I

106TH CONGRESS

1ST SESSION H. R. 746

To amend title XVIII of the Social Security Act to provide for home health

case manager services under the Medicare Program.

IN THE HOUSE OF REPRESENTATIVES

FEBRUARY 11, 1999

Mr. STARK 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 provide

for home health case manager services under the Medicare Program.

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled,

3 SECTION 1. SHORT TITLE; FINDINGS.

4 SHORT TITLE.—This Act may be cited as the ‘‘Medi5 care Home Health Case Manager Act of 1999’’.
2

•HR 746 IH

1 SEC. 2. ESTABLISHMENT OF MEDICARE HOME HEALTH

2 CARE CASE MANAGERS FOR LONG TERM

3 HOME HEALTH SPELLS OF ILLNESS.

4 (a) REQUIREMENT FOR CASE MANAGEMENT PLAN

5 FOR BENEFICIARIES REQUIRING EXTENDED HOME

6 HEALTH SERVICES.—

7 (1) IN GENERAL.—Section 1861(m) of the So8 cial Security Act (42 U.S.C. 1395x(m)) is amended,

9 in the matter preceding paragraph (1), by inserting

10 after ‘‘under a plan (for furnishing such items and

11 services to such individual) established and periodi12 cally reviewed by a physician’’ the following: ‘‘and,

13 in the case of such services furnished (or likely to

14 be required to be furnished) for an extended period

15 (as defined by the Secretary in regulations), under

16 a home health case management plan (as defined in

17 subsection (uu)(2)) established by a home health

18 case manager (as defined in subsection (uu)(1)) in

19 consultation with the physician and, if available, the

20 family of the individual’’.

21 (2) DEFINITIONS.—Section 1861 of such Act

22 (42 U.S.C. 1395x) is amended by adding at the end

23 the following new subsection:
3

•HR 746 IH

1 ‘‘Home Health Case Manager

2 ‘‘(uu)(1) The term ‘home health case manager’

3 means a public agency or private organization (or a sub4 division thereof) that—

5 ‘‘(A) develops, coordinates, and monitors the

6 delivery of home health services by home health

7 agencies to an individual;

8 ‘‘(B) has experience and expertise in the fur9 nishing of home health services; and

10 ‘‘(C) meets such other standards as the Sec11 retary finds necessary for the effective and efficient

12 development and oversight of home health case man13 agement plans and to ensure the health and safety

14 of individuals furnished services under such a plan.

15 ‘‘(2) The term ‘home health case management plan’

16 means a structured plan for the delivery of home health

17 services that is developed by a home health case manager,

18 after consultation with the physician and, if available, the

19 family of the individual involved.

20 ‘‘(3) The term ‘home health case manager services’

21 means the development, coordination, and monitoring of

22 a home health case management plan for an individual

23 furnished (or likely to be required to be furnished) home

24 health services for an extended period (as defined by the
4

•HR 746 IH

1 Secretary in regulations under subsection (m)) and in2 cludes the periodic review of such a plan.’’.

3 (3) GUIDANCE ON INITIATION OF CASE MAN4 AGER SERVICES.—The Secretary of Health and

5 Human Services shall provide guidance on the proc6 ess or processes that may be used to identify Medi7 care beneficiaries requiring home health services for

8 extended periods and to develop home health case

9 management plans on a timely basis.

10 (4) LIMITATION ON REFERRALS.—Section 1877

11 of the Social Security Act (42 U.S.C. 1395nn) shall

12 apply to a referral by a home health case manager

13 to a home health agency in the same manner as

14 such section applies to a referral by a physician to

15 an entity described in section 1877(a)(2) of such

16 Act.

17 (b) COVERAGE OF AND PAYMENT FOR HOME

18 HEALTH CASE MANAGER SERVICES.—

19 (1) PART A.—

20 (A) COVERAGE.—Section 1812(a)(3) of

21 such Act (42 U.S.C. 1395d(a)(3)) is amended

22 by inserting before the semicolon ‘‘, and home

23 health case manager services (as defined in sec24 tion 1861(uu)(3))’’.
5

•HR 746 IH

1 (B) ELIGIBILITY.—Section 1814(a)(2)(C)

2 of such Act (42 U.S.C. 1395f(a)(2)(C)) is

3 amended by inserting ‘‘and, in the case of such

4 services furnished (or likely to be required to be

5 furnished) for an extended period (as defined

6 by the Secretary under section 1861(m)), under

7 a home health case management plan that has

8 been established and periodically reviewed by a

9 home health case manager’’ after ‘‘is periodi10 cally reviewed by a physician’’.

11 (C) PAYMENT.—Section 1812 of such Act

12 (42 U.S.C. 1395d) is amended by adding at the

13 end the following new subsection:

14 ‘‘(h)(1) Payment under this part for home health

15 case manager services (as defined in section 1861(uu)(3))

16 shall be made pursuant to the fee schedule established by

17 the Secretary under section 1834(m).

18 ‘‘(2) Payment may be made under this title for home

19 health case manager services with respect to an individual

20 only—

21 ‘‘(A) for the initial development of the home

22 health case management plan for the individual, and

23 ‘‘(B) for the subsequent review and modifica24 tion of such plan, as provided by the Secretary in

25 regulations.’’.
6

•HR 746 IH

1 (2) PART B.—

2 (A) COVERAGE.—Section 1832(a)(2)(A) of

3 such Act (42 U.S.C. 1395k(a)(2)(A)) is amend4 ed by inserting before the semicolon ‘‘, and

5 home health case manager services (as defined

6 in section 1861(uu)(3))’’.

7 (B) ELIGIBILITY.—Section 1835(a)(2) of

8 such Act (42 U.S.C. 1395n(a)(2)) is amended

9 by inserting ‘‘and, in the case of such services

10 furnished (or likely to be required to be fur11 nished) for an extended period (as defined by

12 the Secretary under section 1861(m)), under a

13 home health case management plan that has

14 been established and periodically reviewed by a

15 home health case manager’’ after ‘‘is periodi16 cally reviewed by a physician’’.

17 (C) PAYMENT.—Section 1833 of such Act

18 (42 U.S.C. 1395l) is amended—

19 (i) in subsection (a)(2)—

20 (I) by striking ‘‘and’’ at the end

21 of subparagraph (F);

22 (II) by adding ‘‘and’’ at the end

23 of subparagraph (G); and
7

•HR 746 IH

1 (III) by adding after subpara2 graph (G) the following new subpara3 graph:

4 ‘‘(H) subject to subsection (u), with re5 spect to home health case manager services (as

6 defined in section 1861(uu)(3), the amount de7 termined under the fee schedule established

8 under section 1834(m);’’, and

9 (ii) by adding at the end the following

10 new subsection:

11 ‘‘(u) Payment may be made under this title for home

12 health case manager services with respect to an individual

13 only—

14 ‘‘(1) for the initial development of the home

15 health case management plan for the individual, and

16 ‘‘(2) for the subsequent review and modification

17 of such plan, as provided by the Secretary in regula18 tions.’’.

19 (3) ESTABLISHMENT OF FEE SCHEDULE.—Sec20 tion 1834 of such Act (42 U.S.C. 1395m) is amend21 ed by adding at the end the following new section:

22 ‘‘(m) ESTABLISHMENT OF FEE SCHEDULE FOR

23 HOME HEALTH CASE MANAGER SERVICES.—

24 ‘‘(1) IN GENERAL.—The Secretary shall estab25 lish a fee schedule for payment for home health case
8

•HR 746 IH

1 manager services. Such schedule may provide for

2 rates that differ for such services that comprise the

3 establishment of a home health case management

4 plan and that comprise review and modification of

5 such a plan.

6 ‘‘(2) CONSIDERATIONS.—In establishing such

7 fee schedule, the Secretary shall consider appro8 priate regional and operational differences and ad9 justments to payment rates to account for inflation

10 and other relevant factors.

11 ‘‘(3) CONSULTATION.—In establishing the fee

12 schedule for home health case manager services

13 under this subsection, the Secretary shall consult

14 with appropriate organizations representing individ15 uals and entities who furnish referral services for

16 home health services and share with such organiza17 tions relevant data in establishing such schedule.

18 ‘‘(4) ALTERNATIVE PAYMENT UNDER COMPETI19 TIVE BIDDING.—

20 ‘‘(A) IN GENERAL.—Notwithstanding the

21 preceding provisions of this subsection, the Sec22 retary may, by region, use a competitive process

23 to contract with home health case managers for

24 furnishing home health case manager services.
9

•HR 746 IH

1 ‘‘(B) PAYMENT.—Payment under this

2 paragraph shall be made on the basis of nego3 tiated all-inclusive rates. The amount of pay4 ment made by the Secretary to a home health

5 case manager for home health case manager

6 services under this title for services covered

7 under a contract shall be less than the aggre8 gate amount of the payments that the Secretary

9 would have otherwise made for the services.

10 ‘‘(C) CONTRACT PERIOD.—A contract pe11 riod shall be three years (subject to renewal), as

12 long as the entity continues to meet quality and

13 other contractual standards.’’.

14 (c) EFFECTIVE DATE.—The amendments made by

15 this section apply with respect to home health services fur16 nished on or after October 1, 2001.

17 SEC. 3. REPORT TO CONGRESS ON FEASIBILITY OF CASE

18 MANAGERS WITH RESPECT TO OTHER MEDI19 CARE SERVICES.

20 (a) STUDY.—The Secretary of Health and Human

21 Services shall conduct a study of the types of services con22 sisting of post-acute hospital care furnished under the

23 Medicare program under title XVIII of the Social Security

24 Act to determine whether use of case managers and case

25 management plans similar to home health case managers
10

•HR 746 IH

1 (as defined in section 1861(uu)(1)) and home health case

2 management plans (as defined in section 1861(uu)(2)) is

3 feasible and appropriate for each such type of service. In

4 conducting the study, the Secretary shall also determine

5 whether such case managers and case management plans

6 may improve quality of care and patient outcomes under

7 the medicare program, may result in cost savings to the

8 program, and may reduce incidents of waste, fraud and

9 abuse against the program.

10 (b) REPORT.—Not later than January 1, 2002, the

11 Secretary shall submit to Congress a report containing the

12 determinations made pursuant to the study conducted

13 under subsection (a) and any recommendations for legisla14 tive and administrative action the Secretary deems appro15 priate.

Æ