II

104TH CONGRESS

1ST SESSION S. 171

To amend title XIX of the Social Security Act to provide for coverage

of alcoholism and drug dependency residential treatment services for

pregnant women and certain family members under the medicaid program, and for other purposes.

IN THE SENATE OF THE UNITED STATES

JANUARY 5, 1995

Mr. DASCHLE (for himself, Mr. SIMON, Mr. KENNEDY, Mr. KERRY, Mr. REID,

and Mr. AKAKA) introduced the following bill; which was read twice and

referred to the Committee on Finance

A BILL

To amend title XIX of the Social Security Act to provide

for coverage of alcoholism and drug dependency residential treatment services for pregnant women and certain

family members under the medicaid program, 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.

4 This Act may be cited as the ‘‘Medicaid Substance

5 Abuse Treatment Act’’.

6 SEC. 2. FINDINGS AND PURPOSE.

7 (a) FINDINGS.—The Congress finds that—
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1 (1) a woman’s ability to bear healthy children

2 is threatened by the consequences of alcoholism and

3 drug addiction;

4 (2) an estimated 375,000 infants each year are

5 born drug-exposed, at least 5,000 infants are born

6 each year with fetal alcohol syndrome, and another

7 35,000 are born each year with fetal alcohol effect,

8 a less severe version of fetal alcohol syndrome;

9 (3) drug use during pregnancy can result in low

10 birthweight, physical deformities, mental retardation,

11 learning disabilities, and heightened nervousness and

12 irritability in newborns;

13 (4) fetal alcohol syndrome is the leading identi14 fiable cause of mental retardation in the United

15 States and the only cause that is 100 percent pre16 ventable;

17 (5) drug-impaired individuals pose extraor18 dinary societal costs in terms of medical, edu19 cational, foster care, residential, and support serv20 ices over the lifetimes of such individuals;

21 (6) women, in general, are underrepresented in

22 drug and alcohol treatment programs;

23 (7) due to fears among service providers con24 cerning the risks pregnancies pose, pregnant women

25 face more obstacles to substance abuse treatment
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1 than do other addicts and many substance abuse

2 treatment programs, in fact, exclude pregnant

3 women or women with children;

4 (8) alcohol and drug treatment is an important

5 prevention strategy to prevent low birthweight,

6 transmission of AIDS, and chronic physical, mental,

7 and emotional disabilities associated with prenatal

8 exposure to alcohol and other drugs;

9 (9) effective substance abuse treatment must

10 address the special needs of pregnant women who

11 are alcohol or drug dependent, including substance12 abusing women who may often face such problems

13 as domestic violence, incest and other sexual abuse,

14 poor housing, poverty, unemployment, lack of edu15 cation and job skills, lack of access to health care,

16 emotional problems, chemical dependency in their

17 family backgrounds, single parenthood, and the need

18 to ensure child care for existing children while un19 dergoing substance abuse treatment;

20 (10) nonhospital residential treatment is an im21 portant component of comprehensive and effective

22 substance abuse treatment for pregnant addicted

23 women, many of whom need long-term, intensive ha24 bilitation outside of their communities to recover
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1 from their addiction and take care of themselves and

2 their families; and

3 (11) a gap exists under the medicaid program

4 for the financing of comprehensive residential care

5 in the existing continuum of medicaid-covered alco6 holism and drug abuse treatment services for low-in7 come pregnant addicted women.

8 (b) PURPOSES.—The purposes of this Act are—

9 (1) to increase the ability of pregnant women

10 who are substance abusers to participate in alcohol

11 and drug treatment;

12 (2) to ensure the availability of comprehensive

13 and effective treatment programs for pregnant

14 women, thus promoting a woman’s ability to bear

15 healthy children;

16 (3) to ensure that nonhospital residential treat17 ment is available to those low-income pregnant ad18 dicted women who need long-term, intensive habili19 tation to recover from their addiction;

20 (4) to create a new optional medicaid residen21 tial treatment service for alcoholism and drug de22 pendency treatment; and

23 (5) to define the core services that must be pro24 vided by treatment providers to ensure that needed

25 services will be available and appropriate.
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1 SEC. 3. MEDICAID COVERAGE OF ALCOHOLISM AND DRUG

2 DEPENDENCY RESIDENTIAL TREATMENT

3 SERVICES FOR PREGNANT WOMEN, CARE4 TAKER PARENTS, AND THEIR CHILDREN.

5 (a) COVERAGE OF ALCOHOLISM AND DRUG DEPEND6 ENCY RESIDENTIAL TREATMENT SERVICES.—

7 (1) OPTIONAL COVERAGE.—Section 1905 of the

8 Social Security Act (42 U.S.C. 1396d) is amended—

9 (A) in subsection (a)—

10 (i) by striking ‘‘and’’ at the end of

11 paragraph (21);

12 (ii) in paragraph (24), by striking the

13 period at the end and inserting a semi14 colon;

15 (iii) by redesignating paragraphs (22),

16 (23), and (24) as paragraphs (25), (22),

17 and (23), respectively, and by transferring

18 and inserting paragraph (25) after para19 graph (23), as so redesignated; and

20 (iv) by inserting after paragraph (23)

21 the following new paragraph:

22 ‘‘(24) alcoholism and drug dependency residen23 tial treatment services (to the extent allowed and as

24 defined in section 1931); and’’; and

25 (B) in the sentence following paragraph

26 (25), as so redesignated—
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1 (i) in subdivision (A), by striking ‘‘or’’

2 at the end;

3 (ii) in subdivision (B), by inserting ‘‘,

4 who is not receiving alcoholism and drug

5 dependency residential treatment services,’’

6 after ‘‘65 years of age’’; and

7 (iii) by inserting after subdivision (B)

8 the following:

9 ‘‘(C) any such payments with respect to alcohol10 ism and drug dependency residential treatment serv11 ices under paragraph (24) for individuals not de12 scribed in section 1931(d).’’.

13 (2) ALCOHOLISM AND DRUG DEPENDENCY RES14 IDENTIAL TREATMENT SERVICES DEFINED.—Title

15 XIX of the Social Security Act (42 U.S.C. 1396 et

16 seq.) is amended by adding at the end the following

17 new section:

18 ‘‘ALCOHOLISM AND DRUG DEPENDENCY RESIDENTIAL

19 TREATMENT SERVICES

20 ‘‘SEC. 1931. (a) ALCOHOLISM AND DRUG DEPEND21 ENCY RESIDENTIAL TREATMENT SERVICES.—The term

22 ‘alcoholism and drug dependency residential treatment

23 services’ means all the required services described in sub24 section (b) which are provided—

25 ‘‘(1) in a coordinated manner by a residential

26 treatment facility that meets the requirements of
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1 subsection (c) either directly or through arrange2 ments with—

3 ‘‘(A) public and nonprofit private entities;

4 ‘‘(B) licensed practitioners or federally

5 qualified health centers with respect to medical

6 services; or

7 ‘‘(C) the Indian Health Service or a tribal

8 or Indian organization that has entered into a

9 contract with the Secretary under section 102

10 of the Indian Self-Determination Act (25

11 U.S.C. 450f) or section 502 of the Indian

12 Health Care Improvement Act (25 U.S.C.

13 1652) with respect to such services provided to

14 women eligible to receive services in Indian

15 Health Facilities; and

16 ‘‘(2) pursuant to a written individualized treat17 ment plan prepared for each individual, which

18 plan—

19 ‘‘(A) states specific objectives necessary to

20 meet the individual’s needs;

21 ‘‘(B) describes the services to be provided

22 to the individual to achieve those objectives;

23 ‘‘(C) is established in consultation with the

24 individual;
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1 ‘‘(D) is periodically reviewed and (as ap2 propriate) revised by the staff of the facility in

3 consultation with the individual;

4 ‘‘(E) reflects the preferences of the individ5 ual; and

6 ‘‘(F) is established in a manner which pro7 motes the active involvement of the individual

8 in the development of the plan and its objec9 tives.

10 ‘‘(b) REQUIRED SERVICES DEFINED.—

11 ‘‘(1) IN GENERAL.—The required services de12 scribed in this subsection are as follows:

13 ‘‘(A) Counseling, addiction education, and

14 treatment provided on an individual, group, and

15 family basis and provided pursuant to individ16 ualized treatment plans, including the oppor17 tunity for involvement in Alcoholics Anonymous

18 and Narcotics Anonymous.

19 ‘‘(B) Parenting skills training.

20 ‘‘(C) Education concerning prevention of

21 HIV infection.

22 ‘‘(D) Assessment of each individual’s need

23 for domestic violence counseling and sexual

24 abuse counseling and provision of such counsel25 ing where needed.
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1 ‘‘(E) Room and board in a structured envi2 ronment with on-site supervision 24 hours-a3 day.

4 ‘‘(F) Therapeutic child care or counseling

5 for children of individuals in treatment.

6 ‘‘(G) Assisting parents in obtaining access

7 to—

8 ‘‘(i) developmental services (to the ex9 tent available) for their preschool children;

10 ‘‘(ii) public education for their school11 age children, including assistance in enroll12 ing them in school; and

13 ‘‘(iii) public education for parents who

14 have not completed high school.

15 ‘‘(H) Facilitating access to prenatal and

16 postpartum health care for women, to pediatric

17 health care for infants and children, and to

18 other health and social services where appro19 priate and to the extent available, including

20 services under title V, services and nutritional

21 supplements provided under the special supple22 mental food program for women, infants, and

23 children (WIC) under section 17 of the Child

24 Nutrition Act of 1966, services provided by fed25 erally qualified health centers, outpatient pedi-
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1 atric services, well-baby care, and early and

2 periodic screening, diagnostic, and treatment

3 services (as defined in section 1905(r)).

4 ‘‘(I) Ensuring supervision of children dur5 ing times their mother is in therapy or engaged

6 in other necessary health or rehabilitative ac7 tivities, including facilitating access to child

8 care services under title IV and title XX.

9 ‘‘(J) Planning for and counseling to assist

10 reentry into society, including appropriate out11 patient treatment and counseling after dis12 charge (which may be provided by the same

13 program, if available and appropriate) to assist

14 in preventing relapses, assistance in obtaining

15 suitable affordable housing and employment

16 upon discharge, and referrals to appropriate

17 educational, vocational, and other employment18 related programs (to the extent available).

19 ‘‘(K) Continuing specialized training for

20 staff in the special needs of residents and their

21 children, designed to enable such staff to stay

22 abreast of the latest and most effective treat23 ment techniques.

24 ‘‘(2) REQUIREMENT FOR CERTAIN SERVICES.—

25 Services under subparagraphs (A), (B), (C), and
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1 (D), of paragraph (1) shall be provided in a cultural

2 context that is appropriate to the individuals and in

3 a manner that ensures that the individuals can com4 municate effectively, either directly or through inter5 preters, with persons providing services.

6 ‘‘(3) LIMITATIONS ON COVERAGE.—

7 ‘‘(A) IN GENERAL.—Subject to subpara8 graph (B), services described in paragraph (1)

9 shall be covered in the amount, duration, and

10 scope therapeutically required for each eligible

11 individual in need of such services.

12 ‘‘(B) RESTRICTIONS ON LIMITING COV13 ERAGE.—A State plan shall not limit coverage

14 of alcoholism and drug dependency residential

15 treatment services for any period of less than

16 12 months per individual, except in those in17 stances where a finding is made that such serv18 ices are no longer therapeutically necessary for

19 an individual.

20 ‘‘(c) FACILITY REQUIREMENTS.—The requirements

21 of this subsection with respect to a facility are as follows:

22 ‘‘(1) The agency designated by the chief execu23 tive officer of the State to administer the State’s al24 cohol and drug abuse prevention and treatment ac25 tivities and programs has certified to the single
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1 State agency under section 1902(a)(5) that the facil2 ity—

3 ‘‘(A) is able to provide all the services de4 scribed in subsection (b) either directly or

5 through arrangements with—

6 ‘‘(i) public and nonprofit private enti7 ties;

8 ‘‘(ii) licensed practitioners or federally

9 qualified health centers with respect to

10 medical services; or

11 ‘‘(iii) the Indian Health Service or

12 with a tribal or Indian organization that

13 has entered into a contract with the Sec14 retary under section 102 of the Indian

15 Self-Determination Act (25 U.S.C. 450f)

16 or section 502 of the Indian Health Care

17 Improvement Act (25 U.S.C. 1652) with

18 respect to such services provided to women

19 eligible to receive services in Indian Health

20 Facilities; and

21 ‘‘(B) except for Indian Health Facilities,

22 meets all applicable State licensure or certifi23 cation requirements for a facility of that type.

24 ‘‘(2)(A) The facility or a distinct part of the fa25 cility provides room and board, except that—
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1 ‘‘(i) subject to subparagraph (B), the facil2 ity shall have no more than 40 beds; and

3 ‘‘(ii) subject to subparagraph (C), the fa4 cility shall not be licensed as a hospital.

5 ‘‘(B) The single State agency may waive the

6 bed limit under subparagraph (A)(i) for one or more

7 facilities subject to review by the Secretary. Waivers,

8 where granted, must be made pursuant to standards

9 and procedures set out in the State plan and must

10 require the facility seeking a waiver to demonstrate

11 that—

12 ‘‘(i) the facility will be able to maintain a

13 therapeutic, family-like environment;

14 ‘‘(ii) the facility can provide quality care in

15 the delivery of each of the services identified in

16 subsection (b);

17 ‘‘(iii) the size of the facility will be appro18 priate to the surrounding community; and

19 ‘‘(iv) the development of smaller facilities

20 is not feasible in that geographic area.

21 ‘‘(C) The Secretary may waive the requirement

22 under subparagraph (A)(ii) that a facility not be a

23 hospital, if the Secretary finds that such facility is

24 located in an Indian Health Service area and that

25 such facility is the only or one of the only facilities
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1 available in such area to provide services under this

2 section.

3 ‘‘(3) With respect to a facility providing the

4 services described in subsection (b) to an individual

5 eligible to receive services in Indian Health Facili6 ties, such a facility demonstrates (as required by the

7 Secretary) an ability to meet the special needs of In8 dian and Native Alaskan women.

9 ‘‘(d) ELIGIBLE INDIVIDUALS.—

10 ‘‘(1) IN GENERAL.—A State plan shall limit

11 coverage of alcoholism and drug dependency residen12 tial treatment services under section 1905(a)(24) to

13 the following individuals otherwise eligible for medi14 cal assistance under this title:

15 ‘‘(A) Women during pregnancy, and until

16 the end of the 12th month following the termi17 nation of the pregnancy.

18 ‘‘(B) Children of a woman described in

19 subparagraph (A).

20 ‘‘(C) At the option of a State, a caretaker

21 parent or parents and children of such a

22 parent.

23 ‘‘(2) INITIAL ASSESSMENT OF ELIGIBLE INDI24 VIDUALS.—An initial assessment of eligible individ25 uals specified in paragraph (1) seeking alcoholism
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1 and drug dependency residential treatment services

2 shall be performed by the agency designated by the

3 chief executive officer of the State to administer the

4 State’s alcohol and drug abuse treatment activities

5 (or its designee). Such assessment shall determine

6 whether such individuals are in need of alcoholism or

7 drug dependency treatment services and, if so, the

8 treatment setting (such as inpatient hospital,

9 nonhospital residential, or outpatient) that is most

10 appropriate in meeting such individual’s health and

11 therapeutic needs and the needs of such individual’s

12 dependent children, if any.

13 ‘‘(e) OVERALL CAP ON MEDICAL ASSISTANCE AND

14 ALLOCATION OF BEDS.—

15 ‘‘(1) TOTAL AMOUNT OF SERVICES AS MEDICAL

16 ASSISTANCE.—

17 ‘‘(A) IN GENERAL.—The total amount of

18 services provided under this section as medical

19 assistance for which payment may be made

20 available under section 1903 shall be limited to

21 the total number of beds allowed to be allocated

22 for such services in any given year as specified

23 under subparagraph (B).

24 ‘‘(B) TOTAL NUMBER OF BEDS.—The total

25 number of beds allowed to be allocated under
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1 this subparagraph (subject to paragraph

2 (2)(C)) for the furnishing of services under this

3 section and for which Federal medical assist4 ance may be made available under section 1903

5 is for calendar year—

6 ‘‘(i) 1995, 1,080 beds;

7 ‘‘(ii) 1996, 2,000 beds;

8 ‘‘(iii) 1997, 3,500 beds;

9 ‘‘(iv) 1998, 5,000 beds;

10 ‘‘(v) 1999, 6,000 beds; and

11 ‘‘(vi) 2000 and for calendar years

12 thereafter, a number of beds determined

13 appropriate by the Secretary.

14 ‘‘(2) ALLOCATION OF BEDS.—

15 ‘‘(A) INITIAL ALLOCATION FORMULA.—For

16 each calendar year, a State exercising the op17 tion to provide the services described in this

18 section shall be allocated from the total number

19 of beds available under paragraph (1)(B)—

20 ‘‘(i) in calendar years 1995 and 1996,

21 20 beds;

22 ‘‘(ii) in calendar years 1997, 1998,

23 and 1999, 40 beds; and

24 ‘‘(iii) in calendar year 2000 and for

25 each calendar year thereafter, a number of
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1 beds determined based on a formula (as

2 provided by the Secretary) distributing

3 beds to States on the basis of the relative

4 percentage of women of childbearing age in

5 a State.

6 ‘‘(B) REALLOCATION OF BEDS.—The Sec7 retary shall provide that in allocating the num8 ber of beds made available to a State for the

9 furnishing of services under this section that, to

10 the extent not all States are exercising the op11 tion of providing services under this section and

12 there are beds available that have not been allo13 cated in a year as provided in paragraph

14 (1)(B), that such beds shall be reallocated

15 among States which are furnishing services

16 under this section based on a formula (as pro17 vided by the Secretary) distributing beds to

18 States on the basis of the relative percentage of

19 women of childbearing age in a State.

20 ‘‘(C) INDIAN HEALTH SERVICE AREAS.—In

21 addition to the beds allowed to be allocated

22 under paragraph (1)(B) there shall be an addi23 tional 20 beds allocated in any calendar year to

24 States for each Indian Health Service area

25 within the State to be utilized by Indian Health
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1 Facilities within such an area and, to the extent

2 such beds are not utilized by a State, the beds

3 shall be reapportioned to Indian Health Service

4 areas in other States.’’.

5 (3) MAINTENANCE OF STATE FINANCIAL EF6 FORT AND 100 PERCENT FEDERAL MATCHING FOR

7 SERVICES FOR INDIAN AND NATIVE ALASKAN

8 WOMEN IN INDIAN HEALTH SERVICES AREAS.—Sec9 tion 1903 of the Social Security Act (42 U.S.C.

10 1396b) is amended by adding at the end the follow11 ing new subsections:

12 ‘‘(x) No payment shall be made to a State under this

13 section in a State fiscal year for alcoholism and drug de14 pendency residential treatment services (described in sec15 tion 1931) unless the State provides assurances satisfac16 tory to the Secretary that the State is maintaining State

17 expenditures for such services at a level that is not less

18 than the average annual level maintained by the State for

19 such services for the 2-year period preceding such fiscal

20 year.

21 ‘‘(y) Notwithstanding the preceding provisions of this

22 section, the Federal medical assistance percentage for pur23 poses of payment under this section for services described

24 in section 1931 provided to individuals residing on or re-
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1 ceiving services in an Indian Health Service area shall be

2 100 percent.’’.

3 (b) PAYMENT ON A COST-RELATED BASIS.—Section

4 1902(a)(13) of the Social Security Act (42 U.S.C.

5 1396a(a)(13)) is amended—

6 (1) by striking ‘‘and’’ at the end of subpara7 graph (E);

8 (2) by adding ‘‘and’’ at the end of subpara9 graph (F); and

10 (3) by adding at the end the following new sub11 paragraph:

12 ‘‘(G) for payment for alcoholism and drug

13 dependency residential treatment services which

14 the State finds, and makes assurances satisfac15 tory to the Secretary, are reasonable and ade16 quate to meet the costs which must be incurred

17 by efficiently and economically operated facili18 ties in order to provide all the services listed in

19 section 1931(b) in conformity with applicable

20 Federal and State laws, regulations, and quality

21 and safety standards and to assure that individ22 uals eligible for such services have reasonable

23 access to such services;’’.

24 (c) CONFORMING AMENDMENTS.—
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1 (1) CLARIFICATION OF OPTIONAL COVERAGE

2 FOR SPECIFIED INDIVIDUALS.—Section 1902(a)(10)

3 of the Social Security Act (42 U.S.C. 1396a(a)(10))

4 is amended, in the matter following subparagraph

5 (F)—

6 (A) by striking ‘‘; and (XI)’’ and inserting

7 ‘‘, (XI)’’;

8 (B) by striking ‘‘, and (XI)’’ and inserting

9 ‘‘, and (XII)’’; and

10 (C) by inserting before the semicolon at

11 the end the following: ‘‘, and (XIII) the making

12 available of alcoholism and drug dependency

13 residential treatment services to individuals de14 scribed in section 1931(d) shall not, by reason

15 of this paragraph, require the making of such

16 services available to other individuals’’.

17 (2) CONTINUATION OF ELIGIBILITY FOR ALCO18 HOLISM AND DRUG DEPENDENCY TREATMENT FOR

19 PREGNANT WOMEN FOR 12 MONTHS FOLLOWING

20 END OF PREGNANCY.—Section 1902 of the Social

21 Security Act (42 U.S.C. 1396a) is amended in sub22 section (e)(5) by striking ‘‘under the plan,’’ and all

23 through the period at the end and inserting ‘‘under

24 the plan—
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1 ‘‘(A) as though she were pregnant, for all preg2 nancy-related and postpartum medical assistance

3 under the plan, through the end of the month in

4 which the 60-day period (beginning on the last day

5 of her pregnancy) ends; and

6 ‘‘(B) for alcoholism and drug dependency resi7 dential treatment services under section 1931

8 through the end of the 1-year period beginning on

9 the last day of her pregnancy.’’.

10 (3) REDESIGNATIONS.—Section 1902 of the So11 cial Security Act (42 U.S.C. 1396a) is further

12 amended—

13 (A) in subsection (a)(10)(C)(iv), by strik14 ing ‘‘(21)’’ and inserting ‘‘(24)’’; and

15 (B) in subsection (j), by striking ‘‘(22)’’

16 and inserting ‘‘(25)’’.

17 (d) ANNUAL EDUCATION AND TRAINING IN INDIAN

18 HEALTH SERVICE AREAS.—The Secretary of Health and

19 Human Services in cooperation with the Indian Health

20 Service shall conduct on at least an annual basis training

21 and education in each of the 12 Indian Health Service

22 areas for tribes, Indian organizations, residential treat23 ment providers, and State health care workers regarding

24 the availability and nature of residential treatment serv-
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1 ices available in such areas under the provisions of this

2 Act.

3 (e) EFFECTIVE DATE; TRANSITION.—(1) The

4 amendments made by this section apply to alcoholism and

5 drug dependency residential treatment services furnished

6 on or after July 1, 1995, without regard to whether or

7 not final regulations to carry out such amendments have

8 been promulgated by such date.

9 (2) The Secretary of Health and Human Services

10 shall not take any compliance, disallowance, penalty, or

11 other regulatory action against a State under title XIX

12 of the Social Security Act with regard to alcoholism and

13 drug dependency residential treatment services (as defined

14 in section 1931(a) of such Act) made available under such

15 title on or after July 1, 1995, before the date the Sec16 retary issues final regulations to carry out the amend17 ments made by this section, if the services are provided

18 under its plan in good faith compliance with such amend19 ments.

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