II 

111TH CONGRESS 

1ST SESSION S. 1004 

To amend title XVIII of the Social Security Act to provide Medicare beneficiaries with access to geriatric assessments and chronic care management and coordination services, and for other purposes. 

IN THE SENATE OF THE UNITED STATES 

MAY 7, 2009 

Mrs. LINCOLN (for herself and Ms. COLLINS) 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 provide 

Medicare beneficiaries with access to geriatric assessments and chronic care management and coordination 

services, and for other purposes. 

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; TABLE OF CONTENTS. 

4 (a) SHORT TITLE.—This Act may be cited as the 

5 ‘‘The Reaching Elders with Assessment and Chronic Care 

6 Management and Coordination Act’’ or the ‘‘RE-Aligning 

7 Care Act’’. 


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1 (b) TABLE OF CONTENTS.—The table of contents of 

2 this Act is as follows: 

Sec. 1. Short title; table of contents. 

Sec. 2. Findings. 

Sec. 3. Medicare coverage of geriatric assessments. 

Sec. 4. Medicare coverage of chronic care management and coordination services. 

Sec. 5. Outreach activities regarding geriatric assessments and chronic care 

management and coordination services under the Medicare program. 

Sec. 6. Utilization of telehealth services to furnish geriatric assessments and 

chronic care management and coordination services under the 

Medicare program. 

Sec. 7. Study and report on geriatric assessments and chronic care management and coordination services under the Medicare program. 

Sec. 8. Rule of construction. 

3 SEC. 2. FINDINGS. 

4 Congress makes the following findings: 

5 (1) The Medicare program must be redesigned 

6 to provide high-quality, cost-effective and coordi7 nated care to the growing population of elderly indi8 viduals with multiple and complex chronic condi9 tions. 

10 (2) Between 2005 and 2030, it is estimated 

11 that the number of adults aged 65 and older will al12 most double from 37,000,000 to more than 

13 70,000,000. The number of those age 80 and over, 

14 is also expected to nearly double from 11,000,000 to 

15 20,000,000. This demographic shift will create the 

16 largest ever proportion of adults over 65, increasing 

17 from 12 percent of the United States population in 

18 2005 to almost 20 percent by 2030. 


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1 (3) With the unprecedented growth of our Na2 tion’s aging population, the number of older patients 

3 with multiple chronic conditions and cognitive im4 pairments is expected to increase. Currently, about 

5 65 percent of Medicare beneficiaries have two or 

6 more chronic conditions. To address the health care 

7 needs unique to older adults with chronic conditions, 

8 it will require innovations in care delivery and com9 prehensive coordinated care. 

10 (4) According to the Congressional Budget Of11 fice, approximately 75 percent of Medicare spending 

12 pays for care for beneficiaries who have five or more 

13 chronic conditions and see an average of 14 different 

14 physicians per year. In addition, approximately 43 

15 percent of Medicare costs can be attributed to 5 per16 cent of Medicare’s most costly beneficiaries. 

17 (5) Total Medicare costs per beneficiary age 65 

18 or older with Alzheimer’s and other dementias were 

19 almost three times higher than for other Medicare 

20 beneficiaries in 2004. 

21 (6) There is a strong pattern of increasing utili22 zation as the number of conditions increase. In 

23 2003, 61 percent of Medicare beneficiaries with 3 

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1 cians compared to 40 percent with 2 conditions and 

2 18 percent of those with 1 condition. 

3 (7) According to a June 2006 MedPAC report, 

4 even if individual providers deliver care efficiently, 

5 overall care for a beneficiary may be inefficient if 

6 providers do not coordinate across settings or assist 

7 beneficiaries in managing their conditions between 

8 visits. Beneficiaries with multiple chronic conditions 

9 may benefit the most from care coordination as they 

10 do not always receive necessary care and often at 

11 high cost. 

12 (8) On average, individuals 65 to 69 years old 

13 take nearly 14 prescriptions per year and individuals 

14 aged 80 to 84 take an average of 18 prescriptions 

15 per year. As the number of chronic conditions in16 creases, so does the number of medications, increas17 ing the risk for negative drug interactions that can 

18 lead to serious injury requiring hospitalization or 

19 can even be fatal. Studies have found that 25 per20 cent to 50 percent adverse drug events among older 

21 persons are preventable and that preventable adverse 

22 drug events may cost the Medicare program 

23 $887,000,000 per year. 

24 (9) Research conducted in the United States 

25 and internationally indicate that the delivery of highVerDate Nov 24 2008 04:05 May 09, 2009 Jkt 079200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\S1004.IS S1004

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1 er quality health care, increased efficiency, and cost2 effectiveness are the result of systems in which pa3 tients are linked with a physician or another quali4 fied health professional who coordinates their care. 

5 According to the Congressional Budget Office, an 

6 intervention that focused on coordinating care for 

7 high-cost beneficiaries with multiple chronic condi8 tions could both improve their health and reduce 

9 Medicare spending. 

10 (10) In addition, chronic care management and 

11 coordination may help prevent negative medication 

12 interactions and prevent hospital stays because the 

13 chronic care team holistically manages and treats ill14 ness. Reducing the rate of preventable adverse drug 

15 events will both improve patient care and may result 

16 in savings to the Medicare program. 

17 (11) The Medicare fee-for-service program cur18 rently does not pay for care coordination services. 

19 Instead, the delivery and payment systems are orga20 nized to support the diagnosis and treatment of 

21 acute or episodic conditions, resulting in fragmented, 

22 ineffective and costly care for beneficiaries with 

23 chronic diseases. It currently rewards the overuse 

24 and duplication of services rather than rewarding 

25 the effective control of chronic conditions, which can 


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1 improve health outcomes and prevent hospitalization 

2 or rehospitalization. 

3 (12) The Institute of Medicine Report, ‘‘Retool4 ing for an Aging America: Building the Health Care 

5 Workforce’’, cited misaligned financial incentives, in6 cluding the inability to reimburse for care coordina7 tion, as factors that result in fragmented care for 

8 older Americans. 

9 (13) Financial incentives within the Medicare 

10 program should be realigned as part of a com11 prehensive system change. The Medicare program 

12 should be restructured to reimburse physicians and 

13 other qualified health professionals for the cost of 

14 coordinating care. 

15 (14) The patient-centered chronic care model 

16 established by the provisions of, and the amend17 ments made by, this Act includes several elements 

18 that are effective in managing older adults with 

19 chronic disease, including— 

20 (A) a comprehensive assessment of the in21 dividual’s physical, cognitive, affective, func22 tional and social status, and caregiving needs; 

23 (B) access to patient-centered care coordi24 nation services provided by interdisciplinary 

25 team members; 


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1 (C) support for patient self-management of 

2 chronic disease; 

3 (D) linkages with community resources; 

4 (E) health care system changes that re5 ward quality chronic care; 

6 (F) practice redesign; 

7 (G) evidence-based clinical practice guide8 lines; and 

9 (H) clinical information systems, such as 

10 electronic medical records and continuity of 

11 care records. 

12 (15) The provisions of, and amendments made 

13 by, this Act are intended to— 

14 (A) improve health outcomes appropriate 

15 for older patients with multiple chronic condi16 tions; 

17 (B) increase beneficiary, caregiver, and 

18 provider satisfaction; 

19 (C) increase cost-effectiveness and high 

20 value to the Medicare program for those served 

21 with multiple chronic conditions; 

22 (D) establish a process to identify those 

23 Medicare beneficiaries most likely to benefit 

24 from having a provider coordinate their health 

25 care needs; and 


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1 (E) establish a payment under the Medi2 care program for— 

3 (i) the assessment of those health care 

4 needs; and 

5 (ii) the activities required to coordi6 nate those health care needs. 

7 SEC. 3. MEDICARE COVERAGE OF GERIATRIC ASSESS8 MENTS. 

9 (a) COVERAGE OF GERIATRIC ASSESSMENTS.— 

10 (1) IN GENERAL.—Section 1861(s)(2) of the 

11 Social Security Act (42 U.S.C. 1395x(s)(2)) is 

12 amended— 

13 (A) in subparagraph (DD), by striking 

14 ‘‘and’’ at the end; 

15 (B) in subparagraph (EE), by adding 

16 ‘‘and’’ at the end; and 

17 (C) by adding at the end the following new 

18 subparagraph: 

19 ‘‘(FF) geriatric assessments (as defined in sub20 section (hhh)(1));’’. 

21 (2) CONFORMING AMENDMENTS.—Clauses (i) 

22 and (ii) of section 1861(s)(2)(K) of the Social Secu23 rity Act (42 U.S.C. 1395x(s)(2)(K)) are each 

24 amended by striking ‘‘subsection (ww)(1)’’ and in25 serting ‘‘subsections (ww)(1) and (hhh)(1)’’. 


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1 (b) GERIATRIC ASSESSMENTS DEFINED.—Section 

2 1861 of the Social Security Act (42 U.S.C. 1395x) is 

3 amended by adding at the end the following new sub4 sections: 

5 ‘‘Geriatric Assessment 

6 ‘‘(hhh)(1) The term ‘geriatric assessment’ means 

7 each of the following: 

8 ‘‘(A) An assessment of the clinical status, func9 tional status, social and environmental functioning, 

10 and need for caregiving of a geriatric assessment eli11 gible individual (as defined in subsection (iii)). The 

12 assessment shall include a comprehensive history 

13 and physical examination and assessments of the fol14 lowing domains using standardized validated clinical 

15 tools: 

16 ‘‘(i) Comprehensive review of medications 

17 and the individual’s adherence to the medica18 tion regimen. 

19 ‘‘(ii) Measurement of affect, cognition and 

20 executive function, mobility, balance, gait, risk 

21 of falling, and sensory function. 

22 ‘‘(iii) Social functioning, environmental 

23 needs, and caregiver resources and needs. 

24 ‘‘(iv) Any other domain determined appro25 priate by the Secretary. 


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1 ‘‘(B) The development of a written care plan 

2 based on the results of the assessment under sub3 paragraph (A) (and any subsequent assessment 

4 under subparagraph (B)). The care plan shall detail 

5 identified problems, outline therapies, assign respon6 sibility for actions, and indicate whether the indi7 vidual is likely to benefit from chronic care manage8 ment and coordination services (as defined in sub9 section (jjj)(1)). If the individual is determined likely 

10 to benefit from chronic care management and co11 ordination services, the care plan shall also provide 

12 the basis for the chronic care management and co13 ordination plan to be developed by the chronic care 

14 manager pursuant to subsection (jjj). 

15 ‘‘(2) A geriatric assessment may only be conducted 

16 by— 

17 ‘‘(A) a physician; 

18 ‘‘(B) a practitioner described in section 

19 1842(b)(18)(C)(i) under the supervision of a physi20 cian; or 

21 ‘‘(C) any other provider that meets such condi22 tions as the Secretary may specify. 

23 ‘‘(3) An individual described in subclause (A), (B), 

24 or, if applicable, (C) may provide for the furnishing of 


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1 services included in the geriatric assessment by other 

2 qualified health care professionals. 

3 ‘‘(4)(A) Subject to subparagraph (B), a geriatric as4 sessment of a geriatric assessment eligible individual may 

5 not be conducted more frequently than annually. 

6 ‘‘(B) A geriatric assessment of a geriatric assessment 

7 eligible individual may be conducted more frequently than 

8 annually if the assessment is medically necessary due to 

9 a significant change in the condition of the individual. 

10 ‘‘Geriatric Assessment Eligible Individual 

11 ‘‘(iii)(1) Subject to paragraph (3), the term ‘geriatric 

12 assessment eligible individual’ means an individual identi13 fied by the Secretary as eligible for a geriatric assessment. 

14 ‘‘(2) In identifying individuals under paragraph (1), 

15 the following rules shall apply: 

16 ‘‘(A) The individual must have at least 1 of the 

17 following present: 

18 ‘‘(i) Multiple chronic conditions that the 

19 Secretary identifies as likely to result in high 

20 expenditures under this title. In identifying 

21 such conditions, the Secretary may consider— 

22 ‘‘(I) the hierarchal condition category 

23 methodology employed for risk adjustment 

24 under part C or other comparable meth25 odologies the Secretary deems appropriate; 


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1 ‘‘(II) data from the Chronic Condition 

2 Data Warehouse under section 723 of the 

3 Medicare Prescription Drug, Improvement, 

4 and Modernization Act of 2003; and 

5 ‘‘(III) indicators of geriatric syn6 dromes, such as experiencing 2 or more 

7 falls in the past year, urinary incontinence, 

8 clinically significant depression, or other 

9 such indicators that the Secretary indicates 

10 as likely to result in high expenditures 

11 under this title when they exist in com12 bination with one or more chronic condi13 tions). 

14 ‘‘(ii) Dementia, as defined in the most re15 cent Diagnostic and Statistical Manual of Men16 tal Disorders, and at least 1 other chronic con17 dition. 

18 ‘‘(iii) Any other factor identified by the 

19 Secretary. 

20 ‘‘(B) The Secretary shall consult with physi21 cians, physician groups and organizations, other 

22 health care professional groups and organizations, 

23 organizations representing individuals with chronic 

24 conditions and older adults, and other stakeholders 

25 in identifying conditions under clauses (i) and (ii) of 


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1 subparagraph (A) and any factors under subpara2 graph (A)(iii). 

3 ‘‘(3) The term ‘geriatric assessment eligible indi4 vidual’ shall not include the following individuals: 

5 ‘‘(A) An individual who is receiving hospice care 

6 under this title. 

7 ‘‘(B) An individual who is residing in a skilled 

8 nursing facility, a nursing facility (as defined in sec9 tion 1919), or any other facility identified by the 

10 Secretary. 

11 ‘‘(C) An individual medically determined to 

12 have end-stage renal disease. 

13 ‘‘(D) An individual enrolled in a Medicare Ad14 vantage plan or a plan under section 1876. 

15 ‘‘(E) An individual enrolled in a PACE pro16 gram under section 1894. 

17 ‘‘(F) Any other categories of individuals deter18 mined appropriate by the Secretary. 

19 ‘‘(4) For purposes of this subsection, the term ‘chron20 ic condition’ means a condition, such as dementia, that 

21 lasts or is expected to last 1 year or longer, limits what 

22 an individual can do, and requires ongoing care.’’. 

23 (c) PAYMENT AND ELIMINATION OF COST-SHAR24 ING.— 


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1 (1) PAYMENT AND ELIMINATION OF COINSUR2 ANCE.—Section 1833(a)(1) of the Social Security 

3 Act (42 U.S.C. 1395l(a)(1)) is amended— 

4 (A) in subparagraph (N), by inserting 

5 ‘‘other than geriatric assessments (as defined in 

6 section 1861(hhh)(1))’’ after ‘‘(as defined in 

7 section 1848(j)(3))’’; 

8 (B) by striking ‘‘and’’ before ‘‘(W)’’; and 

9 (C) by inserting before the semicolon at 

10 the end the following: ‘‘, and (X) with respect 

11 to geriatric assessments (as defined in section 

12 1861(hhh)(1)), the amount paid shall be 100 

13 percent of the lesser of the actual charge for 

14 the services or the amount determined under 

15 section 1848(o)’’. 

16 (2) PAYMENT.— 

17 (A) IN GENERAL.—Section 1848 of the So18 cial Security Act (42 U.S.C. 1395w–4) is 

19 amended by adding at the end the following 

20 new subsection: 

21 ‘‘(o) PAYMENT FOR GERIATRIC ASSESSMENTS.— 

22 ‘‘(1) ESTABLISHMENT.— 

23 ‘‘(A) IN GENERAL.—The Secretary shall 

24 establish— 


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1 ‘‘(i) a payment code (or codes) under 

2 this section for a geriatric assessment (as 

3 defined in section 1861(hhh)(1)) furnished 

4 to a geriatric assessment eligible individual 

5 (as defined in section 1861(iii)) by a physi6 cian, practitioner, or other provider de7 scribed in section 1861(hhh)(2); and 

8 ‘‘(ii) a payment amount for each such 

9 code. 

10 ‘‘(B) REQUIREMENTS.—In establishing 

11 payment amounts under subparagraph (A)(ii), 

12 the Secretary shall— 

13 ‘‘(i) take into account— 

14 ‘‘(I) the amount of work required 

15 to perform a geriatric assessment, in16 cluding the time and effort put forth 

17 by each qualified health care profes18 sional involved in performing the geri19 atric assessment; and 

20 ‘‘(II) all of the costs associated 

21 with the geriatric assessment, includ22 ing labor, supplies, equipment, and 

23 the costs of health information tech24 nologies and systems incurred by the 

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1 vider (as described in section 

2 1861(hhh)(2)) in providing the assess3 ment; and 

4 ‘‘(ii) ensure that such payments do 

5 not result in a reduction in payments for 

6 office visits or other evaluation and man7 agement services that would otherwise be 

8 allowable. 

9 ‘‘(2) SEPARATE PAYMENTS FROM PAYMENTS

10 FOR CHRONIC CARE MANAGEMENT AND COORDINA11 TION SERVICES.—Payments for geriatric assess12 ments shall be made separately from payments for 

13 chronic care management and coordination services 

14 (as defined in section 1861(jjj)(1)) and other serv15 ices for which payment is made under this title.’’. 

16 (B) CONFORMING AMENDMENT.—Section 

17 1848(j)(3) of the Social Security Act (42 

18 U.S.C. 1395w–4(j)(3)), as amended by section 

19 3(c)(2), is amended by inserting ‘‘(2)(FF),’’ 

20 after ‘‘(2)(EE),’’. 

21 (3) ELIMINATION OF COINSURANCE IN OUT22 PATIENT HOSPITAL SETTINGS.— 

23 (A) EXCLUSION FROM OPD FEE SCHED24 ULE.—Section 1833(t)(1)(B)(iv) of the Social 

25 Security Act (42 U.S.C. 1395l(t)(1)(B)(iv)) is 


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1 amended by striking ‘‘and diagnostic mammog2 raphy’’ and inserting ‘‘, diagnostic mammog3 raphy, or geriatric assessments (as defined in 

4 section 1861(hhh)(1))’’. 

5 (B) CONFORMING AMENDMENTS.—Section 

6 1833(a)(2) of the Social Security Act (42 

7 U.S.C. 1395l(a)(2)) is amended— 

8 (i) in subparagraph (F), by striking 

9 ‘‘and’’ at the end; 

10 (ii) in subparagraph (G)(ii), by strik11 ing the comma at the end and inserting ‘‘; 

12 and’’; and 

13 (iii) by inserting after subparagraph 

14 (G)(ii) the following new subparagraph: 

15 ‘‘(H) with respect to geriatric assessments 

16 (as defined in section 1861(hhh)(1)) furnished 

17 by an outpatient department of a hospital, the 

18 amount determined under paragraph (1)(X),’’. 

19 (4) ELIMINATION OF DEDUCTIBLE.—The first 

20 sentence of section 1833(b) of the Social Security 

21 Act (42 U.S.C. 1395l(b)) is amended— 

22 (A) by striking ‘‘and’’ before ‘‘(9)’’; and 

23 (B) by inserting before the period the fol24 lowing: ‘‘, and (10) such deductible shall not 


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1 apply with respect to geriatric assessments (as 

2 defined in section 1861(hhh)(1))’’. 

3 (d) FREQUENCY LIMITATION.—Section 1862(a) of 

4 the Social Security Act (42 U.S.C. 1395y(a)(1)) is amend5 ed— 

6 (1) in paragraph (1)— 

7 (A) in subparagraph (N), by striking 

8 ‘‘and’’ at the end; 

9 (B) in subparagraph (O) by striking the 

10 semicolon at the end and inserting ‘‘, and’’; and 

11 (C) by adding at the end the following new 

12 subparagraph: 

13 ‘‘(P) in the case of geriatric assessments (as de14 fined in section 1861(hhh)(1)), which are performed 

15 more frequently than is covered under such sec16 tion;’’; and 

17 (2) in paragraph (7), by striking ‘‘or (K)’’ and 

18 inserting ‘‘(K), or (P)’’. 

19 (e) EXCEPTION TO LIMITS ON PHYSICIAN REFER20 RALS.—Section 1877(b) of the Social Security Act (42 

21 U.S.C. 1395nn(b)) is amended by adding at the end the 

22 following new paragraph: 

23 ‘‘(6) GERIATRIC ASSESSMENTS.—In the case of 

24 a designated health service, if the designated health 


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1 service is a geriatric assessment (as defined in sec2 tion 1861(hhh)(1)) and furnished by a physician.’’. 

3 (f) RULEMAKING.—The Secretary of Health and 

4 Human Services shall define such terms, establish such 

5 procedures, and promulgate such regulations as the Sec6 retary determines necessary to implement the amend7 ments made by, and the provisions of, this section, includ8 ing the establishment of additional domains under sub9 section (hhh)(1)(A)(iv) of section 1861 of the Social Secu10 rity Act, as added by subsection (b). In promulgating such 

11 regulations, the Secretary shall consult with physicians, 

12 physician groups and organizations, other health care pro13 fessional groups and organizations representing individ14 uals with chronic conditions and older adults. 

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

16 this section shall apply to assessments furnished on or 

17 after January 1, 2010. 

18 SEC. 4. MEDICARE COVERAGE OF CHRONIC CARE MANAGE19 MENT AND COORDINATION SERVICES. 

20 (a) PART B COVERAGE OF CHRONIC CARE MANAGE21 MENT AND COORDINATION SERVICES.— 

22 (1) IN GENERAL.—Section 1861(s)(2) of the 

23 Social Security Act (42 U.S.C. 1395x(s)(2)), as 

24 amended by section 3(a)(1), is amended— 


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1 (A) in subparagraph (EE), by striking 

2 ‘‘and’’ at the end; 

3 (B) in subparagraph (FF), by adding 

4 ‘‘and’’ at the end; and 

5 (C) by adding at the end the following new 

6 subparagraph: 

7 ‘‘(GG) chronic care management and coordina8 tion services (as defined in subsection (jjj));’’. 

9 (2) CONFORMING AMENDMENTS.—(A) Clauses 

10 (i) and (ii) of section 1861(s)(2)(K) of the Social Se11 curity Act (42 U.S.C. 1395x(s)(2)(K)), as amended 

12 by section 3(a)(2), are each amended by striking 

13 ‘‘subsections (ww)(1) and (hhh)(1)’’ and inserting 

14 ‘‘subsections (ww)(1), (hhh)(1), and (jjj)(1)’’. 

15 (B) Section 1862(a)(7) of the Social Security 

16 Act (42 U.S.C. 1395y(a)(7)), as amended by section 

17 3(d), is amended by striking ‘‘section 1861(s)(10)’’ 

18 and inserting ‘‘paragraphs (2)(GG) and (10) of sec19 tion 1861(s)’’. 

20 (b) SERVICES DESCRIBED.—Section 1861 of the So21 cial Security Act (42 U.S.C. 1395x), as amended by sec22 tion 3(b), is amended by adding at the end the following 

23 new subsection: 


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1 ‘‘Chronic Care Management and Coordination Services; 

2 Chronic Care Manager; Chronic Care Eligible Individual 

3 ‘‘(jjj)(1) The term ‘chronic care management and co4 ordination services’ means services that are furnished to 

5 a chronic care eligible individual (as defined in paragraph 

6 (3)) by, or under the supervision of, a single chronic care 

7 manager (as defined in paragraph (2)) chosen by the 

8 chronic care eligible individual, a caregiver designated by 

9 the individual in writing, or a representative authorized 

10 to make decisions on the individual’s behalf, under a plan 

11 of care prescribed by such chronic care manager for the 

12 purpose of chronic care coordination, including dementia 

13 as appropriate, which may include any of the following 

14 services: 

15 ‘‘(A) The development of an initial plan of care 

16 (based on the results of a geriatric assessment, as 

17 defined in subsection (hhh)), and subsequent appro18 priate revisions to that plan of care. 

19 ‘‘(B) The management of, and referral for, 

20 medical and other health services, including inter21 disciplinary care conferences and management with 

22 other providers. 

23 ‘‘(C) The monitoring and management of medi24 cations. 

25 ‘‘(D) Patient education and counseling services. 


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1 ‘‘(E) Family caregiver education and counseling 

2 services, including preventive care consistent with 

3 the patient’s condition. 

4 ‘‘(F) Self-management services, including 

5 health education and risk appraisal to identify be6 havioral risk factors through self-assessment. 

7 ‘‘(G) Providing access for individuals, and care8 givers or authorized representatives as appropriate, 

9 by telephone and email to physicians or other appro10 priate health care professionals, including 24-hour 

11 availability of such professionals for after hours con12 sultation. 

13 ‘‘(H) Coordination with the principal nonprofes14 sional caregiver in the home. 

15 ‘‘(I) Managing and facilitating transitions that 

16 occur among health care professionals and across 

17 settings of care, including the following: 

18 ‘‘(i) Pursuing the treatment option elected 

19 by the individual. 

20 ‘‘(ii) Including any advance directive exe21 cuted by the individual in the medical file of the 

22 individual. 

23 ‘‘(J) Information about pain management and 

24 palliative care. 


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1 ‘‘(K) Information about, and referral to, hos2 pice care, including patient and family caregiver 

3 education and counseling about hospice care, and fa4 cilitating transition to hospice care when elected. 

5 ‘‘(L) Information about, referral to, and coordi6 nation with, community resources. 

7 ‘‘(M) Such additional services for which pay8 ment would not otherwise be made under this title 

9 that the Secretary may specify that encourage the 

10 receipt of, or improve the effectiveness of, the serv11 ices described in the preceding subparagraphs. 

12 ‘‘(2)(A) For purposes of this subsection, the term 

13 ‘chronic care manager’ means an individual or entity 

14 that— 

15 ‘‘(i) is— 

16 ‘‘(I) a physician; 

17 ‘‘(II) a practitioner described in clause (i) 

18 or (iv) of section 1842(b)(18)(C); or 

19 ‘‘(III) any other provider that meets such 

20 conditions as the Secretary may specify; 

21 ‘‘(ii) has entered into a chronic care manage22 ment and coordination agreement with the Sec23 retary; and 

24 ‘‘(iii) is working in collaboration with, or under 

25 the supervision of, as determined by the Secretary— 


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1 ‘‘(I) the physician, practitioner, or other 

2 provider who completed the geriatric assessment 

3 of the individual; or 

4 ‘‘(II) a physician, practitioner, or other 

5 provider to whom the individual’s care was 

6 transferred by the physician, practitioner, or 

7 other provider who performed the geriatric as8 sessment. 

9 ‘‘(B)(i) For purposes of subparagraph (A)(ii), each 

10 chronic care management and coordination agreement 

11 shall meet the requirements described in subparagraph 

12 (C) and shall— 

13 ‘‘(I) subject to clause (ii), be entered into for a 

14 period of 3 years and may be renewed if the Sec15 retary is satisfied that the chronic care manager 

16 continues to meet such terms and conditions as the 

17 Secretary may require; and 

18 ‘‘(II) contain such other terms and conditions 

19 as the Secretary may require. 

20 ‘‘(ii) Each chronic care management and coordination 

21 agreement shall provide for the termination of such agree22 ment prior to such 3-year period in the case where the 

23 chronic care manager— 

24 ‘‘(I) is no longer able to provide chronic care 

25 services; or 


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1 ‘‘(II) does not meet such terms and conditions 

2 as the Secretary may require. 

3 ‘‘(C)(i) Subject to clause (ii), the requirements of this 

4 subparagraph are met if the agreement requires the chron5 ic care manager to perform, or provide for the perform6 ance of, the following services: 

7 ‘‘(I) Advocating for, and providing ongoing sup8 port, oversight, and guidance with respect to the im9 plementation of a plan of care that provides an inte10 grated, coherent, and cross-disciplined plan for ongo11 ing medical care that is developed in partnership 

12 with the chronic care eligible individual and all other 

13 physicians and other care providers and agencies (in14 cluding home health agencies) providing care to the 

15 chronic care eligible individual. 

16 ‘‘(II) Using evidence-based medicine and clin17 ical decision support tools to guide decision making 

18 at the point of care and on the basis of specific pa19 tient factors. 

20 ‘‘(III) Using health information technology, in21 cluding, where appropriate, remote monitoring and 

22 patient registries, to monitor and track the health 

23 status of patients and to provide patients with en24 hanced and convenient access to health care services. 


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1 ‘‘(IV) Encouraging patients to engage in the 

2 management of their own health through education 

3 and support systems. 

4 ‘‘(V) Incorporating family caregivers into the 

5 chronic care planning process. 

6 ‘‘(ii) The Secretary may modify the services required 

7 under the agreement under clause (i), including by requir8 ing different services or services in addition to those de9 scribed in subclauses (I) through (V) of such clause. 

10 ‘‘(D) The Secretary shall adopt procedures which ex11 empt providers in rural areas from providing 1 or more 

12 of the services otherwise required to be provided under 

13 subparagraph (C) or modify such requirements for such 

14 providers. In establishing such procedures, the Secretary 

15 shall ensure that such exemptions and modifications do 

16 not impact the quality of chronic care management and 

17 coordination services furnished by such providers. 

18 ‘‘(3) For purposes of this subsection, the term ‘chron19 ic care eligible individual’ means a geriatric assessment 

20 eligible individual (as defined in subsection (iii)) who has 

21 undergone a geriatric assessment (as defined in subsection 

22 (hhh)(1)) which determined that the individual would ben23 efit from chronic care management and coordination. 


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1 ‘‘(4) Chronic care management and coordination 

2 services may be furnished in the chronic care eligible indi3 vidual’s home or residence.’’. 

4 (c) PAYMENT AND ELIMINATION OF COST-SHAR5 ING.— 

6 (1) PAYMENT AND ELIMINATION OF COINSUR7 ANCE.—Section 1833(a)(1) of the Social Security 

8 Act (42 U.S.C. 1395l(a)(1)), as amended by section 

9 3(c)(1), is amended— 

10 (A) in subparagraph (N), by inserting ‘‘or 

11 chronic care management and coordination 

12 services (as defined in section 1861(jjj)(1))’’ 

13 after ‘‘other than geriatric assessments (as de14 fined in section 1861(hhh)(1))’’; 

15 (B) by striking ‘‘and’’ before ‘‘(X)’’; and 

16 (C) by inserting before the semicolon at 

17 the end the following: ‘‘, and (Y) with respect 

18 to chronic care management and coordination 

19 services (as defined in section 1861(jjj)(1)), the 

20 amount paid shall be 100 percent of the lesser 

21 of the actual charge for the services or the 

22 amount determined under section 1848(p)’’. 

23 (2) PAYMENT.— 

24 (A) IN GENERAL.—Section 1848 of the So25 cial Security Act (42 U.S.C. 1395w–4), as 


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1 amended by section 3(c)(2), is amended by add2 ing at the end the following new subsection: 

3 ‘‘(p) PAYMENT FOR CHRONIC CARE MANAGEMENT

4 AND COORDINATION SERVICES.— 

5 ‘‘(1) ESTABLISHMENT.— 

6 ‘‘(A) IN GENERAL.—The Secretary shall 

7 establish— 

8 ‘‘(i) a payment code (or codes) under 

9 this section for chronic care management 

10 and coordination services (as defined in 

11 paragraph (1) of section 1861(jjj)) fur12 nished to a chronic care eligible individual 

13 (as defined in paragraph (3) of such sec14 tion) by a chronic care manager (as de15 fined in paragraph (2) of such section); 

16 and 

17 ‘‘(ii) a payment amount for each such 

18 code. 

19 ‘‘(B) REQUIREMENTS.—In establishing 

20 payment amounts under subparagraph (A)(ii), 

21 the Secretary shall— 

22 ‘‘(i) take into account— 

23 ‘‘(I) the amount of work required 

24 of the chronic care manager in pro25 viding chronic care management and 


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1 coordination services to eligible indi2 viduals; and 

3 ‘‘(II) all of the costs associated 

4 with providing chronic care manage5 ment and coordination services, in6 cluding labor, supplies, equipment, 

7 and the costs of health information 

8 technologies and systems incurred by 

9 the chronic care manager in providing 

10 such services; 

11 ‘‘(ii) ensure that such payments are 

12 for such services furnished during a 30-day 

13 period; and 

14 ‘‘(iii) ensure that such payments do 

15 not result in a reduction in payments for 

16 office visits or other evaluation and man17 agement services that would otherwise be 

18 allowable. 

19 ‘‘(2) SEPARATE PAYMENTS FROM PAYMENTS

20 FOR GERIATRIC ASSESSMENTS.—Payments for 

21 chronic care management and coordination services 

22 shall be made separately from payments for geriatric 

23 assessments (as defined in section 1861(hhh)(1)) 

24 and other services for which payment is made under 

25 this title.’’. 


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1 (B) CONFORMING AMENDMENT.—Section 

2 1848(j)(3) of the Social Security Act (42 

3 U.S.C. 1395w–4(j)(3)), as amended by section 

4 3(c)(2), is amended by inserting ‘‘(2)(GG),’’ 

5 after ‘‘(2)(FF),’’. 

6 (3) ELIMINATION OF COINSURANCE IN OUT7 PATIENT HOSPITAL SETTINGS.— 

8 (A) EXCLUSION FROM OPD FEE SCHED9 ULE.—Section 1833(t)(1)(B)(iv) of the Social 

10 Security Act (42 U.S.C. 1395l(t)(1)(B)(iv)), as 

11 amended by section 3(c)(3)(A), is amended by 

12 striking ‘‘or geriatric assessments (as defined in 

13 section 1861(hhh)(1))’’ and inserting ‘‘geriatric 

14 assessments (as defined in section 

15 1861(hhh)(1)), or chronic care management 

16 and coordination services (as defined in section 

17 1861(jjj)(1))’’. 

18 (B) CONFORMING AMENDMENTS.—Section 

19 1833(a)(2) of the Social Security Act (42 

20 U.S.C. 1395l(a)(2)), as amended by section 

21 3(c)(3)(B), is amended— 

22 (i) in subparagraph (G)(ii), by strik23 ing ‘‘and’’ at the end; 


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1 (ii) in subparagraph (H), by striking 

2 the comma at the end and inserting ‘‘; 

3 and’’; and 

4 (iii) by inserting after subparagraph 

5 (H) the following new subparagraph: 

6 ‘‘(I) with respect to chronic care manage7 ment and coordination services (as defined in 

8 section 1861(jjj)(1)) furnished by an outpatient 

9 department of a hospital, the amount deter10 mined under paragraph (1)(Y),’’. 

11 (4) ELIMINATION OF DEDUCTIBLE.—Paragraph 

12 (10) of section 1833(b) of the Social Security Act 

13 (42 U.S.C. 1395l(b)), as added by section 3(c)(4), is 

14 amended by inserting ‘‘or chronic care management 

15 and coordination services (as defined in section 

16 1861(jjj)(1))’’ after ‘‘geriatric assessments (as de17 fined in section 1861(hhh)(1))’’. 

18 (d) EXCEPTION TO LIMITS ON PHYSICIAN REFER19 RALS.—Section 1877(b)(6) of the Social Security Act (42 

20 U.S.C. 1395nn(b)(6)), as amended by section 3(e), is 

21 amended to read as follows: 

22 ‘‘(6) GERIATRIC ASSESSMENTS AND CHRONIC

23 CARE MANAGEMENT AND COORDINATION SERV24 ICES.—In the case of a designated health service, if 

25 the designated health service is— 


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1 ‘‘(A) a geriatric assessment or a chronic 

2 care management and coordination service (as 

3 defined in subsections (hhh)(1) or (jjj)(1) of 

4 section 1861, respectively); and 

5 ‘‘(B) furnished by a physician.’’. 

6 (e) RULEMAKING.—The Secretary of Health and 

7 Human Services shall define such terms, establish such 

8 procedures, and promulgate such regulations as the Sec9 retary determines necessary to implement the amend10 ments made by, and the provisions of, this section. In pro11 mulgating such regulations, the Secretary shall consult 

12 with physicians, physician groups and organizations, other 

13 health care professional groups and organizations, and or14 ganizations representing individuals with chronic condi15 tions and older adults. 

16 (f) EFFECTIVE DATE.—The amendments made by 

17 this section shall apply to chronic care management and 

18 coordination services furnished on or after January 1, 

19 2010. 

20 SEC. 5. OUTREACH ACTIVITIES REGARDING GERIATRIC AS21 SESSMENTS AND CHRONIC CARE MANAGE22 MENT AND COORDINATION SERVICES UNDER 

23 THE MEDICARE PROGRAM. 

24 The Secretary of Health and Human Services shall 

25 conduct outreach activities to individuals likely to be eligiVerDate Nov 24 2008 04:05 May 09, 2009 Jkt 079200 PO 00000 Frm 00032 Fmt 6652 Sfmt 6201 E:\BILLS\S1004.IS S1004

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1 ble to receive coverage of geriatric assessments (as defined 

2 in subsection (hhh)(1) of section 1861 of the Social Secu3 rity Act, as added by section 3) under the Medicare pro4 gram and individuals likely to be eligible to receive cov5 erage of chronic care management and coordination serv6 ices (as defined in subsection (jjj)(1) of such section 1861, 

7 as added by section 4) under the Medicare program, to 

8 inform such individuals about the availability of such ben9 efits under the Medicare program. 

10 SEC. 6. UTILIZATION OF TELEHEALTH SERVICES TO FUR11 NISH GERIATRIC ASSESSMENTS AND CHRON12 IC CARE MANAGEMENT AND COORDINATION 

13 SERVICES UNDER THE MEDICARE PROGRAM. 

14 (a) IN GENERAL.—Section 1834(m)(4)(F) of the So15 cial Security Act (42 U.S.C. 1395m(m)(4)(F)) is amended 

16 by adding at the end the following new clause: 

17 ‘‘(iii) GERIATRIC ASSESSMENTS AND

18 CHRONIC CARE MANAGEMENT AND CO19 ORDINATION SERVICES.—The term ‘tele20 health service’ shall also include geriatric 

21 assessments (as defined in section 

22 1861(hhh)(1)) and chronic care manage23 ment and coordination services (as defined 

24 in section 1861(jjj)).’’. 


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

2 this section shall apply to services furnished on or after 

3 January 1, 2010. 

4 SEC. 7. STUDY AND REPORT ON GERIATRIC ASSESSMENTS 

5 AND CHRONIC CARE MANAGEMENT AND CO6 ORDINATION SERVICES UNDER THE MEDI7 CARE PROGRAM. 

8 (a) STUDY.—The Secretary of Health and Human 

9 Services shall enter into a contract with an entity to con10 duct a study on— 

11 (1) the effectiveness of the coverage of geriatric 

12 assessments and chronic care management and co13 ordination services, including an evaluation of the 

14 use of interdisciplinary teams in providing such serv15 ices, under the Medicare program (under the amend16 ments made by sections 3 and 4) on improving the 

17 quality of care provided to Medicare beneficiaries 

18 with chronic conditions, including dementia; and 

19 (2) the impact of such geriatric assessments 

20 and care coordination services on reducing expendi21 tures under title XVIII of the Social Security Act, 

22 including reduced expenditures that may result 

23 from— 

24 (A) reducing preventable hospital admis25 sions; 


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1 (B) more appropriate use of pharma2 ceuticals; and 

3 (C) reducing duplicate or unnecessary 

4 tests. 

5 (b) REPORT.—Not later than 3 years after the date 

6 of enactment of this Act, the entity conducting the study 

7 under subsection (a) shall submit to Congress and the Sec8 retary of Health and Human Services a report on the 

9 study, together with recommendations for such legislation 

10 or administrative action as such entity determines appro11 priate. 

12 (c) AUTHORIZATION OF APPROPRIATIONS.—There 

13 are authorized to be appropriated such sums as may be 

14 necessary to carry out this section. 

15 SEC. 8. RULE OF CONSTRUCTION. 

16 Nothing in the provisions of, or in the amendments 

17 made by, this Act shall be construed as requiring an indi18 vidual to receive a geriatric assessment (as defined in sec19 tion 1861(hhh)(1) of the Social Security Act, as added by 

20 section 3(b)) or chronic care management and coordina21 tion services (as defined in section 1861(jjj)(1) of such 

22 Act, as added by section 4(b)). 

Æ 


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