodically reviewed by a physician or, to the extent permitted under the laws of the State in which the services are furnished, a non-physician mental health professional (in consultation with appropriate staff participating in such services), which plan sets forth the patient’s diagnosis, the type, amount, frequency, and duration of the items and services provided under the plan, and the goals for treatment under the plan.
The items and services described in this paragraph are the items and services described in subparagraph (B) that are reasonable and necessary for the diagnosis or treatment of the individual’s condition, reasonably expected to improve or maintain the individual’s condition and functional level and to prevent relapse or hospitalization, and furnished pursuant to such guidelines relating to frequency and duration of services as the Secretary shall by regulation establish (taking into account accepted norms of clinical practice).
For purposes of subparagraph (A), the items and services described in this paragraph are as follows:
Psychiatric rehabilitation.
Assertive community treatment.
Intensive case management.
Day treatment for individuals under 21 years of age.
Ambulatory detoxification.
Such other items and services as the Secretary may provide (but in no event to include meals and transportation).
The context described in this paragraph for the provision of intensive outpatient services is as follows:
Such services are furnished in a facility, home, or community setting.
Such services are furnished—
to assist the individual to compensate for, or eliminate, functional deficits and interpersonal and environmental barriers created by the disability; and
to restore skills to the individual for independent living, socialization, and effective life management.
Such services are furnished by an individual or entity that—
is legally authorized to furnish such services under State law (or the State regulatory mechanism provided by State law) or meets such certification requirements that the Secretary may impose; and
meets such other requirements as the Secretary may impose to assure the quality of the intensive outpatient services provided.
.
Payment
In general
With respect to intensive outpatient services (as defined in section 1861(ccc)(1) of the Social Security Act (as added by subsection (b)) furnished under the medicare program, the amount of payment under such Act for such services shall be 80 percent of—
during 2006 and 2007, the reasonable costs of furnishing such services; and
on or after January 1, 2008, the amount of payment established for such services under the prospective payment system established by the Secretary under paragraph (2) for such services.
Establishment of pps
In general
With respect to
intensive outpatient services (as defined in section 1861(ccc)(1)) of the
Social Security Act (as added by
subsection (b)) furnished under the medicare program on or after January 1,
2008, the Secretary of Health and Human Services (in this paragraph referred to
as the Secretary
) shall establish a prospective payment system
for payment for such services. Such system shall include an adequate patient
classification system that reflects the differences in patient resource use and
costs and shall provide for an annual update to the rates of payment
established under the system.
Adjustments
In establishing the system under subparagraph (A), the Secretary shall provide for adjustments in the prospective payment amount for variations in wage and wage-related costs, case mix, and such other factors as the Secretary determines appropriate.
Collection of data and evaluation
In developing the system described in subparagraph (A), the Secretary may require providers of services under the medicare program to submit such information to the Secretary as the Secretary may require to develop the system, including the most recently available data.
Reports to Congress
Not later than October 1 of each of 2006 and 2007, the Secretary shall submit to Congress a report on the progress of the Secretary in establishing the prospective payment system under this paragraph.
Conforming amendments
Section 1835(a)(2) of the Social Security Act (42 U.S.C. 1395n(a)(2)) is amended—
in subparagraph (E), by striking
and
at the end;
in subparagraph (F), by striking the period
at the end and inserting ; and
; and
by inserting after subparagraph (F) the following new subparagraph:
in the case of intensive outpatient services, (i) that those services are reasonably expected to improve or maintain the individual’s condition and functional level and to prevent relapse or hospitalization, (ii) an individualized, written plan for furnishing such services has been established by a physician and is reviewed periodically by a physician or, to the extent permitted under the laws of the State in which the services are furnished, a non-physician mental health professional, and (iii) such services are or were furnished while the individual is or was under the care of a physician or, to the extent permitted under the law of the State in which the services are furnished, a non-physician mental health professional.
.
Section 1861(s)(2)(B) of the
Social Security Act (42 U.S.C.
1395x(s)(2)(B)) is amended by inserting and intensive outpatient
services
after partial hospitalization services
.
Section 1861(ff)(1) of the Social Security Act (42 U.S.C. 1395x(ff)(1)) is amended—
by inserting or, to the extent
permitted under the law of the State in which the services are furnished, a
non-physician mental health professional,
after under the
supervision of a physician
and after periodically reviewed by a
physician
; and
by striking physician’s
and
inserting patient’s
.
Section 1861(cc) of the Social Security Act (42 U.S.C. 1395x(cc)) is amended—
in paragraph (1), in the matter preceding
subparagraph (A), by striking physician—
and inserting
physician or, to the extent permitted under the law of the State in
which the services are furnished, a non-physician mental health
professional—
; and
in paragraph (2)(E), by inserting before
the semicolon at the end the following: , except that a patient
receiving social and psychological services under paragraph (1)(D) may be under
the care of a non-physician mental health professional with respect to such
services to the extent permitted under the law of the State in which the
services are furnished
.
Effective date
The amendments made by this section shall apply to items and services furnished on or after January 1, 2006.
Improving beneficiary access to medicare-covered services
Excluding clinical social worker services from coverage under the medicare skilled nursing facility prospective payment system and consolidated payment
In general
Section
1888(e)(2)(A)(ii) of the Social Security
Act (42 U.S.C. 1395yy(e)(2)(A)(ii)) is amended by inserting
clinical social worker services,
after qualified
psychologist services,
.
Conforming amendment
Section 1861(hh)(2)
of the Social Security Act (42 U.S.C.
1395x(hh)(2)) is amended by striking and other than services furnished
to an inpatient of a skilled nursing facility which the facility is required to
provide as a requirement for participation
.
Effective date
The amendments made by this section shall apply to items and services furnished on or after January 1, 2006.
Coverage of marriage and family therapist services
Coverage of services
Section 1861(s)(2) of the Social Security Act (42 U.S.C. 1395x(s)(2)) is amended—
in subparagraph (Y), by striking
and
at the end;
in subparagraph (Z), by adding
and
at the end; and
by adding at the end the following new subparagraph:
marriage and family therapist services (as defined in subsection (ddd));
.
Definition
Section 1861 of the Social Security Act (42 U.S.C. 1395x), as amended by sections 201(b) and 202(b), is amended by adding at the end the following new subsection:
Marriage and family therapist services
The term marriage and family therapist services means services performed by a marriage and family therapist (as defined in paragraph (2)) for the diagnosis and treatment of mental illnesses, which the marriage and family therapist is legally authorized to perform under State law (or the State regulatory mechanism provided by State law) of the State in which such services are performed, provided such services are covered under this title, as would otherwise be covered if furnished by a physician or as incident to a physician’s professional service, but only if no facility or other provider charges or is paid any amounts with respect to the furnishing of such services.
The term marriage and family therapist means an individual who—
possesses a master’s or doctoral degree which qualifies for licensure or certification as a marriage and family therapist pursuant to State law;
after obtaining such degree has performed at least 2 years of clinical supervised experience in marriage and family therapy; and
is licensed or certified as a marriage and family therapist in the State in which marriage and family therapist services are performed.
.
Provision for payment under part b
Section 1832(a)(2)(B) of the Social Security Act (42 U.S.C. 1395k(a)(2)(B)) is amended by adding at the end the following new clause:
marriage and family therapist services;
.
Amount of payment
In general
Section 1833(a)(1) of the Social Security Act (42 U.S.C. 1395l(a)(1)) is amended—
by striking and
before
(V)
; and
by inserting before the semicolon at the
end the following: , and (W) with respect to marriage and family
therapist services under section 1861(s)(2)(AA), the amounts paid shall be 80
percent of the lesser of (i) the actual charge for the services or (ii) 75
percent of the amount determined for payment of a psychologist under
subparagraph (L)
.
Development of criteria with respect to consultation with a physician
The Secretary of Health and Human Services shall, taking into consideration concerns for patient confidentiality, develop criteria with respect to payment for marriage and family therapist services for which payment may be made directly to the marriage and family therapist under part B of title XVIII of the Social Security Act (42 U.S.C. 1395j et seq.) under which such a therapist must agree to consult with a patient’s attending or primary care physician in accordance with such criteria.
Exclusion of marriage and family therapist services from skilled nursing facility prospective payment system
Section 1888(e)(2)(A)(ii) of the
Social Security Act (42 U.S.C.
1395yy(e)(2)(A)(ii)), as amended in section 301(a), is amended by inserting
marriage and family therapist services (as defined in subsection
(ddd)(1)),
after clinical social worker
services,
.
Coverage of marriage and family therapist services provided in rural health clinics and federally qualified health centers
Section 1861(aa)(1)(B) of the
Social Security Act (42 U.S.C.
1395x(aa)(1)(B)) is amended by striking or by a clinical social worker
(as defined in subsection (hh)(1)),,
and inserting , by a
clinical social worker (as defined in subsection (hh)(1)), or by a marriage and
family therapist (as defined in subsection (ddd)(2)),
.
Inclusion of marriage and family therapists as practitioners for assignment of claims
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:
A marriage and family therapist (as defined in section 1861(ddd)(2)).
.
Effective date
The amendments made by this section shall apply to items and services furnished on or after January 1, 2006.
Coverage of mental health counselor services
Coverage of services
Section 1861(s)(2) of the Social Security Act (42 U.S.C. 1395x(s)(2)), as amended in section 302(a), is amended—
in subparagraph (Z), by striking
and
at the end;
in subparagraph (AA), by inserting
and
at the end; and
by adding at the end the following new subparagraph:
mental health counselor services (as defined in subsection (eee)(2));
.
Definition
Section 1861 of the Social Security Act (42 U.S.C. 1395x), as amended by sections 201(b), 202(b), and 302(b), is amended by adding at the end the following new subsection:
Mental health counselor; mental health counselor services
The term mental health counselor means an individual who—
possesses a master’s or doctor’s degree in mental health counseling or a related field;
after obtaining such a degree has performed at least 2 years of supervised mental health counselor practice; and
is licensed or certified as a mental health counselor or professional counselor by the State in which the services are performed.
The term mental health counselor services means services performed by a mental health counselor (as defined in paragraph (1)) for the diagnosis and treatment of mental illnesses which the mental health counselor is legally authorized to perform under State law (or the State regulatory mechanism provided by the State law) of the State in which such services are performed, provided such services are covered under this title, as would otherwise be covered if furnished by a physician or as incident to a physician’s professional service, but only if no facility or other provider charges or is paid any amounts with respect to the furnishing of such services.
.
Payment
In general
Section 1833(a)(1) of the Social Security Act (42 U.S.C. 1395l(a)(1)), as amended by section 302(d), is amended—
by striking and
before
(W)
; and
by inserting before the semicolon at the
end the following: , and (X) with respect to mental health counselor
services under section 1861(s)(2)(BB), the amounts paid shall be 80 percent of
the lesser of (i) the actual charge for the services or (ii) 75 percent of the
amount determined for payment of a psychologist under subparagraph
(L)
.
Development of criteria with respect to consultation with a physician
The Secretary of Health and Human Services shall, taking into consideration concerns for patient confidentiality, develop criteria with respect to payment for mental health counselor services for which payment may be made directly to the mental health counselor under part B of title XVIII of the Social Security Act (42 U.S.C. 1395j et seq.) under which such a counselor must agree to consult with a patient’s attending or primary care physician in accordance with such criteria.
Exclusion of mental health counselor services from skilled nursing facility prospective payment system
Section
1888(e)(2)(A)(ii) of the Social Security
Act (42 U.S.C. 1395yy(e)(2)(A)(ii)), as amended by sections 301(a)
and 302(e), is amended by inserting mental health counselor services (as
defined in section 1861(eee)(2)),
after marriage and family
therapist services (as defined in subsection (ddd)(1)),
.
Coverage of mental health counselor services provided in rural health clinics and federally qualified health centers
Section 1861(aa)(1)(B) of the Social Security Act (42 U.S.C. 1395x(aa)(1)(B)), as amended by section 302(f), is amended—
by striking or by a marriage
and inserting by a marriage
; and
by inserting or a mental health
counselor (as defined in subsection (eee)(1)),
after marriage
and family therapist (as defined in subsection (ddd)(2)),
.
Inclusion of mental health counselors as practitioners for assignment of claims
Section 1842(b)(18)(C) of the Social Security Act (42 U.S.C. 1395u(b)(18)(C)), as amended by section 302(g), is amended by adding at the end the following new clause:
A mental health counselor (as defined in section 1861(eee)(1)).
.
Effective date
The amendments made by this section shall apply to items and services furnished on or after January 1, 2006.
Study of coverage criteria for Alzheimer’s disease and related mental illnesses
Study
In general
The Secretary of
Health and Human Services (in this section referred to as the
Secretary
) shall conduct a study to determine whether the
criteria for coverage of any therapy service (including occupational therapy
services and physical therapy services) or any outpatient mental health care
service under the medicare program under title XVIII of the
Social Security Act (42 U.S.C. 1395 et
seq.) unduly restricts the access of any medicare beneficiary who has been
diagnosed with Alzheimer’s disease or a related mental illness to such a
service because the coverage criteria requires the medicare beneficiary to
display continuing clinical improvement to continue to receive the
service.
Determination of new coverage criteria
If the Secretary determines that the coverage criteria described in paragraph (1) unduly restricts the access of any medicare beneficiary to the services described in such paragraph, the Secretary shall identify alternative coverage criteria that would permit a medicare beneficiary who has been diagnosed with Alzheimer’s disease or a related mental illness to receive coverage for health care services under the medicare program that are designed to control symptoms, maintain functional capabilities, reduce or deter deterioration, and prevent or reduce hospitalization of the beneficiary.
Report
Not later than 1 year after the date of enactment of this Act, the Secretary shall submit to the committees of jurisdiction of Congress a report on the study conducted under subsection (a) together with such recommendations for legislative and administrative action as the Secretary determines appropriate.