I
104TH CONGRESS
1ST SESSION
H. R. 507
To amend title XVIII of the Social Security Act to provide for coverage
of expanded nursing facility and in-home services for dependent individ-
uals under the medicare program, to provide for coverage of outpatient
prescription drugs under part B of such program, and for other purposes.
IN THE HOUSE OF REPRESENTATIVES
JANUARY 13, 1995
Mr. ENGEL introduced the following bill; which was referred to the Committee
on 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, to provide for coverage of outpatient prescrip-
tion drugs under part B of such program, 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.
This Act may be cited as the ‘‘Comprehensive Long-
Term Care Act of 1995’’.
SEC. 2. EXPANDED LONG-TERM CARE SERVICES UNDER
MEDICARE PROGRAM FOR DEPENDENT INDI-
VIDUALS.
(a) IN GENERAL.—
(1) PART A.—Section 1812 of the Social Secu-
rity Act (42 U.S.C. 1395d) is amended—
(A) in subsection (a)—
(i) in paragraph (2)(B), by striking
‘‘subsection (f),’’ and inserting ‘‘subsection
(f) and section 1890,’’,
(ii) by striking ‘‘and’’ at the end of
paragraph (3),
(iii) by striking the period at the end
of paragraph (4) and inserting ‘‘; and’’,
and
(iv) by adding at the end the following
new paragraph:
‘‘(5) long-term care services consisting of ex-
tended care services (in accordance with section
1890).’’; and
(B) in subsection (b)(2), by striking ‘‘post-
hospital’’ and inserting ‘‘except as provided in
section 1890, post-hospital’’.
(2) PART B.—Section 1861(s)(2) of such Act
(42 U.S.C. 1395x(s)(2)), as amended by section
147(f)(6)(B)(iii) of the Social Security Act Amend-
ments of 1994, is amended—
(A) in subparagraph (N), by striking
‘‘and’’ at the end;
(B) in subparagraph (O), by striking
‘‘and’’ at the end; and
(C) by inserting after subparagraph (O)
the following new subparagraph:
‘‘(P) long-term care services consisting of in-
home care (in accordance with section 1890); and’’.
(b) DESCRIPTION OF SERVICES; ELIGIBILITY.—Title
XVIII of the Social Security Act is amended by inserting
after section 1889 the following new section:
‘‘LONG-TERM CARE SERVICES FOR DEPENDENT
INDIVIDUALS
‘‘SEC. 1890. (a) IN GENERAL.—An individual enti-
tled to benefits under this part shall be entitled to have
payments made on the individual’s behalf for long-term
care services if—
‘‘(1) the individual is a dependent individual;
and
‘‘(2) such services are provided in accordance
with a case management plan developed by a case
management agency.
‘‘(b) SERVICES PROVIDED.—In this section, the term
‘long-term care services’ means—
‘‘(1) in-home care (as defined in subsection (e));
and
‘‘(2) extended care services (as defined in sec-
tion 1861(h)), but only with respect to a chronically
dependent individual.
‘‘(c) PAYMENT FOR SERVICES.—
‘‘(1) IN GENERAL.—Subject to paragraph (2),
the amount payable for long-term care services
under this section shall be determined in accordance
with a fee schedule for such services established by
the Secretary.
‘‘(2) 
IMPOSITION
OF
DEDUCTIBLE.—The
amount otherwise payable for long-term care services
under this section furnished during a calendar year
shall be reduced by a deduction equal to the deduct-
ible imposed for inpatient hospital services for the
year under section 1813(a)(1).
‘‘(d) DEPENDENT INDIVIDUAL DEFINED.—
‘‘(1) IN GENERAL.—In this section, the term
‘dependent individual’ means an individual who—
‘‘(A) is unable to perform (without sub-
stantial assistance from another individual) be-
cause of physical or cognitive impairment at
least 2 of the following activities of daily living:
bathing, dressing, toileting, transferring, and
eating; or
‘‘(B) has a similar level of disability due to
cognitive impairment that requires substantial
direction, instruction, or supervision of another
individual in order—
‘‘(i) to perform 2 or more of the ac-
tivities of daily living described in subpara-
graph (A), or
‘‘(ii) to remain in the community
without causing harm to self or others be-
cause of inappropriate behavioral patterns.
‘‘(2) CHRONICALLY DEPENDENT INDIVIDUAL.—
In this section, the term ‘chronically dependent indi-
vidual’ means an individual described in paragraph
(1) who—
‘‘(A) for purposes of subparagraph (A) of
such paragraph, is unable to perform at least 3
of the activities of daily living described in such
subparagraph; or
‘‘(B) for purposes of subparagraph (B)(i)
of such paragraph, has a level of disability that
requires direction, instruction, or supervision of
another individual to perform 3 or more of such
activities of daily living.
‘‘(3) ACTIVITIES OF DAILY LIVING DEFINED.—
The ‘activities of daily living’ referred to in this sub-
section are as follows:
‘‘(A) Eating.
‘‘(B) Bathing.
‘‘(C) Dressing.
‘‘(D) Toileting.
‘‘(E) Transferring in and out of a bed or
in and out of a chair.
‘‘(e) IN-HOME CARE.—
‘‘(1) IN GENERAL.—For purposes of this sec-
tion, the term ‘in-home care’ means the items and
services described in paragraph (2) furnished to an
individual by a home care agency (as defined in sec-
tion 1861(oo)) or by others under arrangements
with them made by the agency provided in a place
of residence used as such individual’s home (other
than services described in paragraph (2)(H)).
‘‘(2) SERVICES
DESCRIBED.—The items and
services described in this paragraph are as follows:
‘‘(A) Nursing care provided by or under
the supervision of a registered professional
nurse.
‘‘(B) Services of a homemaker/home health
aide who has successfully completed a training
and competency evaluation program approved
by the Secretary.
‘‘(C) Personal care services.
‘‘(D) Medical social services.
‘‘(E) Physical, occupational, or respiratory
therapy or speech-language pathology.
‘‘(F) Medical supplies (other than drugs
and biologicals) and durable medical equipment,
while under such a plan.
‘‘(G) Patient and caregiver (including fam-
ily caregiver) education and training to develop
skills necessary to permit the individual to re-
main in the home setting.
‘‘(H) Community care services furnished
outside of the place of residence.
‘‘(I) Such other home-based items and
services (other than room and board) as the
Secretary may approve.
‘‘(f) CASE MANAGEMENT REQUIREMENTS.—
‘‘(1) REQUESTS FOR ASSESSMENT.—Each indi-
vidual entitled to benefits under this title (or an-
other person on such individual’s behalf) may re-
quest a case management agency to conduct an as-
sessment under this section to determine whether
the individual is a dependent individual or a chron-
ically dependent individual.
‘‘(2) DESCRIPTION OF PLANS.—For purposes of
this section, a ‘case management plan’ means, with
respect to an individual, a written plan of care
which—
‘‘(A) is established and periodically re-
viewed and revised by a case management agen-
cy; and
‘‘(B) reflects the individual’s needs identi-
fied in the assessment under paragraph (1).
‘‘(3) CASE MANAGEMENT AGENCY DEFINED.—
In this section, the term ‘case management agency’
means a nonprofit or public agency or organization
(or a nonprofit or public subdivision of such an
agency or organization) certified by the Secretary to
conduct assessments and establish case management
plans under this subsection which—
‘‘(A) is experienced in conducting assess-
ments, in establishing and periodically reviewing
and revising case management plans for nurs-
ing facility services and in-home care, and in
coordinating and reviewing the quality of the
provision of such services and care;
‘‘(B) is capable of efficiently and effectively
performing directly or through contracts under
paragraph (4) such duties; and
‘‘(C) does not provide nursing facility serv-
ices or in-home care and does not have a direct
or indirect ownership or control interest in, or
direct or indirect affiliation or relationship with,
an entity that provides, such services or care.
‘‘(4) 
CONTRACTING
OUT
CERTAIN
FUNC-
TIONS.—The Secretary shall permit a case manage-
ment agency, to the extent necessary to carry out
functions under this section, to provide for assess-
ments and case management plans through con-
tracts with nonprofit or public organizations which
do not provide nursing facility services or in-home
care and do not have a direct or indirect ownership
or control interest in, or direct or indirect affiliation
or relationship with, an entity that provides, such
services or care.’’.
(c) 
CONFORMING
AMENDMENTS.—(1) 
Section
1833(a)(1) of such Act (42 U.S.C. 1395l(a)(1)) is amend-
ed—
(A) by striking ‘‘and (P)’’ and inserting ‘‘(P)’’;
and
‘‘(4) meets such other requirements as the Sec-
retary may find necessary in the interest of the
health and safety of individuals who are furnished
services by such agency or organization and for the
effective and efficient operation of the program.’’.
(d) EFFECTIVE DATE.—The amendments made by
this section shall apply to items and services furnished on
or after January 1, 1996.
SEC. 3. MEDICARE COVERAGE OF OUTPATIENT PRESCRIP-
TION DRUGS.
(a) 
DESCRIPTION
OF
COVERED
OUTPATIENT
DRUGS.—
(1) COVERAGE.—Section 1861(s)(2)(J) of the
Social Security Act (42 U.S.C. 1395x(s)(2)(J)) is
amended to read as follows:
‘‘(J) covered outpatient drugs;’’.
(2) DRUGS
DESCRIBED.—Section 1861(t) of
such Act (42 U.S.C. 1395x(t)) is amended—
(1) in the heading, by adding at the end the fol-
lowing: ‘‘; Covered Outpatient Drugs’’;
(2) in paragraph (1)—
(A) by striking ‘‘paragraph (2)’’ and in-
serting ‘‘the succeeding paragraphs of this sub-
section’’, and