I 

108TH CONGRESS 

2D SESSION H. R. 4689 

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

IN THE HOUSE OF REPRESENTATIVES 

JUNE 24, 2004 

Mr. GREEN of Texas (for himself, Mr. HINCHEY, Mr. RANGEL, Mr. FROST, 

Mr. GUTIERREZ, and Mr. ENGEL) introduced the following bill; which 

was referred to the Committee on Energy and Commerce, and in addition 

to the Committee on Ways and Means, 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 provide 

Medicare beneficiaries with access to geriatric assessments and chronic care management, 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 ‘‘Geriatric and Chronic Care Management Act of 2004’’. 
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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 services. 

Sec. 5. Study and report on best practices for medicare chronic care management. 

3 SEC. 2. FINDINGS. 

4 Congress makes the following findings: 

5 (1) We must redesign the medicare system to 

6 provide high-quality, cost-effective care to a growing 

7 population: elderly individuals with multiple chronic 

8 conditions. 

9 (2) According to the Congressional Budget Of10 fice, 50 percent of medicare costs can be attributed 

11 to 5 percent of medicare’s most costly beneficiaries. 

12 (3) Currently, 82 percent of the medicare population has at least 1 chronic condition, and 2 13 ⁄3 have 

14 more than 1 chronic condition. The 20 percent of 

15 beneficiaries with 5 or more chronic conditions account for 2 16 ⁄3 of all medicare spending. In addition, 

17 the large Baby Boomer generation is moving toward 

18 retirement and medicare eligibility. 

19 (4) In general, the prevalence of chronic condi20 tions increases with age: 74 percent of the 65- to 

21 69-year-old group have a least 1 chronic condition, 

22 while 86 percent of the 85 years and older group 
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1 have at least 1 chronic condition. Similarly, just 14 

2 percent of the 65- to 69-year-olds have 5 or more 

3 chronic conditions, but 28 percent of the 85 years 

4 and older group have 5 or more chronic conditions. 

5 (5) There is a strong pattern of increasing utili6 zation as the number of conditions increase. Fifty7 five percent of medicare beneficiaries with 5 or more 

8 conditions experienced an inpatient hospital stay 

9 compared to 5 percent for those with 1 condition or 

10 9 percent for those with 2 conditions. 

11 (6) In terms of physician visits, the average 

12 medicare beneficiary has over 15 physician visits an13 nually and sees 6 different physicians annually. 

14 (7) There is almost a 4-fold increase in visits by 

15 people with 5 chronic conditions compared to visits 

16 by people with 1 chronic condition. The number of 

specific physicians seen increases almost 21 17 ⁄2 times 

18 for people with 5 or more chronic conditions relative 

19 to those with just 1 chronic condition. 

20 (8) When Alzheimer’s disease and dementia are 

21 present along with 1 or more other chronic condi22 tions, utilization also increases. For example, in 

23 2000, total average per person medicare expendi24 tures for those with congestive heart failure and Alz25 heimer’s or dementia were 47 percent higher than 
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1 for those with congestive heart failure and no de2 mentia. 

3 (9) Based on numerous studies in the United 

4 States and internationally, we know that the delivery 

5 of higher quality health care, increased efficiency 

6 and cost-effectiveness are the result of systems in 

7 which patients are linked with a physician or other 

8 qualified health professional who coordinates their 

9 care. 

10 (10) The current medicare program penalizes 

11 physicians for integrating and coordinating health 

12 care because these services are not explicitly recog13 nized and distinctly paid for. Instead, physicians are 

14 incentivized to provide episodic care and to generate 

15 more individual patient visits to the doctor’s office 

16 and hospital for separately reimbursed tests and 

17 procedures. 

18 (11) The chronic care model established by this 

19 Act includes several elements that are effective in 

20 managing chronic disease— 

21 (A) linkages with community resources; 

22 (B) health care system changes that re23 ward quality chronic care; 

24 (C) support for patient self-management of 

25 chronic disease; 
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1 (D) practice redesign; 

2 (E) evidence-based clinical practice guide3 lines; and 

4 (F) clinical information systems, such as 

5 electronic medical records and continuity of 

6 care records. 

7 (12) We must realign the financial incentives 

8 within medicare as part of a comprehensive system 

9 change. Medicare should be restructured to reim10 burse physicians and other qualified health profes11 sionals for the cost of coordinating care. 

12 SEC. 3. MEDICARE COVERAGE OF GERIATRIC ASSESS13 MENTS. 

14 (a) PART B COVERAGE OF GERIATRIC ASSESS15 MENTS.— 

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

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

18 amended by section 642(a) of the Medicare Prescrip19 tion Drug, Improvement, and Modernization Act of 

20 2003 (Public Law 108–173; 117 Stat. 2322), is 

21 amended— 

22 (A) in subparagraph (Y), by striking 

23 ‘‘and’’ after the semicolon at the end; 

24 (B) in subparagraph (Z), by adding ‘‘and’’ 

25 after the semicolon at the end; and 
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1 (C) by adding at the end the following new 

2 subparagraph: 

3 ‘‘(AA) geriatric assessments (as defined in sub4 section (bbb)(1)).’’. 

5 (2) CONFORMING AMENDMENTS.—(A) Section 

6 1862(a)(7) of the Social Security Act (42 U.S.C. 

7 1395y(a)(7)), as amended by section 611(d)(1)(B) 

8 of the Medicare Prescription Drug, Improvement, 

9 and Modernization Act of 2003 (Public Law 108– 

10 173; 117 Stat. 2304), is amended by striking ‘‘or 

11 (K)’’ and inserting ‘‘(K), or (AA)’’. 

12 (B) Clauses (i) and (ii) of section 

13 1861(s)(2)(K) of the Social Security Act (42 U.S.C. 

14 1395x(s)(2)(K)), as amended by section 611(d)(2) of 

15 the Medicare Prescription Drug, Improvement, and 

16 Modernization Act of 2003 (Public Law 108–173; 

17 117 Stat. 2304), are each amended by striking 

18 ‘‘subsection (ww)(1)’’ and inserting ‘‘subsections 

19 (ww)(1) and (bbb)(1)’’. 

20 (b) GERIATRIC ASSESSMENTS DEFINED.—Section 

21 1861 of the Social Security Act (42 U.S.C. 1395x), as 

22 amended by section 706(b) of the Medicare Prescription 

23 Drug, Improvement, and Modernization Act of 2003 (Pub24 lic Law 108–173; 117 Stat. 2339), is amended by adding 

25 at the end the following new subsection: 
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1 ‘‘Geriatric Assessment; Eligible Individual 

2 ‘‘(bbb)(1) The term ‘geriatric assessment’ means— 

3 ‘‘(A) an initial assessment of an eligible individ4 ual’s medical condition, functional and cognitive ca5 pacity, primary caregiver needs, and environmental 

6 and psychosocial needs that is conducted by a physi7 cian or an entity that meets such conditions as the 

8 Secretary may specify (which may include physi9 cians, physician group practices, or other health care 

10 professionals or entities the Secretary may find ap11 propriate) working in collaboration with a physician; 

12 and 

13 ‘‘(B) subsequent assessments, which may not be 

14 conducted more frequently than annually, unless a 

15 physician or chronic care manager of the eligible in16 dividual determines that such assessments are re17 quired due to sentinel health events or changes in 

18 the health status of the individual that may require 

19 changes in plans of care developed for the individual. 

20 ‘‘(2)(A) For purposes of this subsection, the term ‘eli21 gible individual’ means an individual who has— 

22 ‘‘(i) at least 5 chronic conditions and an inabil23 ity to manage care (as defined by the Secretary); or 

24 ‘‘(ii) a mental or cognitive impairment, includ25 ing dementia, and at least 1 other chronic condition. 
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1 ‘‘(B) For purposes of this paragraph, the term 

2 ‘chronic condition’ means an illness, functional limitation, 

3 or cognitive impairment that is expected to last at least 

4 1 year, limits the activities of an individual, and requires 

5 ongoing care.’’. 

6 (c) PAYMENT AND ELIMINATION OF COST-SHAR7 ING.— 

8 (1) PAYMENT AND ELIMINATION OF COINSUR9 ANCE.—Section 1833(a)(1) of the Social Security 

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

11 302(b)(2) of the Medicare Prescription Drug, Im12 provement, and Modernization Act of 2003 (Public 

13 Law 108–173; 117 Stat. 2229), is amended— 

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

15 ‘‘other than geriatric assessments (as defined in 

16 section 1861(bbb)(1))’’ after ‘‘(as defined in 

17 section 1848(j)(3))’’; 

18 (B) by striking ‘‘and’’ before ‘‘(V)’’; and 

19 (C) by inserting before the semicolon at 

20 the end the following: ‘‘, and (W) with respect 

21 to geriatric assessments (as defined in section 

22 1861(bbb)(1)), the amount paid shall be 100 

23 percent of the lesser of the actual charge for 

24 the services or the amount determined under 
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1 the payment basis determined under section 

2 1848’’. 

3 (2) PAYMENT UNDER PHYSICIAN FEE SCHED4 ULE.—Section 1848(j)(3) of the Social Security Act 

5 (42 U.S.C. 1395w–4(j)(3)), as amended by section 

6 611(c) of the Medicare Prescription Drug, Improve7 ment, and Modernization Act of 2003 (Public Law 

8 108–173; 117 Stat. 2304), is amended by inserting 

9 ‘‘(2)(AA),’’ after ‘‘(2)(W),’’. 

10 (3) ELIMINATION OF COINSURANCE IN OUT11 PATIENT HOSPITAL SETTINGS.— 

12 (A) EXCLUSION FROM OPD FEE SCHED13 ULE.—Section 1833(t)(1)(B)(iv) of the Social 

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

15 amended by section 614 of the Medicare Pre16 scription Drug, Improvement, and Moderniza17 tion Act of 2003 (Public Law 108–173; 117 

18 Stat. 2306), is amended by striking ‘‘and diag19 nostic mammography’’ and inserting ‘‘, diag20 nostic mammography, or geriatric assessments 

21 (as defined in section 1861(bbb)(1))’’. 

22 (B) CONFORMING AMENDMENTS.—Section 

23 1833(a)(2) of the Social Security Act (42 

24 U.S.C. 1395l(a)(2)) is amended— 
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1 (i) in subparagraph (F), by striking 

2 ‘‘and’’ after the semicolon at the end; 

3 (ii) in subparagraph (G)(ii), by strik4 ing the comma at the end and inserting ‘‘; 

5 and’’; and 

6 (iii) by inserting after subparagraph 

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

8 ‘‘(H) with respect to geriatric assessments 

9 (as defined in section 1861(bbb)(1)) furnished 

10 by an outpatient department of a hospital, the 

11 amount determined under paragraph (1)(W),’’. 

12 (4) ELIMINATION OF DEDUCTIBLE.—The first 

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

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

15 (A) by striking ‘‘and’’ before ‘‘(6)’’; and 

16 (B) by inserting before the period the fol17 lowing: ‘‘, and (7) such deductible shall not 

18 apply with respect to geriatric assessments (as 

19 defined in section 1861(bbb)(1))’’. 

20 (d) FREQUENCY LIMITATION.—Section 1862(a)(1) of 

21 the Social Security Act (42 U.S.C. 1395y(a)(1)), as 

22 amended by section 613(c) of the Medicare Prescription 

23 Drug, Improvement, and Modernization Act of 2003 (Pub24 lic Law 108–173; 117 Stat. 2306), is amended— 
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1 (1) by striking ‘‘and’’ at the end of subpara2 graph (L); 

3 (2) by striking the semicolon at the end of sub4 paragraph (M) and inserting ‘‘, and’’; and 

5 (3) by adding at the end the following new sub6 paragraph: 

7 ‘‘(N) in the case of geriatric assessments (as 

8 defined in section 1861(bbb)(1)), which are per9 formed more frequently than is covered under such 

10 section;’’. 

11 (e) EXCEPTION TO LIMITS ON PHYSICIAN REFER12 RALS.—Section 1877(b) of the Social Security Act (42 

13 U.S.C. 1395nn(b)), as amended by section 101(e)(8)(B) 

14 of the Medicare Prescription Drug, Improvement, and 

15 Modernization Act of 2003 (Public Law 108–173; 117 

16 Stat. 2306), is amended by adding at the end the following 

17 new paragraph: 

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

19 a designated health service, if the designated health 

20 service is a geriatric assessment (as defined in sec21 tion 1861(bbb)(1)) and furnished by a physician.’’. 

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

23 Human Services shall define such terms and establish 

24 such procedures as the Secretary determines necessary to 

25 implement the provisions of this section. 
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1 (g) EFFECTIVE DATE.—The amendments made by 

2 this section shall apply to assessments and chronic care 

3 management services furnished on or after January 1, 

4 2005. 

5 SEC. 4. MEDICARE COVERAGE OF CHRONIC CARE MANAGE6 MENT SERVICES. 

7 (a) PART B COVERAGE OF CHRONIC CARE MANAGE8 MENT SERVICES.— 

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

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

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

12 (A) in subparagraph (Z), by striking 

13 ‘‘and’’ after the semicolon at the end; 

14 (B) in subparagraph (AA), by adding 

15 ‘‘and’’ after the semicolon at the end; and 

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

17 subparagraph: 

18 ‘‘(BB) chronic care management services (as 

19 defined in subsection (ccc));’’. 

20 (2) CONFORMING AMENDMENTS.—(A) Section 

21 1862(a)(7) of the Social Security Act (42 U.S.C. 

22 1395y(a)(7)), as amended section 3(a)(2)(A), is 

23 amended by striking ‘‘or (AA)’’ and inserting ‘‘(AA), 

24 or (BB)’’. 
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1 (B) Clauses (i) and (ii) of section 

2 1861(s)(2)(K) of the Social Security Act (42 U.S.C. 

3 1395x(s)(2)(K)), as amended by section 3(a)(2)(B), 

4 are each amended by striking ‘‘subsections (ww)(1) 

5 and (bbb)’’ and inserting ‘‘subsections (ww)(1), 

6 (bbb), and (ccc)’’. 

7 (b) SERVICES DESCRIBED.—Section 1861 of the So8 cial Security Act (42 U.S.C. 1395x), as amended by sec9 tion 3(b), is amended by adding at the end the following 

10 new subsection: 

11 ‘‘Chronic Care Management Services; Chronic Care 

12 Manager; Eligible Individual 

13 ‘‘(ccc)(1) The term ‘chronic care management serv14 ices’ means services that are furnished to an eligible indi15 vidual (as defined in paragraph (3)) by a chronic care 

16 manager (as defined in paragraph (2)) under a plan of 

17 care prescribed by such chronic care manager for the pur18 pose of chronic care management, which may include any 

19 of the following services: 

20 ‘‘(A) The development of an initial plan of care, 

21 and subsequent appropriate revisions to that plan of 

22 care. 

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

24 medical and other health services, including multi-
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1 disciplinary care conferences and management with 

2 other providers. 

3 ‘‘(C) The monitoring and management of medi4 cations. 

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

6 ‘‘(E) Family caregiver education and counseling 

7 services. 

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

9 health education and risk appraisal to identify be10 havioral risk factors through self-assessment. 

11 ‘‘(G) Providing access for consultations by tele12 phone with physicians and other appropriate health 

13 care professionals, including 24-hour availability of 

14 such professionals for emergency consultations. 

15 ‘‘(H) Management with the principal nonprofes16 sional caregiver in the home. 

17 ‘‘(I) Managing and facilitating transitions 

18 among health care professionals and across settings 

19 of care, including the following: 

20 ‘‘(i) Pursuing the treatment option elected 

21 by the individual. 

22 ‘‘(ii) Including any advance directive exe23 cuted by the individual in the medical file of the 

24 individual. 
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1 ‘‘(J) Information about, and referral to, hospice 

2 services, including patient and family caregiver edu3 cation and counseling about hospice, and facilitating 

4 transition to hospice when elected. 

5 ‘‘(K) Information about, referral to, and man6 agement with, community services. 

7 ‘‘(L) 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 to improve the effectiveness of, the 

11 services 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 (as defined in subsection 

17 (r)(1)); or 

18 ‘‘(II) a practitioner described in section 

19 1842(b)(18)(C) or an entity that meets such 

20 conditions as the Secretary may specify (which 

21 may include physicians, physician group prac22 tices, or other health care professionals or enti23 ties the Secretary may find appropriate) work24 ing in collaboration with a physician; 
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1 ‘‘(ii) has entered into a chronic care manage2 ment agreement with the Secretary; and 

3 ‘‘(iii) meets such other criteria as the Secretary 

4 may establish (which may include experience in the 

5 provision of chronic care management or primary 

6 care physicians’ services). 

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

8 chronic care management agreement shall— 

9 ‘‘(i) be entered into for a period of 1 year and 

10 may be renewed if the Secretary is satisfied that the 

11 chronic care manager continues to meet the condi12 tions of participation specified in subparagraph (A); 

13 ‘‘(ii) ensure that the chronic care manager will 

14 submit reports to the Secretary on the functional 

15 and medical status of eligible individuals who receive 

16 chronic care management services, expenditures re17 lating to such services, and health outcomes relating 

18 to such services, except that the Secretary may not 

19 require a chronic care manager to submit more than 

20 one such report during a year; and 

21 ‘‘(iii) contain such other terms and conditions 

22 as the Secretary may require. 

23 ‘‘(3) For purposes of this subsection, the term ‘eligi24 ble individual’ means an eligible individual (as defined in 

25 subsection (bbb)(2)) who has undergone a geriatric assess-
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1 ment (as defined in subsection (bbb)(1)) and who a physi2 cian has determined would benefit from chronic care man3 agement.’’. 

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 services (as defined in 

12 section 1861(ccc))’’ after ‘‘other than geriatric 

13 assessments (as defined in section 

14 1861(bbb)(1))’’; 

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

16 (C) by inserting before the semicolon at 

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

18 to chronic care management services (as de19 fined in section 1861(ccc)), the amount paid 

20 shall be 100 percent of the amount determined 

21 under section 1834(n)’’. 

22 (2) PAYMENT.—Section 1834 of the Social Se23 curity Act (42 U.S.C. 1395m) is amended by adding 

24 at the end the following new subsection: 
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1 ‘‘(n) PAYMENT FOR CHRONIC CARE MANAGEMENT

2 SERVICES.— 

3 ‘‘(1) IN GENERAL.—The Secretary shall pay for 

4 chronic care management services (as defined in sec5 tion 1861(ccc)(1)) furnished to an eligible individual 

6 (as defined in section 1861(ccc)(3)) by a chronic 

7 care manager (as defined in section 1861(ccc)(2))— 

8 ‘‘(A) separately from geriatric assessments 

9 (as defined in section 1861(bbb)(1)) and other 

10 services for which payment is made under this 

11 title; and 

12 ‘‘(B) based on the methodology selected by 

13 the chronic care manager (as so defined) from 

14 among the methodologies developed and imple15 mented by the Secretary under paragraph (2). 

16 ‘‘(2) DEVELOPMENT AND IMPLEMENTATION OF

17 PAYMENT METHODOLOGIES.—The Secretary, in con18 sultation with national membership associations rep19 resenting physicians, qualified health professionals, 

20 and patients, shall develop and implement payment 

21 methodologies applicable with respect to chronic care 

22 management services (as defined in section 

23 1861(ccc)(1)) as follows: 

24 ‘‘(A) UNADJUSTED MONTHLY CAPITATED

25 PAYMENT AMOUNT.—A per patient per month 
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1 chronic care management fee separate from 

2 evaluation and management services for which 

3 payment is made under the physician fee sched4 ule under section 1848 that does not take into 

5 account the severity of the eligible individual’s 

6 condition. 

7 ‘‘(B) ADJUSTED MONTHLY CAPITATED

8 PAYMENT AMOUNT.—A per patient per month 

9 chronic care management fee separate from 

10 evaluation and management services for which 

11 payment is made under the physician fee sched12 ule under section 1848 that provides for an ad13 justment to the payment amount based on the 

14 severity of the eligible individual’s condition. 

15 ‘‘(C) UNADJUSTED FEE SCHEDULE

16 AMOUNT.—A chronic care management fee for 

17 care coordination that includes payment for re18 lated evaluation and management services for 

19 which payment would otherwise be made under 

20 the physician fee schedule under section 1848 

21 that does not take into account the severity of 

22 the eligible individual’s condition. 

23 ‘‘(D) ADJUSTED FEE SCHEDULE

24 AMOUNT.—A chronic care management fee for 

25 care coordination that includes payment for re-
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1 lated evaluation and management services for 

2 which payment would otherwise be made under 

3 the physician fee schedule under section 1848 

4 that provides for an adjustment to the payment 

5 amount based on the severity of the eligible in6 dividual’s condition. 

7 ‘‘(E) OTHER PAYMENT METHODOLO8 GIES.—Any other payment methodology that 

9 the Secretary determines effective in creating 

10 incentives for physicians and other chronic care 

11 managers to make practice-based improvements 

12 to improve the quality and cost-effectiveness of 

13 care provided to eligible individuals.’’. 

14 (3) ELIMINATION OF COINSURANCE IN OUT15 PATIENT HOSPITAL SETTINGS.— 

16 (A) EXCLUSION FROM OPD FEE SCHED17 ULE.—Section 1833(t)(1)(B)(iv) of the Social 

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

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

20 striking ‘‘or geriatric assessments (as defined in 

21 section 1861(bbb)(1))’’ and inserting ‘‘geriatric 

22 assessments (as defined in section 

23 1861(bbb)(1)), or chronic care management 

24 services (as defined in section 1861(ccc)(1))’’. 
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1 (B) CONFORMING AMENDMENTS.—Section 

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

3 U.S.C. 1395l(a)(2)) is amended— 

4 (i) in subparagraph (G)(ii), by strik5 ing ‘‘and’’ after the semicolon at the end; 

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

7 the comma at the end and inserting ‘‘; 

8 and’’; and 

9 (iii) by inserting after subparagraph 

10 (H) the following new subparagraph: 

11 ‘‘(I) with respect to chronic care manage12 ment services (as defined in section 

13 1861(ccc)(1)) furnished by an outpatient de14 partment of a hospital, the amount determined 

15 under section 1834(n),’’. 

16 (4) ELIMINATION OF DEDUCTIBLE.—Section 

17 1833(b)(7) of the Social Security Act (42 U.S.C. 

18 1395l(b)(7)), as added by section 3(c)(4), is amend19 ed by inserting ‘‘or chronic care management serv20 ices (as defined in section 1861(ccc)(1))’’ after 

21 ‘‘geriatric assessments (as defined in section 

22 1861(bbb)(1))’’. 

23 (d) APPLICATION OF LIMITS ON BILLING.—Section 

24 1842(b)(18)(C) of the Social Security Act (42 U.S.C. 
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1 1395u(b)(18)(C)) is amended by adding at the end the 

2 following new clause: 

3 ‘‘(vii) A chronic care manager (as defined in 

4 section 1861(ccc)(2)) that is not a physician.’’. 

5 (e) EXCEPTION TO LIMITS ON PHYSICIAN REFER6 RALS.—Section 1877(b)(6) of the Social Security Act (42 

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

8 amended to read as follows: 

9 ‘‘(6) GERIATRIC ASSESSMENTS AND CHRONIC

10 CARE MANAGEMENT SERVICES.—In the case of a 

11 designated health service, if the designated health 

12 service is— 

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

14 care management service (as defined in sub15 sections (bbb)(1) or (ccc)(1) of section 1861, 

16 respectively); and 

17 ‘‘(B) provided by a physician or a chronic 

18 care manager (as defined in section 

19 1861(ccc)(2)).’’. 

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

21 Human Services shall define such terms and establish 

22 such procedures as the Secretary determines necessary to 

23 implement the provisions of this section. 

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

25 this section shall apply to assessments and chronic care 
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1 management services furnished on or after January 1, 

2 2005. 

3 SEC. 5. STUDY AND REPORT ON BEST PRACTICES FOR 

4 MEDICARE CHRONIC CARE MANAGEMENT. 

5 (a) STUDY.—The Secretary, in consultation with the 

6 Medicare Payment Advisory Commission, shall conduct a 

7 thorough study of the following issues: 

8 (1) The effectiveness of the different payment 

9 methodologies applicable with respect to chronic care 

10 management services developed and implemented 

11 under section 1834(n)(2) of the Social Security Act 

12 (as added by section 4(c)(2)). 

13 (2) The effectiveness of pay-for-performance 

14 programs to serve medicare beneficiaries with mul15 tiple chronic conditions, including dementia. 

16 (3) Process measures and outcomes for medi17 care beneficiaries with multiple chronic illnesses, in18 cluding dementia. 

19 (4) The cost-effectiveness and quality associated 

20 with chronic care management under the medicare 

21 program. 

22 (5) The feasibility of broadening and incor23 porating the findings of the Assessing Care of Vul24 nerable Elders (ACOVE) study into the medicare 

25 program. 
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1 (b) REPORT.—Not later than the date that is 1 year 

2 after the date of enactment of this Act, the Secretary of 

3 Health and Human Services shall submit to Congress a 

4 report on the study conducted under subsection (a) that 

5 contains— 

6 (1) recommendations on the best practices for 

7 chronic care management of the conditions of medi8 care beneficiaries with multiple chronic conditions, 

9 including dementia; and 

10 (2) such other recommendations for legislation 

11 or administrative action as the Secretary determines 

12 appropriate. 

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