I

104TH CONGRESS

1ST SESSION H. R. 1456

To amend title XVIII of the Social Security Act to provide expanded coverage

of mental health and substance abuse treatment services under the medicare program.

IN THE HOUSE OF REPRESENTATIVES

APRIL 6, 1995

Mr. STARK (for himself, Mr. WAXMAN, and Mr. MCDERMOTT) 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

expanded coverage of mental health and substance abuse

treatment 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; REFERENCES IN ACT.

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

5 ‘‘Medicare Mental Health Improvement Act’’.

6 (b) REFERENCES TO SOCIAL SECURITY ACT.—

7 Whenever in this Act an amendment is expressed in terms

8 of an amendment to or repeal of a section or other provi-
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1 sion, the reference shall be considered to be made to that

2 section or other provision of the Social Security Act.

3 SEC. 2. INPATIENT PSYCHIATRIC HOSPITAL SERVICES.

4 (a) SERVICES COVERED.—Section 1812(a) (42

5 U.S.C. 1395d(a)) is amended—

6 (1) by striking ‘‘and’’ at the end of paragraph

7 (3);

8 (2) by striking the period at the end of para9 graph (4) and inserting ‘‘; and’’; and

10 (3) by adding at the end the following new

11 paragraph:

12 ‘‘(5) inpatient hospital services furnished pri13 marily for the diagnosis or treatment of mental ill14 ness or substance abuse for up to 60 days during a

15 year.’’.

16 (b) LIMITATION ON COVERAGE.—Section 1812(b)(3)

17 (42 U.S.C. 1395d(b)) is amended to read as follows:

18 ‘‘(3) inpatient hospital services furnished pri19 marily for the diagnosis or treatment of mental ill20 ness or substance abuse that are furnished to the in21 dividual during a year after such services have been

22 furnished to the individual for a total of 60 days

23 during the year.’’.

24 (c) CONFORMING AMENDMENTS.—(1) Section

25 1812(a)(1) (42 U.S.C. 1395d(a)(1)) is amended by insert-
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1 ing ‘‘(other than services described in paragraph (5))’’

2 after ‘‘inpatient hospital services’’ the first place it ap3 pears.

4 (2) Section 1812(b)(1) (42 U.S.C. 1395d(b)(1)) is

5 amended by inserting ‘‘(other than services described in

6 paragraph (3))’’ after ‘‘inpatient hospital services’’ the

7 first place it appears.

8 (3) Section 1812 (42 U.S.C. 1395d) is amended by

9 striking subsection (c).

10 (4) Section 1814(a) (42 U.S.C. 1395f(a)) is amend11 ed—

12 (A) in paragraph (2), by striking subparagraph

13 (A);

14 (B) in paragraph (3), by striking ‘‘(other than

15 inpatient psychiatric hospital services)’’; and

16 (C) by striking paragraph (4).

17 (5) Section 1861 (42 U.S.C. 1395x) is amended by

18 striking subsection (c).

19 (d) EFFECTIVE DATE; TRANSITION.—The amend20 ments made by this section shall take effect January 1,

21 1996, except that—

22 (1) an individual who at any time prior to such

23 date has been furnished inpatient psychiatric hos24 pital services (as defined for purposes of title XVIII

25 of the Social Security Act as of the date of the en-
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1 actment of this Act) for 190 consecutive days is not

2 entitled to any services under section 1812(a)(5) (as

3 added by subsection (a)(3)); and

4 (2) in the case of an individual who is not de5 scribed in paragraph (1) and is receiving inpatient

6 psychiatric hospital services (as defined for purposes

7 of title XVIII of the Social Security Act as of the

8 date of the enactment of this Act) on December 31,

9 1995, for which payment may be made under section

10 1812 of such Act, the number of days of services for

11 which the individual is entitled under section

12 1812(a)(5) (and the number of days applicable

13 under section 1812(b)(3)) shall be equal to the

14 greater of 60 or the difference between 190 days

15 and the number of days of such inpatient psychiatric

16 hospital services furnished to the individual prior to

17 January 1, 1996.

18 SEC. 3. INTENSIVE RESIDENTIAL SERVICES.

19 (a) COVERAGE UNDER PART A.—Section 1812(a)

20 (42 U.S.C. 1395d(a)), as amended by section 2(a), is

21 amended—

22 (1) by striking ‘‘and’’ at the end of paragraph

23 (4);

24 (2) by striking the period at the end of para25 graph (5) and inserting ‘‘; and’’; and
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1 (3) by adding at the end the following new

2 paragraph:

3 ‘‘(6) intensive residential services (as described

4 in section 1861(qq)) furnished to an individual for

5 up to 120 days during any calendar year, except

6 that such services may be furnished to the individual

7 for additional days during the year if necessary for

8 the individual to complete a course of treatment to

9 the extent that the number of days of inpatient hos10 pital services described in paragraph (5) that may be

11 furnished to the individual during the year (as re12 duced under such paragraph) is not less than 15.’’.

13 (2) SERVICES DESCRIBED.—Section 1861 (42

14 U.S.C. 1395x), as amended by section 146(a) of the

15 Social Security Act Amendments of 1994, is amend16 ed by adding at the end the following new sub17 section:

18 ‘‘Intensive Residential Services

19 ‘‘(mm)(1) Subject to paragraph (2), the term ‘inten20 sive residential services’ means inpatient services provided

21 in any of the following facilities:

22 ‘‘(A) Residential detoxification centers.

23 ‘‘(B) Crisis residential programs or mental ill24 ness residential treatment programs.
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1 ‘‘(C) Therapeutic family or group treatment

2 homes.

3 ‘‘(D) Residential centers for substance abuse

4 treatment.

5 ‘‘(2) No service may be treated as an intensive resi6 dential service under paragraph (1) unless the facility at

7 which the service is provided—

8 ‘‘(A) is legally authorized to provide such serv9 ice under the law of the State (or under a State reg10 ulatory mechanism provided by State law) in which

11 the facility is located or is certified to provide such

12 service by an appropriate accreditation entity ap13 proved by the State in consultation with the Sec14 retary; and

15 ‘‘(B) meets such other requirements as the Sec16 retary may impose to assure the quality of the inten17 sive residential services provided.

18 ‘‘(3) No service may be treated as an intensive resi19 dential service under paragraph (1) unless the service is

20 furnished in accordance with standards established by the

21 Secretary for the management of such services.’’.

22 (3) REDUCTION IN DAYS OF COVERAGE FOR IN23 PATIENT SERVICES.—Section 1812(a)(5) and section

24 1812(b)(3), as amended by section 2, are each

25 amended by striking the period at the end and in-
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1 serting the following: ‘‘, reduced by a number of

2 days determined by the Secretary so that the actuar3 ial value of providing such number of days of serv4 ices under this paragraph to the individual is equal

5 to the actuarial value of the days of inpatient resi6 dential services furnished to the individual under

7 paragraph (6) during the year after such services

8 have been furnished to the individual for 120 days

9 during the year (rounded to the nearest day).’’.

10 (4) AMOUNT OF PAYMENT.—Section 1814 (42

11 U.S.C. 1395f) is amended—

12 (A) in subsection (b) in the matter preced13 ing paragraph (1), by inserting ‘‘other than in14 tensive residential services,’’ after ‘‘hospice

15 care,’’; and

16 (B) by adding at the end the following new

17 subsection:

18 ‘‘Payment for Intensive Residential Services

19 ‘‘(m) The amount of payment under this part for in20 tensive residential services under section 1812(a)(6) shall

21 be equal to—

22 ‘‘(1) the lesser of—

23 ‘‘(A) the reasonable cost of such services,

24 as determined under section 1861(v), or
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1 ‘‘(B) the customary charges with respect to

2 such services,

3 less the amount a provider may charge as described

4 in clause (ii) of section 1866(a)(2)(A):

5 ‘‘(2) if such services are furnished by a public

6 provider of services or by another provider which

7 demonstrates to the satisfaction of the Secretary

8 that a significant portion of its patients are low-in9 come (and requests that payment be made under

10 this clause), free of charge or at nominal charges to

11 the public, the amount determined in accordance

12 with subsection (b)(2); and

13 ‘‘(3) if (and for so long as) the conditions de14 scribed in subsection (b)(3) are met, the amounts

15 determined under the reimbursement system de16 scribed in such section.’’.

17 SEC. 4. LOWERING COINSURANCE FOR CERTAIN OUT18 PATIENT MENTAL HEALTH AND SUBSTANCE

19 ABUSE SERVICES.

20 (a) IN GENERAL.—Section 1833(c) (42 U.S.C.

21 1395l(c)) is amended by striking ‘‘mental, psychoneurotic,

22 and personality disorders’’ and all that follows through

23 ‘‘are incurred’’ and inserting the following: ‘‘mental illness

24 or substance abuse of an individual who, at the time such

25 expenses are incurred, is over 18 years of age, is not an
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1 inpatient of a hospital, and has received 5 or more sessions

2 of such treatment during the calendar year,’’.

3 (b) REQUIRING SERVICES TO BE FURNISHED IN AC4 CORDANCE WITH MANAGEMENT STANDARDS.—Section

5 1862(a) (42 U.S.C. 1395y(a)), as amended by section

6 156(a)(2)(D) of the Social Security Act Amendments of

7 1994, is amended—

8 (1) by striking ‘‘or’’ at the end of paragraph

9 (14);

10 (2) by striking the period at the end of para11 graph (15) and inserting ‘‘; or’’; and

12 (3) by inserting after paragraph (15) the fol13 lowing new paragraph:

14 ‘‘(16) in the case of any items or services fur15 nished under part B for the treatment of mental ill16 ness or emotional disturbance (including substance

17 abuse), if the services are not furnished in accord18 ance with standards established by the Secretary for

19 the management of such services.’’.

20 SEC. 5. INTENSIVE COMMUNITY-BASED SERVICES.

21 (a) COVERAGE.—

22 (1) IN GENERAL.—Section 1832(a)(2)(J) (42

23 U.S.C. 1395k(a)(2)(J)) is amended to read as fol24 lows:
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1 ‘‘(J) intensive community-based services

2 (as described in section 1861(ff))—

3 ‘‘(i) for an unlimited number of days

4 during any calendar year, in the case of

5 services described in section 1861(ff)(2)(E)

6 that are furnished to an individual who is

7 a seriously mentally ill adult, a seriously

8 emotionally disturbed child, or an adult or

9 child with serious substance abuse disorder

10 (as determined in accordance with criteria

11 established by the Secretary),

12 ‘‘(ii) in the case of day treatment

13 services for an individual under 19 years of

14 age described in section 1861(ff)(2)(C), for

15 up to 180 days during any calendar year,

16 except that such services may be furnished

17 to the individual for a number of addi18 tional days during the year equal to the

19 difference between the total number of

20 days of intensive residential services which

21 the individual may receive during the year

22 under part A (as determined under section

23 1812(a)(6)) and the number of days of

24 such services which the individual has re25 ceived during the year, or
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1 ‘‘(iii) in the case of any other such

2 services, for up to 90 days during any cal3 endar year, except that such services may

4 be furnished to the individual for the num5 ber of additional days during the year de6 scribed in clause (ii).’’.

7 (2) REDUCTION IN NUMBER OF DAYS OF IN8 TENSIVE RESIDENTIAL SERVICES.—Section

9 1812(a)(6) (42 U.S.C. 1395d(a)(6)), as added by

10 section 3(a), is amended—

11 (A) by inserting ‘‘(A)’’ before ‘‘such serv12 ices’’; and

13 (B) by striking the period at the end and

14 inserting the following: ‘‘, and (B) reduced by

15 a number of days determined by the Secretary

16 so that the actuarial value of providing such

17 number of days of services under this para18 graph to the individual is equal to the actuarial

19 value of the days of intensive community-based

20 services furnished to the individual under sec21 tion 1832(a)(2)(J) during the year after such

22 services have been furnished to the individual

23 for 90 days (or, in the case of services described

24 in section 1832(a)(2)(J)(ii), for 180 days) dur25 ing the year (rounded to the nearest day).’’.
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1 (b) SERVICES DESCRIBED.—Section 1861(ff)(2) (42

2 U.S.C. 1395x(ff)(2)) is amended—

3 (1) in the matter preceding subparagraph (A),

4 by striking ‘‘are—’’ and inserting ‘‘are as follows:’’;

5 (2) in subparagraph (C)—

6 (A) by inserting ‘‘behavioral aide services,’’

7 after ‘‘nurses’’, and

8 (B) by adding at the end the following:

9 ‘‘(to the extent authorized under State law)’’;

10 (3) by adding ‘‘and’’ at the end of subpara11 graph (G);

12 (4) in subparagraph (H), by striking ‘‘, and’’

13 and inserting a period;

14 (5) by redesignating subparagraphs (A) through

15 (H) as clauses (i) through (viii) and moving such

16 subparagraphs 2 ems to the right;

17 (6) by inserting before clause (i) (as so redesig18 nated) the following:

19 ‘‘(A) Partial hospitalization services con20 sisting of—’’;

21 (7) by inserting after clause (viii) (as so redes22 ignated) the following new subparagraphs:

23 ‘‘(B) Psychiatric rehabilitation services.

24 ‘‘(C) Day treatment services for substance

25 abuse treatment for individuals of any age and for
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1 other mental health services for individuals under 19

2 years of age.

3 ‘‘(D) In-home services.

4 ‘‘(E) Case management services, including col5 lateral services designated as such case management

6 services by the Secretary.

7 ‘‘(F) Ambulatory detoxification services.’’; and

8 (8) in subparagraph (I)—

9 (A) by striking ‘‘such’’ and inserting

10 ‘‘Such’’, and

11 (B) by redesignating such subparagraph as

12 subparagraph (G).

13 (c) PERMITTING NON-PHYSICIAN PROVIDERS TO SU14 PERVISE INDIVIDUAL PROGRAM OF TREATMENT.—Sec15 tion 1861(ff)(1) (42 U.S.C. 1395x(ff)(1)) is amended by

16 inserting after ‘‘supervision of a physician’’ the following:

17 ‘‘(or, to the extent permitted under the law of the State

18 in which the services are furnished, a non-physician men19 tal health or substance abuse treatment professional)’’.

20 (d) REQUIRING SERVICES TO MEET MANAGEMENT

21 STANDARDS.—Section 1861(ff)(1) (42 U.S.C.

22 1395x(ff)(1)) is amended by striking the period at the end

23 and inserting the following: ‘‘, but does not include any

24 item or service that is not furnished in accordance with
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1 standards established by the Secretary for the manage2 ment of such services.’’.

3 (e) PROGRAMS ELIGIBLE TO PROVIDE SERVICES.—

4 Section 1861(ff)(3) (42 U.S.C. 1395x(ff)(3)) is amended

5 to read as follows:

6 ‘‘(3) A program described in this paragraph is a pro7 gram (whether facility-based or freestanding) which is fur8 nished by an entity—

9 ‘‘(A) legally authorized to furnish such a pro10 gram under State law (or the State regulatory mech11 anism provided by State law) or certified to furnish

12 such a program by an appropriate accreditation en13 tity approved by the State in consultation with the

14 Secretary; and

15 ‘‘(B) meeting such other requirements as the

16 Secretary may impose to assure the quality of the

17 intensive community-based services provided.’’.

18 (f) WAIVER OF COPAYMENT FOR CASE MANAGE19 MENT SERVICES FURNISHED TO CERTAIN INDIVID20 UALS.—Section 1833(a)(2) (42 U.S.C. 1395l(a)(2)), as

21 amended by section 147(f)(6)(C) of the Social Security

22 Act Amendments of 1994, is amended—

23 (1) in subparagraph (B), by striking ‘‘or (E)’’

24 and inserting ‘‘(E), or (F)’’;
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1 (2) by striking ‘‘and’’ at the end of subpara2 graph (E);

3 (3) by adding ‘‘and’’ at the end of subpara4 graph (F); and

5 (4) by adding at the end the following new sub6 paragraph:

7 ‘‘(G) with respect to services described in

8 section 1832(a)(2)(J)(i), the amount deter9 mined under subparagraph (B), except that

10 ‘100 percent’ shall be substituted for any ref11 erence in such subparagraph to ‘80 percent’;’’.

12 (g) CONFORMING AMENDMENTS.—(1) Section

13 1835(a)(2)(F) (42 U.S.C. 1395n(a)(2)(F)) is amended—

14 (A) by striking ‘‘partial hospitalization’’ and in15 serting ‘‘intensive community-based’’; and

16 (B) in clause (ii), by striking ‘‘physician’’ and

17 inserting ‘‘physician (or, to the extent permitted

18 under the law of the State in which the services are

19 furnished, a non-physician mental health profes20 sional)’’.

21 (2) Section 1861(s)(2)(B) (42 U.S.C.

22 1395x(s)(2)(B)) is amended by striking ‘‘partial hos23 pitalization’’ and inserting ‘‘intensive community-based’’.

24 (3) Section 1861(ff) (42 U.S.C. 1395x(ff)) is amend25 ed—
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1 (A) in the heading, by striking ‘‘Partial Hos2 pitalization’’ and inserting ‘‘Intensive Community3 Based’’; and

4 (B) in paragraph (1), by striking ‘‘partial hos5 pitalization’’ and inserting ‘‘intensive community6 based’’.

7 (4) Section 1866(e)(2) (42 U.S.C. 1395cc(e)(2)) is

8 amended by striking ‘‘partial hospitalization’’ and insert9 ing ‘‘intensive community-based’’.

10 SEC. 6. EFFECTIVE DATE.

11 The amendments made by this Act shall apply to

12 items and services furnished on or after January 1, 1996.

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