II

106TH CONGRESS

2D SESSION S. 3233

To amend title XVIII of the Social Security Act to provide for medicare

beneficiary copayments for outpatient mental health services that are

the same as beneficiary copayments for other part B services, and for

other purposes.

IN THE SENATE OF THE UNITED STATES

OCTOBER 25 (legislative day, SEPTEMBER 22), 2000

Mr. WELLSTONE 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

for medicare beneficiary copayments for outpatient mental health services that are the same as beneficiary copayments for other part B services, 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 ‘‘Medicare Mental

5 Health Modernization Act of 2000’’.

6 SEC. 2. FINDINGS.

7 The Senate finds the following:
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1 (1) Older people have the highest rate of suicide

2 of any population in the United States, and the sui3 cide rate of that population increases with age, with

4 individuals 65 and older accounting for 20 percent

5 of all suicide deaths in the United States, while com6 prising only 13 percent of the population of the

7 United States.

8 (2) Disability due to mental illness in individ9 uals over 65 years old will become a major public

10 health problem in the near future because of demo11 graphic changes. In particular, dementia, depression,

12 schizophrenia, among other conditions, will all

13 present special problems for this age group.

14 (3) Major depression is strikingly prevalent

15 among older people, with between 8 and 20 percent

16 of older people in community studies and up to 37

17 percent of those seen in primary care settings expe18 riencing symptoms of depression.

19 (4) Almost 20 percent of the population of indi20 viduals age 55 and older, experience specific mental

21 disorders that are not part of normal aging.

22 (5) Unrecognized and untreated depression,

23 Alzheimer’s disease, anxiety, late-life schizophrenia,

24 and other mental conditions can be severely impair25 ing and may even be fatal.
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1 (6) Substance abuse, particularly the abuse of

2 alcohol and prescription drugs, among adults 65 and

3 older is one of the fastest growing health problems

4 in the United States, with 17 percent of this age

5 group suffering from addiction or substance abuse.

6 While addiction often goes undetected and untreated

7 among older adults, aging and disability makes the

8 body more vulnerable to the effects of alcohol and

9 drugs, further exacerbating other age-related health

10 problems. Medicare coverage for addiction treatment

11 of the elderly needs to recognize these special

12 vulnerabilities.

13 (7) The disabled are another population receiv14 ing inadequate mental health care through medicare.

15 According to the Health Care Financing Administra16 tion, medicare is the primary health care coverage

17 for the 5,000,000 non-elderly, disabled people on So18 cial Security Disability Insurance. Up to 40 percent

19 of these individuals have a diagnosis of mental ill20 ness, and also face severe discrimination in mental

21 health coverage.
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1 SEC. 3. DECREASE IN MEDICARE BENEFICIARY COPAY2 MENT FOR OUTPATIENT MENTAL HEALTH

3 SERVICES.

4 (a) IN GENERAL.—Section 1833(c) of the Social Se5 curity Act (42 U.S.C. 1395l(c)) is repealed.

6 (b) CONFORMING AMENDMENT.—Section

7 1866(a)(2)(A) of such Act (42 U.S.C. 1395cc(a)(2)(A))

8 is amended by striking the second sentence.

9 (c) EFFECTIVE DATE.—The amendments made by

10 subsections (a) and (b) shall apply to items and services

11 furnished on or after the date of enactment of this Act.

12 SEC. 4. INTENSIVE RESIDENTIAL SERVICES.

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

14 (42 U.S.C. 1395d(a)) is amended—

15 (1) in paragraph (4), by striking ‘‘and’’ at the

16 end;

17 (2) in paragraph (5), by striking the period at

18 the end of and inserting ‘‘; and’’; and

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

20 paragraph:

21 ‘‘(5) intensive residential services (as defined in

22 section 1861(uu)) furnished to an individual for up

23 to 120 days during any calendar year.’’.

24 (b) INTENSIVE RESIDENTIAL SERVICES DEFINED.—

25 Section 1861 of the Social Security Act (42 U.S.C. 1395x)
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1 is amended by adding at the end the following new sub2 section:

3 ‘‘Intensive Residential Services

4 ‘‘(uu)(1) Subject to paragraphs (2) and (3), the term

5 ‘intensive residential services’ means inpatient services

6 provided in any of the following facilities:

7 ‘‘(A) Residential detoxification centers.

8 ‘‘(B) Crisis residential programs or mental ill9 ness residential treatment programs.

10 ‘‘(C) Therapeutic family or group treatment

11 homes.

12 ‘‘(D) Residential centers for substance abuse

13 treatment.

14 ‘‘(2) No service may be treated as an intensive resi15 dential service unless the facility at which the service is

16 provided—

17 ‘‘(A) is legally authorized to provide such serv18 ice under the law of the State (or under a State reg19 ulatory mechanism provided by State law) in which

20 the facility is located or is certified to provide such

21 service by an appropriate accreditation entity ap22 proved by the State in consultation with the Sec23 retary; and
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1 ‘‘(B) meets such other requirements as the Sec2 retary may impose to assure the quality of the inten3 sive residential services provided.

4 ‘‘(3) No service may be treated as an intensive resi5 dential service under paragraph (1) unless the service is

6 furnished in accordance with standards established by the

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

8 (c) REDUCTION IN DAYS OF COVERAGE FOR INPA9 TIENT SERVICES.—Section 1812(b)(3) of the Social Secu10 rity Act (42 U.S.C. 1395d(b)(3)) is amended by striking

11 the period at the end and inserting the following: ‘‘, re12 duced by a number of days determined by the Secretary

13 so that the actuarial value of providing such number of

14 days of services under this paragraph to the individual is

15 equal to the actuarial value of the days of inpatient resi16 dential services furnished to the individual under sub17 section (a)(5) during the year after such services have

18 been furnished to the individual for 120 days during the

19 year (rounded to the nearest day).’’.

20 (d) AMOUNT OF PAYMENT.—Section 1814 of the So21 cial Security Act (42 U.S.C. 1395f) is amended—

22 (1) in subsection (b), in the matter preceding

23 paragraph (1), by inserting ‘‘other than a provider

24 of intensive residential services,’’ after ‘‘hospice

25 care,’’; and
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1 (2) by adding at the end the following new sub2 section:

3 ‘‘Payment for Intensive Residential Services

4 ‘‘(m)(1) Except as provided in paragraphs (2) and

5 (3), the amount of payment under this part for intensive

6 residential services under section 1812(a)(5) shall be equal

7 to the lesser of—

8 ‘‘(A) the reasonable cost of such services, as de9 termined under section 1861(v), or

10 ‘‘(B) the customary charges with respect to

11 such services,

12 less the amount a provider may charge as described in

13 clause (ii) of section 1866(a)(2)(A).

14 ‘‘(2) If intensive residential services are furnished by

15 a public provider of services or by another provider which

16 demonstrates to the satisfaction of the Secretary that a

17 significant portion of its patients are low-income (and re18 quests that payment be made under this clause), free of

19 charge or at nominal charges to the public, the Secretary

20 shall determine the amount of payment for such services

21 in accordance with subsection (b)(2).

22 ‘‘(3) If (and for so long as) the conditions described

23 in subsection (b)(3) are met, the Secretary shall determine

24 the amount of payment for intensive residential services
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1 under the reimbursement system described in such sub2 section.’’.

3 SEC. 5. STUDY OF COVERAGE CRITERIA FOR ALZHEIMER’S

4 DISEASE AND RELATED MENTAL ILLNESSES.

5 (a) STUDY.—

6 (1) IN GENERAL.—The Secretary of Health and

7 Human Services (in this section referred to as the

8 ‘‘Secretary’’) shall conduct a study to determine

9 whether the criteria for coverage of any therapy

10 service (including occupational therapy services and

11 physical therapy services) or any outpatient mental

12 health care service under the medicare program

13 under title XVIII of the Social Security Act unduly

14 restricts the access of any medicare beneficiary who

15 has been diagnosed with Alzheimer’s disease or a re16 lated mental illness to such a service because the

17 coverage criteria requires the medicare beneficiary to

18 display continuing clinical improvement to continue

19 to receive the service.

20 (2) DETERMINATION OF NEW COVERAGE CRI21 TERIA.—If the Secretary determines that the cov22 erage criteria described in paragraph (1) unduly re23 stricts the access of any medicare beneficiary to the

24 services described in such paragraph, the Secretary

25 shall identify alternative coverage criteria that would
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1 permit a medicare beneficiary who has been diag2 nosed with Alzheimer’s disease or a related mental

3 illness to receive coverage for health care services

4 under the medicare program that are designed to

5 control symptoms, maintain functional capabilities,

6 reduce or deter deterioration, and prevent or reduce

7 hospitalization of the beneficiary.

8 (b) REPORT.—Not later than 1 year after the date

9 of enactment of this Act, the Secretary shall submit to

10 the committees of jurisdiction of Congress a report on the

11 study conducted under subsection (a) together with such

12 recommendations for legislative and administrative action

13 as the Secretary determines appropriate.

14 SEC. 6. MENTAL HEALTH COUNSELING SERVICES.

15 (a) ADDING MENTAL HEALTH COUNSELOR SERV16 ICES TO THE DEFINITION OF MEDICAL AND OTHER

17 HEALTH SERVICES.—Section 1861(s)(2) of the Social Se18 curity Act (42 U.S.C. 1395(s)(2)) is amended—

19 (1) in subparagraph (S), by striking ‘‘and’’ at

20 the end;

21 (2) in subparagraph (T)(ii), by adding ‘‘and’’ at

22 the end; and

23 (3) by adding at the end the following new sub24 paragraph:
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1 ‘‘(U) mental health counselor services (as

2 defined in subsection (vv));’’.

3 (b) MENTAL HEALTH COUNSELOR; MENTAL

4 HEALTH COUNSELOR SERVICES DEFINED.—Section

5 1861 of the Social Security Act (42 U.S.C. 1395x), as

6 amended by section 4, is amended by adding at the end

7 the following new subsection:

8 ‘‘Mental Health Counselor; Mental Health Counselor

9 Services

10 ‘‘(vv)(1) The term ‘mental health counselor’ means

11 an individual who—

12 ‘‘(A) possesses a master’s or doctor’s degree in

13 counseling or a related field;

14 ‘‘(B) after obtaining such a degree has per15 formed at least 2 years of supervised mental health

16 counselor practice; and

17 ‘‘(C)(i) is licensed or certified as a mental

18 health counselor or professional counselor by the

19 State in which the services are performed; or

20 ‘‘(ii) in the case of an individual in a State that

21 does not provide for licensure or certification—

22 ‘‘(I) has completed at least 2 years or

23 3,000 hours of post-master’s degree supervised

24 mental health counselor practice under the su25 pervision of a master’s or doctor’s level mental
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1 health provider in an appropriate setting (as de2 termined by the Secretary); and

3 ‘‘(II) meet such other criteria as the Sec4 retary establishes.

5 ‘‘(2) The term ‘mental health counselor services’

6 means services performed by a mental health counselor (as

7 defined in paragraph (1)) for the diagnosis and treatment

8 of mental illnesses which the mental health counselor is

9 legally authorized to perform under State law (or the

10 State regulatory mechanism provided by the State law) of

11 the State in which such services as performed as would

12 otherwise be covered if furnished by a physician or as inci13 dent to a physician’s professional service.’’.

14 (c) PAYMENT.—Section 1833(a)(1) of the Social Se15 curity Act (42 U.S.C. 1395l(a)(1)) is amended—

16 (1) by striking ‘‘and’’ before ‘‘(S)’’; and

17 (2) by inserting before the semicolon at the end

18 the following: ‘‘, and (T) with respect to mental

19 health counselor services under section

20 1861(s)(2)(U), the amounts paid shall be 80 percent

21 of (i) the actual charge for the services or (ii) 75

22 percent of the amount determined for payment of a

23 psychologist under clause (L)’’.
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1 SEC. 7. EXCLUDING CLINICAL SOCIAL WORKER SERVICES

2 FROM COVERAGE UNDER THE MEDICARE

3 SKILLED NURSING FACILITY PROSPECTIVE

4 PAYMENT SYSTEM AND CONSOLIDATED PAY5 MENT.

6 (a) IN GENERAL.—Section 1888(e)(2)(A)(ii) of the

7 Social Security Act (42 U.S.C. 1395yy(e)(2)(A)(ii)) is

8 amended by inserting ‘‘clinical social worker services,’’

9 after ‘‘qualified psychologist services,’’.

10 (b) CONFORMING AMENDMENT.—Section

11 1861(hh)(2) of such Act (42 U.S.C. 1395x(hh)(2)) is

12 amended by striking ‘‘and other than services furnished

13 to an inpatient of a skilled nursing facility which the facil14 ity is required to provide as a requirement for participa15 tion’’.

16 (c) EFFECTIVE DATE.—The amendments made by

17 this section apply as if included in the enactment of sec18 tion 4432(a) of the Balanced Budget Act of 1997.

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