I 
111TH CONGRESS 
1ST SESSION H. R. 2307 
To amend title XVIII of the Social Security Act to provide Medicare bene-
ficiaries with access to geriatric assessments and chronic care manage-
ment and coordination services, and for other purposes. 
IN THE HOUSE OF REPRESENTATIVES 
MAY 7, 2009 
Mr. GENE GREEN of Texas (for himself and Mr. UPTON) introduced the fol-
lowing bill; which was referred to the Committee on Energy and Com-
merce, and in addition to the Committee on Ways and Means, for a pe-
riod to be subsequently determined by the Speaker, in each case for con-
sideration of such provisions as fall within the jurisdiction of the com-
mittee concerned 
A BILL 
To amend title XVIII of the Social Security Act to provide 
Medicare beneficiaries with access to geriatric assess-
ments and chronic care management and coordination 
services, and for other purposes. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 
(a) SHORT TITLE.—This Act may be cited as the 
‘‘The Reaching Elders with Assessment and Chronic Care 
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Management and Coordination Act’’ or the ‘‘RE-Aligning 
Care Act’’. 
(b) TABLE OF CONTENTS.—The table of contents of 
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 serv-
ices. 
Sec. 5. Outreach activities regarding geriatric assessments and chronic care 
management and coordination services under the Medicare pro-
gram. 
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 manage-
ment and coordination services under the Medicare program. 
Sec. 8. Rule of construction. 
SEC. 2. FINDINGS. 
Congress makes the following findings: 
(1) The Medicare program must be redesigned 
to provide high-quality, cost-effective and coordi-
nated care to the growing population of elderly indi-
viduals with multiple and complex chronic condi-
tions. 
(2) Between 2005 and 2030, it is estimated 
that the number of adults aged 65 and older will al-
most double from 37,000,000 to more than 
70,000,000. The number of those age 80 and over, 
is also expected to nearly double from 11,000,000 to 
20,000,000. This demographic shift will create the 
largest ever proportion of adults over 65, increasing 
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from 12 percent of the United States population in 
2005 to almost 20 percent by 2030. 
(3) With the unprecedented growth of our Na-
tion’s aging population, the number of older patients 
with multiple chronic conditions and cognitive im-
pairments is expected to increase. Currently, about 
65 percent of Medicare beneficiaries have two or 
more chronic conditions. To address the health care 
needs unique to older adults with chronic conditions, 
it will require innovations in care delivery and com-
prehensive coordinated care. 
(4) According to the Congressional Budget Of-
fice, approximately 75 percent of Medicare spending 
pays for care for beneficiaries who have five or more 
chronic conditions and see an average of 14 different 
physicians per year. In addition, approximately 43 
percent of Medicare costs can be attributed to 5 per-
cent of Medicare’s most costly beneficiaries. 
(5) Total Medicare costs per beneficiary age 65 
or older with Alzheimer’s and other dementias were 
almost three times higher than for other Medicare 
beneficiaries in 2004. 
(6) There is a strong pattern of increasing utili-
zation as the number of conditions increase. In 
2003, 61 percent of Medicare beneficiaries with 3 
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chronic conditions saw 10 or more different physi-
cians compared to 40 percent with 2 conditions and 
18 percent of those with 1 condition. 
(7) According to a June 2006 MedPAC report, 
even if individual providers deliver care efficiently, 
overall care for a beneficiary may be inefficient if 
providers do not coordinate across settings or assist 
beneficiaries in managing their conditions between 
visits. Beneficiaries with multiple chronic conditions 
may benefit the most from care coordination as they 
do not always receive necessary care and often at 
high cost. 
(8) On average, individuals 65 to 69 years old 
take nearly 14 prescriptions per year and individuals 
aged 80 to 84 take an average of 18 prescriptions 
per year. As the number of chronic conditions in-
creases, so does the number of medications, increas-
ing the risk for negative drug interactions that can 
lead to serious injury requiring hospitalization or 
can even be fatal. Studies have found that 25 per-
cent to 50 percent adverse drug events among older 
persons are preventable and that preventable adverse 
drug events may cost the Medicare program 
$887,000,000 per year. 
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(9) Research conducted in the United States 
and internationally indicate that the delivery of high-
er quality health care, increased efficiency, and cost- 
effectiveness are the result of systems in which pa-
tients are linked with a physician or another quali-
fied health professional who coordinates their care. 
According to the Congressional Budget Office, an 
intervention that focused on coordinating care for 
high-cost beneficiaries with multiple chronic condi-
tions could both improve their health and reduce 
Medicare spending. 
(10) In addition, chronic care management and 
coordination may help prevent negative medication 
interactions and prevent hospital stays because the 
chronic care team holistically manages and treats ill-
ness. Reducing the rate of preventable adverse drug 
events will both improve patient care and may result 
in savings to the Medicare program. 
(11) The Medicare fee-for-service program cur-
rently does not pay for care coordination services. 
Instead, the delivery and payment systems are orga-
nized to support the diagnosis and treatment of 
acute or episodic conditions, resulting in fragmented, 
ineffective and costly care for beneficiaries with 
chronic diseases. It currently rewards the overuse 
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and duplication of services rather than rewarding 
the effective control of chronic conditions, which can 
improve health outcomes and prevent hospitalization 
or rehospitalization. 
(12) The Institute of Medicine Report, ‘‘Retool-
ing for an Aging America: Building the Health Care 
Workforce’’, cited misaligned financial incentives, in-
cluding the inability to reimburse for care coordina-
tion, as factors that result in fragmented care for 
older Americans. 
(13) Financial incentives within the Medicare 
program should be realigned as part of a com-
prehensive system change. The Medicare program 
should be restructured to reimburse physicians and 
other qualified health professionals for the cost of 
coordinating care. 
(14) The patient-centered chronic care model 
established by the provisions of, and the amend-
ments made by, this Act includes several elements 
that are effective in managing older adults with 
chronic disease, including— 
(A) a comprehensive assessment of the in-
dividual’s physical, cognitive, affective, func-
tional and social status, and caregiving needs; 
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(B) access to patient-centered care coordi-
nation services provided by interdisciplinary 
team members; 
(C) support for patient self-management of 
chronic disease; 
(D) linkages with community resources; 
(E) health care system changes that re-
ward quality chronic care; 
(F) practice redesign; 
(G) evidence-based clinical practice guide-
lines; and 
(H) clinical information systems, such as 
electronic medical records and continuity of 
care records. 
(15) The provisions of, and amendments made 
by, this Act are intended to— 
(A) improve health outcomes appropriate 
for older patients with multiple chronic condi-
tions; 
(B) increase beneficiary, caregiver, and 
provider satisfaction; 
(C) increase cost-effectiveness and high 
value to the Medicare program for those served 
with multiple chronic conditions; 
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(D) establish a process to identify those 
Medicare beneficiaries most likely to benefit 
from having a provider coordinate their health 
care needs; and 
(E) establish a payment under the Medi-
care program for— 
(i) the assessment of those health care 
needs; and 
(ii) the activities required to coordi-
nate those health care needs. 
SEC. 3. MEDICARE COVERAGE OF GERIATRIC ASSESS-
MENTS. 
(a) COVERAGE OF GERIATRIC ASSESSMENTS.— 
(1) IN
GENERAL.—Section 1861(s)(2) of the 
Social Security Act (42 U.S.C. 1395x(s)(2)) is 
amended— 
(A) in subparagraph (DD), by striking 
‘‘and’’ at the end; 
(B) in subparagraph (EE), by adding 
‘‘and’’ at the end; and 
(C) by adding at the end the following new 
subparagraph: 
‘‘(FF) geriatric assessments (as defined in sub-
section (hhh)(1));’’. 
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(2) CONFORMING
AMENDMENTS.—Clauses (i) 
and (ii) of section 1861(s)(2)(K) of the Social Secu-
rity Act (42 U.S.C. 1395x(s)(2)(K)) are each 
amended by striking ‘‘subsection (ww)(1)’’ and in-
serting ‘‘subsections (ww)(1) and (hhh)(1)’’. 
(b) GERIATRIC ASSESSMENTS DEFINED.—Section 
1861 of the Social Security Act (42 U.S.C. 1395x) is 
amended by adding at the end the following new sub-
sections: 
‘‘Geriatric Assessment 
‘‘(hhh)(1) The term ‘geriatric assessment’ means 
each of the following: 
‘‘(A) An assessment of the clinical status, func-
tional status, social and environmental functioning, 
and need for caregiving of a geriatric assessment eli-
gible individual (as defined in subsection (iii)). The 
assessment shall include a comprehensive history 
and physical examination and assessments of the fol-
lowing domains using standardized validated clinical 
tools: 
‘‘(i) Comprehensive review of medications 
and the individual’s adherence to the medica-
tion regimen. 
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‘‘(ii) Measurement of affect, cognition and 
executive function, mobility, balance, gait, risk 
of falling, and sensory function. 
‘‘(iii) Social functioning, environmental 
needs, and caregiver resources and needs. 
‘‘(iv) Any other domain determined appro-
priate by the Secretary. 
‘‘(B) The development of a written care plan 
based on the results of the assessment under sub-
paragraph (A) (and any subsequent assessment 
under subparagraph (B)). The care plan shall detail 
identified problems, outline therapies, assign respon-
sibility for actions, and indicate whether the indi-
vidual is likely to benefit from chronic care manage-
ment and coordination services (as defined in sub-
section (jjj)(1)). If the individual is determined likely 
to benefit from chronic care management and co-
ordination services, the care plan shall also provide 
the basis for the chronic care management and co-
ordination plan to be developed by the chronic care 
manager pursuant to subsection (jjj). 
‘‘(2) A geriatric assessment may only be conducted 
by— 
‘‘(A) a physician; 
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‘‘(B) 
a 
practitioner 
described 
in 
section 
1842(b)(18)(C)(i) under the supervision of a physi-
cian; or 
‘‘(C) any other provider that meets such condi-
tions as the Secretary may specify. 
‘‘(3) An individual described in subclause (A), (B), 
or, if applicable, (C) may provide for the furnishing of 
services included in the geriatric assessment by other 
qualified health care professionals. 
‘‘(4)(A) Subject to subparagraph (B), a geriatric as-
sessment of a geriatric assessment eligible individual may 
not be conducted more frequently than annually. 
‘‘(B) A geriatric assessment of a geriatric assessment 
eligible individual may be conducted more frequently than 
annually if the assessment is medically necessary due to 
a significant change in the condition of the individual. 
‘‘Geriatric Assessment Eligible Individual 
‘‘(iii)(1) Subject to paragraph (3), the term ‘geriatric 
assessment eligible individual’ means an individual identi-
fied by the Secretary as eligible for a geriatric assessment. 
‘‘(2) In identifying individuals under paragraph (1), 
the following rules shall apply: 
‘‘(A) The individual must have at least 1 of the 
following present: 
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‘‘(i) Multiple chronic conditions that the 
Secretary identifies as likely to result in high 
expenditures under this title. In identifying 
such conditions, the Secretary may consider— 
‘‘(I) the hierarchal condition category 
methodology employed for risk adjustment 
under part C or other comparable meth-
odologies the Secretary deems appropriate; 
‘‘(II) data from the Chronic Condition 
Data Warehouse under section 723 of the 
Medicare Prescription Drug, Improvement, 
and Modernization Act of 2003; and 
‘‘(III) indicators of geriatric syn-
dromes, such as experiencing 2 or more 
falls in the past year, urinary incontinence, 
clinically significant depression, or other 
such indicators that the Secretary indicates 
as likely to result in high expenditures 
under this title when they exist in com-
bination with one or more chronic condi-
tions). 
‘‘(ii) Dementia, as defined in the most re-
cent Diagnostic and Statistical Manual of Men-
tal Disorders, and at least 1 other chronic con-
dition. 
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‘‘(iii) Any other factor identified by the 
Secretary. 
‘‘(B) The Secretary shall consult with physi-
cians, physician groups and organizations, other 
health care professional groups and organizations, 
organizations representing individuals with chronic 
conditions and older adults, and other stakeholders 
in identifying conditions under clauses (i) and (ii) of 
subparagraph (A) and any factors under subpara-
graph (A)(iii). 
‘‘(3) The term ‘geriatric assessment eligible indi-
vidual’ shall not include the following individuals: 
‘‘(A) An individual who is receiving hospice care 
under this title. 
‘‘(B) An individual who is residing in a skilled 
nursing facility, a nursing facility (as defined in sec-
tion 1919), or any other facility identified by the 
Secretary. 
‘‘(C) An individual medically determined to 
have end-stage renal disease. 
‘‘(D) An individual enrolled in a Medicare Ad-
vantage plan or a plan under section 1876. 
‘‘(E) An individual enrolled in a PACE pro-
gram under section 1894. 
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‘‘(F) Any other categories of individuals deter-
mined appropriate by the Secretary. 
‘‘(4) For purposes of this subsection, the term ‘chron-
ic condition’ means a condition, such as dementia, that 
lasts or is expected to last 1 year or longer, limits what 
an individual can do, and requires ongoing care.’’. 
(c) PAYMENT
AND ELIMINATION
OF COST-SHAR-
ING.— 
(1) PAYMENT AND ELIMINATION OF COINSUR-
ANCE.—Section 1833(a)(1) of the Social Security 
Act (42 U.S.C. 1395l(a)(1)) is amended— 
(A) in subparagraph (N), by inserting 
‘‘other than geriatric assessments (as defined in 
section 1861(hhh)(1))’’ after ‘‘(as defined in 
section 1848(j)(3))’’; 
(B) by striking ‘‘and’’ before ‘‘(W)’’; and 
(C) by inserting before the semicolon at 
the end the following: ‘‘, and (X) with respect 
to geriatric assessments (as defined in section 
1861(hhh)(1)), the amount paid shall be 100 
percent of the lesser of the actual charge for 
the services or the amount determined under 
section 1848(o)’’. 
(2) PAYMENT.— 
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(A) IN GENERAL.—Section 1848 of the So-
cial Security Act (42 U.S.C. 1395w–4) is 
amended by adding at the end the following 
new subsection: 
‘‘(o) PAYMENT FOR GERIATRIC ASSESSMENTS.— 
‘‘(1) ESTABLISHMENT.— 
‘‘(A) IN
GENERAL.—The Secretary shall 
establish— 
‘‘(i) a payment code (or codes) under 
this section for a geriatric assessment (as 
defined in section 1861(hhh)(1)) furnished 
to a geriatric assessment eligible individual 
(as defined in section 1861(iii)) by a physi-
cian, practitioner, or other provider de-
scribed in section 1861(hhh)(2); and 
‘‘(ii) a payment amount for each such 
code. 
‘‘(B) 
REQUIREMENTS.—In 
establishing 
payment amounts under subparagraph (A)(ii), 
the Secretary shall— 
‘‘(i) take into account— 
‘‘(I) the amount of work required 
to perform a geriatric assessment, in-
cluding the time and effort put forth 
by each qualified health care profes-
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sional involved in performing the geri-
atric assessment; and 
‘‘(II) all of the costs associated 
with the geriatric assessment, includ-
ing labor, supplies, equipment, and 
the costs of health information tech-
nologies and systems incurred by the 
physician, practitioner, or other pro-
vider 
(as 
described 
in 
section 
1861(hhh)(2)) in providing the assess-
ment; and 
‘‘(ii) ensure that such payments do 
not result in a reduction in payments for 
office visits or other evaluation and man-
agement services that would otherwise be 
allowable. 
‘‘(2) SEPARATE
PAYMENTS
FROM
PAYMENTS 
FOR CHRONIC CARE MANAGEMENT AND COORDINA-
TION
SERVICES.—Payments for geriatric assess-
ments shall be made separately from payments for 
chronic care management and coordination services 
(as defined in section 1861(jjj)(1)) and other serv-
ices for which payment is made under this title.’’. 
(B) CONFORMING
AMENDMENT.—Section 
1848(j)(3) of the Social Security Act (42 
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U.S.C. 1395w–4(j)(3)), as amended by section 
3(c)(2)), is amended by inserting ‘‘(2)(FF),’’ 
after ‘‘(2)(EE),’’. 
(3) ELIMINATION
OF
COINSURANCE
IN
OUT-
PATIENT HOSPITAL SETTINGS.— 
(A) EXCLUSION FROM OPD FEE SCHED-
ULE.—Section 1833(t)(1)(B)(iv) of the Social 
Security Act (42 U.S.C. 1395l(t)(1)(B)(iv)) is 
amended by striking ‘‘and diagnostic mammog-
raphy’’ and inserting ‘‘, diagnostic mammog-
raphy, or geriatric assessments (as defined in 
section 1861(hhh)(1))’’. 
(B) CONFORMING AMENDMENTS.—Section 
1833(a)(2) of the Social Security Act (42 
U.S.C. 1395l(a)(2)) is amended— 
(i) in subparagraph (F), by striking 
‘‘and’’ at the end; 
(ii) in subparagraph (G)(ii), by strik-
ing the comma at the end and inserting ‘‘; 
and’’; and 
(iii) by inserting after subparagraph 
(G)(ii) the following new subparagraph: 
‘‘(H) with respect to geriatric assessments 
(as defined in section 1861(hhh)(1)) furnished 
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by an outpatient department of a hospital, the 
amount determined under paragraph (1)(X),’’. 
(4) ELIMINATION OF DEDUCTIBLE.—The first 
sentence of section 1833(b) of the Social Security 
Act (42 U.S.C. 1395l(b)) is amended— 
(A) by striking ‘‘and’’ before ‘‘(9)’’; and 
(B) by inserting before the period the fol-
lowing: ‘‘, and (10) such deductible shall not 
apply with respect to geriatric assessments (as 
defined in section 1861(hhh)(1))’’. 
(d) FREQUENCY LIMITATION.—Section 1862(a) of 
the Social Security Act (42 U.S.C. 1395y(a)(1)) is amend-
ed— 
(1) in paragraph (1)— 
(A) in subparagraph (N), by striking 
‘‘and’’ at the end; 
(B) in subparagraph (O) by striking the 
semicolon at the end and inserting ‘‘, and’’; and 
(C) by adding at the end the following new 
subparagraph: 
‘‘(P) in the case of geriatric assessments (as de-
fined in section 1861(hhh)(1)), which are performed 
more frequently than is covered under such sec-
tion;’’; and 
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(2) in paragraph (7), by striking ‘‘or (K)’’ and 
inserting ‘‘(K), or (P)’’. 
(e) EXCEPTION TO LIMITS ON PHYSICIAN REFER-
RALS.—Section 1877(b) of the Social Security Act (42 
U.S.C. 1395nn(b)) is amended by adding at the end the 
following new paragraph: 
‘‘(6) GERIATRIC ASSESSMENTS.—In the case of 
a designated health service, if the designated health 
service is a geriatric assessment (as defined in sec-
tion 1861(hhh)(1)) and furnished by a physician.’’. 
(f) RULEMAKING.—The Secretary of Health and 
Human Services shall define such terms, establish such 
procedures, and promulgate such regulations as the Sec-
retary determines necessary to implement the amend-
ments made by, and the provisions of, this section, includ-
ing the establishment of additional domains under sub-
section (hhh)(1)(A)(iv) of section 1861 of the Social Secu-
rity Act, as added by subsection (b). In promulgating such 
regulations, the Secretary shall consult with physicians, 
physician groups and organizations, other health care pro-
fessional groups and organizations representing individ-
uals with chronic conditions and older adults. 
(g) EFFECTIVE DATE.—The amendments made by 
this section shall apply to assessments furnished on or 
after January 1, 2010. 
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SEC. 4. MEDICARE COVERAGE OF CHRONIC CARE MANAGE-
MENT AND COORDINATION SERVICES. 
(a) PART B COVERAGE OF CHRONIC CARE MANAGE-
MENT AND COORDINATION SERVICES.— 
(1) IN
GENERAL.—Section 1861(s)(2) of the 
Social Security Act (42 U.S.C. 1395x(s)(2)), as 
amended by section 3(a)(1), is amended— 
(A) in subparagraph (EE), by striking 
‘‘and’’ at the end; 
(B) in subparagraph (FF), by adding 
‘‘and’’ at the end; and 
(C) by adding at the end the following new 
subparagraph: 
‘‘(GG) chronic care management and coordina-
tion services (as defined in subsection (jjj));’’. 
(2) CONFORMING AMENDMENTS.—(A) Clauses 
(i) and (ii) of section 1861(s)(2)(K) of the Social Se-
curity Act (42 U.S.C. 1395x(s)(2)(K)), as amended 
by section 3(a)(2), are each amended by striking 
‘‘subsections (ww)(1) and (hhh)(1)’’ and inserting 
‘‘subsections (ww)(1), (hhh)(1), and (jjj)(1)’’. 
(B) Section 1862(a)(7) of the Social Security 
Act (42 U.S.C. 1395y(a)(7)), as amended by section 
3(d), is amended by striking ‘‘section 1861(s)(10)’’ 
and inserting ‘‘paragraphs (2)(GG) and (10) of sec-
tion 1861(s)’’. 
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(b) SERVICES DESCRIBED.—Section 1861 of the So-
cial Security Act (42 U.S.C. 1395x), as amended by sec-
tion 3(b), is amended by adding at the end the following 
new subsection: 
‘‘Chronic Care Management and Coordination Services; 
Chronic Care Manager; Chronic Care Eligible Individual 
‘‘(jjj)(1) The term ‘chronic care management and co-
ordination services’ means services that are furnished to 
a chronic care eligible individual (as defined in paragraph 
(3)) by, or under the supervision of, a single chronic care 
manager (as defined in paragraph (2)) chosen by the 
chronic care eligible individual, a caregiver designated by 
the individual in writing, or a representative authorized 
to make decisions on the individual’s behalf, under a plan 
of care prescribed by such chronic care manager for the 
purpose of chronic care coordination, including dementia 
as appropriate, which may include any of the following 
services: 
‘‘(A) The development of an initial plan of care 
(based on the results of a geriatric assessment, as 
defined in subsection (hhh)), and subsequent appro-
priate revisions to that plan of care. 
‘‘(B) The management of, and referral for, 
medical and other health services, including inter-
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