I

106TH CONGRESS

1ST SESSION H. R. 131

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

of expanded nursing facility and in-home services for dependent individuals under the Medicare Program.

IN THE HOUSE OF REPRESENTATIVES

JANUARY 6, 1999

Mr. ENGEL introduced the following bill; which was referred to the Committee

on the Commerce, and in addition to the Committee on Ways and Means,

for a period to be subsequently determined by the Speaker, in each case

for consideration of such provisions as fall within the jurisdiction of the

committee concerned

A BILL

To amend title XVIII of the Social Security Act to provide

for coverage of expanded nursing facility and in-home

services for dependent individuals under the Medicare

Program.

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 ‘‘Comprehensive Long5 Term Care Act of 1999’’.
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1 SEC. 2. EXPANDED LONG-TERM CARE SERVICES UNDER

2 MEDICARE PROGRAM FOR DEPENDENT INDI3 VIDUALS.

4 (a) IN GENERAL.—

5 (1) PART A.—Section 1812 of the Social Secu6 rity Act (42 U.S.C. 1395d) is amended—

7 (A) in subsection (a)—

8 (i) in paragraph (2)(B), by striking

9 ‘‘subsection (f),’’ and inserting ‘‘subsection

10 (f) and section 1889,’’,

11 (ii) by striking ‘‘and’’ at the end of

12 paragraph (3),

13 (iii) by striking the period at the end

14 of paragraph (4) and inserting ‘‘; and’’,

15 and

16 (iv) by adding at the end the following

17 new paragraph:

18 ‘‘(5) long-term care services consisting of ex19 tended care services (in accordance with section

20 1889).’’; and

21 (B) in subsection (b)(2), by striking ‘‘post22 hospital’’ and inserting ‘‘except as provided in

23 section 1889, post-hospital’’.

24 (2) PART B.—Section 1861(s)(2) of such Act

25 (42 U.S.C. 1395x(s)(2)) is amended—
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1 (A) in subparagraph (S), by striking

2 ‘‘and’’ at the end;

3 (B) in subparagraph (T), by striking the

4 period at the end and inserting ‘‘; and’’; and

5 (C) by inserting after subparagraph (T)

6 the following new subparagraph:

7 ‘‘(U) long-term care services consisting of in8 home care (in accordance with section 1889);’’.

9 (b) DESCRIPTION OF SERVICES; ELIGIBILITY.—Title

10 XVIII of such Act is amended by inserting after section

11 1888 the following new section:

12 ‘‘LONG-TERM CARE SERVICES FOR DEPENDENT

13 INDIVIDUALS

14 ‘‘SEC. 1889. (a) IN GENERAL.—An individual enti15 tled to benefits under this part shall be entitled to have

16 payments made on the individual’s behalf for long-term

17 care services if—

18 ‘‘(1) the individual is a dependent individual;

19 and

20 ‘‘(2) such services are provided in accordance

21 with a case management plan developed by a case

22 management agency.

23 ‘‘(b) SERVICES PROVIDED.—In this section, the term

24 ‘long-term care services’ means—

25 ‘‘(1) in-home care (as defined in subsection (e));

26 and
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1 ‘‘(2) extended care services (as defined in sec2 tion 1861(h)), but only with respect to a chronically

3 dependent individual.

4 ‘‘(c) PAYMENT FOR SERVICES.—

5 ‘‘(1) IN GENERAL.—Subject to paragraph (2),

6 the amount payable for long-term care services

7 under this section shall be determined in accordance

8 with a fee schedule for such services established by

9 the Secretary.

10 ‘‘(2) IMPOSITION OF DEDUCTIBLE.—The

11 amount otherwise payable for long-term care services

12 under this section furnished during a calendar year

13 shall be reduced by an amount equal to the deduct14 ible imposed for inpatient hospital services for the

15 year under section 1813(a)(1).

16 ‘‘(d) DEPENDENT INDIVIDUAL DEFINED.—

17 ‘‘(1) IN GENERAL.—In this section, the term

18 ‘dependent individual’ means an individual who—

19 ‘‘(A) is unable to perform (without sub20 stantial assistance from another individual) be21 cause of physical or cognitive impairment at

22 least 2 of the following activities of daily living:

23 bathing, dressing, toileting, transferring, and

24 eating; or
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1 ‘‘(B) has a similar level of disability due to

2 cognitive impairment that requires substantial

3 direction, instruction, or supervision of another

4 individual in order—

5 ‘‘(i) to perform 2 or more of the ac6 tivities of daily living described in subpara7 graph (A), or

8 ‘‘(ii) to remain in the community

9 without causing harm to self or others be10 cause of inappropriate behavioral patterns.

11 ‘‘(2) CHRONICALLY DEPENDENT INDIVIDUAL.—

12 In this section, the term ‘chronically dependent indi13 vidual’ means an individual described in paragraph

14 (1) who—

15 ‘‘(A) for purposes of subparagraph (A) of

16 such paragraph, is unable to perform at least 3

17 of the activities of daily living described in such

18 subparagraph; or

19 ‘‘(B) for purposes of subparagraph (B)(i)

20 of such paragraph, has a level of disability that

21 requires direction, instruction, or supervision of

22 another individual to perform 3 or more of such

23 activities of daily living.
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1 ‘‘(3) ACTIVITIES OF DAILY LIVING DEFINED.—

2 The ‘activities of daily living’ referred to in this sub3 section are as follows:

4 ‘‘(A) Eating.

5 ‘‘(B) Bathing.

6 ‘‘(C) Dressing.

7 ‘‘(D) Toileting.

8 ‘‘(E) Transferring in and out of a bed or

9 in and out of a chair.

10 ‘‘(e) IN-HOME CARE.—

11 ‘‘(1) IN GENERAL.—For purposes of this sec12 tion, the term ‘in-home care’ means the items and

13 services described in paragraph (2) furnished to an

14 individual by a home care agency (as defined in sec15 tion 1861(uu)) or by others under arrangements

16 with them made by the agency provided in a place

17 of residence used as such individual’s home (other

18 than services described in paragraph (2)(H)).

19 ‘‘(2) SERVICES DESCRIBED.—The items and

20 services described in this paragraph are as follows:

21 ‘‘(A) Nursing care provided by or under

22 the supervision of a registered professional

23 nurse.

24 ‘‘(B) Services of a homemaker/home health

25 aide who has successfully completed a training
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1 and competency evaluation program approved

2 by the Secretary.

3 ‘‘(C) Personal care services.

4 ‘‘(D) Medical social services.

5 ‘‘(E) Physical, occupational, or respiratory

6 therapy or speech-language pathology.

7 ‘‘(F) Medical supplies (other than drugs

8 and biologicals) and durable medical equipment,

9 while under such a plan.

10 ‘‘(G) Patient and caregiver (including fam11 ily caregiver) education and training to develop

12 skills necessary to permit the individual to re13 main in the home setting.

14 ‘‘(H) Community care services furnished

15 outside of the place of residence.

16 ‘‘(I) Such other home-based items and

17 services (other than room and board) as the

18 Secretary may approve.

19 ‘‘(f) CASE MANAGEMENT REQUIREMENTS.—

20 ‘‘(1) REQUESTS FOR ASSESSMENT.—Each indi21 vidual entitled to benefits under this title (or an22 other person on such individual’s behalf) may re23 quest a case management agency to conduct an as24 sessment under this section to determine whether
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1 the individual is a dependent individual or a chron2 ically dependent individual.

3 ‘‘(2) DESCRIPTION OF PLANS.—For purposes of

4 this section, a ‘case management plan’ means, with

5 respect to an individual, a written plan of care

6 which—

7 ‘‘(A) is established and periodically re8 viewed and revised by a case management agen9 cy; and

10 ‘‘(B) reflects the individual’s needs identi11 fied in the assessment under paragraph (1).

12 ‘‘(3) CASE MANAGEMENT AGENCY DEFINED.—

13 In this section, the term ‘case management agency’

14 means a nonprofit or public agency or organization

15 (or a nonprofit or public subdivision of such an

16 agency or organization) certified by the Secretary to

17 conduct assessments and establish case management

18 plans under this subsection which—

19 ‘‘(A) is experienced in conducting assess20 ments, in establishing and periodically reviewing

21 and revising case management plans for nurs22 ing facility services and in-home care, and in

23 coordinating and reviewing the quality of the

24 provision of such services and care;
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1 ‘‘(B) is capable of efficiently and effectively

2 performing directly or through contracts under

3 paragraph (4) such duties; and

4 ‘‘(C) does not provide nursing facility serv5 ices or in-home care and does not have a direct

6 or indirect ownership or control interest in, or

7 direct or indirect affiliation or relationship with,

8 an entity that provides, such services or care.

9 ‘‘(4) CONTRACTING OUT CERTAIN FUNC10 TIONS.—The Secretary shall permit a case manage11 ment agency, to the extent necessary to carry out

12 functions under this section, to provide for assess13 ments and case management plans through con14 tracts with nonprofit or public organizations which

15 do not provide nursing facility services or in-home

16 care and do not have a direct or indirect ownership

17 or control interest in, or direct or indirect affiliation

18 or relationship with, an entity that provides, such

19 services or care.’’.

20 (c) CONFORMING AMENDMENTS.—(1) Section

21 1833(a)(1) of such Act (42 U.S.C. 1395l(a)(1)) is

22 amended—

23 (A) by striking ‘‘and (P)’’ and inserting ‘‘(P)’’;

24 and
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1 (B) by striking the semicolon at the end and in2 serting the following: ‘‘, and (Q) with respect to ex3 penses incurred for services described in section

4 1861(s)(2)(P), the amounts paid shall be the

5 amounts determined under section 1889(c);’’.

6 (2) Section 1861 of such Act (42 U.S.C. 1395x) is

7 amended by adding at the end the following new sub8 section:

9 ‘‘HOME CARE AGENCY

10 ‘‘(uu) The term ‘home care agency’ means a public

11 agency or private organization, or a subdivision of such

12 an agency or organization, which is a home health agency

13 (as defined in subsection (o)) or—

14 ‘‘(1) is primarily engaged in providing services

15 of homemaker/home health aides and personal care

16 aides;

17 ‘‘(2) maintains clinical records on all patients;

18 ‘‘(3) in the case of an agency or organization in

19 any State in which State or applicable local law pro20 vides for the licensing of agencies or organizations of

21 this nature—

22 ‘‘(A) is licensed pursuant to such law, or

23 ‘‘(B) is approved, by the agency of such

24 State or locality, responsible for licensing agen25 cies or organizations of this nature, as meeting
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1 the standards established for such licensing;

2 and

3 ‘‘(4) meets such other requirements as the Sec4 retary may find necessary in the interest of the

5 health and safety of individuals who are furnished

6 services by such agency or organization and for the

7 effective and efficient operation of the program.’’.

8 (d) EFFECTIVE DATE.—The amendments made by

9 this section shall apply to items and services furnished on

10 or after January 1, 2000.

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