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[Congressional Bills 111th Congress]
[From the U.S. Government Publishing Office]
[S. 1640 Introduced in Senate (IS)]

111th CONGRESS
  1st Session
                                S. 1640

To amend title XVIII of the Social Security Act to provide coverage of 
                     intensive lifestyle treatment.

_______________________________________________________________________

                   IN THE SENATE OF THE UNITED STATES

                             August 6, 2009

  Mr. Wyden (for himself, Mr. Cornyn, and Mr. Harkin) introduced the 
 following bill; which was read twice and referred to the Committee on 
                                Finance

_______________________________________________________________________

                                 A BILL

 
To amend title XVIII of the Social Security Act to provide coverage of 
                     intensive lifestyle treatment.

    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 ``Take Back Your Health Act of 2009''.

SEC. 2. COVERAGE OF INTENSIVE LIFESTYLE TREATMENT.

    (a) Intensive Lifestyle Treatment Program.--
            (1) In general.--Section 1861 of the Social Security Act 
        (42 U.S.C. 1395x) is amended--
                    (A) in subsection (s)(2)--
                            (i) in subparagraph (DD) by striking 
                        ``and'' at the end;
                            (ii) in subparagraph (EE) by inserting 
                        ``and'' at the end; and
                            (iii) by adding at the end the following 
                        new subparagraph:
                    ``(FF) items and services furnished under an 
                intensive lifestyle treatment program (as defined in 
                paragraph (hhh)(1)) to eligible beneficiaries (as 
                defined in paragraph (hhh)(4));''; and
                    (B) by adding at the end the following new 
                subsection:

                ``Intensive Lifestyle Treatment Program

    ``(hhh)(1) The term `intensive lifestyle treatment program' means a 
physician-supervised program (as defined in paragraph (2)) that 
furnishes the items and services described in paragraph (3) intended to 
beneficially affect the progression of chronic diseases to eligible 
beneficiaries (as defined in paragraph (4)).
    ``(2) A program described in this paragraph is a program under 
which--
            ``(A) items and services under the program are delivered--
                    ``(i) in a physician's office or clinic;
                    ``(ii) in a hospital on an outpatient basis; or
                    ``(iii) in other settings determined appropriate by 
                the Secretary;
            ``(B) a physician (as defined in section 1861(r)(1)) is 
        immediately available and accessible for medical consultation 
        and medical emergencies at all times items and services are 
        being furnished under the program, except that, in the case of 
        items and services furnished under such a program in a 
        hospital, such availability shall be presumed;
            ``(C) individualized treatment is furnished under a written 
        plan established and designed by a physician (as so defined) in 
        advance of the start of the program and reviewed and signed by 
        a physician every 60 days that describes--
                    ``(i) the individual's diagnosis;
                    ``(ii) the type, amount, frequency, and duration of 
                the items and services furnished under the plan; and
                    ``(iii) the goals set for the individual under the 
                plan;
            ``(D) items and services may be provided in a series of 72 
        one-hour sessions (as defined in section 1848(b)(6)), up to 6 
        sessions per day, over a period of 18 weeks, and may include 
        group sessions with up to 15 other eligible beneficiaries; and
            ``(E) items and services may be provided--
                    ``(i) by an intensive lifestyle team;
                    ``(ii) under the direction of a physician (as so 
                defined); and
                    ``(iii) if determined appropriate by the Secretary, 
                in the case of such items and services provided in 
                underserved areas, by a physician assistant, nurse 
                practitioner, or clinical nurse specialist as provided 
                under State law.
    ``(3) The items and services described in this paragraph are--
            ``(A) exercise;
            ``(B) risk factor modification, including education, 
        counseling, and behavioral intervention (to the extent such 
        education, counseling, and behavioral intervention is closely 
        related to the individual's care and treatment and is tailored 
        to the individual's needs);
            ``(C) psychosocial assessment;
            ``(D) provider consultation;
            ``(E) care coordination;
            ``(F) medication management;
            ``(G) medical nutritional therapy;
            ``(H) tobacco cessation;
            ``(I) outcomes assessment; and
            ``(J) such other items and services as the Secretary 
        determines appropriate, but only if such items and services 
        are--
                    ``(i) reasonable and necessary for the diagnosis or 
                active treatment of the individual's condition;
                    ``(ii) reasonably expected to improve or maintain 
                the individual's condition and functional level; and
                    ``(iii) furnished under such guidelines relating to 
                the frequency and duration of such items and services 
                as the Secretary shall establish, taking into account 
                accepted norms of medical practice and the reasonable 
                expectation of improvement of the individual.
    ``(4) The term `eligible beneficiary' means an individual who is 
entitled to, or enrolled for, benefits under part A and enrolled under 
this part and who has been diagnosed with 1 or more of the following 
conditions:
            ``(A) Coronary heart disease.
            ``(B) Type 2 diabetes.
            ``(C) Metabolic syndrome.
            ``(D) Prostate cancer.
            ``(E) Breast cancer.''.
            (2) Payment for intensive lifestyle treatment programs.--
                    (A) Inclusion in physicians' services.--Section 
                1848(j)(3) of the Social Security Act (42 U.S.C. 1395w-
                4(j)(3)) is amended by inserting ``(2)(FF),'' after 
                ``(2)(EE).''.
                    (B) Conforming amendment.--Section 1848(b) of the 
                Social Security Act (42 U.S.C. 1395w-4(b)) is amended 
                by adding at the end the following new paragraph:
            ``(6) Treatment of intensive lifestyle treatment program.--
                    ``(A) In general.--In the case of an intensive 
                lifestyle treatment program described in section 
                1861(hhh)(2), the Secretary shall establish an 
                aggregate payment for items and services furnished 
                under such program (as described in section 
                1861(hhh)(3)) not to exceed the cost to the program 
                under this title for a hospitalization for a similarly 
                situated eligible beneficiary, subject to the 
                limitation under subparagraph (C).
                    ``(B) Payment schedule.--The Secretary shall--
                            ``(i) make a payment to such a program in 
                        an amount that is equal to 50 percent of the 
                        amount established under subparagraph (A) upon 
                        completion of the initial consultation under 
                        the program; and
                            ``(ii) subject to the limitation described 
                        in subparagraph (C), make a second payment to a 
                        program for the balance of the amount defined 
                        in subparagraph (A) upon completion of 
                        treatment under the program.
                    ``(C) Limitation.--
                            ``(i) In general.--Notwithstanding the 
                        provisions of subparagraph (B), an intensive 
                        lifestyle treatment program shall not receive 
                        the payment described in subparagraph (B)(ii) 
                        unless it documents, upon the completion of the 
                        program by an eligible beneficiary, that 
                        services provided to such beneficiary under the 
                        program are beneficially affecting the 
                        progression of chronic disease or diseases in 
                        the beneficiary, as measured under clause (ii) 
                        with respect to 2 or more of the following 
                        measures:
                                    ``(I) Measures described in 
                                subclauses (I) through (V) of section 
                                1861(eee)(4)(A)(ii).
                                    ``(II) High density lipoprotein.
                                    ``(III) Hemoglobin A1C.
                                    ``(IV) C-reactive protein.
                                    ``(V) Waist size.
                                    ``(VI) Elimination of cotinine 
                                level as evidence that the eligible 
                                beneficiary no longer uses tobacco.
                                    ``(VII) Prostate specific antigen 
                                or other prognostic biomarkers of 
                                prostate cancer.
                                    ``(VIII) Prognostic biomarkers of 
                                breast cancer.
                            ``(ii) Measurement.--The Secretary shall 
                        determine the beneficial progression of chronic 
                        disease or diseases under clause (i), using the 
                        level of 2 or more of the measures described in 
                        subclause (i) before receiving services under 
                        such program and such levels after completion 
                        of treatment under the program--
                                    ``(I) by normalization (as defined 
                                by the Secretary); and
                                    ``(II) in the case of--
                                            ``(aa) measures described 
                                        in subclauses (I) through (V), 
                                        (VII), and (VIII), by at least 
                                        10 percent reduction; or
                                            ``(bb) the measure 
                                        described in subclause (VI), by 
                                        elimination.
                            ``(iii) Refund of payments or costs in 
                        certain circumstances.--In the case of an 
                        eligible beneficiary who, within 1 year of 
                        receiving an initial consultation under the 
                        program, receives any other treatment covered 
                        under part A or this part for any condition 
                        that relates to the initial diagnosis resulting 
                        in eligibility for the intensive lifestyle 
                        treatment program, except for a physician 
                        office visit for the purpose of making 
                        adjustments to medication prescribed to the 
                        eligible beneficiary, such program shall refund 
                        to the Secretary the lesser of--
                                    ``(I) any payments made under 
                                paragraph (B) for services provided to 
                                the eligible beneficiary under the 
                                program; or
                                    ``(II) the cost of such other 
                                treatment covered under part A or this 
                                part such condition.
                    ``(D) Coverage of sessions.--
                            ``(i) In general.--Items and services 
                        provided under the program in a series of 72 
                        one-hour sessions (as defined in clause (ii)), 
                        up to 6 sessions per day, over a period of 18 
                        weeks shall, subject to the limitation under 
                        subparagraph (C), be eligible for the aggregate 
                        payment established under subparagraph (A).
                            ``(ii) Definition of session.--Each of the 
                        services described in subparagraphs (A) through 
                        (J) of section 1861(hhh)(3), when furnished for 
                        1 hour, is a separate session under an 
                        intensive lifestyle treatment program.''.
    (b) Copayments for Intensive Lifestyle Treatment Items and 
Services.--Section 1833(a)(1) of the Social Security Act (42 U.S.C. 
1395l(a)(1)) is amended--
            (1) by striking ``and'' before (W);
            (2) by inserting before the semicolon at the end the 
        following: ``, and (X) with respect to items and services 
        furnished under an intensive lifestyle treatment program (as 
        defined in section 1861(hhh)(2)), the amount paid shall be 100 
        percent of the lesser of the actual charge for the services or 
        the amount determined under section 1848(b)(6)(A)''.
    (c) Lifestyle Rewards Program.--Title XVIII of the Social Security 
Act is amended by adding at the end the following new section:

``SEC. 1899. LIFESTYLE REWARDS PROGRAMS.

    ``(a) Establishment.--The Secretary shall establish a Lifestyle 
Rewards Program (in this section referred to as the `program') for 
eligible beneficiaries (as defined in section 1861(s)(2)(hhh)(4)) who 
have successfully completed an intensive lifestyle treatment program 
(as defined in section 1861(hhh)(2)) and meet the requirements 
described in subsection (b).
    ``(b) Requirements.--In order to receive an award under the 
program, an eligible beneficiary must--
            ``(1) demonstrate that the program has beneficially 
        affected the progression of chronic disease or diseases in the 
        beneficiary upon completion of the program, as measured under 
        clause (ii) of section 1848(b)(6)(C) with respect to 2 or more 
        of the measures described in clause (i) of such section; and
            ``(2) during the 1 year period beginning on the date of an 
        initial consultation under the lifestyle treatment program, 
        receive no other treatment under part A or this part for any 
        condition that relates to the initial diagnosis resulting in 
        eligibility for the intensive lifestyle treatment program, 
        except for a physician office visit for the purpose of making 
        adjustments to medication prescribed to the eligible 
        beneficiary.
    ``(c) Form of Reward.--The Secretary shall make such award to 
eligible beneficiaries described in subsection (a) in such form and 
manner as the Secretary, by regulation, shall prescribe.
    ``(d) Amount of Reward.--The amount of such award for each such 
eligible beneficiary shall be $200.''.
    (d) Effective Date.--The amendments made by this section shall 
apply to items and services furnished on or after January 1, 2010.

SEC. 3. SENSE OF THE CONGRESS.

    It is the sense of the Congress that the services provided under a 
intensive lifestyle treatment program (as defined in section 
1861(hhh)(2) of the Social Security Act, as added by section 2(a))--
            (1) would benefit individuals with chronic diseases who are 
        not enrolled in the Medicare Program under title XVIII of the 
        Social Security Act; and
            (2) should be covered by all public and private payers.
                                 <all>
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