I

106TH CONGRESS

1ST SESSION H. R. 1998

To amend title XVIII of the Social Security Act to promote the coverage

of frail elderly Medicare beneficiaries permanently residing in nursing

facilities in specialized health insurance programs for the frail elderly.

IN THE HOUSE OF REPRESENTATIVES

MAY 27, 1999

Mr. RAMSTAD (for himself and Mr. CARDIN) 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 promote

the coverage of frail elderly Medicare beneficiaries permanently residing in nursing facilities in specialized

health insurance programs for the frail elderly.

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 ‘‘Medicare’s Elderly Re5 ceiving Innovative Treatments (MERIT) Act of 1999’’.
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1 SEC. 2. MODIFICATION OF PAYMENT RULES.

2 Section 1853 of the Social Security Act (42 U.S.C.

3 1395w–23) is amended—

4 (1) in subsection (a)(1)(A), by striking ‘‘sub5 sections (e) and (f)’’ and inserting ‘‘subsections (e)

6 through (i)’’;

7 (2) in subsection (a)(3)(D), by inserting ‘‘and

8 paragraph (4)’’ after ‘‘section 1859(e)(4)’’; and

9 (3) by adding at the end of subsection (a) the

10 following new paragraph:

11 ‘‘(4) EXEMPTION FROM RISK-ADJUSTMENT SYS12 TEM FOR FRAIL ELDERLY BENEFICIARIES EN13 ROLLED IN SPECIALIZED PROGRAMS FOR THE FRAIL

14 ELDERLY.—

15 ‘‘(A) IN GENERAL.—During the period de16 scribed in subparagraph (B), the risk-adjust17 ment described in paragraph (3) shall not apply

18 to a frail elderly Medicare+Choice beneficiary

19 (as defined in subsection (i)(3)) who is enrolled

20 in a Medicare+Choice plan under a specialized

21 program for the frail elderly (as defined in sub22 section (i)(2)).

23 ‘‘(B) PERIOD OF APPLICATION.—The pe24 riod described in this subparagraph begins with

25 January 2000 and ends with the first month

26 for which the Secretary certifies to Congress
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1 that a comprehensive risk adjustment method2 ology under paragraph (3)(C) (that takes into

3 account the types of factors described in sub4 section (i)(1)) is being fully implemented.’’; and

5 (4) by adding at the end the following new sub6 section:

7 ‘‘(i) SPECIAL RULES FOR FRAIL ELDERLY EN8 ROLLED IN SPECIALIZED PROGRAMS FOR THE FRAIL EL9 DERLY.—

10 ‘‘(1) DEVELOPMENT AND IMPLEMENTATION OF

11 NEW PAYMENT SYSTEM.—The Secretary shall de12 velop and implement (as soon as possible after the

13 date of the enactment of this subsection), during the

14 period described in subsection (a)(4)(B), a payment

15 methodology for frail elderly Medicare+Choice bene16 ficiaries enrolled in a Medicare+Choice plan under

17 a specialized program for the frail elderly (as defined

18 in paragraph (2)(A)). Such methodology shall ac19 count for the prevalence, mix, and severity of chron20 ic conditions among such beneficiaries and shall in21 clude medical diagnostic factors from all provider

22 settings (including hospital and nursing facility set23 tings). It shall include functional indicators of health

24 status and such other factors as may be necessary
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1 to achieve appropriate payments for plans serving

2 such beneficiaries.

3 ‘‘(2) SPECIALIZED PROGRAM FOR THE FRAIL

4 ELDERLY DESCRIBED.—

5 ‘‘(A) IN GENERAL.—For purposes of this

6 part, the term ‘specialized program for the frail

7 elderly’ means a program which the Secretary

8 determines—

9 ‘‘(i) if offered under this part as a

10 distinct part of a Medicare+Choice plan;

11 ‘‘(ii) primarily enrolls frail elderly

12 Medicare+Choice beneficiaries; and

13 ‘‘(iii) has a clinical delivery system

14 that is specifically designed to serve the

15 special needs of such beneficiaries and to

16 coordinate short-term and long-term care

17 for such beneficiaries through the use of a

18 team described in subparagraph (B) and

19 through the provision of primary care serv20 ices to such beneficiaries by means of such

21 a team at the nursing facility involved.

22 ‘‘(B) SPECIALIZED TEAM.—A team de23 scribed in this subparagraph—

24 ‘‘(i) includes—

25 ‘‘(I) a physician, and
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1 ‘‘(II) a nurse practitioner or geri2 atric care manager, or both; and

3 ‘‘(ii) has as members individuals who

4 have special training and specialize in the

5 care and management of the frail elderly

6 beneficiaries.

7 ‘‘(3) FRAIL ELDERLY MEDICARE+CHOICE BEN8 EFICIARY DESCRIBED.—For purposes of this part,

9 the term ‘frail elderly Medicare+Choice beneficiary’

10 means a Medicare+Choice eligible individual who—

11 ‘‘(A) is residing in a skilled nursing facility

12 or a nursing facility (as defined for purposes of

13 title XIX) for an indefinite period and without

14 any intention of residing outside the facility;

15 and

16 ‘‘(B) has a severity of condition that

17 makes the individual frail (as determined under

18 guidelines approved by the Secretary).’’.

19 SEC. 3. CONTINUOUS OPEN ENROLLMENT FOR QUALIFIED

20 INDIVIDUALS.

21 (a) IN GENERAL.—Section 1851(e) of the Social Se22 curity Act (42 U.S.C. 1395w–21(e)) is amended by adding

23 at the end the following new paragraph:

24 ‘‘(7) SPECIAL RULES FOR FRAIL ELDERLY

25 MEDICARE+CHOICE BENEFICIARIES ENROLLING IN
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1 SPECIALIZED PROGRAMS FOR THE FRAIL ELDER2 LY.—There shall be a continuous open enrollment

3 period for any frail elderly Medicare+Choice bene4 ficiary (as defined in section 1853(i)(3)) who is

5 seeking to enroll in a Medicare+Choice plan under

6 a specialized program for the frail elderly (as defined

7 in section 1853(i)(2)).’’.

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

9 subsection (a) takes effect on the date of the enactment

10 of this Act.

11 SEC. 4. DEVELOPMENT OF QUALITY MEASUREMENT PRO12 GRAM.

13 (a) IN GENERAL.—Section 1852(e) of the Social Se14 curity Act (42 U.S.C. 1395w–22(e)) is amended by adding

15 at the end the following new paragraph:

16 ‘‘(5) QUALITY MEASUREMENT PROGRAM FOR

17 SPECIALIZED PROGRAMS FOR THE FRAIL ELDERLY

18 AS PART OF MEDICARE+CHOICE PLANS.—The Sec19 retary shall develop and implement a program to

20 measure the quality of care provided in specialized

21 programs for the frail elderly (as defined in section

22 1853(i)(2)) in order to reflect the unique health as23 pects and needs of frail elderly Medicare+Choice

24 beneficiaries (as defined in section 1853(i)(3)). Such

25 quality measurements may include indicators of the
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1 prevalence of pressure sores, reduction of iatrogenic

2 disease, use of urinary catheters, use of anti-anxiety

3 medications, use of advance directives, incidence of

4 pneumonia, and incidence of congestive heart fail5 ure.’’.

6 (b) EFFECTIVE DATE.—The Secretary of Health and

7 Human Services shall first provide for the implementation

8 of the quality measurement program for specialized pro9 grams for the frail elderly under the amendment made by

10 subsection (a) by not later than July 1, 2000.

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