II

105TH CONGRESS

1ST SESSION S. 147

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 21, 1997

Mr. DASCHLE (for himself, Mr. CHAFEE, Mr. KENNEDY, Mr. JOHNSON, and

Mr. REID) 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 of 1997’’.

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 and particularly by the use of alcohol

4 and drugs during pregnancy;

5 (2) hundreds of thousands of infants each year

6 are born drug-exposed, approximately 12,000 infants

7 are born each year with fetal alcohol syndrome, and

8 thousands more are born each year with fetal alcohol

9 effects, a less severe version of fetal alcohol syn10 drome;

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

12 birthweight, physical deformities, mental retardation,

13 learning disabilities, and heightened nervousness and

14 irritability in newborns;

15 (4) fetal alcohol syndrome is the leading identi16 fiable cause of mental retardation in the United

17 States and the only cause that is 100 percent pre18 ventable;

19 (5) drug-impaired individuals pose extraor20 dinary societal costs in terms of medical, edu21 cational, foster care, residential, and support serv22 ices over the lifetimes of such individuals;

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

24 drug and alcohol treatment programs;
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1 (7) due to fears among service providers con2 cerning the risks pregnancies pose, pregnant women

3 face more obstacles to substance abuse treatment

4 than do other addicts and many substance abuse

5 treatment programs, in fact, exclude pregnant

6 women or women with children;

7 (8) residential alcohol and drug treatment is an

8 important prevention strategy to prevent low

9 birthweight, transmission of AIDS, and chronic

10 physical, mental, and emotional disabilities associ11 ated with prenatal exposure to alcohol and other

12 drugs;

13 (9) effective substance abuse treatment must

14 address the special needs of pregnant women who

15 are alcohol or drug dependent, including substance16 abusing women who may often face such problems

17 as domestic violence, incest and other sexual abuse,

18 poor housing, poverty, unemployment, lack of edu19 cation and job skills, lack of access to health care,

20 emotional problems, chemical dependency in their

21 family backgrounds, single parenthood, and the need

22 to ensure child care for existing children while un23 dergoing substance abuse treatment;

24 (10) nonhospital residential treatment is an im25 portant component of comprehensive and effective
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1 substance abuse treatment for pregnant addicted

2 women, many of whom need long-term, intensive ha3 bilitation outside of their communities to recover

4 from their addiction and take care of themselves and

5 their families; and

6 (11) a gap exists under the medicaid program

7 for the financing of comprehensive residential care

8 in the existing continuum of covered alcoholism and

9 drug abuse treatment services for pregnant medicaid

10 beneficiaries.

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

12 (1) to increase the ability of pregnant women

13 who are substance abusers to participate in alcohol

14 and drug treatment;

15 (2) to ensure the availability of comprehensive

16 and effective treatment programs for pregnant

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

18 healthy children;

19 (3) to ensure that nonhospital residential treat20 ment is available to those low-income pregnant ad21 dicted women who need long-term, intensive habili22 tation to recover from their addiction;

23 (4) to create a new optional medicaid residen24 tial treatment service for alcoholism and drug de25 pendency treatment; and
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1 (5) to define the core services that must be pro2 vided by treatment providers to ensure that needed

3 services will be available and appropriate.

4 SEC. 3. MEDICAID COVERAGE OF ALCOHOLISM AND DRUG

5 DEPENDENCY RESIDENTIAL TREATMENT

6 SERVICES FOR PREGNANT WOMEN, CARE7 TAKER PARENTS, AND THEIR CHILDREN.

8 (a) COVERAGE OF ALCOHOLISM AND DRUG DEPEND9 ENCY RESIDENTIAL TREATMENT SERVICES.—

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

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

12 (A) in subsection (a)—

13 (i) in paragraph (24), by striking

14 ‘‘and’’ at the end;

15 (ii) by redesignating paragraph (25)

16 as paragraph (26); and

17 (iii) by inserting after paragraph (24)

18 the following new paragraph:

19 ‘‘(25) alcoholism and drug dependency residen20 tial treatment services (to the extent allowed and as

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

22 (B) in the sentence following paragraph

23 (26), as so redesignated—

24 (i) in subparagraph (A), by striking

25 ‘‘or’’ at the end;
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1 (ii) in subparagraph (B), by striking

2 the period and inserting ‘‘; or’’; and

3 (iii) by inserting after subdivision (B)

4 the following:

5 ‘‘(C) any such payments with respect to alcohol6 ism and drug dependency residential treatment serv7 ices under paragraph (25) for individuals not de8 scribed in section 1932(d).’’.

9 (2) ALCOHOLISM AND DRUG DEPENDENCY RES10 IDENTIAL TREATMENT SERVICES DEFINED.—Title

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

12 seq.) is amended—

13 (A) by redesignating section 1932 as sec14 tion 1933; and

15 (B) by inserting after section 1931, the

16 following:

17 ‘‘ALCOHOLISM AND DRUG DEPENDENCY RESIDENTIAL

18 TREATMENT SERVICES

19 ‘‘SEC. 1932. (a) ALCOHOLISM AND DRUG DEPEND20 ENCY RESIDENTIAL TREATMENT SERVICES.—The term

21 ‘alcoholism and drug dependency residential treatment

22 services’ means all the required services described in sub23 section (b) which are provided—

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

25 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
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1 Nutrition Act of 1966, services provided by fed2 erally qualified health centers, outpatient pedi3 atric services, well-baby care, and early and

4 periodic screening, diagnostic, and treatment

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

6 ‘‘(I) Ensuring supervision of children dur7 ing times their mother is in therapy or engaged

8 in other necessary health or rehabilitative ac9 tivities, including facilitating access to child

10 care services under title IV and title XX.

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

12 reentry into society, including appropriate out13 patient treatment and counseling after dis14 charge (which may be provided by the same

15 program, if available and appropriate) to assist

16 in preventing relapses, assistance in obtaining

17 suitable affordable housing and employment

18 upon discharge, and referrals to appropriate

19 educational, vocational, and other employment20 related programs (to the extent available).

21 ‘‘(K) Continuing specialized training for

22 staff in the special needs of residents and their

23 children, designed to enable such staff to stay

24 abreast of the latest and most effective treat25 ment techniques.
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1 ‘‘(2) REQUIREMENT FOR CERTAIN SERVICES.—

2 Services under subparagraphs (A), (B), (C), and

3 (D), of paragraph (1) shall be provided in a cultural

4 context that is appropriate to the individuals and in

5 a manner that ensures that the individuals can com6 municate effectively, either directly or through inter7 preters, with persons providing services.

8 ‘‘(3) LIMITATIONS ON COVERAGE.—

9 ‘‘(A) IN GENERAL.—Subject to subpara10 graph (B), services described in paragraph (1)

11 shall be covered in the amount, duration, and

12 scope therapeutically required for each eligible

13 individual in need of such services.

14 ‘‘(B) RESTRICTIONS ON LIMITING COV15 ERAGE.—A State plan shall not limit coverage

16 of alcoholism and drug dependency residential

17 treatment services for any period of less than

18 12 months per individual, except in those in19 stances where a finding is made that such serv20 ices are no longer therapeutically necessary for

21 an individual.

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

23 of this subsection with respect to a facility are as follows:
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1 ‘‘(1) The agency designated by the chief execu2 tive officer of the State to administer the State’s al3 cohol and drug abuse prevention and treatment ac4 tivities and programs has certified to the single

5 State agency under section 1902(a)(5) that the facil6 ity—

7 ‘‘(A) is able to provide all the services de8 scribed in subsection (b) either directly or

9 through arrangements with—

10 ‘‘(i) public and nonprofit private enti11 ties;

12 ‘‘(ii) licensed practitioners or federally

13 qualified health centers with respect to

14 medical services; or

15 ‘‘(iii) the Indian Health Service or

16 with a tribal or Indian organization that

17 has entered into a contract with the Sec18 retary under section 102 of the Indian

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

20 or section 502 of the Indian Health Care

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

22 respect to such services provided to women

23 eligible to receive services in Indian Health

24 Facilities; and
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1 ‘‘(B) except for Indian Health Facilities,

2 meets all applicable State licensure or certifi3 cation requirements for a facility of that type.

4 ‘‘(2)(A) The facility or a distinct part of the fa5 cility provides room and board, except that—

6 ‘‘(i) subject to subparagraph (B), the facil7 ity shall have no more than 40 beds; and

8 ‘‘(ii) subject to subparagraph (C), the fa9 cility shall not be licensed as a hospital.

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

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

12 facilities subject to review by the Secretary. Waivers,

13 where granted, must be made pursuant to standards

14 and procedures set out in the State plan and must

15 require the facility seeking a waiver to demonstrate

16 that—

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

18 therapeutic, family-like environment;

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

20 the delivery of each of the services identified in

21 subsection (b);

22 ‘‘(iii) the size of the facility will be appro23 priate to the surrounding community; and

24 ‘‘(iv) the development of smaller facilities

25 is not feasible in that geographic area.
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1 ‘‘(C) The Secretary may waive the requirement

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

3 hospital, if the Secretary finds that such facility is

4 located in an Indian Health Service area and that

5 such facility is the only or one of the only facilities

6 available in such area to provide services under this

7 section.

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

9 services described in subsection (b) to an individual

10 eligible to receive services in Indian Health Facili11 ties, such a facility demonstrates (as required by the

12 Secretary) an ability to meet the special needs of In13 dian and Native Alaskan women.

14 ‘‘(d) ELIGIBLE INDIVIDUALS.—

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

16 coverage of alcoholism and drug dependency residen17 tial treatment services under section 1905(a)(24) to

18 the following individuals otherwise eligible for medi19 cal assistance under this title:

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

21 the end of the 12th month following the termi22 nation of the pregnancy.

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

24 subparagraph (A).
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1 ‘‘(C) At the option of a State, a caretaker

2 parent or parents and children of such a

3 parent.

4 ‘‘(2) INITIAL ASSESSMENT OF ELIGIBLE INDI5 VIDUALS.—An initial assessment of eligible individ6 uals specified in paragraph (1) seeking alcoholism

7 and drug dependency residential treatment services

8 shall be performed by the agency designated by the

9 chief executive officer of the State to administer the

10 State’s alcohol and drug abuse treatment activities

11 (or its designee). Such assessment shall determine

12 whether such individuals are in need of alcoholism or

13 drug dependency treatment services and, if so, the

14 treatment setting (such as inpatient hospital, non15 hospital residential, or outpatient) that is most ap16 propriate in meeting such individual’s health and

17 therapeutic needs and the needs of such individual’s

18 dependent children, if any.

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

20 ALLOCATION OF BEDS.—

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

22 ASSISTANCE.—

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

24 services provided under this section as medical

25 assistance for which payment may be made
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1 available under section 1903 shall be limited to

2 the total number of beds allowed to be allocated

3 for such services in any given year as specified

4 under subparagraph (B).

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

6 number of beds allowed to be allocated under

7 this subparagraph (subject to paragraph

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

9 section and for which Federal medical assist10 ance may be made available under section 1903

11 is for calendar year—

12 ‘‘(i) 1998, 1,080 beds;

13 ‘‘(ii) 1998, 2,000 beds;

14 ‘‘(iii) 2000, 3,500 beds;

15 ‘‘(iv) 2001, 5,000 beds;

16 ‘‘(v) 2002, 6,000 beds; and

17 ‘‘(vi) 2003 and for calendar years

18 thereafter, a number of beds determined

19 appropriate by the Secretary.

20 ‘‘(2) ALLOCATION OF BEDS.—

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

22 each calendar year, a State exercising the op23 tion to provide the services described in this

24 section shall be allocated from the total number

25 of beds available under paragraph (1)(B)—
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1 ‘‘(i) in calendar years 1998 and 1999,

2 20 beds;

3 ‘‘(ii) in calendar years 2000, 2001,

4 and 2002, 40 beds; and

5 ‘‘(iii) in calendar year 2003 and for

6 each calendar year thereafter, a number of

7 beds determined based on a formula (as

8 provided by the Secretary) distributing

9 beds to States on the basis of the relative

10 percentage of women of childbearing age in

11 a State.

12 ‘‘(B) REALLOCATION OF BEDS.—The Sec13 retary shall provide that in allocating the num14 ber of beds made available to a State for the

15 furnishing of services under this section that, to

16 the extent not all States are exercising the op17 tion of providing services under this section and

18 there are beds available that have not been allo19 cated in a year as provided in paragraph

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

21 among States which are furnishing services

22 under this section based on a formula (as pro23 vided by the Secretary) distributing beds to

24 States on the basis of the relative percentage of

25 women of childbearing age in a State.
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1 ‘‘(C) INDIAN HEALTH SERVICE AREAS.—In

2 addition to the beds allowed to be allocated

3 under paragraph (1)(B) there shall be an addi4 tional 20 beds allocated in any calendar year to

5 States for each Indian Health Service area

6 within the State to be utilized by Indian Health

7 Facilities within such an area and, to the extent

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

9 shall be reapportioned to Indian Health Service

10 areas in other States.’’.

11 (3) MAINTENANCE OF STATE FINANCIAL EF12 FORT AND 100 PERCENT FEDERAL MATCHING FOR

13 SERVICES FOR INDIAN AND NATIVE ALASKAN

14 WOMEN IN INDIAN HEALTH SERVICES AREAS.—Sec15 tion 1903 of the Social Security Act (42 U.S.C.

16 1396b) is amended by adding at the end the follow17 ing new subsections:

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

19 section in a State fiscal year for alcoholism and drug de20 pendency residential treatment services (described in sec21 tion 1932) unless the State provides assurances satisfac22 tory to the Secretary that the State is maintaining State

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

24 than the average annual level maintained by the State for
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1 such services for the 2-year period preceding such fiscal

2 year.

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

4 section, the Federal medical assistance percentage for pur5 poses of payment under this section for services described

6 in section 1932 provided to individuals residing on or re7 ceiving services in an Indian Health Service area shall be

8 100 percent.’’.

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

10 1902(a)(13) of the Social Security Act (42 U.S.C.

11 1396a(a)(13)) is amended—

12 (1) by striking ‘‘and’’ at the end of subpara13 graph (E);

14 (2) by adding ‘‘and’’ at the end of subpara15 graph (F); and

16 (3) by adding at the end the following new sub17 paragraph:

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

19 dependency residential treatment services which

20 the State finds, and makes assurances satisfac21 tory to the Secretary, are reasonable and ade22 quate to meet the costs which must be incurred

23 by efficiently and economically operated facili24 ties in order to provide all the services listed in

25 section 1932(b) in conformity with applicable
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1 Federal and State laws, regulations, and quality

2 and safety standards and to assure that individ3 uals eligible for such services have reasonable

4 access to such services;’’.

5 (c) CONFORMING AMENDMENTS.—

6 (1) CLARIFICATION OF OPTIONAL COVERAGE

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

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

9 is amended, in the matter following subparagraph

10 (F)—

11 (A) by striking ‘‘; and (XIII)’’ and insert12 ing ‘‘, (XIII)’’; and

13 (B) by inserting before the semicolon at

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

15 available of alcoholism and drug dependency

16 residential treatment services to individuals de17 scribed in section 1932(d) shall not, by reason

18 of this paragraph, require the making of such

19 services available to other individuals’’.

20 (2) CONTINUATION OF ELIGIBILITY FOR ALCO21 HOLISM AND DRUG DEPENDENCY TREATMENT FOR

22 PREGNANT WOMEN FOR 12 MONTHS FOLLOWING

23 END OF PREGNANCY.—Section 1902 of the Social

24 Security Act (42 U.S.C. 1396a) is amended in sub25 section (e)(5) by striking ‘‘under the plan,’’ and all
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1 through the period at the end and inserting ‘‘under

2 the plan—

3 ‘‘(A) as though she were pregnant, for all preg4 nancy-related and postpartum medical assistance

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

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

7 of her pregnancy) ends; and

8 ‘‘(B) for alcoholism and drug dependency resi9 dential treatment services under section 1932

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

11 the last day of her pregnancy.’’.

12 (3) REDESIGNATIONS.—Section 1902 of the So13 cial Security Act (42 U.S.C. 1396a) is further

14 amended in subsection (a)(10)(C)(iv), by striking

15 ‘‘(24)’’ and inserting ‘‘(25)’’.

16 (d) ANNUAL EDUCATION AND TRAINING IN INDIAN

17 HEALTH SERVICE AREAS.—The Secretary of Health and

18 Human Services in cooperation with the Indian Health

19 Service shall conduct on at least an annual basis training

20 and education in each of the 12 Indian Health Service

21 areas for tribes, Indian organizations, residential treat22 ment providers, and State health care workers regarding

23 the availability and nature of residential treatment serv24 ices available in such areas under the provisions of this

25 Act.
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1 (e) EFFECTIVE DATE; TRANSITION.—(1) The

2 amendments made by this section apply to alcoholism and

3 drug dependency residential treatment services furnished

4 on or after January 1, 1998, without regard to whether

5 or not final regulations to carry out such amendments

6 have been promulgated by such date.

7 (2) The Secretary of Health and Human Services

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

9 other regulatory action against a State under title XIX

10 of the Social Security Act with regard to alcoholism and

11 drug dependency residential treatment services (as defined

12 in section 1932(a) of such Act) made available under such

13 title on or after January 1, 1998, before the date the Sec14 retary issues final regulations to carry out the amend15 ments made by this section, if the services are provided

16 under its plan in good faith compliance with such amend17 ments.

Æ