II

106TH CONGRESS

1ST SESSION S. 1459

To amend title XVIII of the Social Security Act to protect the right of

a medicare beneficiary enrolled in a Medicare+Choice plan to receive

services at a skilled nursing facility selected by that individual.

IN THE SENATE OF THE UNITED STATES

JULY 29, 1999

Mr. MACK (for himself, Mrs. FEINSTEIN, Mr. HELMS, and Mr. ROBB) introduced the following bill; which was read twice and referred to the Committee on Finance

A BILL

To amend title XVIII of the Social Security Act to protect

the right of a medicare beneficiary enrolled in a

Medicare+Choice plan to receive services at a skilled

nursing facility selected by that individual.

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 Return To

5 Home Act of 1999’’.
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1 SEC. 2. ENSURING CHOICE FOR SKILLED NURSING FACIL2 ITY SERVICES UNDER THE

3 MEDICARE+CHOICE PROGRAM.

4 (a) IN GENERAL.—Section 1852 of the Social Secu5 rity Act (42 U.S.C. 1395w–22) is amended by adding at

6 the end the following:

7 ‘‘(l) ENSURING CHOICE OF SKILLED NURSING FA8 CILITY SERVICES.—

9 ‘‘(1) COVERAGE OF SERVICES PROVIDED AT A

10 SNF LOCATED IN ENROLLEE’S CONTINUING CARE

11 RETIREMENT COMMUNITY OR AT A SNF IN WHICH

12 ENROLLEE PREVIOUSLY RESIDED.—Subject to para13 graph (2), a Medicare+Choice organization may not

14 deny coverage for any service provided to an enrollee

15 of a Medicare+Choice plan (offered by such organi16 zation) by—

17 ‘‘(A) a skilled nursing facility located with18 in the continuing care retirement community in

19 which the enrollee resided prior to being admit20 ted to a hospital; or

21 ‘‘(B) a skilled nursing facility in which the

22 enrollee resided immediately prior to being ad23 mitted to a hospital.

24 The requirement described in the preceding sentence

25 shall apply whether or not the Medicare+Choice or-
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1 ganization has a contract with such skilled nursing

2 facility to provide such services.

3 ‘‘(2) REQUIRED FACTORS.—Paragraph (1) shall

4 not apply unless the following factors exist:

5 ‘‘(A) The Medicare+Choice organization

6 would be required to provide reimbursement for

7 the service under the Medicare+Choice plan in

8 which the individual is enrolled if the skilled

9 nursing facility was under contract with the

10 Medicare+Choice organization.

11 ‘‘(B) The individual—

12 ‘‘(i) had a contractual or other right

13 to return, after hospitalization, to the con14 tinuing care retirement community de15 scribed in paragraph (1)(A) or the skilled

16 nursing facility described in paragraph

17 (1)(B); and

18 ‘‘(ii) elects to receive services from the

19 skilled nursing facility after the hos20 pitalization, whether or not, in the case of

21 a skilled nursing facility described in para22 graph (1)(A), the individual resided in

23 such facility before entering the hospital.
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1 ‘‘(C) The skilled nursing facility has the

2 capacity to provide the services the individual

3 requires.

4 ‘‘(D) The skilled nursing facility agrees to

5 accept substantially similar payment under the

6 same terms and conditions that apply to simi7 larly situated skilled nursing facilities that are

8 under contract with the Medicare+Choice orga9 nization.

10 ‘‘(3) COVERAGE OF SNF SERVICES TO PREVENT

11 HOSPITALIZATION.—A Medicare+Choice organiza12 tion may not deny payment for services provided to

13 an enrollee of a Medicare+Choice plan (offered by

14 such organization) by a skilled nursing facility in

15 which the enrollee resides, without a preceding hos16 pital stay, regardless of whether the

17 Medicare+Choice organization has a contract with

18 such facility to provide such services, if—

19 ‘‘(A) the Medicare+Choice organization

20 has determined that the service is necessary to

21 prevent the hospitalization of the enrollee; and

22 ‘‘(B) the factors specified in subpara23 graphs (A), (C), and (D) of paragraph (2)

24 exist.
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1 ‘‘(4) COVERAGE OF SERVICES PROVIDED IN SNF

2 WHERE SPOUSE RESIDES.—A Medicare+Choice or3 ganization may not deny payment for services pro4 vided to an enrollee of a Medicare+Choice plan (of5 fered by such organization) by a skilled nursing fa6 cility in which the enrollee resides, regardless of

7 whether the Medicare+Choice organization has a

8 contract with such facility to provide such services,

9 if the spouse of the enrollee is a resident of such fa10 cility and the factors specified in subparagraphs (A),

11 (C), and (D) of paragraph (2) exist.

12 ‘‘(5) SKILLED NURSING FACILITY MUST MEET

13 MEDICARE PARTICIPATION REQUIREMENTS.—This

14 subsection shall not apply unless the skilled nursing

15 facility involved meets all applicable participation re16 quirements under this title.

17 ‘‘(6) PROHIBITIONS.—A Medicare+Choice or18 ganization offering a Medicare+Choice plan may

19 not—

20 ‘‘(A) deny to an individual eligibility, or

21 continued eligibility, to enroll or to renew cov22 erage under such plan, solely for the purpose of

23 avoiding the requirements of this subsection;

24 ‘‘(B) provide monetary payments or re25 bates to enrollees to encourage such enrollees to
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1 accept less than the minimum protections avail2 able under this subsection;

3 ‘‘(C) penalize or otherwise reduce or limit

4 the reimbursement of a health care provider or

5 organization because such provider or organiza6 tion provided services to the individual in ac7 cordance with this subsection; or

8 ‘‘(D) provide incentives (monetary or oth9 erwise) to a health care provider or organiza10 tion to induce such provider or organization to

11 provide care to a participant or beneficiary in a

12 manner inconsistent with this subsection.

13 ‘‘(7) COST-SHARING.—Nothing in this sub14 section shall be construed as preventing a

15 Medicare+Choice organization offering a

16 Medicare+Choice plan from imposing deductibles,

17 coinsurance, or other cost-sharing for services cov18 ered under this subsection if such deductibles, coin19 surance, or other cost-sharing would have applied if

20 the skilled nursing facility in which the enrollee re21 ceived such services was under contract with the

22 Medicare+Choice organization.

23 ‘‘(8) NONPREEMPTION OF STATE LAW.—The

24 provisions of this subsection shall not be construed

25 to preempt any provision of State law that affords
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1 greater protections to beneficiaries with regard to

2 coverage of items and services provided by a skilled

3 nursing facility than is afforded by such provisions

4 of this subsection.

5 ‘‘(9) DEFINITIONS.—In this subsection:

6 ‘‘(A) CONTINUING CARE RETIREMENT

7 COMMUNITY.—The term ‘continuing care retire8 ment community’ means an organization that

9 provides or arranges for the provision of hous10 ing and health-related services to an older per11 son under an agreement.

12 ‘‘(B) SKILLED NURSING FACILITY.—The

13 term ‘skilled nursing facility’ has the meaning

14 given such term in section 1819(a).’’.

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

16 this section shall apply with respect to contracts entered

17 into or renewed on or after the date of enactment of this

18 Act.

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