I 

108TH CONGRESS 

1ST SESSION H. R. 796

To amend title XVIII of the Social Security Act to provide for coverage 

of expanded nursing facility and in-home services for dependent individuals under the Medicare Program. 

IN THE HOUSE OF REPRESENTATIVES 

FEBRUARY 13, 2003

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 

for coverage of expanded nursing facility and in-home 

services for dependent individuals under the Medicare 

Program.

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 ‘‘Comprehensive Long5 Term Care Act of 2003’’. 
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1 SEC. 2. EXPANDED LONG-TERM CARE SERVICES UNDER 

2 MEDICARE PROGRAM FOR DEPENDENT INDI3 VIDUALS. 

4 (a) IN GENERAL.—

5 (1) PART A.—Section 1812 of the Social Secu6 rity Act (42 U.S.C. 1395d) is amended—

7 (A) in subsection (a)—

8 (i) in paragraph (2)(B), by striking 

9 ‘‘subsection (f),’’ and inserting ‘‘subsection 

10 (f) and section 1889,’’, 

11 (ii) by striking ‘‘and’’ at the end of 

12 paragraph (3), 

13 (iii) by striking the period at the end 

14 of paragraph (4) and inserting ‘‘; and’’, 

15 and 

16 (iv) by adding at the end the following 

17 new paragraph: 

18 ‘‘(5) long-term care services consisting of ex19 tended care services (in accordance with section 

20 1889).’’; and 

21 (B) in subsection (b)(2), by striking ‘‘post22 hospital’’ and inserting ‘‘except as provided in 

23 section 1889, post-hospital’’. 

24 (2) PART B.—Section 1861(s)(2) of the Social 

25 Security Act (42 U.S.C. 1395x(s)(2)) is amended—
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1 (1) by striking ‘‘and’’ at the end of subpara2 graph (U); 

3 (2) by inserting ‘‘and’’ at the end of subpara4 graph (V); and 

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

7 ‘‘(W) long-term care services consisting of in8 home care (in accordance with section 1889);’’. 

9 (b) DESCRIPTION OF SERVICES; ELIGIBILITY.—Title 

10 XVIII of such Act is amended by inserting after section 

11 1888 the following new section: 

12 ‘‘LONG-TERM CARE SERVICES FOR DEPENDENT

13 INDIVIDUALS

14 ‘‘SEC. 1889. (a) IN GENERAL.—Benefits are payable 

15 under this title for long-term care services under this sec16 tion only if—

17 ‘‘(1) the individual is a dependent individual; 

18 and 

19 ‘‘(2) such services are provided in accordance 

20 with a case management plan developed by a case 

21 management agency. 

22 ‘‘(b) SERVICES PROVIDED.—In this section, the term 

23 ‘long-term care services’ means—

24 ‘‘(1) in-home care (as defined in subsection (e)); 

25 and
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1 ‘‘(2) extended care services (as defined in sec2 tion 1861(h)), but only with respect to a chronically 

3 dependent individual (as defined in subsection 

4 (d)(2)). 

5 ‘‘(c) PAYMENT FOR SERVICES.—

6 ‘‘(1) IN GENERAL.—Subject to paragraph (2), 

7 Notwithstanding any other provision of law, the 

8 amount payable under this title for long-term care 

9 services under this section shall be determined in ac10 cordance with a fee schedule for such services estab11 lished by the Secretary. 

12 ‘‘(2) IMPOSITION OF DEDUCTIBLE.—The 

13 amount otherwise payable under this title for long14 term care services under this section furnished dur15 ing a calendar year shall be reduced by an amount 

16 equal to the deductible imposed for inpatient hos17 pital services for the year under section 1813(a)(1). 

18 ‘‘(d) DEPENDENT INDIVIDUAL DEFINED.—

19 ‘‘(1) IN GENERAL.—In this section, the term 

20 ‘dependent individual’ means an individual who—

21 ‘‘(A) is unable to perform (without sub22 stantial assistance from another individual) be23 cause of physical or cognitive impairment at 

24 least 2 activities of daily living (as defined in 

25 paragraph (3)); or 
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1 ‘‘(B) has a similar level of disability due to 

2 cognitive impairment that requires substantial 

3 direction, instruction, or supervision of another 

4 individual in order—

5 ‘‘(i) to perform at least 2 activities of 

6 daily living; or 

7 ‘‘(ii) to remain in the community 

8 without causing harm to self or others be9 cause of inappropriate behavioral patterns. 

10 ‘‘(2) CHRONICALLY DEPENDENT INDIVIDUAL.—

11 In this section, the term ‘chronically dependent indi12 vidual’ means a dependent individual who would 

13 meet the requirements of paragraph (1) if ‘3 activi14 ties of daily living’ were substituted for ‘2 activities 

15 of daily living’. 

16 ‘‘(3) ACTIVITIES OF DAILY LIVING DEFINED.—

17 The ‘activities of daily living’ referred to in this sub18 section are as follows: 

19 ‘‘(A) Eating. 

20 ‘‘(B) Bathing. 

21 ‘‘(C) Dressing. 

22 ‘‘(D) Toileting. 

23 ‘‘(E) Transferring in and out of a bed or 

24 in and out of a chair. 

25 ‘‘(e) IN-HOME CARE.—
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1 ‘‘(1) IN GENERAL.—For purposes of this sec2 tion, the term ‘in-home care’ means the items and 

3 services described in paragraph (2) furnished to an 

4 individual by a home care agency (as defined in sec5 tion 1861(ww)) or by others under arrangements 

6 with them made by the agency provided in a place 

7 of residence used as such individual’s home (other 

8 than services described in paragraph (2)(H)). 

9 ‘‘(2) SERVICES DESCRIBED.—The items and 

10 services described in this paragraph are as follows: 

11 ‘‘(A) Nursing care provided by or under 

12 the supervision of a registered professional 

13 nurse. 

14 ‘‘(B) Services of a homemaker/home health 

15 aide who has successfully completed a training 

16 and competency evaluation program approved 

17 by the Secretary. 

18 ‘‘(C) Personal care services. 

19 ‘‘(D) Medical social services. 

20 ‘‘(E) Physical, occupational, or respiratory 

21 therapy or speech-language pathology services. 

22 ‘‘(F) Medical supplies (other than drugs 

23 and biologicals) and durable medical equipment, 

24 while under such a plan. 
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1 ‘‘(G) Patient and caregiver (including fam2 ily caregiver) education and training to develop 

3 skills necessary to permit the individual to re4 main in the home setting. 

5 ‘‘(H) Community care services furnished 

6 outside of the place of residence. 

7 ‘‘(I) Such other home-based items and 

8 services (other than room and board) as the 

9 Secretary may approve. 

10 ‘‘(f) CASE MANAGEMENT REQUIREMENTS.—

11 ‘‘(1) REQUESTS FOR ASSESSMENT.—Each indi12 vidual entitled to benefits under part A or part B 

13 (or another person on such individual’s behalf) may 

14 request a case management agency to conduct an as15 sessment under this subsection to determine whether 

16 the individual is a dependent individual or a chron17 ically dependent individual and to assess the individ18 ual’s needs for long-term care services under this 

19 section. 

20 ‘‘(2) DESCRIPTION OF PLANS.—For purposes of 

21 this section, a ‘case management plan’ means, with 

22 respect to an individual, a written plan of care 

23 which—
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1 ‘‘(A) is established and periodically re2 viewed and revised by a case management agen3 cy; and 

4 ‘‘(B) reflects the individual’s needs identi5 fied in the assessment under paragraph (1). 

6 ‘‘(3) CASE MANAGEMENT AGENCY DEFINED.—

7 In this section, the term ‘case management agency’ 

8 means a nonprofit or public agency or organization 

9 (or a nonprofit or public subdivision of such an 

10 agency or organization) certified by the Secretary to 

11 conduct assessments and establish case management 

12 plans under this subsection which—

13 ‘‘(A) is experienced in conducting assess14 ments, in establishing and periodically reviewing 

15 and revising case management plans for nurs16 ing facility services and in-home care, and in 

17 coordinating and reviewing the quality of the 

18 provision of such services and care; 

19 ‘‘(B) is capable of efficiently and effectively 

20 performing directly or through contracts under 

21 paragraph (4) such duties; and 

22 ‘‘(C) does not provide long-term care serv23 ices or nursing facility services and does not 

24 have a direct or indirect ownership or control 

25 interest in, or direct or indirect affiliation or re-
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1 lationship with, an entity that provides, such 

2 services. 

3 ‘‘(4) CONTRACTING OUT CERTAIN FUNC4 TIONS.—The Secretary shall permit a case manage5 ment agency, to the extent necessary to carry out 

6 functions under this section, to provide for assess7 ments and case management plans through con8 tracts with nonprofit or public organizations which 

9 do not provide long-term care services or nursing fa10 cility services and do not have a direct or indirect 

11 ownership or control interest in, or direct or indirect 

12 affiliation or relationship with, an entity that pro13 vides, such services.’’. 

14 (c) CONFORMING AMENDMENTS.—(1) Section 

15 1833(a)(1) of the Social Security Act (42 U.S.C. 

16 1395l(a)(1)) is amended—

17 (A) by striking ‘‘and’’ before ‘‘(U)’’; and 

18 (B) by inserting before the semicolon at the end 

19 the following: ‘‘, and (V) with respect to expenses in20 curred for services described in section 

21 1861(s)(2)(W), the amounts paid shall be the 

22 amounts determined under section 1889(c);’’. 

23 (2) Section 1861 of the Social Security Act (42 

24 U.S.C. 1395x) is amended by adding at the end the fol25 lowing new subsection: 
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1 ‘‘HOME CARE AGENCY

2 ‘‘(ww) The term ‘home care agency’ means a public 

3 agency or private organization, or a subdivision of such 

4 an agency or organization, which is a home health agency 

5 (as defined in subsection (o)) or—

6 ‘‘(1) is primarily engaged in providing services 

7 of homemaker/home health aides and personal care 

8 aides; 

9 ‘‘(2) maintains clinical records on all patients; 

10 ‘‘(3) in the case of an agency or organization in 

11 any State in which State or applicable local law pro12 vides for the licensing of agencies or organizations of 

13 this nature—

14 ‘‘(A) is licensed pursuant to such law, or 

15 ‘‘(B) is approved, by the agency of such 

16 State or locality, responsible for licensing agen17 cies or organizations of this nature, as meeting 

18 the standards established for such licensing; 

19 and 

20 ‘‘(4) meets such other requirements as the Sec21 retary may find necessary in the interest of the 

22 health and safety of individuals who are furnished 

23 services by such agency or organization and for the 

24 effective and efficient operation of the program.’’. 
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1 (d) EFFECTIVE DATE.—The amendments made by 

2 this section shall apply to items and services furnished on 

3 or after January 1, 2004.

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