I
106TH CONGRESS
1ST SESSION
H. R. 1998
To amend title XVIII of the Social Security Act to promote the coverage
of frail elderly Medicare beneficiaries permanently residing in nursing
facilities in specialized health insurance programs for the frail elderly.
IN THE HOUSE OF REPRESENTATIVES
MAY 27, 1999
Mr. RAMSTAD (for himself and Mr. CARDIN) introduced the following bill;
which was referred to the Committee on Ways and Means, and in addi-
tion to the Committee on Commerce, for a period to be subsequently de-
termined 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 promote
the coverage of frail elderly Medicare beneficiaries per-
manently residing in nursing facilities in specialized
health insurance programs for the frail elderly.
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 ‘‘Medicare’s Elderly Re-
ceiving Innovative Treatments (MERIT) Act of 1999’’.
SEC. 2. MODIFICATION OF PAYMENT RULES.
Section 1853 of the Social Security Act (42 U.S.C.
1395w–23) is amended—
(1) in subsection (a)(1)(A), by striking ‘‘sub-
sections (e) and (f)’’ and inserting ‘‘subsections (e)
through (i)’’;
(2) in subsection (a)(3)(D), by inserting ‘‘and
paragraph (4)’’ after ‘‘section 1859(e)(4)’’; and
(3) by adding at the end of subsection (a) the
following new paragraph:
‘‘(4) EXEMPTION FROM RISK-ADJUSTMENT SYS-
TEM
FOR
FRAIL
ELDERLY
BENEFICIARIES
EN-
ROLLED IN SPECIALIZED PROGRAMS FOR THE FRAIL
ELDERLY.—
‘‘(A) IN GENERAL.—During the period de-
scribed in subparagraph (B), the risk-adjust-
ment described in paragraph (3) shall not apply
to a frail elderly Medicare+Choice beneficiary
(as defined in subsection (i)(3)) who is enrolled
in a Medicare+Choice plan under a specialized
program for the frail elderly (as defined in sub-
section (i)(2)).
‘‘(B) PERIOD OF APPLICATION.—The pe-
riod described in this subparagraph begins with
January 2000 and ends with the first month
for which the Secretary certifies to Congress
that a comprehensive risk adjustment method-
ology under paragraph (3)(C) (that takes into
account the types of factors described in sub-
section (i)(1)) is being fully implemented.’’; and
(4) by adding at the end the following new sub-
section:
‘‘(i) SPECIAL RULES
FOR FRAIL ELDERLY EN-
ROLLED IN SPECIALIZED PROGRAMS FOR THE FRAIL EL-
DERLY.—
‘‘(1) DEVELOPMENT AND IMPLEMENTATION OF
NEW
PAYMENT
SYSTEM.—The Secretary shall de-
velop and implement (as soon as possible after the
date of the enactment of this subsection), during the
period described in subsection (a)(4)(B), a payment
methodology for frail elderly Medicare+Choice bene-
ficiaries enrolled in a Medicare+Choice plan under
a specialized program for the frail elderly (as defined
in paragraph (2)(A)). Such methodology shall ac-
count for the prevalence, mix, and severity of chron-
ic conditions among such beneficiaries and shall in-
clude medical diagnostic factors from all provider
settings (including hospital and nursing facility set-
tings). It shall include functional indicators of health
status and such other factors as may be necessary
to achieve appropriate payments for plans serving
such beneficiaries.
‘‘(2) SPECIALIZED PROGRAM FOR THE FRAIL
ELDERLY DESCRIBED.—
‘‘(A) IN GENERAL.—For purposes of this
part, the term ‘specialized program for the frail
elderly’ means a program which the Secretary
determines—
‘‘(i) if offered under this part as a
distinct part of a Medicare+Choice plan;
‘‘(ii) primarily enrolls frail elderly
Medicare+Choice beneficiaries; and
‘‘(iii) has a clinical delivery system
that is specifically designed to serve the
special needs of such beneficiaries and to
coordinate short-term and long-term care
for such beneficiaries through the use of a
team described in subparagraph (B) and
through the provision of primary care serv-
ices to such beneficiaries by means of such
a team at the nursing facility involved.
‘‘(B) SPECIALIZED
TEAM.—A team de-
scribed in this subparagraph—
‘‘(i) includes—
‘‘(I) a physician, and
‘‘(II) a nurse practitioner or geri-
atric care manager, or both; and
‘‘(ii) has as members individuals who
have special training and specialize in the
care and management of the frail elderly
beneficiaries.
‘‘(3) FRAIL ELDERLY MEDICARE+CHOICE BEN-
EFICIARY DESCRIBED.—For purposes of this part,
the term ‘frail elderly Medicare+Choice beneficiary’
means a Medicare+Choice eligible individual who—
‘‘(A) is residing in a skilled nursing facility
or a nursing facility (as defined for purposes of
title XIX) for an indefinite period and without
any intention of residing outside the facility;
and
‘‘(B) has a severity of condition that
makes the individual frail (as determined under
guidelines approved by the Secretary).’’.
SEC. 3. CONTINUOUS OPEN ENROLLMENT FOR QUALIFIED
INDIVIDUALS.
(a) IN GENERAL.—Section 1851(e) of the Social Se-
curity Act (42 U.S.C. 1395w–21(e)) is amended by adding
at the end the following new paragraph:
‘‘(7) SPECIAL
RULES
FOR
FRAIL
ELDERLY
MEDICARE+CHOICE BENEFICIARIES ENROLLING IN
SPECIALIZED
PROGRAMS
FOR
THE
FRAIL
ELDER-
LY.—There shall be a continuous open enrollment
period for any frail elderly Medicare+Choice bene-
ficiary (as defined in section 1853(i)(3)) who is
seeking to enroll in a Medicare+Choice plan under
a specialized program for the frail elderly (as defined
in section 1853(i)(2)).’’.
(b) EFFECTIVE DATE.—The amendment made by
subsection (a) takes effect on the date of the enactment
of this Act.
SEC. 4. DEVELOPMENT OF QUALITY MEASUREMENT PRO-
GRAM.
(a) IN GENERAL.—Section 1852(e) of the Social Se-
curity Act (42 U.S.C. 1395w–22(e)) is amended by adding
at the end the following new paragraph:
‘‘(5) QUALITY
MEASUREMENT
PROGRAM
FOR
SPECIALIZED PROGRAMS FOR THE FRAIL ELDERLY
AS PART OF MEDICARE+CHOICE PLANS.—The Sec-
retary shall develop and implement a program to
measure the quality of care provided in specialized
programs for the frail elderly (as defined in section
1853(i)(2)) in order to reflect the unique health as-
pects and needs of frail elderly Medicare+Choice
beneficiaries (as defined in section 1853(i)(3)). Such
quality measurements may include indicators of the
prevalence of pressure sores, reduction of iatrogenic
disease, use of urinary catheters, use of anti-anxiety
medications, use of advance directives, incidence of
pneumonia, and incidence of congestive heart fail-
ure.’’.
(b) EFFECTIVE DATE.—The Secretary of Health and
Human Services shall first provide for the implementation
of the quality measurement program for specialized pro-
grams for the frail elderly under the amendment made by
subsection (a) by not later than July 1, 2000.
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