I

106TH CONGRESS

1ST SESSION H. R. 1543

To amend title XVIII of the Social Security Act to combat fraud and abuse

under the Medicare Program with respect to partial hospitalization services.

IN THE HOUSE OF REPRESENTATIVES

APRIL 22, 1999

Mr. STARK (for himself, Mrs. THURMAN, Mr. SHAYS, Mr. WEYGAND, Mr.

LEWIS of Georgia, Ms. DEGETTE, Mr. BROWN of Ohio, Mr. CROWLEY,

Mr. CLEMENT, Mr. LAMPSON, Mr. RODRIGUEZ, Mr. GREEN of Texas,

and Mr. PAUL) introduced the following bill; which was referred to the

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

Commerce, 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 combat

fraud and abuse under the Medicare Program with respect to partial hospitalization services.

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 ‘‘Partial Hospitalization

5 Services Integrity Act of 1999’’.
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1 SEC. 2. LIMITATION ON LOCATION OF PROVISION OF SERV2 ICES.

3 (a) IN GENERAL.—Section 1861(ff)(2) of the Social

4 Security Act (42 U.S.C. 1395x(ff)(2)) is amended in the

5 matter following subparagraph (I)—

6 (1) by striking ‘‘and furnished’’ and inserting

7 ‘‘furnished’’; and

8 (2) by inserting before the period the following:

9 ‘‘, and furnished other than in a skilled nursing fa10 cility, residential treatment facility or other residen11 tial setting (as determined by the Secretary)’’.

12 (b) EFFECTIVE DATE.—The amendments made by

13 subsection (a) apply with respect to partial hospitalization

14 services furnished on or after the first day of the third

15 month beginning after the date of the enactment of this

16 Act.

17 SEC. 3. QUALIFICATIONS FOR COMMUNITY MENTAL

18 HEALTH CENTERS.

19 (a) IN GENERAL.—Section 1861(ff)(3)(B) of the So20 cial Security Act (42 U.S.C. 1395x(ff)(3)(B)) is amended

21 by striking ‘‘entity’’ and all that follows and inserting the

22 following: ‘‘entity that—

23 ‘‘(i)(I) provides the mental health services de24 scribed in section 1913(c)(1) of the Public Health

25 Service Act; or
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1 ‘‘(II) in the case of an entity operating in a

2 State that by law precludes the entity from pro3 viding a service described in such section itself, pro4 vides for such service by contract with an approved

5 organization or entity (as determined by the Sec6 retary);

7 ‘‘(ii) meets applicable licensing or certification

8 requirements for community mental health centers

9 in the State in which it is located; and

10 ‘‘(iii) meets such additional conditions as the

11 Secretary shall specify to ensure (I) the health and

12 safety of individuals being furnished such services,

13 (II) the effective and efficient furnishing of such

14 services, and (III) the compliance of such entity with

15 the criteria described in such section.’’.

16 (b) CLARIFICATION OF CRITERIA FOR COMMUNITY

17 MENTAL HEALTH CENTERS.—Section 1913(c)(1)(E) of

18 the Public Health Service Act (42 U.S.C. 300x–

19 3(c)(1)(E)) is amended to read as follows:

20 ‘‘(E) Determining the clinical appropriate21 ness of admissions to any inpatient psychiatric

22 hospitals by engaging a full-time mental health

23 professional who is licensed or certified to make

24 such a determination by the State involved.’’.
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1 (c) EFFECTIVE DATE.—The amendments made by

2 this section apply with respect to community mental

3 health centers furnishing services under the medicare pro4 gram on or after the first day of the third month begin5 ning after the date of the enactment of this Act.

6 SEC. 4. GUIDELINES FOR ITEMS AND SERVICES COM7 PRISING PARTIAL HOSPITALIZATION SERV8 ICES.

9 Not later than 180 days after the date of the enact10 ment of this Act, the Secretary shall first adopt national

11 coverage and administrative policies for partial hos12 pitalization services furnished under title XVIII of the So13 cial Security Act, using a negotiated rulemaking process

14 under subchapter III of chapter 5 of title 5, United States

15 Code.

16 SEC. 5. REFINEMENT OF PERIODICITY OF REVIEW OF PLAN

17 FOR PARTIAL HOSPITALIZATION SERVICES.

18 (a) IN GENERAL.—Section 1835(a)(2)(F)(ii) of the

19 Social Security Act (42 U.S.C. 1395n(a)(2)(F)(ii)) is

20 amended by inserting ‘‘at a reasonable rate (as determined

21 by the Secretary)’’ after ‘‘is reviewed periodically’’.

22 (b) EFFECTIVE DATE.—The amendment made by

23 subsection (a) applies with respect to plans for furnishing

24 partial hospitalization services established on or after the
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1 first day of the third month beginning after the date of

2 the enactment of this Act.

3 SEC. 6. RECERTIFICATION OF PROVIDERS OF PARTIAL

4 HOSPITALIZATION SERVICES.

5 (a) IN GENERAL.—With respect to each community

6 mental health center that furnishes partial hospitalization

7 services for which payment is made under title XVIII of

8 the Social Security Act, the Secretary of Health and

9 Human Services shall provide for periodic recertification

10 to ensure that the provision of such services complies with

11 applicable requirements of such title.

12 (b) DEADLINE FOR FIRST RECERTIFICATION.—The

13 first recertification under subsection (a) shall be com14 pleted not later than one year after the date of the enact15 ment of this Act.

16 SEC. 7. CIVIL MONETARY PENALTIES FOR FALSE CERTIFI17 CATION OF ELIGIBILITY FOR HOSPICE CARE

18 OR PARTIAL HOSPITALIZATION SERVICES.

19 (a) IN GENERAL.—Section 1128A(b)(3) of the Social

20 Security Act (42 U.S.C. 1320a–7a(b)(3)) is amended—

21 (1) in subparagraph (A)(ii), by inserting ‘‘, hos22 pice care, or partial hospitalization services’’ after

23 ‘‘home health services’’; and

24 (2) in subparagraph (B), by inserting ‘‘, section

25 1814(a)(7) in the case of hospice care, or section
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1 1835(a)(2)(F) in the case of partial hospitalization

2 services’’ after ‘‘in the case of home health services’’.

3 (b) EFFECTIVE DATE.—The amendments made by

4 subsection (a) apply with respect to certifications of eligi5 bility for hospice care or partial hospitalization services

6 under the medicare program made on or after the first

7 day of the third month beginning after the date of the

8 enactment of this Act.

9 SEC. 8. DEMONSTRATION FOR COST EFFECTIVE WRAP

10 AROUND MENTAL HEALTH SERVICES.

11 (a) ESTABLISHMENT.—

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

13 Human Services shall implement a demonstration

14 project (in this section referred to as the ‘‘project’’)

15 under part B of title XVIII of the Social Security

16 Act under which community mental health centers

17 may offer wrap around mental health services (as

18 defined in paragraph (2)(A)) for purposes of pro19 viding for a full continuum of ambulatory behavioral

20 health care services.

21 (2) DEFINITIONS.—

22 (A) WRAP AROUND MENTAL HEALTH

23 SERVICES DEFINED.—The term ‘‘wrap around

24 mental health services’’ means comprehensive

25 outpatient mental health services furnished to
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1 an individual pursuant to an individualized

2 treatment plan developed by a mental health

3 professional, in consultation with the family of

4 the individual (if available). Such services are

5 furnished to the individual through a com6 prehensive, multidisciplinary health and social

7 services delivery system that provides coordi8 nated therapeutic interventions, including med9 ical services, psychotherapy services, occupa10 tional therapy services, and social work services.

11 (B) LICENSED MENTAL HEALTH PROFES12 SIONAL.—The term ‘‘mental health profes13 sional’’ means any of the following individuals

14 who are licensed by the State in which the indi15 vidual furnishes services (as that term is de16 fined in paragraphs (1), (2)(M), and (2)(N) of

17 section 1861(s) of the Social Security Act (42

18 U.S.C. 1395x(s))) to design and execute treat19 ment plans described in subparagraph (A) with20 out the supervision of another health care prac21 titioner:

22 (i) A physician, as defined in section

23 1861(r)(1) of such Act (42 U.S.C.

24 1395x(r)(1)).
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1 (ii) A clinical psychologist, as defined

2 by the Secretary pursuant to section

3 1861(ii) of such Act (42 U.S.C. 1395x(ii)).

4 (iii) A clinical social worker, as de5 fined in section 1861(hh) of such Act (42

6 U.S.C. 1395x(hh)).

7 (b) SELECTION OF CENTERS.—For purposes of im8 plementing such project, the Secretary shall select for par9 ticipation in the project community mental health centers

10 that serve populations in three different States, one of

11 which predominantly serves rural populations.

12 (c) CAPITATED PAYMENT.—The Secretary shall es13 tablish and make prospective monthly payments of a capi14 tation amount for individuals receiving wrap around men15 tal health services under this project.

16 (d) EVALUATION AND REPORT.—

17 (1) EVALUATION.—The Secretary shall evaluate

18 the project. Such evaluation shall include an exam19 ination of—

20 (A) the project’s effect on the health, well21 being, condition, and functional level of bene22 ficiaries receiving wrap around mental health

23 services;

24 (B) any savings to the medicare program

25 by reason of capitated payments for wrap
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1 around medical services consisting of partial

2 hospitalization services (as that term is defined

3 in section 1861(ff) of the Social Security Act

4 (42 U.S.C. 1395x(ff));

5 (C) the impact of basing payment for such

6 services on a capitated basis; and

7 (D) the project’s effect on utilization of in8 patient services (including inpatient mental

9 health services) and associated costs.

10 (2) REPORT.—Not later than four years after

11 the date of the enactment of this Act, the Secretary

12 shall submit to Congress a report containing a state13 ment of the findings and conclusions of the Sec14 retary pursuant to the evaluation conducted under

15 paragraph (1), together with any recommendations

16 for legislation the Secretary considers appropriate

17 with respect to—

18 (A) the provision of additional mental

19 health services by community mental health

20 centers under partial hospitalization services;

21 and

22 (B) payment for such services on a

23 capitated basis.

24 (e) DURATION.—The project shall be conducted for

25 a three year period.
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1 (f) FUNDING.—The Secretary shall provide for the

2 transfer from the Federal Hospital Insurance Trust Fund,

3 established under section 1817 of the Social Security Act

4 (42 U.S.C. 1395i), of such funds as are necessary for the

5 costs of carrying out the demonstration project under this

6 section.

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