HR 1998 IH
106th CONGRESS
1st Session
H. R. 1998
To amend 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.
IN THE HOUSE OF REPRESENTATIVES
May 27, 1999
Mr. RAMSTAD (for himself and Mr. CARDIN) introduced the following bill; which
was referred to the Committee on Ways and Means, and in addition to the
Committee on Commerce, 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 promote the
coverage of frail elderly Medicare beneficiaries permanently residing in nursing
facilities in specialized health insurance programs for the frail
elderly.
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)(1)(A), by striking `subsections (e) and (f)' and
inserting `subsections (e) through (i)';
(2) in subsection (a)(3)(D), by inserting `and paragraph (4)' after
`section 1859(e)(4)'; and
(3) by adding at the end of subsection (a) the following new
paragraph:
`(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
(4) by adding at the end the following new subsection:
`(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 the
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) if 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--
`(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 new paragraph:
`(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) EFFECTIVE DATE- The amendment made by subsection (a) takes effect on
the date of the 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 new paragraph:
`(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.
END