Medicare Home Health Case Manager Act of 1998

Summary: Medicare Home Health Case Manager Act of 1998 - Amends title XVIII (Medicare) of the Social Security Act with regard to home health services to:  (1) require a case management plan established by a home health case manager for beneficiaries requiring extended home health services; and (2) provide for coverage of and payment for home health case manager services under Medicare part A (Hospital Insurance) and B (Supplementary Medical Insurance). 
Directs the Secretary of Health and Human Services to:  (1) establish a fee schedule for payment for home health case manager services; and (2) study and report to the Congress on the feasibility of case managers with respect to Medicare post-acute hospital care services.

SECTION 1. SHORT TITLE; FINDINGS.

    (a) Short Title.--This Act may be cited as the ``Medicare Home 
Health Case Manager Act of 1998''.
    (b) Findings.--The Congress finds as follows:
            (1) A Medicare beneficiary experiencing a severe or chronic 
        illness faces a bewildering array of home health and post-acute 
        care hospital services at a time in life when the Medicare 
        beneficiary is least able to ``manage'' the choices, especially 
        for beneficiaries who do not have family members to help them 
        consider the choices.
            (2) Such a Medicare beneficiary may be unaware of the 
        financial relationships between institutions and agencies which 
        may cause the patient to be referred for home health services 
        that are unnecessary or not furnished in the most appropriate 
        setting.
            (3) Medicare fee-for-service does not currently have a 
        system in which a physician or other health care provider is 
        encouraged to guide the patient through this maze of services 
        and help ensure that choices are made that maximize benefits 
        while minimizing costs.
            (4) Chronically ill medicare patients need an independent 
        ombudsman to help develop a plan of care and to periodically 
        adjust the plan for the sole benefit of the patient and the 
        patient's family.

SEC. 2. ESTABLISHMENT OF MEDICARE HOME HEALTH CARE CASE MANAGERS FOR 
              LONG TERM HOME HEALTH SPELLS OF ILLNESS.

    (a) Requirement for Case Management Plan for Beneficiaries 
Requiring Extended Home Health Services.--
            (1) In general.--Section 1861(m) of the Social Security Act 
        (42 U.S.C. 1395x(m)) is amended, in the matter preceding 
        paragraph (1), by inserting after ``under a plan (for 
        furnishing such items and services to such individual) 
        established and periodically reviewed by a physician'' the 
        following: ``and, in the case of such services furnished (or 
        likely to be required to be furnished) for an extended period 
        (as defined by the Secretary in regulations), under a home 
        health case management plan (as defined in subsection (uu)(2)) 
        established by a home health case manager (as defined in 
        subsection (uu)(1)) in consultation with the physician and, if 
        available, the family of the individual''.
            (2) Definitions.--Section 1861 of such Act (42 U.S.C. 
        1395x) is amended by adding at the end the following new 
        subsection:

                       ``Home Health Case Manager

    ``(uu)(1) The term `home health case manager' means a public agency 
or private organization (or a subdivision thereof) that--
            ``(A) develops, coordinates, and monitors the delivery of 
        home health services by home health agencies to an individual;
            ``(B) has experience and expertise in the furnishing of 
        home health services; and
            ``(C) meets such other standards as the Secretary finds 
        necessary for the effective and efficient development and 
        oversight of home health case management plans and to ensure 
        the health and safety of individuals furnished services under 
        such a plan.
    ``(2) The term `home health case management plan' means a 
structured plan for the delivery of home health services that is 
developed by a home health case manager, after consultation with the 
physician and, if available, the family of the individual involved.
    ``(3) The term `home health case manager services' means the 
development, coordination, and monitoring of a home health case 
management plan for an individual furnished (or likely to be required 
to be furnished) home health services for an extended period (as 
defined by the Secretary in regulations under subsection (m)) and 
includes the periodic review of such a plan.''.
            (3) Guidance on initiation of case manager services.--The 
        Secretary of Health and Human Services shall provide guidance 
        on the process or processes that may be used to identify 
        Medicare beneficiaries requiring home health services for 
        extended periods and to develop home health case management 
        plans on a timely basis.
            (4) Limitation on referrals.--Section 1877 of the Social 
        Security Act (42 U.S.C. 1395nn) shall apply to a referral by a 
        home health case manager to a home health agency in the same 
        manner as such section applies to a referral by a physician to 
        an entity described in section 1877(a)(2) of such Act.
    (b) Coverage of and Payment for Home Health Case Manager 
Services.--
            (1) Part a.--
                    (A) Coverage.--Section 1812(a)(3) of such Act (42 
                U.S.C. 1395d(a)(3)) is amended by inserting before the 
                semicolon ``, and home health case manager services (as 
                defined in section 1861(uu)(3))''.
                    (B) Eligibility.--Section 1814(a)(2)(C) of such Act 
                (42 U.S.C. 1395f(a)(2)(C)) is amended by inserting 
                ``and, in the case of such services furnished for an 
                extended period (as defined by the Secretary under 
                section 1861(m)), under a home health case management 
                plan that has been established and periodically 
                reviewed by a home health case manager'' after ``is 
                periodically reviewed by a physician''.
                    (C) Payment.--Section 1812 of such Act (42 U.S.C. 
                1395d) is amended by adding at the end the following 
                new subsection:
    ``(h)(1) Payment under this part for home health case manager 
services (as defined in section 1861(uu)(3)) shall be made pursuant to 
the fee schedule established by the Secretary under section 1834(m).
    ``(2)(A) Payment may be made under this title for home health case 
manager services in the case of an individual only--
            ``(i) for the initial development of the home health case 
        management plan for the individual, and
            ``(ii) for the subsequent review and modification of such 
        plan, as provided by the Secretary in regulations.''.
            (2) Coverage under part b.--
                    (A) In general.--Section 1832(a)(2)(A) of such Act 
                (42 U.S.C. 1395k(a)(2)(A)) is amended by inserting 
                before the semicolon ``, and home health case manager 
                services (as defined in section 1861(uu)(3))''.
                    (B) Eligibility.--Section 1835(a)(2) of such Act 
                (42 U.S.C. 1395n(a)(2)) is amended by inserting ``and, 
                in the case of such services furnished for an extended 
                period (as defined by the Secretary under section 
                1861(m)), under a home health case management plan that 
                has been established and periodically reviewed by a 
                home health case manager'' after ``is periodically 
                reviewed by a physician''.
                    (C) Payment.--Section 1833 of such Act (42 U.S.C. 
                1395l) is amended--
                            (i) in subsection (a)(2)--
                                    (I) by striking ``and'' at the end 
                                of subparagraph (F);
                                    (II) by adding ``and'' at the end 
                                of subparagraph (G); and
                                    (III) by adding after subparagraph 
                                (G) the following new subparagraph:
                    ``(H) subject to subsection (u), with respect to 
                home health case manager services (as defined in 
                section 1861(uu)(3), the amount determined under the 
                fee schedule established under section 1834(m);'', and
                            (ii) by adding at the end the following new 
                        subsection:
    ``(u)(1) Payment may be made under this title for home health case 
manager services in the case of an individual only--
            ``(A) for the initial development of the home health case 
        management plan for the individual, and
            ``(B) for the subsequent review and modification of such 
        plan, as provided by the Secretary in regulations.''.
            (3) Establishment of Fee Schedule.--Section 1834 of such 
        Act (42 U.S.C. 1395m) is amended by adding at the end the 
        following new section:
    ``(m) Establishment of Fee Schedule for Home Health Case Manager 
Services.--
            ``(1) In general.--The Secretary shall establish a fee 
        schedule for payment for home health case manager services. 
        Such schedule may provide for rates that differ for such 
        services that comprise the establishment of a home health case 
        management plan and that comprise review and modification of 
        such a plan.
            ``(2) Considerations.--In establishing such fee schedule, 
        the Secretary shall consider appropriate regional and 
        operational differences and adjustments to payment rates to 
        account for inflation and other relevant factors.
            ``(3) Consultation.--In establishing the fee schedule for 
        home health case manager services under this subsection, the 
        Secretary shall consult with appropriate organizations 
        representing individuals and entities who furnish referral 
        services for home health services and share with such 
        organizations relevant data in establishing such schedule.''.
    (c) Effective Dates.--
            (1) Requirement of case management plan.--The amendment 
        made by subsection (a)(1) applies with respect to home health 
        services furnished on or after October 1, 2000.
            (2) Payment for case manager services.--The amendments made 
        by subsection (b) apply to home health case manager services 
        furnished on or after 6 months before the effective date 
        specified in paragraph (1).

SEC. 3. REPORT TO CONGRESS ON FEASIBILITY OF CASE MANAGERS WITH RESPECT 
              TO OTHER MEDICARE SERVICES.

    (a) Study.--The Secretary of Health and Human Services shall 
conduct a study of the types of services consisting of post-acute 
hospital care furnished under the Medicare program under title XVIII of 
the Social Security Act to determine whether use of case managers and 
case management plans similar to home health case managers (as defined 
in section 1861(uu)(1)) and home health case management plans (as 
defined in section 1861(uu)(2)) is feasible and appropriate for each 
such type of service. In conducting the study, the Secretary shall also 
determine whether such case managers and case management plans may 
improve quality of care and patient outcomes under the medicare 
program, may result in cost savings to the program, and may reduce 
incidents of waste, fraud and abuse against the program.
    (b) Report.--Not later than January 1, 2001, the Secretary shall 
submit to Congress a report containing the determinations made pursuant 
to the study conducted under subsection (a) and any recommendations for 
legislative and administrative action the Secretary deems appropriate.