I 

111TH CONGRESS 

1ST SESSION H. R. 2307 

To amend title XVIII of the Social Security Act to provide Medicare beneficiaries with access to geriatric assessments and chronic care management and coordination services, and for other purposes. 

IN THE HOUSE OF REPRESENTATIVES 

MAY 7, 2009 

Mr. GENE GREEN of Texas (for himself and Mr. UPTON) introduced the following bill; which was referred to the Committee on Energy and Commerce, and in addition to the Committee on Ways and Means, 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 

Medicare beneficiaries with access to geriatric assessments and chronic care management and coordination 

services, and for other purposes. 

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; TABLE OF CONTENTS. 

4 (a) SHORT TITLE.—This Act may be cited as the 

5 ‘‘The Reaching Elders with Assessment and Chronic Care 


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1 Management and Coordination Act’’ or the ‘‘RE-Aligning 

2 Care Act’’. 

3 (b) TABLE OF CONTENTS.—The table of contents of 

4 this Act is as follows: 

Sec. 1. Short title; table of contents. 

Sec. 2. Findings. 

Sec. 3. Medicare coverage of geriatric assessments. 

Sec. 4. Medicare coverage of chronic care management and coordination services. 

Sec. 5. Outreach activities regarding geriatric assessments and chronic care 

management and coordination services under the Medicare program. 

Sec. 6. Utilization of telehealth services to furnish geriatric assessments and 

chronic care management and coordination services under the 

Medicare program. 

Sec. 7. Study and report on geriatric assessments and chronic care management and coordination services under the Medicare program. 

Sec. 8. Rule of construction. 

5 SEC. 2. FINDINGS. 

6 Congress makes the following findings: 

7 (1) The Medicare program must be redesigned 

8 to provide high-quality, cost-effective and coordi9 nated care to the growing population of elderly indi10 viduals with multiple and complex chronic condi11 tions. 

12 (2) Between 2005 and 2030, it is estimated 

13 that the number of adults aged 65 and older will al14 most double from 37,000,000 to more than 

15 70,000,000. The number of those age 80 and over, 

16 is also expected to nearly double from 11,000,000 to 

17 20,000,000. This demographic shift will create the 

18 largest ever proportion of adults over 65, increasing 


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1 from 12 percent of the United States population in 

2 2005 to almost 20 percent by 2030. 

3 (3) With the unprecedented growth of our Na4 tion’s aging population, the number of older patients 

5 with multiple chronic conditions and cognitive im6 pairments is expected to increase. Currently, about 

7 65 percent of Medicare beneficiaries have two or 

8 more chronic conditions. To address the health care 

9 needs unique to older adults with chronic conditions, 

10 it will require innovations in care delivery and com11 prehensive coordinated care. 

12 (4) According to the Congressional Budget Of13 fice, approximately 75 percent of Medicare spending 

14 pays for care for beneficiaries who have five or more 

15 chronic conditions and see an average of 14 different 

16 physicians per year. In addition, approximately 43 

17 percent of Medicare costs can be attributed to 5 per18 cent of Medicare’s most costly beneficiaries. 

19 (5) Total Medicare costs per beneficiary age 65 

20 or older with Alzheimer’s and other dementias were 

21 almost three times higher than for other Medicare 

22 beneficiaries in 2004. 

23 (6) There is a strong pattern of increasing utili24 zation as the number of conditions increase. In 

25 2003, 61 percent of Medicare beneficiaries with 3 


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1 chronic conditions saw 10 or more different physi2 cians compared to 40 percent with 2 conditions and 

3 18 percent of those with 1 condition. 

4 (7) According to a June 2006 MedPAC report, 

5 even if individual providers deliver care efficiently, 

6 overall care for a beneficiary may be inefficient if 

7 providers do not coordinate across settings or assist 

8 beneficiaries in managing their conditions between 

9 visits. Beneficiaries with multiple chronic conditions 

10 may benefit the most from care coordination as they 

11 do not always receive necessary care and often at 

12 high cost. 

13 (8) On average, individuals 65 to 69 years old 

14 take nearly 14 prescriptions per year and individuals 

15 aged 80 to 84 take an average of 18 prescriptions 

16 per year. As the number of chronic conditions in17 creases, so does the number of medications, increas18 ing the risk for negative drug interactions that can 

19 lead to serious injury requiring hospitalization or 

20 can even be fatal. Studies have found that 25 per21 cent to 50 percent adverse drug events among older 

22 persons are preventable and that preventable adverse 

23 drug events may cost the Medicare program 

24 $887,000,000 per year. 


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1 (9) Research conducted in the United States 

2 and internationally indicate that the delivery of high3 er quality health care, increased efficiency, and cost4 effectiveness are the result of systems in which pa5 tients are linked with a physician or another quali6 fied health professional who coordinates their care. 

7 According to the Congressional Budget Office, an 

8 intervention that focused on coordinating care for 

9 high-cost beneficiaries with multiple chronic condi10 tions could both improve their health and reduce 

11 Medicare spending. 

12 (10) In addition, chronic care management and 

13 coordination may help prevent negative medication 

14 interactions and prevent hospital stays because the 

15 chronic care team holistically manages and treats ill16 ness. Reducing the rate of preventable adverse drug 

17 events will both improve patient care and may result 

18 in savings to the Medicare program. 

19 (11) The Medicare fee-for-service program cur20 rently does not pay for care coordination services. 

21 Instead, the delivery and payment systems are orga22 nized to support the diagnosis and treatment of 

23 acute or episodic conditions, resulting in fragmented, 

24 ineffective and costly care for beneficiaries with 

25 chronic diseases. It currently rewards the overuse 


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1 and duplication of services rather than rewarding 

2 the effective control of chronic conditions, which can 

3 improve health outcomes and prevent hospitalization 

4 or rehospitalization. 

5 (12) The Institute of Medicine Report, ‘‘Retool6 ing for an Aging America: Building the Health Care 

7 Workforce’’, cited misaligned financial incentives, in8 cluding the inability to reimburse for care coordina9 tion, as factors that result in fragmented care for 

10 older Americans. 

11 (13) Financial incentives within the Medicare 

12 program should be realigned as part of a com13 prehensive system change. The Medicare program 

14 should be restructured to reimburse physicians and 

15 other qualified health professionals for the cost of 

16 coordinating care. 

17 (14) The patient-centered chronic care model 

18 established by the provisions of, and the amend19 ments made by, this Act includes several elements 

20 that are effective in managing older adults with 

21 chronic disease, including— 

22 (A) a comprehensive assessment of the in23 dividual’s physical, cognitive, affective, func24 tional and social status, and caregiving needs; 


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1 (B) access to patient-centered care coordi2 nation services provided by interdisciplinary 

3 team members; 

4 (C) support for patient self-management of 

5 chronic disease; 

6 (D) linkages with community resources; 

7 (E) health care system changes that re8 ward quality chronic care; 

9 (F) practice redesign; 

10 (G) evidence-based clinical practice guide11 lines; and 

12 (H) clinical information systems, such as 

13 electronic medical records and continuity of 

14 care records. 

15 (15) The provisions of, and amendments made 

16 by, this Act are intended to— 

17 (A) improve health outcomes appropriate 

18 for older patients with multiple chronic condi19 tions; 

20 (B) increase beneficiary, caregiver, and 

21 provider satisfaction; 

22 (C) increase cost-effectiveness and high 

23 value to the Medicare program for those served 

24 with multiple chronic conditions; 


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1 (D) establish a process to identify those 

2 Medicare beneficiaries most likely to benefit 

3 from having a provider coordinate their health 

4 care needs; and 

5 (E) establish a payment under the Medi6 care program for— 

7 (i) the assessment of those health care 

8 needs; and 

9 (ii) the activities required to coordi10 nate those health care needs. 

11 SEC. 3. MEDICARE COVERAGE OF GERIATRIC ASSESS12 MENTS. 

13 (a) COVERAGE OF GERIATRIC ASSESSMENTS.— 

14 (1) IN GENERAL.—Section 1861(s)(2) of the 

15 Social Security Act (42 U.S.C. 1395x(s)(2)) is 

16 amended— 

17 (A) in subparagraph (DD), by striking 

18 ‘‘and’’ at the end; 

19 (B) in subparagraph (EE), by adding 

20 ‘‘and’’ at the end; and 

21 (C) by adding at the end the following new 

22 subparagraph: 

23 ‘‘(FF) geriatric assessments (as defined in sub24 section (hhh)(1));’’. 


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1 (2) CONFORMING AMENDMENTS.—Clauses (i) 

2 and (ii) of section 1861(s)(2)(K) of the Social Secu3 rity Act (42 U.S.C. 1395x(s)(2)(K)) are each 

4 amended by striking ‘‘subsection (ww)(1)’’ and in5 serting ‘‘subsections (ww)(1) and (hhh)(1)’’. 

6 (b) GERIATRIC ASSESSMENTS DEFINED.—Section 

7 1861 of the Social Security Act (42 U.S.C. 1395x) is 

8 amended by adding at the end the following new sub9 sections: 

10 ‘‘Geriatric Assessment 

11 ‘‘(hhh)(1) The term ‘geriatric assessment’ means 

12 each of the following: 

13 ‘‘(A) An assessment of the clinical status, func14 tional status, social and environmental functioning, 

15 and need for caregiving of a geriatric assessment eli16 gible individual (as defined in subsection (iii)). The 

17 assessment shall include a comprehensive history 

18 and physical examination and assessments of the fol19 lowing domains using standardized validated clinical 

20 tools: 

21 ‘‘(i) Comprehensive review of medications 

22 and the individual’s adherence to the medica23 tion regimen. 


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1 ‘‘(ii) Measurement of affect, cognition and 

2 executive function, mobility, balance, gait, risk 

3 of falling, and sensory function. 

4 ‘‘(iii) Social functioning, environmental 

5 needs, and caregiver resources and needs. 

6 ‘‘(iv) Any other domain determined appro7 priate by the Secretary. 

8 ‘‘(B) The development of a written care plan 

9 based on the results of the assessment under sub10 paragraph (A) (and any subsequent assessment 

11 under subparagraph (B)). The care plan shall detail 

12 identified problems, outline therapies, assign respon13 sibility for actions, and indicate whether the indi14 vidual is likely to benefit from chronic care manage15 ment and coordination services (as defined in sub16 section (jjj)(1)). If the individual is determined likely 

17 to benefit from chronic care management and co18 ordination services, the care plan shall also provide 

19 the basis for the chronic care management and co20 ordination plan to be developed by the chronic care 

21 manager pursuant to subsection (jjj). 

22 ‘‘(2) A geriatric assessment may only be conducted 

23 by— 

24 ‘‘(A) a physician; 


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1 ‘‘(B) a practitioner described in section 

2 1842(b)(18)(C)(i) under the supervision of a physi3 cian; or 

4 ‘‘(C) any other provider that meets such condi5 tions as the Secretary may specify. 

6 ‘‘(3) An individual described in subclause (A), (B), 

7 or, if applicable, (C) may provide for the furnishing of 

8 services included in the geriatric assessment by other 

9 qualified health care professionals. 

10 ‘‘(4)(A) Subject to subparagraph (B), a geriatric as11 sessment of a geriatric assessment eligible individual may 

12 not be conducted more frequently than annually. 

13 ‘‘(B) A geriatric assessment of a geriatric assessment 

14 eligible individual may be conducted more frequently than 

15 annually if the assessment is medically necessary due to 

16 a significant change in the condition of the individual. 

17 ‘‘Geriatric Assessment Eligible Individual 

18 ‘‘(iii)(1) Subject to paragraph (3), the term ‘geriatric 

19 assessment eligible individual’ means an individual identi20 fied by the Secretary as eligible for a geriatric assessment. 

21 ‘‘(2) In identifying individuals under paragraph (1), 

22 the following rules shall apply: 

23 ‘‘(A) The individual must have at least 1 of the 

24 following present: 


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1 ‘‘(i) Multiple chronic conditions that the 

2 Secretary identifies as likely to result in high 

3 expenditures under this title. In identifying 

4 such conditions, the Secretary may consider— 

5 ‘‘(I) the hierarchal condition category 

6 methodology employed for risk adjustment 

7 under part C or other comparable meth8 odologies the Secretary deems appropriate; 

9 ‘‘(II) data from the Chronic Condition 

10 Data Warehouse under section 723 of the 

11 Medicare Prescription Drug, Improvement, 

12 and Modernization Act of 2003; and 

13 ‘‘(III) indicators of geriatric syn14 dromes, such as experiencing 2 or more 

15 falls in the past year, urinary incontinence, 

16 clinically significant depression, or other 

17 such indicators that the Secretary indicates 

18 as likely to result in high expenditures 

19 under this title when they exist in com20 bination with one or more chronic condi21 tions). 

22 ‘‘(ii) Dementia, as defined in the most re23 cent Diagnostic and Statistical Manual of Men24 tal Disorders, and at least 1 other chronic con25 dition. 


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1 ‘‘(iii) Any other factor identified by the 

2 Secretary. 

3 ‘‘(B) The Secretary shall consult with physi4 cians, physician groups and organizations, other 

5 health care professional groups and organizations, 

6 organizations representing individuals with chronic 

7 conditions and older adults, and other stakeholders 

8 in identifying conditions under clauses (i) and (ii) of 

9 subparagraph (A) and any factors under subpara10 graph (A)(iii). 

11 ‘‘(3) The term ‘geriatric assessment eligible indi12 vidual’ shall not include the following individuals: 

13 ‘‘(A) An individual who is receiving hospice care 

14 under this title. 

15 ‘‘(B) An individual who is residing in a skilled 

16 nursing facility, a nursing facility (as defined in sec17 tion 1919), or any other facility identified by the 

18 Secretary. 

19 ‘‘(C) An individual medically determined to 

20 have end-stage renal disease. 

21 ‘‘(D) An individual enrolled in a Medicare Ad22 vantage plan or a plan under section 1876. 

23 ‘‘(E) An individual enrolled in a PACE pro24 gram under section 1894. 


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1 ‘‘(F) Any other categories of individuals deter2 mined appropriate by the Secretary. 

3 ‘‘(4) For purposes of this subsection, the term ‘chron4 ic condition’ means a condition, such as dementia, that 

5 lasts or is expected to last 1 year or longer, limits what 

6 an individual can do, and requires ongoing care.’’. 

7 (c) PAYMENT AND ELIMINATION OF COST-SHAR8 ING.— 

9 (1) PAYMENT AND ELIMINATION OF COINSUR10 ANCE.—Section 1833(a)(1) of the Social Security 

11 Act (42 U.S.C. 1395l(a)(1)) is amended— 

12 (A) in subparagraph (N), by inserting 

13 ‘‘other than geriatric assessments (as defined in 

14 section 1861(hhh)(1))’’ after ‘‘(as defined in 

15 section 1848(j)(3))’’; 

16 (B) by striking ‘‘and’’ before ‘‘(W)’’; and 

17 (C) by inserting before the semicolon at 

18 the end the following: ‘‘, and (X) with respect 

19 to geriatric assessments (as defined in section 

20 1861(hhh)(1)), the amount paid shall be 100 

21 percent of the lesser of the actual charge for 

22 the services or the amount determined under 

23 section 1848(o)’’. 

24 (2) PAYMENT.— 


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1 (A) IN GENERAL.—Section 1848 of the So2 cial Security Act (42 U.S.C. 1395w–4) is 

3 amended by adding at the end the following 

4 new subsection: 

5 ‘‘(o) PAYMENT FOR GERIATRIC ASSESSMENTS.— 

6 ‘‘(1) ESTABLISHMENT.— 

7 ‘‘(A) IN GENERAL.—The Secretary shall 

8 establish— 

9 ‘‘(i) a payment code (or codes) under 

10 this section for a geriatric assessment (as 

11 defined in section 1861(hhh)(1)) furnished 

12 to a geriatric assessment eligible individual 

13 (as defined in section 1861(iii)) by a physi14 cian, practitioner, or other provider de15 scribed in section 1861(hhh)(2); and 

16 ‘‘(ii) a payment amount for each such 

17 code. 

18 ‘‘(B) REQUIREMENTS.—In establishing 

19 payment amounts under subparagraph (A)(ii), 

20 the Secretary shall— 

21 ‘‘(i) take into account— 

22 ‘‘(I) the amount of work required 

23 to perform a geriatric assessment, in24 cluding the time and effort put forth 

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1 sional involved in performing the geri2 atric assessment; and 

3 ‘‘(II) all of the costs associated 

4 with the geriatric assessment, includ5 ing labor, supplies, equipment, and 

6 the costs of health information tech7 nologies and systems incurred by the 

8 physician, practitioner, or other pro9 vider (as described in section 

10 1861(hhh)(2)) in providing the assess11 ment; and 

12 ‘‘(ii) ensure that such payments do 

13 not result in a reduction in payments for 

14 office visits or other evaluation and man15 agement services that would otherwise be 

16 allowable. 

17 ‘‘(2) SEPARATE PAYMENTS FROM PAYMENTS

18 FOR CHRONIC CARE MANAGEMENT AND COORDINA19 TION SERVICES.—Payments for geriatric assess20 ments shall be made separately from payments for 

21 chronic care management and coordination services 

22 (as defined in section 1861(jjj)(1)) and other serv23 ices for which payment is made under this title.’’. 

24 (B) CONFORMING AMENDMENT.—Section 

25 1848(j)(3) of the Social Security Act (42 


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1 U.S.C. 1395w–4(j)(3)), as amended by section 

2 3(c)(2)), is amended by inserting ‘‘(2)(FF),’’ 

3 after ‘‘(2)(EE),’’. 

4 (3) ELIMINATION OF COINSURANCE IN OUT5 PATIENT HOSPITAL SETTINGS.— 

6 (A) EXCLUSION FROM OPD FEE SCHED7 ULE.—Section 1833(t)(1)(B)(iv) of the Social 

8 Security Act (42 U.S.C. 1395l(t)(1)(B)(iv)) is 

9 amended by striking ‘‘and diagnostic mammog10 raphy’’ and inserting ‘‘, diagnostic mammog11 raphy, or geriatric assessments (as defined in 

12 section 1861(hhh)(1))’’. 

13 (B) CONFORMING AMENDMENTS.—Section 

14 1833(a)(2) of the Social Security Act (42 

15 U.S.C. 1395l(a)(2)) is amended— 

16 (i) in subparagraph (F), by striking 

17 ‘‘and’’ at the end; 

18 (ii) in subparagraph (G)(ii), by strik19 ing the comma at the end and inserting ‘‘; 

20 and’’; and 

21 (iii) by inserting after subparagraph 

22 (G)(ii) the following new subparagraph: 

23 ‘‘(H) with respect to geriatric assessments 

24 (as defined in section 1861(hhh)(1)) furnished 


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1 by an outpatient department of a hospital, the 

2 amount determined under paragraph (1)(X),’’. 

3 (4) ELIMINATION OF DEDUCTIBLE.—The first 

4 sentence of section 1833(b) of the Social Security 

5 Act (42 U.S.C. 1395l(b)) is amended— 

6 (A) by striking ‘‘and’’ before ‘‘(9)’’; and 

7 (B) by inserting before the period the fol8 lowing: ‘‘, and (10) such deductible shall not 

9 apply with respect to geriatric assessments (as 

10 defined in section 1861(hhh)(1))’’. 

11 (d) FREQUENCY LIMITATION.—Section 1862(a) of 

12 the Social Security Act (42 U.S.C. 1395y(a)(1)) is amend13 ed— 

14 (1) in paragraph (1)— 

15 (A) in subparagraph (N), by striking 

16 ‘‘and’’ at the end; 

17 (B) in subparagraph (O) by striking the 

18 semicolon at the end and inserting ‘‘, and’’; and 

19 (C) by adding at the end the following new 

20 subparagraph: 

21 ‘‘(P) in the case of geriatric assessments (as de22 fined in section 1861(hhh)(1)), which are performed 

23 more frequently than is covered under such sec24 tion;’’; and 


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1 (2) in paragraph (7), by striking ‘‘or (K)’’ and 

2 inserting ‘‘(K), or (P)’’. 

3 (e) EXCEPTION TO LIMITS ON PHYSICIAN REFER4 RALS.—Section 1877(b) of the Social Security Act (42 

5 U.S.C. 1395nn(b)) is amended by adding at the end the 

6 following new paragraph: 

7 ‘‘(6) GERIATRIC ASSESSMENTS.—In the case of 

8 a designated health service, if the designated health 

9 service is a geriatric assessment (as defined in sec10 tion 1861(hhh)(1)) and furnished by a physician.’’. 

11 (f) RULEMAKING.—The Secretary of Health and 

12 Human Services shall define such terms, establish such 

13 procedures, and promulgate such regulations as the Sec14 retary determines necessary to implement the amend15 ments made by, and the provisions of, this section, includ16 ing the establishment of additional domains under sub17 section (hhh)(1)(A)(iv) of section 1861 of the Social Secu18 rity Act, as added by subsection (b). In promulgating such 

19 regulations, the Secretary shall consult with physicians, 

20 physician groups and organizations, other health care pro21 fessional groups and organizations representing individ22 uals with chronic conditions and older adults. 

23 (g) EFFECTIVE DATE.—The amendments made by 

24 this section shall apply to assessments furnished on or 

25 after January 1, 2010. 


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1 SEC. 4. MEDICARE COVERAGE OF CHRONIC CARE MANAGE2 MENT AND COORDINATION SERVICES. 

3 (a) PART B COVERAGE OF CHRONIC CARE MANAGE4 MENT AND COORDINATION SERVICES.— 

5 (1) IN GENERAL.—Section 1861(s)(2) of the 

6 Social Security Act (42 U.S.C. 1395x(s)(2)), as 

7 amended by section 3(a)(1), is amended— 

8 (A) in subparagraph (EE), by striking 

9 ‘‘and’’ at the end; 

10 (B) in subparagraph (FF), by adding 

11 ‘‘and’’ at the end; and 

12 (C) by adding at the end the following new 

13 subparagraph: 

14 ‘‘(GG) chronic care management and coordina15 tion services (as defined in subsection (jjj));’’. 

16 (2) CONFORMING AMENDMENTS.—(A) Clauses 

17 (i) and (ii) of section 1861(s)(2)(K) of the Social Se18 curity Act (42 U.S.C. 1395x(s)(2)(K)), as amended 

19 by section 3(a)(2), are each amended by striking 

20 ‘‘subsections (ww)(1) and (hhh)(1)’’ and inserting 

21 ‘‘subsections (ww)(1), (hhh)(1), and (jjj)(1)’’. 

22 (B) Section 1862(a)(7) of the Social Security 

23 Act (42 U.S.C. 1395y(a)(7)), as amended by section 

24 3(d), is amended by striking ‘‘section 1861(s)(10)’’ 

25 and inserting ‘‘paragraphs (2)(GG) and (10) of sec26 tion 1861(s)’’. 


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1 (b) SERVICES DESCRIBED.—Section 1861 of the So2 cial Security Act (42 U.S.C. 1395x), as amended by sec3 tion 3(b), is amended by adding at the end the following 

4 new subsection: 

5 ‘‘Chronic Care Management and Coordination Services; 

6 Chronic Care Manager; Chronic Care Eligible Individual 

7 ‘‘(jjj)(1) The term ‘chronic care management and co8 ordination services’ means services that are furnished to 

9 a chronic care eligible individual (as defined in paragraph 

10 (3)) by, or under the supervision of, a single chronic care 

11 manager (as defined in paragraph (2)) chosen by the 

12 chronic care eligible individual, a caregiver designated by 

13 the individual in writing, or a representative authorized 

14 to make decisions on the individual’s behalf, under a plan 

15 of care prescribed by such chronic care manager for the 

16 purpose of chronic care coordination, including dementia 

17 as appropriate, which may include any of the following 

18 services: 

19 ‘‘(A) The development of an initial plan of care 

20 (based on the results of a geriatric assessment, as 

21 defined in subsection (hhh)), and subsequent appro22 priate revisions to that plan of care. 

23 ‘‘(B) The management of, and referral for, 

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1 disciplinary care conferences and management with 

2 other providers. 

3 ‘‘(C) The monitoring and management of medi4 cations. 

5 ‘‘(D) Patient education and counseling services. 

6 ‘‘(E) Family caregiver education and counseling 

7 services, including preventive care consistent with 

8 the patient’s condition. 

9 ‘‘(F) Self-management services, including 

10 health education and risk appraisal to identify be11 havioral risk factors through self-assessment. 

12 ‘‘(G) Providing access for individuals, and care13 givers or authorized representatives as appropriate, 

14 by telephone and e-mail to physicians or other ap15 propriate health care professionals, including 24- 

16 hour availability of such professionals for after hours 

17 consultation. 

18 ‘‘(H) Coordination with the principal nonprofes19 sional caregiver in the home. 

20 ‘‘(I) Managing and facilitating transitions that 

21 occur among health care professionals and across 

22 settings of care, including the following: 

23 ‘‘(i) Pursuing the treatment option elected 

24 by the individual. 


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1 ‘‘(ii) Including any advance directive exe2 cuted by the individual in the medical file of the 

3 individual. 

4 ‘‘(J) Information about pain management and 

5 palliative care. 

6 ‘‘(K) Information about, and referral to, hos7 pice care, including patient and family caregiver 

8 education and counseling about hospice care, and fa9 cilitating transition to hospice care when elected. 

10 ‘‘(L) Information about, referral to, and coordi11 nation with, community resources. 

12 ‘‘(M) Such additional services for which pay13 ment would not otherwise be made under this title 

14 that the Secretary may specify that encourage the 

15 receipt of, or improve the effectiveness of, the serv16 ices described in the preceding subparagraphs. 

17 ‘‘(2)(A) For purposes of this subsection, the term 

18 ‘chronic care manager’ means an individual or entity 

19 that— 

20 ‘‘(i) is— 

21 ‘‘(I) a physician; 

22 ‘‘(II) a practitioner described in clause (i) 

23 or (iv) of section 1842(b)(18)(C); or 

24 ‘‘(III) any other provider that meets such 

25 conditions as the Secretary may specify; 


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1 ‘‘(ii) has entered into a chronic care manage2 ment and coordination agreement with the Sec3 retary; and 

4 ‘‘(iii) is working in collaboration with, or under 

5 the supervision of, as determined by the Secretary— 

6 ‘‘(I) the physician, practitioner, or other 

7 provider who completed the geriatric assessment 

8 of the individual; or 

9 ‘‘(II) a physician, practitioner, or other 

10 provider to whom the individual’s care was 

11 transferred by the physician, practitioner, or 

12 other provider who performed the geriatric as13 sessment. 

14 ‘‘(B)(i) For purposes of subparagraph (A)(ii), each 

15 chronic care management and coordination agreement 

16 shall meet the requirements described in subparagraph 

17 (C) and shall— 

18 ‘‘(I) subject to clause (ii), be entered into for a 

19 period of 3 years and may be renewed if the Sec20 retary is satisfied that the chronic care manager 

21 continues to meet such terms and conditions as the 

22 Secretary may require; and 

23 ‘‘(II) contain such other terms and conditions 

24 as the Secretary may require. 


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1 ‘‘(ii) Each chronic care management and coordination 

2 agreement shall provide for the termination of such agree3 ment prior to such 3-year period in the case where the 

4 chronic care manager— 

5 ‘‘(I) is no longer able to provide chronic care 

6 services; or 

7 ‘‘(II) does not meet such terms and conditions 

8 as the Secretary may require. 

9 ‘‘(C)(i) Subject to clause (ii), the requirements of this 

10 subparagraph are met if the agreement requires the chron11 ic care manager to perform, or provide for the perform12 ance of, the following services: 

13 ‘‘(I) Advocating for, and providing ongoing sup14 port, oversight, and guidance with respect to the im15 plementation of a plan of care that provides an inte16 grated, coherent, and cross-disciplined plan for ongo17 ing medical care that is developed in partnership 

18 with the chronic care eligible individual and all other 

19 physicians and other care providers and agencies (in20 cluding home health agencies) providing care to the 

21 chronic care eligible individual. 

22 ‘‘(II) Using evidence-based medicine and clin23 ical decision support tools to guide decisionmaking 

24 at the point of care and on the basis of specific pa25 tient factors. 


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1 ‘‘(III) Using health information technology, in2 cluding, where appropriate, remote monitoring and 

3 patient registries, to monitor and track the health 

4 status of patients and to provide patients with en5 hanced and convenient access to health care services. 

6 ‘‘(IV) Encouraging patients to engage in the 

7 management of their own health through education 

8 and support systems. 

9 ‘‘(V) Incorporating family caregivers into the 

10 chronic care planning process. 

11 ‘‘(ii) The Secretary may modify the services required 

12 under the agreement under clause (i), including by requir13 ing different services or services in addition to those de14 scribed in subclauses (I) through (V) of such clause. 

15 ‘‘(D) The Secretary shall adopt procedures which ex16 empt providers in rural areas from providing 1 or more 

17 of the services otherwise required to be provided under 

18 subparagraph (C) or modify such requirements for such 

19 providers. In establishing such procedures, the Secretary 

20 shall ensure that such exemptions and modifications do 

21 not impact the quality of chronic care management and 

22 coordination services furnished by such providers. 

23 ‘‘(3) For purposes of this subsection, the term ‘chron24 ic care eligible individual’ means a geriatric assessment 

25 eligible individual (as defined in subsection (iii)) who has 


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1 undergone a geriatric assessment (as defined in subsection 

2 (hhh)(1)) which determined that the individual would ben3 efit from chronic care management and coordination. 

4 ‘‘(4) Chronic care management and coordination 

5 services may be furnished in the chronic care eligible indi6 vidual’s home or residence.’’. 

7 (c) PAYMENT AND ELIMINATION OF COST-SHAR8 ING.— 

9 (1) PAYMENT AND ELIMINATION OF COINSUR10 ANCE.—Section 1833(a)(1) of the Social Security 

11 Act (42 U.S.C. 1395l(a)(1)), as amended by section 

12 3(c)(1), is amended— 

13 (A) in subparagraph (N), by inserting ‘‘or 

14 chronic care management and coordination 

15 services (as defined in section 1861(jjj)(1))’’ 

16 after ‘‘other than geriatric assessments (as de17 fined in section 1861(hhh)(1))’’; 

18 (B) by striking ‘‘and’’ before ‘‘(X)’’; and 

19 (C) by inserting before the semicolon at 

20 the end the following: ‘‘, and (Y) with respect 

21 to chronic care management and coordination 

22 services (as defined in section 1861(jjj)(1)), the 

23 amount paid shall be 100 percent of the lesser 

24 of the actual charge for the services or the 

25 amount determined under section 1848(p)’’. 


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1 (2) PAYMENT.— 

2 (A) IN GENERAL.—Section 1848 of the So3 cial Security Act (42 U.S.C. 1395w–4), as 

4 amended by section 3(c)(2), is amended by add5 ing at the end the following new subsection: 

6 ‘‘(p) PAYMENT FOR CHRONIC CARE MANAGEMENT

7 AND COORDINATION SERVICES.— 

8 ‘‘(1) ESTABLISHMENT.— 

9 ‘‘(A) IN GENERAL.—The Secretary shall 

10 establish— 

11 ‘‘(i) a payment code (or codes) under 

12 this section for chronic care management 

13 and coordination services (as defined in 

14 paragraph (1) of section 1861(jjj)) fur15 nished to a chronic care eligible individual 

16 (as defined in paragraph (3) of such sec17 tion) by a chronic care manager (as de18 fined in paragraph (2) of such section); 

19 and 

20 ‘‘(ii) a payment amount for each such 

21 code. 

22 ‘‘(B) REQUIREMENTS.—In establishing 

23 payment amounts under subparagraph (A)(ii), 

24 the Secretary shall— 

25 ‘‘(i) take into account— 


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1 ‘‘(I) the amount of work required 

2 of the chronic care manager in pro3 viding chronic care management and 

4 coordination services to eligible indi5 viduals; and 

6 ‘‘(II) all of the costs associated 

7 with providing chronic care manage8 ment and coordination services, in9 cluding labor, supplies, equipment, 

10 and the costs of health information 

11 technologies and systems incurred by 

12 the chronic care manager in providing 

13 such services; 

14 ‘‘(ii) ensure that such payments are 

15 for such services furnished during a 30-day 

16 period; and 

17 ‘‘(iii) ensure that such payments do 

18 not result in a reduction in payments for 

19 office visits or other evaluation and man20 agement services that would otherwise be 

21 allowable. 

22 ‘‘(2) SEPARATE PAYMENTS FROM PAYMENTS

23 FOR GERIATRIC ASSESSMENTS.—Payments for 

24 chronic care management and coordination services 

25 shall be made separately from payments for geriatric 


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1 assessments (as defined in section 1861(hhh)(1)) 

2 and other services for which payment is made under 

3 this title.’’. 

4 (B) CONFORMING AMENDMENT.—Section 

5 1848(j)(3) of the Social Security Act (42 

6 U.S.C. 1395w–4(j)(3)), as amended by section 

7 3(c)(2)), is amended by inserting ‘‘(2)(GG),’’ 

8 after ‘‘(2)(FF),’’. 

9 (3) ELIMINATION OF COINSURANCE IN OUT10 PATIENT HOSPITAL SETTINGS.— 

11 (A) EXCLUSION FROM OPD FEE SCHED12 ULE.—Section 1833(t)(1)(B)(iv) of the Social 

13 Security Act (42 U.S.C. 1395l(t)(1)(B)(iv)), as 

14 amended by section 3(c)(3)(A), is amended by 

15 striking ‘‘or geriatric assessments (as defined in 

16 section 1861(hhh)(1))’’ and inserting ‘‘geriatric 

17 assessments (as defined in section 

18 1861(hhh)(1)), or chronic care management 

19 and coordination services (as defined in section 

20 1861(jjj)(1))’’. 

21 (B) CONFORMING AMENDMENTS.—Section 

22 1833(a)(2) of the Social Security Act (42 

23 U.S.C. 1395l(a)(2)), as amended by section 

24 3(c)(3)(B), is amended— 


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1 (i) in subparagraph (G)(ii), by strik2 ing ‘‘and’’ at the end; 

3 (ii) in subparagraph (H), by striking 

4 the comma at the end and inserting ‘‘; 

5 and’’; and 

6 (iii) by inserting after subparagraph 

7 (H) the following new subparagraph: 

8 ‘‘(I) with respect to chronic care manage9 ment and coordination services (as defined in 

10 section 1861(jjj)(1)) furnished by an outpatient 

11 department of a hospital, the amount deter12 mined under paragraph (1)(Y),’’. 

13 (4) ELIMINATION OF DEDUCTIBLE.—Paragraph 

14 (10) of section 1833(b) of the Social Security Act 

15 (42 U.S.C. 1395l(b)), as added by section 3(c)(4), is 

16 amended by inserting ‘‘or chronic care management 

17 and coordination services (as defined in section 

18 1861(jjj)(1))’’ after ‘‘geriatric assessments (as de19 fined in section 1861(hhh)(1))’’. 

20 (d) EXCEPTION TO LIMITS ON PHYSICIAN REFER21 RALS.—Section 1877(b)(6) of the Social Security Act (42 

22 U.S.C. 1395nn(b)(6)), as amended by section 3(e), is 

23 amended to read as follows: 

24 ‘‘(6) GERIATRIC ASSESSMENTS AND CHRONIC

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1 ICES.—In the case of a designated health service, if 

2 the designated health service is— 

3 ‘‘(A) a geriatric assessment or a chronic 

4 care management and coordination service (as 

5 defined in subsections (hhh)(1) or (jjj)(1) of 

6 section 1861, respectively); and 

7 ‘‘(B) furnished by a physician.’’. 

8 (e) RULEMAKING.—The Secretary of Health and 

9 Human Services shall define such terms, establish such 

10 procedures, and promulgate such regulations as the Sec11 retary determines necessary to implement the amend12 ments made by, and the provisions of, this section. In pro13 mulgating such regulations, the Secretary shall consult 

14 with physicians, physician groups and organizations, other 

15 health care professional groups and organizations, and or16 ganizations representing individuals with chronic condi17 tions and older adults. 

18 (f) EFFECTIVE DATE.—The amendments made by 

19 this section shall apply to chronic care management and 

20 coordination services furnished on or after January 1, 

21 2010. 


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1 SEC. 5. OUTREACH ACTIVITIES REGARDING GERIATRIC AS2 SESSMENTS AND CHRONIC CARE MANAGE3 MENT AND COORDINATION SERVICES UNDER 

4 THE MEDICARE PROGRAM. 

5 The Secretary of Health and Human Services shall 

6 conduct outreach activities to individuals likely to be eligi7 ble to receive coverage of geriatric assessments (as defined 

8 in subsection (hhh)(1) of section 1861 of the Social Secu9 rity Act, as added by section 3) under the Medicare pro10 gram and individuals likely to be eligible to receive cov11 erage of chronic care management and coordination serv12 ices (as defined in subsection (jjj)(1) of such section 1861, 

13 as added by section 4) under the Medicare program, to 

14 inform such individuals about the availability of such ben15 efits under the Medicare program. 

16 SEC. 6. UTILIZATION OF TELEHEALTH SERVICES TO FUR17 NISH GERIATRIC ASSESSMENTS AND CHRON18 IC CARE MANAGEMENT AND COORDINATION 

19 SERVICES UNDER THE MEDICARE PROGRAM. 

20 (a) IN GENERAL.—Section 1834(m)(4)(F) of the So21 cial Security Act (42 U.S.C. 1395m(m)(4)(F)) is amended 

22 by adding at the end the following new clause: 

23 ‘‘(iii) GERIATRIC ASSESSMENTS AND

24 CHRONIC CARE MANAGEMENT AND CO25 ORDINATION SERVICES.—The term ‘tele26 health service’ shall also include geriatric 


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1 assessments (as defined in section 

2 1861(hhh)(1)) and chronic care manage3 ment and coordination services (as defined 

4 in section 1861(jjj)).’’. 

5 (b) EFFECTIVE DATE.—The amendments made by 

6 this section shall apply to services furnished on or after 

7 January 1, 2010. 

8 SEC. 7. STUDY AND REPORT ON GERIATRIC ASSESSMENTS 

9 AND CHRONIC CARE MANAGEMENT AND CO10 ORDINATION SERVICES UNDER THE MEDI11 CARE PROGRAM. 

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

13 Services shall enter into a contract with an entity to con14 duct a study on— 

15 (1) the effectiveness of the coverage of geriatric 

16 assessments and chronic care management and co17 ordination services, including an evaluation of the 

18 use of interdisciplinary teams in providing such serv19 ices, under the Medicare program (under the amend20 ments made by sections 3 and 4) on improving the 

21 quality of care provided to Medicare beneficiaries 

22 with chronic conditions, including dementia; and 

23 (2) the impact of such geriatric assessments 

24 and care coordination services on reducing expendi25 tures under title XVIII of the Social Security Act, 


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1 including reduced expenditures that may result 

2 from— 

3 (A) reducing preventable hospital admis4 sions; 

5 (B) more appropriate use of pharma6 ceuticals; and 

7 (C) reducing duplicate or unnecessary 

8 tests. 

9 (b) REPORT.—Not later than 3 years after the date 

10 of enactment of this Act, the entity conducting the study 

11 under subsection (a) shall submit to Congress and the Sec12 retary of Health and Human Services a report on the 

13 study, together with recommendations for such legislation 

14 or administrative action as such entity determines appro15 priate. 

16 (c) AUTHORIZATION OF APPROPRIATIONS.—There 

17 are authorized to be appropriated such sums as may be 

18 necessary to carry out this section. 

19 SEC. 8. RULE OF CONSTRUCTION. 

20 Nothing in the provisions of, or in the amendments 

21 made by, this Act shall be construed as requiring an indi22 vidual to receive a geriatric assessment (as defined in sec23 tion 1861(hhh)(1) of the Social Security Act, as added by 

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1 tion services (as defined in section 1861(jjj)(1) of such 

2 Act, as added by section 4(b)). 

Æ 


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