S 3233 IS

To amend title XVIII of the Social Security Act to provide for medicare beneficiary copayments for outpatient mental health services that are the same as beneficiary copayments for other part B services, and for other purposes.

October 25 (legislative day, SEPTEMBER 22), 2000

Mr. WELLSTONE introduced the following bill; which was read twice and referred to the Committee on Finance

To amend title XVIII of the Social Security Act to provide for medicare beneficiary copayments for outpatient mental health services that are the same as beneficiary copayments for other part B services, 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.

This Act may be cited as the `Medicare Mental Health Modernization Act of 2000'.

SEC. 2. FINDINGS.

The Senate finds the following:

(1) 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.

(2) 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, dementia, depression, schizophrenia, among other conditions, will all present special problems for this age group.

(3) 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.

(4) Almost 20 percent of the population of individuals age 55 and older, experience specific mental disorders that are not part of normal aging.

(5) Unrecognized and untreated depression, Alzheimer's disease, anxiety, late-life schizophrenia, and other mental conditions can be severely impairing and may even be fatal.

(6) 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.

(7) The disabled are another population receiving inadequate mental health care through medicare. According to the Health Care Financing Administration, medicare is the primary health care coverage for the 5,000,000 non-elderly, disabled people on Social Security Disability Insurance. Up to 40 percent of these individuals have a diagnosis of mental illness, and also face severe discrimination in mental health coverage.

SEC. 3. DECREASE IN MEDICARE BENEFICIARY COPAYMENT FOR OUTPATIENT MENTAL HEALTH SERVICES.

(a) IN GENERAL- Section 1833(c) of the Social Security Act (42 U.S.C. 1395l(c)) is repealed.

(b) CONFORMING AMENDMENT- Section 1866(a)(2)(A) of such Act (42 U.S.C. 1395cc(a)(2)(A)) is amended by striking the second sentence.

(c) EFFECTIVE DATE- The amendments made by subsections (a) and (b) shall apply to items and services furnished on or after the date of enactment of this Act.

SEC. 4. INTENSIVE RESIDENTIAL SERVICES.

(a) COVERAGE UNDER PART A- Section 1812(a) (42 U.S.C. 1395d(a)) is amended--

(1) in paragraph (4), by striking `and' at the end;

(2) in paragraph (5), by striking the period at the end of and inserting `; and'; and

(3) by adding at the end the following new paragraph:

`(5) intensive residential services (as defined in section 1861(uu)) furnished to an individual for up to 120 days during any calendar year.'.

(b) INTENSIVE RESIDENTIAL 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:

`Intensive Residential Services

`(uu)(1) Subject to paragraphs (2) and (3), the term `intensive residential services' means inpatient services provided in any of the following facilities:

`(A) Residential detoxification centers.

`(B) Crisis residential programs or mental illness residential treatment programs.

`(C) Therapeutic family or group treatment homes.

`(D) Residential centers for substance abuse treatment.

`(2) No service may be treated as an intensive residential service unless the facility at which the service is provided--

`(A) 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 is certified to provide such service by an appropriate accreditation entity approved by the State in consultation with the Secretary; and

`(B) meets such other requirements as the Secretary may impose to assure the quality of the intensive residential services provided.

`(3) 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.'.

(c) REDUCTION IN DAYS OF COVERAGE FOR INPATIENT SERVICES- Section 1812(b)(3) of the Social Security Act (42 U.S.C. 1395d(b)(3)) is amended by striking the period at the end and inserting the following: `, reduced by a number of days determined by the Secretary so that the actuarial value of providing such number of days of services under this paragraph to the individual is equal to the actuarial value of the days of inpatient residential services furnished to the individual under subsection (a)(5) during the year after such services have been furnished to the individual for 120 days during the year (rounded to the nearest day).'.

(d) AMOUNT OF PAYMENT- Section 1814 of the Social Security Act (42 U.S.C. 1395f) is amended--

(1) in subsection (b), in the matter preceding paragraph (1), by inserting `other than a provider of intensive residential services,' after `hospice care,'; and

(2) by adding at the end the following new subsection:

`Payment for Intensive Residential Services

`(m)(1) Except as provided in paragraphs (2) and (3), the amount of payment under this part for intensive residential services under section 1812(a)(5) shall be equal to the lesser of--

`(A) the reasonable cost of such services, as determined under section 1861(v), or

`(B) the customary charges with respect to such services,

less the amount a provider may charge as described in clause (ii) of section 1866(a)(2)(A).

`(2) If intensive residential services are furnished by a public provider of services or by another provider which demonstrates to the satisfaction of the Secretary that a significant portion of its patients are low-income (and requests that payment be made under this clause), free of charge or at nominal charges to the public, the Secretary shall determine the amount of payment for such services in accordance with subsection (b)(2).

`(3) If (and for so long as) the conditions described in subsection (b)(3) are met, the Secretary shall determine the amount of payment for intensive residential services under the reimbursement system described in such subsection.'.

SEC. 5. STUDY OF COVERAGE CRITERIA FOR ALZHEIMER'S DISEASE AND RELATED MENTAL ILLNESSES.

(a) STUDY-

(1) 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 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.

(2) 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.

(b) 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.

SEC. 6. MENTAL HEALTH COUNSELING SERVICES.

(a) ADDING MENTAL HEALTH COUNSELOR SERVICES TO THE DEFINITION OF MEDICAL AND OTHER HEALTH SERVICES- Section 1861(s)(2) of the Social Security Act (42 U.S.C. 1395(s)(2)) is amended--

(1) in subparagraph (S), by striking `and' at the end;

(2) in subparagraph (T)(ii), by adding `and' at the end; and

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

`(U) mental health counselor services (as defined in subsection (vv));'.

(b) MENTAL HEALTH COUNSELOR; MENTAL HEALTH COUNSELOR SERVICES DEFINED- Section 1861 of the Social Security Act (42 U.S.C. 1395x), as amended by section 4, is amended by adding at the end the following new subsection:

`Mental Health Counselor; Mental Health Counselor Services

`(vv)(1) The term `mental health counselor' means an individual who--

`(A) possesses a master's or doctor's degree in counseling or a related field;

`(B) after obtaining such a degree has performed at least 2 years of supervised mental health counselor practice; and

`(C)(i) is licensed or certified as a mental health counselor or professional counselor by the State in which the services are performed; or

`(ii) in the case of an individual in a State that does not provide for licensure or certification--

`(I) has completed at least 2 years or 3,000 hours of post-master's degree supervised mental health counselor practice under the supervision of a master's or doctor's level mental health provider in an appropriate setting (as determined by the Secretary); and

`(II) meet such other criteria as the Secretary establishes.

`(2) 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 as performed as would otherwise be covered if furnished by a physician or as incident to a physician's professional service.'.

(c) PAYMENT- Section 1833(a)(1) of the Social Security Act (42 U.S.C. 1395l(a)(1)) is amended--

(1) by striking `and' before `(S)'; and

(2) by inserting before the semicolon at the end the following: `, and (T) with respect to mental health counselor services under section 1861(s)(2)(U), the amounts paid shall be 80 percent of (i) the actual charge for the services or (ii) 75 percent of the amount determined for payment of a psychologist under clause (L)'.

SEC. 7. EXCLUDING CLINICAL SOCIAL WORKER SERVICES FROM COVERAGE UNDER THE MEDICARE SKILLED NURSING FACILITY PROSPECTIVE PAYMENT SYSTEM AND CONSOLIDATED PAYMENT.

(a) 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,'.

(b) CONFORMING AMENDMENT- Section 1861(hh)(2) of such 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'.

(c) EFFECTIVE DATE- The amendments made by this section apply as if included in the enactment of section 4432(a) of the Balanced Budget Act of 1997.

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