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106TH CONGRESS

1ST SESSION S. 1499

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 SENATE OF THE UNITED STATES

AUGUST 5, 1999

Mr. MACK (for himself, Ms. MIKULSKI, Mr. GRAMS, Mr. WELLSTONE, and

Mr. GRASSLEY) 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 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’’.

6 SEC. 2. MODIFICATION OF PAYMENT RULES.

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

8 1395w–23) is amended—
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1 (1) in subsection (a)—

2 (A) in paragraph (1)(A), by striking ‘‘sub3 sections (e) and (f)’’ and inserting ‘‘subsections

4 (e) through (i)’’;

5 (B) in paragraph (3)(D), by inserting ‘‘and

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

7 (C) by adding at the end the following:

8 ‘‘(4) EXEMPTION FROM RISK-ADJUSTMENT SYS9 TEM FOR FRAIL ELDERLY BENEFICIARIES EN10 ROLLED IN SPECIALIZED PROGRAMS FOR THE FRAIL

11 ELDERLY.—

12 ‘‘(A) IN GENERAL.—During the period de13 scribed in subparagraph (B), the risk-adjust14 ment described in paragraph (3) shall not apply

15 to a frail elderly Medicare+Choice beneficiary

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

17 in a Medicare+Choice plan under a specialized

18 program for the frail elderly (as defined in sub19 section (i)(2)).

20 ‘‘(B) PERIOD OF APPLICATION.—The pe21 riod described in this subparagraph begins with

22 January 2000, and ends with the first month

23 for which the Secretary certifies to Congress

24 that a comprehensive risk adjustment method25 ology under paragraph (3)(C) (that takes into
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1 account the types of factors described in sub2 section (i)(1)) is being fully implemented.’’; and

3 (2) by adding at the end the following:

4 ‘‘(i) SPECIAL RULES FOR FRAIL ELDERLY EN5 ROLLED IN SPECIALIZED PROGRAMS FOR THE FRAIL EL6 DERLY.—

7 ‘‘(1) DEVELOPMENT AND IMPLEMENTATION OF

8 NEW PAYMENT SYSTEM.—The Secretary shall de9 velop and implement (as soon as possible after the

10 date of enactment of this subsection), during the pe11 riod described in subsection (a)(4)(B), a payment

12 methodology for frail elderly Medicare+Choice bene13 ficiaries enrolled in a Medicare+Choice plan under

14 a specialized program for the frail elderly (as defined

15 in paragraph (2)(A)). Such methodology shall ac16 count for the prevalence, mix, and severity of chron17 ic conditions among such beneficiaries and shall in18 clude medical diagnostic factors from all provider

19 settings (including hospital and nursing facility set20 tings). It shall include functional indicators of health

21 status and such other factors as may be necessary

22 to achieve appropriate payments for plans serving

23 such beneficiaries.

24 ‘‘(2) SPECIALIZED PROGRAM FOR THE FRAIL

25 ELDERLY DESCRIBED.—
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1 ‘‘(A) IN GENERAL.—For purposes of this

2 part, the term ‘specialized program for the frail

3 elderly’ means a program which the Secretary

4 determines—

5 ‘‘(i) is offered under this part as a

6 distinct part of a Medicare+Choice plan;

7 ‘‘(ii) primarily enrolls frail elderly

8 Medicare+Choice beneficiaries; and

9 ‘‘(iii) has a clinical delivery system

10 that is specifically designed to serve the

11 special needs of such beneficiaries and to

12 coordinate short-term and long-term care

13 for such beneficiaries through the use of a

14 team described in subparagraph (B) and

15 through the provision of primary care serv16 ices to such beneficiaries by means of such

17 a team at the nursing facility involved.

18 ‘‘(B) SPECIALIZED TEAM.—A team de19 scribed in this subparagraph—

20 ‘‘(i) includes—

21 ‘‘(I) a physician; and

22 ‘‘(II) a nurse practitioner or geri23 atric care manager, or both; and

24 ‘‘(ii) has as members individuals who

25 have special training and specialize in the
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1 care and management of the frail elderly

2 beneficiaries.

3 ‘‘(3) FRAIL ELDERLY MEDICARE+CHOICE BEN4 EFICIARY DESCRIBED.—For purposes of this part,

5 the term ‘frail elderly Medicare+Choice beneficiary’

6 means a Medicare+Choice eligible individual who—

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

8 or a nursing facility (as defined for purposes of

9 title XIX) for an indefinite period and without

10 any intention of residing outside the facility;

11 and

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

13 makes the individual frail (as determined under

14 guidelines approved by the Secretary).’’.

15 SEC. 3. CONTINUOUS OPEN ENROLLMENT FOR QUALIFIED

16 INDIVIDUALS.

17 (a) IN GENERAL.—Section 1851(e) of the Social Se18 curity Act (42 U.S.C. 1395w–21(e)) is amended by adding

19 at the end the following:

20 ‘‘(7) SPECIAL RULES FOR FRAIL ELDERLY

21 MEDICARE+CHOICE BENEFICIARIES ENROLLING IN

22 SPECIALIZED PROGRAMS FOR THE FRAIL ELDER23 LY.—There shall be a continuous open enrollment

24 period for any frail elderly Medicare+Choice bene25 ficiary (as defined in section 1853(i)(3)) who is
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1 seeking to enroll in a Medicare+Choice plan under

2 a specialized program for the frail elderly (as defined

3 in section 1853(i)(2)).’’.

4 (b) CONFORMING AMENDMENTS.—

5 (1) OPEN ENROLLMENT PERIODS.—Section

6 1851(e)(6) of the Social Security Act (42 U.S.C.

7 1395w–21(e)(6)) is amended—

8 (A) in subparagraph (A), by striking

9 ‘‘and’’ at the end;

10 (B) by redesignating subparagraph (B) as

11 subparagraph (C); and

12 (C) by inserting at the end of subpara13 graph (A) the following:

14 ‘‘(B) that is offering a specialized program

15 for the frail elderly (as defined in section

16 1853(i)(2)), shall accept elections at any time

17 for purposes of enrolling frail elderly

18 Medicare+Choice beneficiaries (as defined in

19 section 1853(i)(3)) in such program; and’’.

20 (2) EFFECTIVENESS OF ELECTIONS.—Section

21 1851(f)(4) of the Social Security Act (42 U.S.C.

22 1395w–21(f)(4)) is amended by striking ‘‘subsection

23 (e)(4)’’ and inserting ‘‘paragraph (4) or (7) of sub24 section (e)’’.
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1 (c) EFFECTIVE DATE.—The amendment made by

2 this section shall take effect on the date of enactment of

3 this Act.

4 SEC. 4. DEVELOPMENT OF QUALITY MEASUREMENT PRO5 GRAM.

6 (a) IN GENERAL.—Section 1852(e) of the Social Se7 curity Act (42 U.S.C. 1395w–22(e)) is amended by adding

8 at the end the following:

9 ‘‘(5) QUALITY MEASUREMENT PROGRAM FOR

10 SPECIALIZED PROGRAMS FOR THE FRAIL ELDERLY

11 AS PART OF MEDICARE+CHOICE PLANS.—The Sec12 retary shall develop and implement a program to

13 measure the quality of care provided in specialized

14 programs for the frail elderly (as defined in section

15 1853(i)(2)) in order to reflect the unique health as16 pects and needs of frail elderly Medicare+Choice

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

18 quality measurements may include indicators of the

19 prevalence of pressure sores, reduction of iatrogenic

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

21 medications, use of advance directives, incidence of

22 pneumonia, and incidence of congestive heart fail23 ure.’’.

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

25 Human Services shall first provide for the implementation
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1 of the quality measurement program for specialized pro2 grams for the frail elderly under the amendment made by

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

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