II

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

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’’.

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

6 NURSING HOME CARE.

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

8 (42 U.S.C. 201 et seq.) is amended—

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

10 300cc et seq.) as title XXVIII; and
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1 (2) by inserting after title XXVI the following

2 new title:

3 ‘‘TITLE XXVII—LIFE CARE: PUB4 LIC INSURANCE PROGRAM

5 FOR NURSING HOME CARE

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

7 CARE INSURANCE PROGRAM.

8 ‘‘The Secretary shall establish a voluntary insurance

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

10 the nursing home stays of such individuals.

11 ‘‘SEC. 2702. BENEFITS.

12 ‘‘(a) IN GENERAL.—Subject to subsection (c), an in13 dividual who meets the eligibility criteria prescribed in sec14 tion 2703 shall be eligible under the program established

15 under this title for coverage for necessary services de16 scribed in subsection (b) (in the amounts described in sub17 section (c)) that are provided to the individual by a nurs18 ing facility while the individual is an inpatient of the facil19 ity.

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

21 title for—

22 ‘‘(1) nursing care provided by or under the su23 pervision of a registered professional nurse;
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1 ‘‘(2) physical, occupational, or speech therapy

2 furnished by a facility or by others under arrange3 ments with a facility;

4 ‘‘(3) medical social services;

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

6 equipment for use in the facility, that is ordinarily

7 furnished by the facility for the care and treatment

8 of an inpatient;

9 ‘‘(5) medical service of an intern or resident-in10 training under an approved teaching program of a

11 hospital with which a facility has in effect a transfer

12 agreement or other diagnostic or therapeutic service

13 provided by a hospital with which a facility has in

14 effect a transfer agreement; and

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

16 health of a patient as are generally provided by a

17 nursing home facility.

18 ‘‘(c) COVERAGE AMOUNT.—

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

20 provided with respect to an eligible individual for the

21 services described in subsection (b) shall, based on

22 an election made by the individual, not exceed

23 $30,000, $60,000, or $90,000 over the lifetime of

24 the eligible individual. Such amounts shall be ad-
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1 justed by the Secretary to reflect increases in the

2 Consumer Price Index.

3 ‘‘(2) ASSET PROTECTION.—An eligible individ4 ual shall be entitled to the asset protection provided

5 under section 2708.

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

7 with respect to an eligible individual for the services de8 scribed in subsection (b) shall be paid from the general

9 fund of the Treasury of the United States.

10 ‘‘SEC. 2703. ELIGIBILITY.

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

12 benefits under this title if—

13 ‘‘(1) the individual—

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

15 States and has elected coverage under sub16 section (c);

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

18 Agency through a screening process (conducted

19 in accordance with section 2707)—

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

21 assistance, supervision, or cueing (as de22 fined in regulations) to perform three or

23 more activities of daily living;

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

25 assistance, supervision, or cueing with at
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1 least such instrumental activity (or activi2 ties) of daily living related to cognitive or

3 mental impairment as the Secretary speci4 fies; or

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

6 more serious behavioral problems (that is

7 on a list of such problems specified by the

8 Secretary) which create a need for super9 vision to prevent harm to self or others;

10 and

11 ‘‘(ii) to require such assistance, super12 vision, or cueing over a period of at least

13 100 days; and

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

15 mental status protocol (or protocols) appro16 priate for measuring the individual’s particular

17 condition specified by the Secretary, that indi18 cates either severe cognitive impairment or se19 vere mental impairment, or both.

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

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

22 under this title;

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

24 filed an application on behalf of an individual who

25 is in need of benefits covered under this title; or
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1 ‘‘(C) the representative of an individual who is

2 cognitively impaired and who is in need of benefits

3 covered under this title has filed an application on

4 behalf of the individual; and

5 ‘‘(3) receiving nursing home services in a nurs6 ing facility would be in the best interest of the indi7 vidual.

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

9 in a hospital or nursing home on the date of the enroll10 ment of the individual in the program established under

11 this title shall be ineligible for coverage under this section

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

13 such date.

14 ‘‘(c) ELECTION OF COVERAGE.—

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

16 an individual shall have the option to purchase cov17 erage under this title when the individual is 35 years

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

19 of age.

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

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

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

23 eligible to purchase insurance under this title, except

24 that such an individual shall not be eligible to pur25 chase such insurance—
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1 ‘‘(A) while confined to a hospital or nurs2 ing home;

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

4 individuals confinement in a nursing home; or

5 ‘‘(C) within the 90-day period after the in6 dividuals confinement in a hospital.

7 Individuals described in the matter preceding sub8 paragraph (A) shall become eligible to receive bene9 fits under this title on the expiration of the 3-year

10 period beginning on the date such individuals pur11 chase insurance under this title.

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

13 individual is confined to a nursing home or hospital

14 during a period that extends beyond the first year

15 after the effective date of this title, an individual

16 shall be eligible to enroll in the program established

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

18 the individual’s spell of illness.

19 ‘‘(4) SUBSEQUENT YEARS.—During years sub20 sequent to the 1-year period referred to in para21 graph (2), an individual shall be eligible to purchase

22 insurance under this title within 6 months of the

23 45th, 55th or 65th birthday of the individual.

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

25 coverage under the insurance program established by
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1 this title, an individual shall have purchased such

2 coverage not later than 1 month prior to admission

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

4 of services is a result of an accident or stroke subse5 quent to the date that such individual enrolled for

6 coverage under this title.

7 ‘‘SEC. 2704. PREMIUM RATES.

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

9 one premium rate for individuals electing to purchase cov10 erage under this title at age 45 (or between the ages of

11 45 and 54 during the initial enrollment period), a separate

12 rate for those individuals who elect such coverage at age

13 55 (or between that ages of 55 and 64 during the initial

14 enrollment period), and a separate rate for those individ15 uals who elect such coverage at age 65 (or at age 65 and

16 over during the initial enrollment period).

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

18 rates annually to increase such rates to reflect the amount

19 of the increase in the cost of living adjustment with re20 spect to benefits under title II of the Social Security Act.

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

22 program established under this title, the Secretary shall

23 establish rates that are expected to cover 100 percent of

24 the estimated costs of nursing home stays for those indi25 viduals enrolled in the program.
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1 ‘‘(d) WAIVER.—An individual electing to purchase

2 coverage under this title shall not be required to pay pre3 miums during any period in which such individual is re4 ceiving benefits under this title.

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

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

7 States.

8 ‘‘SEC. 2705. QUALIFIED SERVICE PROVIDERS.

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

10 nursing home service under this title, such service must

11 have been provided by a qualified service provider.

12 ‘‘(b) TYPES.—A provider shall be considered a quali13 fied service provider under this title if the provider is a

14 nursing facility that is certified by the State and meets

15 the requirements of this title and any other standards es16 tablished by the Secretary by regulation for the safe and

17 efficient provision of services covered under this title.

18 ‘‘SEC. 2706. REIMBURSEMENT.

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

20 facility services under this title shall equal 65 percent of

21 the amount the Secretary determines to be reasonable and

22 appropriate to cover the cost of care provided under this

23 title, taking into account the average cost of providing ap24 propriate care in the most efficient manner.
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1 ‘‘(b) PROSPECTIVE PAYMENT.—To the extent fea2 sible, the Secretary shall establish a prospective payment

3 mechanism for payment for nursing home services under

4 this title that takes into account the expected resource uti5 lization of individual patients based on their degree of dis6 ability and other factors determining service requirements.

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

8 receiving benefits under this program shall be responsible

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

10 is equal to—

11 ‘‘(1) with respect to the initial 6 months of con12 finement to a nursing facility, 20 percent of the av13 erage per diem rate paid by the Secretary to nursing

14 facilities receiving reimbursement under this title;

15 and

16 ‘‘(2) with respect to subsequent periods of con17 finement, 35 percent of the average per diem rate

18 paid by the Secretary to nursing facilities receiving

19 reimbursement under this title.

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

21 provision of this title, reimbursement for nursing facility

22 services provided under this title to an individual shall,

23 to the extent available, be made under the Medicare pro24 gram, under Department of Veterans Affairs’ programs,
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1 or under private insurance policies prior to reimbursement

2 under this title.

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

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

5 with entities to act as Long-Term Care Screening Agen6 cies (hereafter referred to in this title as the ‘Screening

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

8 the responsibility of such agency to assess the eligibility

9 of individuals residing in the geographic jurisdiction of the

10 Agency, for services provided under this title according to

11 the requirements of this title and regulations prescribed

12 by the Secretary. In entering into such contracts, the Sec13 retary shall give preference to State governmental entities.

14 ‘‘(b) ELIGIBILITY.—The Screening Agency shall de15 termine the eligibility of an individual under this title

16 based on the results of a preliminary telephone interview

17 or written questionnaire (completed by the applicant, by

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

19 or representative of the applicant) that shall be validated

20 through the use of a screening tool administered in person

21 to each applicant determined eligible through initial tele22 phone or written questionnaire interviews not later than

23 15 days from the date on which such individual initially

24 applied for services under this title.

25 ‘‘(c) QUESTIONNAIRES AND SCREENING TOOLS.—
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1 ‘‘(1) IN GENERAL.—The Secretary shall estab2 lish a telephone or written questionnaire and a

3 screening tool to be used by the Screening Agency

4 to determine the eligibility of an individual for serv5 ices under this title consistent with requirements of

6 this title and the standards established by the Sec7 retary by regulation.

8 ‘‘(2) QUESTIONNAIRES.—The questionnaire

9 shall include questions about the functional impair10 ment, mental status, and living arrangement of an

11 individual and other criteria that the Secretary shall

12 prescribe by regulation.

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

14 should measure functional impairment caused by

15 physical or cognitive conditions as well as informa16 tion concerning cognition disability, behavioral prob17 lems (such as wandering or abusive and aggressive

18 behavior), the living arrangement of an individual,

19 availability of caregivers, and any other criteria that

20 the Secretary shall prescribe by regulation. The

21 screening tool shall be administered in person.

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

23 the date on which an individual initially applied for serv24 ices under this title (by telephone or written question25 naire), the Screening Agency shall notify such individual
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1 that such individual is not eligible for benefits, or that

2 such individuals must schedule an in-person screening to

3 determine final eligibility for benefits under this title. The

4 Screening Agency shall notify such individual of its final

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

6 screening.

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

8 legal guardian or representative of such individual) whose

9 application for benefits under this title is denied on the

10 basis of information provided through a telephone or writ11 ten questionnaire, shall be notified of such individual’s

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

13 health care professionals.

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

15 mechanism for hearings and appeals in cases in which in16 dividuals contest the eligibility findings of the Screening

17 Agency.

18 ‘‘SEC. 2708. RELATION TO TITLE XIX OF THE SOCIAL SECU19 RITY ACT; ASSET PROTECTION.

20 ‘‘Notwithstanding any other provision of law, the as21 sets an eligible individual may retain and continue to be

22 determined eligible for nursing facility benefits under

23 State Medicaid programs (in accordance with section

24 1902(a)(10)) shall be increased by the amount of coverage
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1 ($30,000, $60,000, or $90,000) elected under section

2 2702.

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

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

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

6 to an individual covered under this title if the coverage

7 under such policy duplicates the coverage provided under

8 this title.

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

10 Secretary shall develop standard health insurance benefits

11 packages that insurers may offer to individuals receiving

12 benefits under this title. Such packages shall provide cov13 erage for benefits that compliment, but do not duplicate,

14 those covered under this title.

15 ‘‘SEC. 2710. DEFINITIONS.

16 ‘‘As used in this title:

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

18 ‘activity of daily living’ includes:

19 ‘‘(A) BATHING.—Getting water and cleans20 ing the whole body, including turning on the

21 water for a bath, shower, or sponge bath, get22 ting to, in, and out of a tub or shower, and

23 washing and drying oneself;

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

25 closets and drawers and then getting dressed,
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1 including putting on braces or other devices and

2 fastening buttons, zippers, snaps, or other clo3 sures, selecting appropriate attire, and dressing

4 in the proper order;

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

6 for bowel and bladder function, transferring on

7 and off the toilet, cleaning after elimination,

8 and arranging clothes;

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

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

11 or

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

13 plate or its equivalent into the body, including

14 cutting food so as to make possible safe inges15 tion.

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

17 facility’ means—

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

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

20 or

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

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

23 meets the requirements of section

24 1819(b)(4)(C) of such Act (relating to nursing

25 care).
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1 ‘‘(3) SPELL OF ILLNESS.—The term ‘spell of

2 illness’ means a period of consecutive days beginning

3 with the first day on which an individual is fur4 nished services as an inpatient in a hospital or nurs5 ing facility and ending with the close of the first 6

6 consecutive months thereafter during which the indi7 vidual is no longer an inpatient of a nursing facility,

8 or 90 days after the individual is no longer an inpa9 tient in a hospital.’’.

10 (b) CONFORMING AMENDMENTS.—

11 (1) Sections 2701 through 2714 of the Public

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

13 300cc–15) are redesignated as sections 2801

14 through 2814, respectively.

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

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

17 out ‘‘2701’’ each place that such appears and insert18 ing in lieu thereof ‘‘2801’’.

Æ