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[Congressional Bills 111th Congress]
[From the U.S. Government Publishing Office]
[H.R. 2390 Introduced in House (IH)]

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.

    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 ``Guidance, Understanding, and 
Information for Dual Eligibles (GUIDE) Act''.

SEC. 2. FINDINGS; PURPOSE.

    (a) Findings.--The Congress finds the following:
            (1) Nearly 8,800,000 Americans were eligible for benefits 
        under the Medicare program and for medical assistance under 
        Medicaid (dual eligible beneficiaries) in fiscal year 2005. Of 
        these ``dual eligible beneficiaries'', almost 40 percent have 
        cognitive impairments, including Alzheimer's disease, dementia, 
        serious mental illnesses, and intellectual disabilities. Until 
        December 31, 2005, dual eligible beneficiaries received 
        outpatient prescription drug benefits through medical 
        assistance under Medicaid. On January 1, 2006, drug coverage 
        for dual eligibles switched from Medicaid to Medicare.
            (2) In 2008, 53 percent of dual eligible beneficiaries had 
        medication access problems and of those, 27 percent experienced 
        significant adverse clinical events.
            (3) Individuals with medication access issues experience 
        significantly more adverse clinical events. Among dual eligible 
        beneficiaries with mental illness who had medication access 
        problems, 27 percent experienced significant adverse clinical 
        events, which included emergency room visits and 
        hospitalizations.
            (4) In total, over 1,000,000 dual eligible beneficiaries 
        and low-income subsidy beneficiaries were automatically auto-
        enrolled to new benchmark prescription drug plans under part D 
        of the Medicare program between 2006 and 2007.
            (5) Community providers are at the front line of helping 
        the most vulnerable dual eligible beneficiaries obtain 
        prescription drug coverage under the Medicare program and 
        navigate complex enrollment and low-income subsidy eligibility 
        requirements under such program.
    (b) Purpose.--It is the purpose of this bill to help low-income 
persons with cognitive impairments to enroll in and navigate the 
prescription drug benefit under the Medicare program by providing front 
line community providers who serve the population daily with financial 
assistance to conduct vigorous education and outreach and direct case 
management.

SEC. 3. MEDICARE PRESCRIPTION DRUG OUTREACH DEMONSTRATION PROGRAM FOR 
              DUAL ELIGIBLE BENEFICIARIES WITH MENTAL DISABILITIES.

    (a) In General.--The Secretary of Health and Human Services (in 
this section referred to as the ``Secretary'') shall establish a 3-year 
demonstration program (in this section referred to as ``the 
demonstration program'') under which the Secretary awards grants and 
contracts to appropriate, qualified community programs and clinics for 
individuals with intellectual or developmental disabilities or such 
programs that are described in subsection (b)(1) of section 1913 of the 
Public Health Services Act, regardless of whether such program meets 
the criteria described in subsection (c) of such section, to employ 
qualified social workers and case managers to provide Medicare 
prescription drug assistance described in subsection (c) to target 
full-benefit dual eligible individuals. As a condition of receipt of a 
grant or contract under this subsection, a program or clinic shall 
collect and maintain data identified by the Centers for Medicare & 
Medicaid Services as critical for the final evaluation and report to 
Congress described in subsection (d).
    (b) Target Full-Benefit Dual Eligible Individual Defined.--For 
purposes of this section, the term ``target full-benefit dual eligible 
individual'' means a part D eligible individual, as defined in section 
1860D-1(a)(3)(A) of the Social Security Act (42 U.S.C. 1395w-
101(a)(3)(A)), who is a full-benefit dual eligible individual (as 
defined in section 1935(c)(6) of the Social Security Act (42 U.S.C. 
1396u-5(c)(6))) with one or more mental disabilities, including mental 
retardation, dementia, mental illnesses, Alzheimer's disease, autism, 
or any other related condition that produces serious cognitive 
impairments.
    (c) Types of Assistance.--For purposes of subsection (a), the 
Medicare prescription drug assistance described in this subsection is 
one-on-one counseling with respect to one or more of the following 
areas of assistance:
            (1) Assistance with initial enrollment in a prescription 
        drug plan under part D of title XVIII of the Social Security 
        Act or in an MA-PD plan under part C of such title.
            (2) Assistance with switching from one such prescription 
        drug plan or MA-PD plan to another such prescription drug plan 
        or MA-PD plan.
            (3) Assistance with filing for an exception to a formulary 
        used by such a plan.
            (4) Assistance with filing a grievance, reconsideration, or 
        appeal under section 1860D-4 of the Social Security Act (42 
        U.S.C. 1395w-104), including assistance with collecting 
        relevant information to file such a grievance, reconsideration, 
        or appeal.
            (5) Assistance with navigating utilization management 
        programs administered by a PDP sponsor offering a prescription 
        drug plan under part D of title XVIII of the Social Security 
        Act or a Medicare Advantage organization offering an MA-PD plan 
        under part C of such title.
            (6) Assistance with obtaining prescription drugs from 
        pharmacies participating with such a plan.
            (7) Assistance with facilitating contact with the Medicare 
        Beneficiary Ombudsman appointed under section 1808(c) of the 
        Social Security Act (42 U.S.C. 1395b-9).
    (d) Evaluation and Report.--
            (1) Evaluation.--The Secretary shall provide for an 
        evaluation of the demonstration program. Such evaluation may 
        include an analysis of--
                    (A) the utilization of the assistance provided 
                under the program;
                    (B) the satisfaction of target full-benefit dual 
                eligible individuals with such assistance; and
                    (C) the success of the program in--
                            (i) facilitating access by such individuals 
                        to covered part D drugs (as defined in section 
                        1860D-2(e) of the Social Security Act (42 
                        U.S.C. 1395w-102(e)); and
                            (ii) medication compliance.
            (2) Report.--Not later than 6 months after the date of the 
        completion of the demonstration program, the Secretary shall 
        submit to Congress a report on such evaluation and shall 
        include in such report recommendations regarding the 
        feasibility of permanently funding an education and outreach 
        program on the prescription drug benefit under the Medicare 
        program for target full-benefit dual eligible individuals.
    (e) Authorization of Appropriations.--There is authorized to be 
appropriated for each of the fiscal years 2011 through 2013--
            (1) to carry out this section (other than subsection (d)), 
        $10,000,000; and
            (2) such sums as may be necessary to carry out subsection 
        (d).
                                 <all>
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