Calendar No. 371

103D CONGRESS

2D SESSION S. 1833

A BILL

To amend the Public Health Service Act to provide

care insurance program, and for other purposes.for the establishment of a voluntary long-term

FEBRUARY 22, 1994

Read the second time and placed on the calendar
II

Calendar No. 371

103D CONGRESS

2D SESSION S. 1833

To amend the Public Health Service Act to provide for the establishment

of a voluntary long-term care insurance program, and for other purposes.

IN THE SENATE OF THE UNITED STATES

FEBRUARY 7 (legislative day, JANUARY 25), 1994

Mr. KENNEDY (for himself and Mr. WOFFORD) introduced the following bill;

which was read the first time

FEBRUARY 22, 1994

Read the second time and placed on the calendar

A BILL

To amend the Public Health Service Act to provide for

the establishment of a voluntary long-term care insurance 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 ‘‘Life Care Act’’.
2

•S 1833 PCS

1 SEC. 2. LIFE CARE: PUBLIC INSURANCE PROGRAM FOR

2 NURSING HOME CARE.

3 (a) IN GENERAL.—The Public Health Service Act

4 (42 U.S.C. 201 et seq.) is amended—

5 (1) by redesignating title XXVII (42 U.S.C.

6 300cc et seq.) as title XXVIII; and

7 (2) by inserting after title XXVI the following

8 new title:

9 ‘‘TITLE XXVII—LIFE CARE: PUB10 LIC INSURANCE PROGRAM

11 FOR NURSING HOME CARE

12 ‘‘SEC. 2701. ESTABLISHMENT OF VOLUNTARY LONG-TERM

13 CARE INSURANCE PROGRAM.

14 ‘‘The Secretary shall establish a voluntary insurance

15 program for individuals 45 years of age and over to cover

16 the nursing home stays of such individuals.

17 ‘‘SEC. 2702. BENEFITS.

18 ‘‘(a) IN GENERAL.—Subject to subsection (c), an in19 dividual who meets the eligibility criteria prescribed in sec20 tion 2703 shall be eligible under the program established

21 under this title for coverage for necessary services de22 scribed in subsection (b) (in the amounts described in sub23 section (c)) that are provided to the individual by a nurs24 ing facility while the individual is an inpatient of the facil25 ity.
3

•S 1833 PCS

1 ‘‘(b) TYPES.—Coverage may be provided under this

2 title for—

3 ‘‘(1) nursing care provided by or under the su4 pervision of a registered professional nurse;

5 ‘‘(2) physical, occupational, or speech therapy

6 furnished by a facility or by others under arrange7 ments with a facility;

8 ‘‘(3) medical social services;

9 ‘‘(4) drug, biological, supply, appliance, and

10 equipment for use in the facility, that is ordinarily

11 furnished by the facility for the care and treatment

12 of an inpatient;

13 ‘‘(5) medical service of an intern or resident-in14 training under an approved teaching program of a

15 hospital with which a facility has in effect a transfer

16 agreement or other diagnostic or therapeutic service

17 provided by a hospital with which a facility has in

18 effect a transfer agreement; and

19 ‘‘(6) such other health services necessary to the

20 health of a patient as are generally provided by a

21 nursing home facility.

22 ‘‘(c) COVERAGE AMOUNT.—

23 ‘‘(1) IN GENERAL.—The amount of coverage

24 provided with respect to an eligible individual for the

25 services described in subsection (b) shall, based on
4

•S 1833 PCS

1 an election made by the individual, not exceed

2 $30,000, $60,000, or $90,000 over the lifetime of

3 the eligible individual. Such amounts shall be ad4 justed by the Secretary to reflect increases in the

5 Consumer Price Index.

6 ‘‘(2) ASSET PROTECTION.—An eligible individ7 ual shall be entitled to the asset protection provided

8 under section 2708.

9 ‘‘(d) PAYMENT.—Amounts provided under this title

10 with respect to an eligible individual for the services de11 scribed in subsection (b) shall be paid from the general

12 fund of the Treasury of the United States.

13 ‘‘SEC. 2703. ELIGIBILITY.

14 ‘‘(a) IN GENERAL.—An individual shall be eligible for

15 benefits under this title if—

16 ‘‘(1) the individual—

17 ‘‘(A) is a legal resident of the United

18 States and has elected coverage under sub19 section (c);

20 ‘‘(B) has been determined by a Screening

21 Agency through a screening process (conducted

22 in accordance with section 2707)—

23 ‘‘(i)(I) to require hands-on or standby

24 assistance, supervision, or cueing (as de-
5

•S 1833 PCS

1 fined in regulations) to perform three or

2 more activities of daily living;

3 ‘‘(II) to require hands-on or standby

4 assistance, supervision, or cueing with at

5 least such instrumental activity (or activi6 ties) of daily living related to cognitive or

7 mental impairment as the Secretary speci8 fies; or

9 ‘‘(III) to display symptoms of one or

10 more serious behavioral problems (that is

11 on a list of such problems specified by the

12 Secretary) which create a need for super13 vision to prevent harm to self or others;

14 and

15 ‘‘(ii) to require such assistance, super16 vision, or cueing over a period of at least

17 100 days; and

18 ‘‘(C) has achieved a score, on a standard

19 mental status protocol (or protocols) appro20 priate for measuring the individual’s particular

21 condition specified by the Secretary, that indi22 cates either severe cognitive impairment or se23 vere mental impairment, or both.
6

•S 1833 PCS

1 ‘‘(2)(A) the individual has filed an application

2 for such benefits, and is in need of, benefits covered

3 under this title;

4 ‘‘(B) the legal guardian of the individual has

5 filed an application on behalf of an individual who

6 is in need of benefits covered under this title; or

7 ‘‘(C) the representative of an individual who is

8 cognitively impaired and who is in need of benefits

9 covered under this title has filed an application on

10 behalf of the individual; and

11 ‘‘(3) receiving nursing home services in a nurs12 ing facility would be in the best interest of the indi13 vidual.

14 ‘‘(b) CURRENT INDIVIDUALS.—An individual who is

15 in a hospital or nursing home on the date of the enroll16 ment of the individual in the program established under

17 this title shall be ineligible for coverage under this section

18 until the individual’s first spell of illness beginning after

19 such date.

20 ‘‘(c) ELECTION OF COVERAGE.—

21 ‘‘(1) IN GENERAL.—Subject to this subsection,

22 an individual shall have the option to purchase cov23 erage under this title when the individual is 35 years

24 of age, 45 years of age, 55 years of age, or 65 years

25 of age.
7

•S 1833 PCS

1 ‘‘(2) INITIAL YEAR.—During the 1-year period

2 beginning on the date of enactment of this title, an

3 individual who is 45 years of age or older shall be

4 eligible to purchase insurance under this title, except

5 that such an individual shall not be eligible to pur6 chase such insurance—

7 ‘‘(A) while confined to a hospital or nurs8 ing home;

9 ‘‘(B) within the 6-month period after the

10 individuals confinement in a nursing home; or

11 ‘‘(C) within the 90-day period after the in12 dividuals confinement in a hospital.

13 Individuals described in the matter preceding sub14 paragraph (A) shall become eligible to receive bene15 fits under this title on the expiration of the 3-year

16 period beginning on the date such individuals pur17 chase insurance under this title.

18 ‘‘(3) EXTENSION BEYOND INITIAL YEAR.—If an

19 individual is confined to a nursing home or hospital

20 during a period that extends beyond the first year

21 after the effective date of this title, an individual

22 shall be eligible to enroll in the program established

23 by this title during the 60-day period beginning after

24 the individual’s spell of illness.
8

•S 1833 PCS

1 ‘‘(4) SUBSEQUENT YEARS.—During years sub2 sequent to the 1-year period referred to in para3 graph (2), an individual shall be eligible to purchase

4 insurance under this title within 6 months of the

5 45th, 55th or 65th birthday of the individual.

6 ‘‘(5) ACTIVATION OF BENEFITS.—To receive

7 coverage under the insurance program established by

8 this title, an individual shall have purchased such

9 coverage not later than 1 month prior to admission

10 to a nursing facility, unless the reason for the need

11 of services is a result of an accident or stroke subse12 quent to the date that such individual enrolled for

13 coverage under this title.

14 ‘‘SEC. 2704. PREMIUM RATES.

15 ‘‘(a) IN GENERAL.—The Secretary shall determine

16 one premium rate for individuals electing to purchase cov17 erage under this title at age 45 (or between the ages of

18 45 and 54 during the initial enrollment period), a separate

19 rate for those individuals who elect such coverage at age

20 55 (or between that ages of 55 and 64 during the initial

21 enrollment period), and a separate rate for those individ22 uals who elect such coverage at age 65 (or at age 65 and

23 over during the initial enrollment period).

24 ‘‘(b) REVISION.—The Secretary shall revise premium

25 rates annually to increase such rates to reflect the amount
9

•S 1833 PCS

1 of the increase in the cost of living adjustment with re2 spect to benefits under title II of the Social Security Act.

3 ‘‘(c) RATES.—In developing premium rates under the

4 program established under this title, the Secretary shall

5 establish rates that are expected to cover 100 percent of

6 the estimated costs of nursing home stays for those indi7 viduals enrolled in the program.

8 ‘‘(d) WAIVER.—An individual electing to purchase

9 coverage under this title shall not be required to pay pre10 miums during any period in which such individual is re11 ceiving benefits under this title.

12 ‘‘(e) PAYMENT.—Premiums shall be paid under this

13 section into the general fund of the Treasury of the United

14 States.

15 ‘‘SEC. 2705. QUALIFIED SERVICE PROVIDERS.

16 ‘‘(a) IN GENERAL.—To be considered as a covered

17 nursing home service under this title, such service must

18 have been provided by a qualified service provider.

19 ‘‘(b) TYPES.—A provider shall be considered a quali20 fied service provider under this title if the provider is a

21 nursing facility that is certified by the State and meets

22 the requirements of this title and any other standards es23 tablished by the Secretary by regulation for the safe and

24 efficient provision of services covered under this title.
10

•S 1833 PCS

1 ‘‘SEC. 2706. REIMBURSEMENT.

2 ‘‘(a) AMOUNT.—Monthly reimbursement for nursing

3 facility services under this title shall equal 65 percent of

4 the amount the Secretary determines to be reasonable and

5 appropriate to cover the cost of care provided under this

6 title, taking into account the average cost of providing ap7 propriate care in the most efficient manner.

8 ‘‘(b) PROSPECTIVE PAYMENT.—To the extent fea9 sible, the Secretary shall establish a prospective payment

10 mechanism for payment for nursing home services under

11 this title that takes into account the expected resource uti12 lization of individual patients based on their degree of dis13 ability and other factors determining service requirements.

14 ‘‘(c) ROOM AND BOARD PAYMENT.—An individual

15 receiving benefits under this program shall be responsible

16 for the payment of an amount for room and board that

17 is equal to—

18 ‘‘(1) with respect to the initial 6 months of con19 finement to a nursing facility, 20 percent of the av20 erage per diem rate paid by the Secretary to nursing

21 facilities receiving reimbursement under this title;

22 and

23 ‘‘(2) with respect to subsequent periods of con24 finement, 35 percent of the average per diem rate

25 paid by the Secretary to nursing facilities receiving

26 reimbursement under this title.
11

•S 1833 PCS

1 ‘‘(d) PRIORITY PAYERS.—Notwithstanding any other

2 provision of this title, reimbursement for nursing facility

3 services provided under this title to an individual shall,

4 to the extent available, be made under the Medicare pro5 gram, under Department of Veterans Affairs’ programs,

6 or under private insurance policies prior to reimbursement

7 under this title.

8 ‘‘SEC. 2707. LONG-TERM CARE SCREENING AGENCY.

9 ‘‘(a) ESTABLISHMENT.—The Secretary shall contract

10 with entities to act as Long-Term Care Screening Agen11 cies (hereafter referred to in this title as the ‘Screening

12 Agency’) for each designated area of a State. It shall be

13 the responsibility of such agency to assess the eligibility

14 of individuals residing in the geographic jurisdiction of the

15 Agency, for services provided under this title according to

16 the requirements of this title and regulations prescribed

17 by the Secretary. In entering into such contracts, the Sec18 retary shall give preference to State governmental entities.

19 ‘‘(b) ELIGIBILITY.—The Screening Agency shall de20 termine the eligibility of an individual under this title

21 based on the results of a preliminary telephone interview

22 or written questionnaire (completed by the applicant, by

23 the caregiver of the applicant, or by the legal guardian

24 or representative of the applicant) that shall be validated

25 through the use of a screening tool administered in person
12

•S 1833 PCS

1 to each applicant determined eligible through initial tele2 phone or written questionnaire interviews not later than

3 15 days from the date on which such individual initially

4 applied for services under this title.

5 ‘‘(c) QUESTIONNAIRES AND SCREENING TOOLS.—

6 ‘‘(1) IN GENERAL.—The Secretary shall estab7 lish a telephone or written questionnaire and a

8 screening tool to be used by the Screening Agency

9 to determine the eligibility of an individual for serv10 ices under this title consistent with requirements of

11 this title and the standards established by the Sec12 retary by regulation.

13 ‘‘(2) QUESTIONNAIRES.—The questionnaire

14 shall include questions about the functional impair15 ment, mental status, and living arrangement of an

16 individual and other criteria that the Secretary shall

17 prescribe by regulation.

18 ‘‘(3) SCREENING TOOLS.—The screening tool

19 should measure functional impairment caused by

20 physical or cognitive conditions as well as informa21 tion concerning cognition disability, behavioral prob22 lems (such as wandering or abusive and aggressive

23 behavior), the living arrangement of an individual,

24 availability of caregivers, and any other criteria that
13

•S 1833 PCS

1 the Secretary shall prescribe by regulation. The

2 screening tool shall be administered in person.

3 ‘‘(d) NOTIFICATION.—Not later than 15 days after

4 the date on which an individual initially applied for serv5 ices under this title (by telephone or written question6 naire), the Screening Agency shall notify such individual

7 that such individual is not eligible for benefits, or that

8 such individuals must schedule an in-person screening to

9 determine final eligibility for benefits under this title. The

10 Screening Agency shall notify such individual of its final

11 decision not later than 2 working days after the in-person

12 screening.

13 ‘‘(e) IN-PERSON SCREENING.—An individual (or the

14 legal guardian or representative of such individual) whose

15 application for benefits under this title is denied on the

16 basis of information provided through a telephone or writ17 ten questionnaire, shall be notified of such individual’s

18 right to an in-person screening by a nurse or appropriate

19 health care professionals.

20 ‘‘(f) APPEALS.—The Secretary shall establish a

21 mechanism for hearings and appeals in cases in which in22 dividuals contest the eligibility findings of the Screening

23 Agency.
14

•S 1833 PCS

1 ‘‘SEC. 2708. RELATION TO TITLE XIX OF THE SOCIAL SECU2 RITY ACT; ASSET PROTECTION.

3 ‘‘Notwithstanding any other provision of law, the as4 sets an eligible individual may retain and continue to be

5 determined eligible for nursing facility benefits under

6 State Medicaid programs (in accordance with section

7 1902(a)(10)) shall be increased by the amount of coverage

8 ($30,000, $60,000, or $90,000) elected under section

9 2702.

10 ‘‘SEC. 2709. RELATION TO PRIVATE INSURANCE.

11 ‘‘(a) IN GENERAL.—Except as provided in subsection

12 (b), an insurer may not offer a health insurance policy

13 to an individual covered under this title if the coverage

14 under such policy duplicates the coverage provided under

15 this title.

16 ‘‘(b) DEVELOPMENT OF STANDARD PACKAGES.—The

17 Secretary shall develop standard health insurance benefits

18 packages that insurers may offer to individuals receiving

19 benefits under this title. Such packages shall provide cov20 erage for benefits that compliment, but do not duplicate,

21 those covered under this title.

22 ‘‘SEC. 2710. DEFINITIONS.

23 ‘‘As used in this title:

24 ‘‘(1) ACTIVITY OF DAILY LIVING.—The term

25 ‘activity of daily living’ includes:
15

•S 1833 PCS

1 ‘‘(A) BATHING.—Getting water and cleans2 ing the whole body, including turning on the

3 water for a bath, shower, or sponge bath, get4 ting to, in, and out of a tub or shower, and

5 washing and drying oneself;

6 ‘‘(B) DRESSING.—Getting clothes from

7 closets and drawers and then getting dressed,

8 including putting on braces or other devices and

9 fastening buttons, zippers, snaps, or other clo10 sures, selecting appropriate attire, and dressing

11 in the proper order;

12 ‘‘(C) TOILETING.—Going to a bathroom

13 for bowel and bladder function, transferring on

14 and off the toilet, cleaning after elimination,

15 and arranging clothes;

16 ‘‘(D) TRANSFERRING.—Moving in and out

17 of bed and in and out of a chair or wheelchair;

18 or

19 ‘‘(E) EATING.—Transferring food from a

20 plate or its equivalent into the body, including

21 cutting food so as to make possible safe inges22 tion.

23 ‘‘(2) NURSING FACILITY.—The term ‘nursing

24 facility’ means—
16

•S 1833 PCS

1 ‘‘(A) a skilled nursing facility (as defined

2 in section 1819(a) of the Social Security Act);

3 or

4 ‘‘(B) a facility that is a nursing facility (as

5 defined in section 1919(a) of such Act) which

6 meets the requirements of section

7 1819(b)(4)(C) of such Act (relating to nursing

8 care).

9 ‘‘(3) SPELL OF ILLNESS.—The term ‘spell of

10 illness’ means a period of consecutive days beginning

11 with the first day on which an individual is fur12 nished services as an inpatient in a hospital or nurs13 ing facility and ending with the close of the first 6

14 consecutive months thereafter during which the indi15 vidual is no longer an inpatient of a nursing facility,

16 or 90 days after the individual is no longer an inpa17 tient in a hospital.’’.

18 (b) CONFORMING AMENDMENTS.—

19 (1) Sections 2701 through 2714 of the Public

20 Health Service Act (42 U.S.C. 300cc through

21 300cc–15) are redesignated as sections 2801

22 through 2814, respectively.

23 (2) Sections 465(f) and 497 of such Act (42

24 U.S.C. 286(f) and 289(f)) are amended by striking
17

•S 1833 PCS

1 out ‘‘2701’’ each place that such appears and insert2 ing in lieu thereof ‘‘2801’’.

Æ