I 
108TH CONGRESS 
2D SESSION 
H. R. 4689 
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 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 provi-
sions 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 assess-
ments and chronic care management, and for other pur-
poses. 
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 
‘‘Geriatric and Chronic Care Management Act of 2004’’.
(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 services. 
Sec. 5. Study and report on best practices for medicare chronic care manage-
ment. 
SEC. 2. FINDINGS. 
Congress makes the following findings: 
(1) We must redesign the medicare system to 
provide high-quality, cost-effective care to a growing 
population: elderly individuals with multiple chronic 
conditions. 
(2) According to the Congressional Budget Of-
fice, 50 percent of medicare costs can be attributed 
to 5 percent of medicare’s most costly beneficiaries. 
(3) Currently, 82 percent of the medicare popu-
lation has at least 1 chronic condition, and 2⁄3 have 
more than 1 chronic condition. The 20 percent of 
beneficiaries with 5 or more chronic conditions ac-
count for 2⁄3 of all medicare spending. In addition, 
the large Baby Boomer generation is moving toward 
retirement and medicare eligibility. 
(4) In general, the prevalence of chronic condi-
tions increases with age: 74 percent of the 65- to 
69-year-old group have a least 1 chronic condition, 
while 86 percent of the 85 years and older group
have at least 1 chronic condition. Similarly, just 14 
percent of the 65- to 69-year-olds have 5 or more 
chronic conditions, but 28 percent of the 85 years 
and older group have 5 or more chronic conditions. 
(5) There is a strong pattern of increasing utili-
zation as the number of conditions increase. Fifty- 
five percent of medicare beneficiaries with 5 or more 
conditions experienced an inpatient hospital stay 
compared to 5 percent for those with 1 condition or 
9 percent for those with 2 conditions. 
(6) In terms of physician visits, the average 
medicare beneficiary has over 15 physician visits an-
nually and sees 6 different physicians annually. 
(7) There is almost a 4-fold increase in visits by 
people with 5 chronic conditions compared to visits 
by people with 1 chronic condition. The number of 
specific physicians seen increases almost 21⁄2 times 
for people with 5 or more chronic conditions relative 
to those with just 1 chronic condition. 
(8) When Alzheimer’s disease and dementia are 
present along with 1 or more other chronic condi-
tions, utilization also increases. For example, in 
2000, total average per person medicare expendi-
tures for those with congestive heart failure and Alz-
heimer’s or dementia were 47 percent higher than
for those with congestive heart failure and no de-
mentia. 
(9) Based on numerous studies in the United 
States and internationally, we know that the delivery 
of higher quality health care, increased efficiency 
and cost-effectiveness are the result of systems in 
which patients are linked with a physician or other 
qualified health professional who coordinates their 
care. 
(10) The current medicare program penalizes 
physicians for integrating and coordinating health 
care because these services are not explicitly recog-
nized and distinctly paid for. Instead, physicians are 
incentivized to provide episodic care and to generate 
more individual patient visits to the doctor’s office 
and hospital for separately reimbursed tests and 
procedures. 
(11) The chronic care model established by this 
Act includes several elements that are effective in 
managing chronic disease— 
(A) linkages with community resources; 
(B) health care system changes that re-
ward quality chronic care; 
(C) support for patient self-management of 
chronic disease;
(D) practice redesign; 
(E) evidence-based clinical practice guide-
lines; and 
(F) clinical information systems, such as 
electronic medical records and continuity of 
care records. 
(12) We must realign the financial incentives 
within medicare as part of a comprehensive system 
change. Medicare should be restructured to reim-
burse physicians and other qualified health profes-
sionals for the cost of coordinating care. 
SEC. 3. MEDICARE COVERAGE OF GERIATRIC ASSESS-
MENTS. 
(a) PART B COVERAGE
OF GERIATRIC ASSESS-
MENTS.— 
(1) IN
GENERAL.—Section 1861(s)(2) of the 
Social Security Act (42 U.S.C. 1395x(s)(2)), as 
amended by section 642(a) of the Medicare Prescrip-
tion Drug, Improvement, and Modernization Act of 
2003 (Public Law 108–173; 117 Stat. 2322), is 
amended— 
(A) in subparagraph (Y), by striking 
‘‘and’’ after the semicolon at the end; 
(B) in subparagraph (Z), by adding ‘‘and’’ 
after the semicolon at the end; and
(C) by adding at the end the following new 
subparagraph: 
‘‘(AA) geriatric assessments (as defined in sub-
section (bbb)(1)).’’. 
(2) CONFORMING AMENDMENTS.—(A) Section 
1862(a)(7) of the Social Security Act (42 U.S.C. 
1395y(a)(7)), as amended by section 611(d)(1)(B) 
of the Medicare Prescription Drug, Improvement, 
and Modernization Act of 2003 (Public Law 108– 
173; 117 Stat. 2304), is amended by striking ‘‘or 
(K)’’ and inserting ‘‘(K), or (AA)’’. 
(B) 
Clauses 
(i) 
and 
(ii) 
of 
section 
1861(s)(2)(K) of the Social Security Act (42 U.S.C. 
1395x(s)(2)(K)), as amended by section 611(d)(2) of 
the Medicare Prescription Drug, Improvement, and 
Modernization Act of 2003 (Public Law 108–173; 
117 Stat. 2304), are each amended by striking 
‘‘subsection (ww)(1)’’ and inserting ‘‘subsections 
(ww)(1) and (bbb)(1)’’. 
(b) GERIATRIC ASSESSMENTS DEFINED.—Section 
1861 of the Social Security Act (42 U.S.C. 1395x), as 
amended by section 706(b) of the Medicare Prescription 
Drug, Improvement, and Modernization Act of 2003 (Pub-
lic Law 108–173; 117 Stat. 2339), is amended by adding 
at the end the following new subsection:
‘‘Geriatric Assessment; Eligible Individual 
‘‘(bbb)(1) The term ‘geriatric assessment’ means— 
‘‘(A) an initial assessment of an eligible individ-
ual’s medical condition, functional and cognitive ca-
pacity, primary caregiver needs, and environmental 
and psychosocial needs that is conducted by a physi-
cian or an entity that meets such conditions as the 
Secretary may specify (which may include physi-
cians, physician group practices, or other health care 
professionals or entities the Secretary may find ap-
propriate) working in collaboration with a physician; 
and 
‘‘(B) subsequent assessments, which may not be 
conducted more frequently than annually, unless a 
physician or chronic care manager of the eligible in-
dividual determines that such assessments are re-
quired due to sentinel health events or changes in 
the health status of the individual that may require 
changes in plans of care developed for the individual. 
‘‘(2)(A) For purposes of this subsection, the term ‘eli-
gible individual’ means an individual who has— 
‘‘(i) at least 5 chronic conditions and an inabil-
ity to manage care (as defined by the Secretary); or 
‘‘(ii) a mental or cognitive impairment, includ-
ing dementia, and at least 1 other chronic condition.
‘‘(B) For purposes of this paragraph, the term 
‘chronic condition’ means an illness, functional limitation, 
or cognitive impairment that is expected to last at least 
1 year, limits the activities of an individual, 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)), as amended by section 
302(b)(2) of the Medicare Prescription Drug, Im-
provement, and Modernization Act of 2003 (Public 
Law 108–173; 117 Stat. 2229), is amended— 
(A) in subparagraph (N), by inserting 
‘‘other than geriatric assessments (as defined in 
section 1861(bbb)(1))’’ after ‘‘(as defined in 
section 1848(j)(3))’’; 
(B) by striking ‘‘and’’ before ‘‘(V)’’; and 
(C) by inserting before the semicolon at 
the end the following: ‘‘, and (W) with respect 
to geriatric assessments (as defined in section 
1861(bbb)(1)), the amount paid shall be 100 
percent of the lesser of the actual charge for 
the services or the amount determined under
the payment basis determined under section 
1848’’. 
(2) PAYMENT UNDER PHYSICIAN FEE SCHED-
ULE.—Section 1848(j)(3) of the Social Security Act 
(42 U.S.C. 1395w–4(j)(3)), as amended by section 
611(c) of the Medicare Prescription Drug, Improve-
ment, and Modernization Act of 2003 (Public Law 
108–173; 117 Stat. 2304), is amended by inserting 
‘‘(2)(AA),’’ after ‘‘(2)(W),’’. 
(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)), as 
amended by section 614 of the Medicare Pre-
scription Drug, Improvement, and Moderniza-
tion Act of 2003 (Public Law 108–173; 117 
Stat. 2306), is amended by striking ‘‘and diag-
nostic mammography’’ and inserting ‘‘, diag-
nostic mammography, or geriatric assessments 
(as defined in section 1861(bbb)(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’’ after the semicolon 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(bbb)(1)) furnished 
by an outpatient department of a hospital, the 
amount determined under paragraph (1)(W),’’. 
(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 ‘‘(6)’’; and 
(B) by inserting before the period the fol-
lowing: ‘‘, and (7) such deductible shall not 
apply with respect to geriatric assessments (as 
defined in section 1861(bbb)(1))’’. 
(d) FREQUENCY LIMITATION.—Section 1862(a)(1) of 
the Social Security Act (42 U.S.C. 1395y(a)(1)), as 
amended by section 613(c) of the Medicare Prescription 
Drug, Improvement, and Modernization Act of 2003 (Pub-
lic Law 108–173; 117 Stat. 2306), is amended—
(1) by striking ‘‘and’’ at the end of subpara-
graph (L); 
(2) by striking the semicolon at the end of sub-
paragraph (M) and inserting ‘‘, and’’; and 
(3) by adding at the end the following new sub-
paragraph: 
‘‘(N) in the case of geriatric assessments (as 
defined in section 1861(bbb)(1)), which are per-
formed more frequently than is covered under such 
section;’’. 
(e) EXCEPTION TO LIMITS ON PHYSICIAN REFER-
RALS.—Section 1877(b) of the Social Security Act (42 
U.S.C. 1395nn(b)), as amended by section 101(e)(8)(B) 
of the Medicare Prescription Drug, Improvement, and 
Modernization Act of 2003 (Public Law 108–173; 117 
Stat. 2306), 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(bbb)(1)) and furnished by a physician.’’. 
(f) RULEMAKING.—The Secretary of Health and 
Human Services shall define such terms and establish 
such procedures as the Secretary determines necessary to 
implement the provisions of this section.
(g) EFFECTIVE DATE.—The amendments made by 
this section shall apply to assessments and chronic care 
management services furnished on or after January 1, 
2005. 
SEC. 4. MEDICARE COVERAGE OF CHRONIC CARE MANAGE-
MENT SERVICES. 
(a) PART B COVERAGE OF CHRONIC CARE MANAGE-
MENT 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 (Z), by striking 
‘‘and’’ after the semicolon at the end; 
(B) in subparagraph (AA), by adding 
‘‘and’’ after the semicolon at the end; and 
(C) by adding at the end the following new 
subparagraph: 
‘‘(BB) chronic care management services (as 
defined in subsection (ccc));’’. 
(2) CONFORMING AMENDMENTS.—(A) Section 
1862(a)(7) of the Social Security Act (42 U.S.C. 
1395y(a)(7)), as amended section 3(a)(2)(A), is 
amended by striking ‘‘or (AA)’’ and inserting ‘‘(AA), 
or (BB)’’.
‘‘(J) Information about, and referral to, hospice 
services, including patient and family caregiver edu-
cation and counseling about hospice, and facilitating 
transition to hospice when elected. 
‘‘(K) Information about, referral to, and man-
agement with, community services. 
‘‘(L) Such additional services for which pay-
ment would not otherwise be made under this title 
that the Secretary may specify that encourage the 
receipt of, or to improve the effectiveness of, the 
services described in the preceding subparagraphs. 
‘‘(2)(A) For purposes of this subsection, the term 
‘chronic care manager’ means an individual or entity 
that— 
‘‘(i) is— 
‘‘(I) a physician (as defined in subsection 
(r)(1)); or 
‘‘(II) a practitioner described in section 
1842(b)(18)(C) or an entity that meets such 
conditions as the Secretary may specify (which 
may include physicians, physician group prac-
tices, or other health care professionals or enti-
ties the Secretary may find appropriate) work-
ing in collaboration with a physician;
‘‘(ii) has entered into a chronic care manage-
ment agreement with the Secretary; and 
‘‘(iii) meets such other criteria as the Secretary 
may establish (which may include experience in the 
provision of chronic care management or primary 
care physicians’ services). 
‘‘(B) For purposes of subparagraph (A)(ii), each 
chronic care management agreement shall— 
‘‘(i) be entered into for a period of 1 year and 
may be renewed if the Secretary is satisfied that the 
chronic care manager continues to meet the condi-
tions of participation specified in subparagraph (A); 
‘‘(ii) ensure that the chronic care manager will 
submit reports to the Secretary on the functional 
and medical status of eligible individuals who receive 
chronic care management services, expenditures re-
lating to such services, and health outcomes relating 
to such services, except that the Secretary may not 
require a chronic care manager to submit more than 
one such report during a year; and 
‘‘(iii) contain such other terms and conditions 
as the Secretary may require. 
‘‘(3) For purposes of this subsection, the term ‘eligi-
ble individual’ means an eligible individual (as defined in 
subsection (bbb)(2)) who has undergone a geriatric assess-
ment (as defined in subsection (bbb)(1)) and who a physi-
cian has determined would benefit from chronic care man-
agement.’’. 
(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)), as amended by section 
3(c)(1), is amended— 
(A) in subparagraph (N), by inserting ‘‘or 
chronic care management services (as defined in 
section 1861(ccc))’’ after ‘‘other than geriatric 
assessments 
(as 
defined 
in 
section 
1861(bbb)(1))’’; 
(B) by striking ‘‘and’’ before ‘‘(W)’’; and 
(C) by inserting before the semicolon at 
the end the following: ‘‘, and (X) with respect 
to chronic care management services (as de-
fined in section 1861(ccc)), the amount paid 
shall be 100 percent of the amount determined 
under section 1834(n)’’. 
(2) PAYMENT.—Section 1834 of the Social Se-
curity Act (42 U.S.C. 1395m) is amended by adding 
at the end the following new subsection:
‘‘(n) PAYMENT FOR CHRONIC CARE MANAGEMENT 
SERVICES.— 
‘‘(1) IN GENERAL.—The Secretary shall pay for 
chronic care management services (as defined in sec-
tion 1861(ccc)(1)) furnished to an eligible individual 
(as defined in section 1861(ccc)(3)) by a chronic 
care manager (as defined in section 1861(ccc)(2))— 
‘‘(A) separately from geriatric assessments 
(as defined in section 1861(bbb)(1)) and other 
services for which payment is made under this 
title; and 
‘‘(B) based on the methodology selected by 
the chronic care manager (as so defined) from 
among the methodologies developed and imple-
mented by the Secretary under paragraph (2). 
‘‘(2) DEVELOPMENT AND IMPLEMENTATION OF 
PAYMENT METHODOLOGIES.—The Secretary, in con-
sultation with national membership associations rep-
resenting physicians, qualified health professionals, 
and patients, shall develop and implement payment 
methodologies applicable with respect to chronic care 
management 
services 
(as 
defined 
in 
section 
1861(ccc)(1)) as follows: 
‘‘(A) UNADJUSTED MONTHLY CAPITATED 
PAYMENT AMOUNT.—A per patient per month
chronic care management fee separate from 
evaluation and management services for which 
payment is made under the physician fee sched-
ule under section 1848 that does not take into 
account the severity of the eligible individual’s 
condition. 
‘‘(B) ADJUSTED
MONTHLY
CAPITATED 
PAYMENT AMOUNT.—A per patient per month 
chronic care management fee separate from 
evaluation and management services for which 
payment is made under the physician fee sched-
ule under section 1848 that provides for an ad-
justment to the payment amount based on the 
severity of the eligible individual’s condition. 
‘‘(C) 
UNADJUSTED
FEE
SCHEDULE 
AMOUNT.—A chronic care management fee for 
care coordination that includes payment for re-
lated evaluation and management services for 
which payment would otherwise be made under 
the physician fee schedule under section 1848 
that does not take into account the severity of 
the eligible individual’s condition. 
‘‘(D) 
ADJUSTED
FEE
SCHEDULE 
AMOUNT.—A chronic care management fee for 
care coordination that includes payment for re-
lated evaluation and management services for 
which payment would otherwise be made under 
the physician fee schedule under section 1848 
that provides for an adjustment to the payment 
amount based on the severity of the eligible in-
dividual’s condition. 
‘‘(E) 
OTHER
PAYMENT
METHODOLO-
GIES.—Any other payment methodology that 
the Secretary determines effective in creating 
incentives for physicians and other chronic care 
managers to make practice-based improvements 
to improve the quality and cost-effectiveness of 
care provided to eligible individuals.’’. 
(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)), as 
amended by section 3(c)(3)(A), is amended by 
striking ‘‘or geriatric assessments (as defined in 
section 1861(bbb)(1))’’ and inserting ‘‘geriatric 
assessments 
(as 
defined 
in 
section 
1861(bbb)(1)), or chronic care management 
services (as defined in section 1861(ccc)(1))’’.