I 

111TH CONGRESS 

1ST SESSION H. R. 2390 

To provide for a Medicare prescription drug outreach demonstration program 

for individuals who are eligible for benefits under the Medicare Program 

and for medical assistance under Medicaid and who have mental disabilities. 

IN THE HOUSE OF REPRESENTATIVES 

MAY 13, 2009 

Ms. ROYBAL-ALLARD (for herself and Mr. SESSIONS) 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 provide for a Medicare prescription drug outreach demonstration program for individuals who are eligible for 

benefits under the Medicare Program and for medical 

assistance under Medicaid and who have mental disabilities. 

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. 

4 This Act may be cited as the ‘‘Guidance, Under5 standing, and Information for Dual Eligibles (GUIDE) 

6 Act’’. 


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1 SEC. 2. FINDINGS; PURPOSE. 

2 (a) FINDINGS.—The Congress finds the following: 

3 (1) Nearly 8,800,000 Americans were eligible 

4 for benefits under the Medicare program and for 

5 medical assistance under Medicaid (dual eligible 

6 beneficiaries) in fiscal year 2005. Of these ‘‘dual eli7 gible beneficiaries’’, almost 40 percent have cognitive 

8 impairments, including Alzheimer’s disease, demen9 tia, serious mental illnesses, and intellectual disabil10 ities. Until December 31, 2005, dual eligible bene11 ficiaries received outpatient prescription drug bene12 fits through medical assistance under Medicaid. On 

13 January 1, 2006, drug coverage for dual eligibles 

14 switched from Medicaid to Medicare. 

15 (2) In 2008, 53 percent of dual eligible bene16 ficiaries had medication access problems and of 

17 those, 27 percent experienced significant adverse 

18 clinical events. 

19 (3) Individuals with medication access issues 

20 experience significantly more adverse clinical events. 

21 Among dual eligible beneficiaries with mental illness 

22 who had medication access problems, 27 percent ex23 perienced significant adverse clinical events, which 

24 included emergency room visits and hospitalizations. 

25 (4) In total, over 1,000,000 dual eligible bene26 ficiaries and low-income subsidy beneficiaries were 


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1 automatically auto-enrolled to new benchmark pre2 scription drug plans under part D of the Medicare 

3 program between 2006 and 2007. 

4 (5) Community providers are at the front line 

5 of helping the most vulnerable dual eligible bene6 ficiaries obtain prescription drug coverage under the 

7 Medicare program and navigate complex enrollment 

8 and low-income subsidy eligibility requirements 

9 under such program. 

10 (b) PURPOSE.—It is the purpose of this bill to help 

11 low-income persons with cognitive impairments to enroll 

12 in and navigate the prescription drug benefit under the 

13 Medicare program by providing front line community pro14 viders who serve the population daily with financial assist15 ance to conduct vigorous education and outreach and di16 rect case management. 

17 SEC. 3. MEDICARE PRESCRIPTION DRUG OUTREACH DEM18 ONSTRATION PROGRAM FOR DUAL ELIGIBLE 

19 BENEFICIARIES WITH MENTAL DISABILITIES. 

20 (a) IN GENERAL.—The Secretary of Health and 

21 Human Services (in this section referred to as the ‘‘Sec22 retary’’) shall establish a 3-year demonstration program 

23 (in this section referred to as ‘‘the demonstration pro24 gram’’) under which the Secretary awards grants and con25 tracts to appropriate, qualified community programs and 


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1 clinics for individuals with intellectual or developmental 

2 disabilities or such programs that are described in sub3 section (b)(1) of section 1913 of the Public Health Serv4 ices Act, regardless of whether such program meets the 

5 criteria described in subsection (c) of such section, to em6 ploy qualified social workers and case managers to provide 

7 Medicare prescription drug assistance described in sub8 section (c) to target full-benefit dual eligible individuals. 

9 As a condition of receipt of a grant or contract under this 

10 subsection, a program or clinic shall collect and maintain 

11 data identified by the Centers for Medicare & Medicaid 

12 Services as critical for the final evaluation and report to 

13 Congress described in subsection (d). 

14 (b) TARGET FULL-BENEFIT DUAL ELIGIBLE INDI15 VIDUAL DEFINED.—For purposes of this section, the term 

16 ‘‘target full-benefit dual eligible individual’’ means a part 

17 D eligible individual, as defined in section 1860D– 

18 1(a)(3)(A) of the Social Security Act (42 U.S.C. 1395w– 

19 101(a)(3)(A)), who is a full-benefit dual eligible individual 

20 (as defined in section 1935(c)(6) of the Social Security 

21 Act (42 U.S.C. 1396u–5(c)(6))) with one or more mental 

22 disabilities, including mental retardation, dementia, men23 tal illnesses, Alzheimer’s disease, autism, or any other re24 lated condition that produces serious cognitive impair25 ments. 


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1 (c) TYPES OF ASSISTANCE.—For purposes of sub2 section (a), the Medicare prescription drug assistance de3 scribed in this subsection is one-on-one counseling with re4 spect to one or more of the following areas of assistance: 

5 (1) Assistance with initial enrollment in a pre6 scription drug plan under part D of title XVIII of 

7 the Social Security Act or in an MA–PD plan under 

8 part C of such title. 

9 (2) Assistance with switching from one such 

10 prescription drug plan or MA–PD plan to another 

11 such prescription drug plan or MA–PD plan. 

12 (3) Assistance with filing for an exception to a 

13 formulary used by such a plan. 

14 (4) Assistance with filing a grievance, reconsid15 eration, or appeal under section 1860D–4 of the So16 cial Security Act (42 U.S.C. 1395w–104), including 

17 assistance with collecting relevant information to file 

18 such a grievance, reconsideration, or appeal. 

19 (5) Assistance with navigating utilization man20 agement programs administered by a PDP sponsor 

21 offering a prescription drug plan under part D of 

22 title XVIII of the Social Security Act or a Medicare 

23 Advantage organization offering an MA–PD plan 

24 under part C of such title. 


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1 (6) Assistance with obtaining prescription drugs 

2 from pharmacies participating with such a plan. 

3 (7) Assistance with facilitating contact with the 

4 Medicare Beneficiary Ombudsman appointed under 

5 section 1808(c) of the Social Security Act (42 

6 U.S.C. 1395b–9). 

7 (d) EVALUATION AND REPORT.— 

8 (1) EVALUATION.—The Secretary shall provide 

9 for an evaluation of the demonstration program. 

10 Such evaluation may include an analysis of— 

11 (A) the utilization of the assistance pro12 vided under the program; 

13 (B) the satisfaction of target full-benefit 

14 dual eligible individuals with such assistance; 

15 and 

16 (C) the success of the program in— 

17 (i) facilitating access by such individ18 uals to covered part D drugs (as defined in 

19 section 1860D–2(e) of the Social Security 

20 Act (42 U.S.C. 1395w–102(e)); and 

21 (ii) medication compliance. 

22 (2) REPORT.—Not later than 6 months after 

23 the date of the completion of the demonstration pro24 gram, the Secretary shall submit to Congress a re25 port on such evaluation and shall include in such reVerDate Nov 24 2008 04:43 May 16, 2009 Jkt 079200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\H2390.IH H2390

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1 port recommendations regarding the feasibility of 

2 permanently funding an education and outreach pro3 gram on the prescription drug benefit under the 

4 Medicare program for target full-benefit dual eligible 

5 individuals. 

6 (e) AUTHORIZATION OF APPROPRIATIONS.—There is 

7 authorized to be appropriated for each of the fiscal years 

8 2011 through 2013— 

9 (1) to carry out this section (other than sub10 section (d)), $10,000,000; and 

11 (2) such sums as may be necessary to carry out 

12 subsection (d). 

Æ 


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