I
105TH CONGRESS
2D SESSION
H. R. 4591
To amend title XVIII of the Social Security Act to provide for home health
case manager services under the Medicare Program.
IN THE HOUSE OF REPRESENTATIVES
SEPTEMBER 17, 1998
Mr. STARK (for himself and Mr. CARDIN) introduced the following bill; which
was referred to the Committee on Ways and Means, and in addition to
the Committee on Commerce, 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 home health case manager services under the Medi-
care Program.
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled,
SECTION 1. SHORT TITLE; FINDINGS.
(a) SHORT TITLE.—This Act may be cited as the
‘‘Medicare Home Health Case Manager Act of 1998’’.
(b) FINDINGS.—The Congress finds as follows:
(1) A Medicare beneficiary experiencing a se-
vere or chronic illness faces a bewildering array of
home health and post-acute care hospital services at
a time in life when the Medicare beneficiary is least
able to ‘‘manage’’ the choices, especially for bene-
ficiaries who do not have family members to help
them consider the choices.
(2) Such a Medicare beneficiary may be un-
aware of the financial relationships between institu-
tions and agencies which may cause the patient to
be referred for home health services that are unnec-
essary or not furnished in the most appropriate set-
ting.
(3) Medicare fee-for-service does not currently
have a system in which a physician or other health
care provider is encouraged to guide the patient
through this maze of services and help ensure that
choices are made that maximize benefits while mini-
mizing costs.
(4) Chronically ill medicare patients need an
independent ombudsman to help develop a plan of
care and to periodically adjust the plan for the sole
benefit of the patient and the patient’s family.
SEC. 2. ESTABLISHMENT OF MEDICARE HOME HEALTH
CARE CASE MANAGERS FOR LONG TERM
HOME HEALTH SPELLS OF ILLNESS.
(a) REQUIREMENT FOR CASE MANAGEMENT PLAN
FOR
BENEFICIARIES
REQUIRING
EXTENDED
HOME
HEALTH SERVICES.—
(1) IN GENERAL.—Section 1861(m) of the So-
cial Security Act (42 U.S.C. 1395x(m)) is amended,
in the matter preceding paragraph (1), by inserting
after ‘‘under a plan (for furnishing such items and
services to such individual) established and periodi-
cally reviewed by a physician’’ the following: ‘‘and,
in the case of such services furnished (or likely to
be required to be furnished) for an extended period
(as defined by the Secretary in regulations), under
a home health case management plan (as defined in
subsection (uu)(2)) established by a home health
case manager (as defined in subsection (uu)(1)) in
consultation with the physician and, if available, the
family of the individual’’.
(2) DEFINITIONS.—Section 1861 of such Act
(42 U.S.C. 1395x) is amended by adding at the end
the following new subsection:
‘‘Home Health Case Manager
‘‘(uu)(1) The term ‘home health case manager’
means a public agency or private organization (or a sub-
division thereof) that—
‘‘(A) develops, coordinates, and monitors the
delivery of home health services by home health
agencies to an individual;
‘‘(B) has experience and expertise in the fur-
nishing of home health services; and
‘‘(C) meets such other standards as the Sec-
retary finds necessary for the effective and efficient
development and oversight of home health case man-
agement plans and to ensure the health and safety
of individuals furnished services under such a plan.
‘‘(2) The term ‘home health case management plan’
means a structured plan for the delivery of home health
services that is developed by a home health case manager,
after consultation with the physician and, if available, the
family of the individual involved.
‘‘(3) The term ‘home health case manager services’
means the development, coordination, and monitoring of
a home health case management plan for an individual
furnished (or likely to be required to be furnished) home
health services for an extended period (as defined by the
Secretary in regulations under subsection (m)) and in-
cludes the periodic review of such a plan.’’.
(3) GUIDANCE ON INITIATION OF CASE MAN-
AGER
SERVICES.—The Secretary of Health and
Human Services shall provide guidance on the proc-
ess or processes that may be used to identify Medi-
care beneficiaries requiring home health services for
extended periods and to develop home health case
management plans on a timely basis.
(4) LIMITATION ON REFERRALS.—Section 1877
of the Social Security Act (42 U.S.C. 1395nn) shall
apply to a referral by a home health case manager
to a home health agency in the same manner as
such section applies to a referral by a physician to
an entity described in section 1877(a)(2) of such
Act.
(b) COVERAGE
OF
AND
PAYMENT
FOR
HOME
HEALTH CASE MANAGER SERVICES.—
(1) PART A.—
(A) COVERAGE.—Section 1812(a)(3) of
such Act (42 U.S.C. 1395d(a)(3)) is amended
by inserting before the semicolon ‘‘, and home
health case manager services (as defined in sec-
tion 1861(uu)(3))’’.
(B) ELIGIBILITY.—Section 1814(a)(2)(C)
of such Act (42 U.S.C. 1395f(a)(2)(C)) is
amended by inserting ‘‘and, in the case of such
services furnished for an extended period (as
defined 
by 
the 
Secretary 
under 
section
1861(m)), under a home health case manage-
ment plan that has been established and peri-
odically reviewed by a home health case man-
ager’’ after ‘‘is periodically reviewed by a physi-
cian’’.
(C) PAYMENT.—Section 1812 of such Act
(42 U.S.C. 1395d) is amended by adding at the
end the following new subsection:
‘‘(h)(1) Payment under this part for home health
case manager services (as defined in section 1861(uu)(3))
shall be made pursuant to the fee schedule established by
the Secretary under section 1834(m).
‘‘(2)(A) Payment may be made under this title for
home health case manager services in the case of an indi-
vidual only—
‘‘(i) for the initial development of the home
health case management plan for the individual, and
‘‘(ii) for the subsequent review and modification
of such plan, as provided by the Secretary in regula-
tions.’’.
(2) COVERAGE UNDER PART B.—
(A) IN GENERAL.—Section 1832(a)(2)(A)
of such Act (42 U.S.C. 1395k(a)(2)(A)) is
amended by inserting before the semicolon ‘‘,
and home health case manager services (as de-
fined in section 1861(uu)(3))’’.
(B) ELIGIBILITY.—Section 1835(a)(2) of
such Act (42 U.S.C. 1395n(a)(2)) is amended
by inserting ‘‘and, in the case of such services
furnished for an extended period (as defined by
the Secretary under section 1861(m)), under a
home health case management plan that has
been established and periodically reviewed by a
home health case manager’’ after ‘‘is periodi-
cally reviewed by a physician’’.
(C) PAYMENT.—Section 1833 of such Act
(42 U.S.C. 1395l) is amended—
(i) in subsection (a)(2)—
(I) by striking ‘‘and’’ at the end
of subparagraph (F);
(II) by adding ‘‘and’’ at the end
of subparagraph (G); and
(III) by adding after subpara-
graph (G) the following new subpara-
graph:
‘‘(H) subject to subsection (u), with re-
spect to home health case manager services (as
defined in section 1861(uu)(3), the amount de-
termined under the fee schedule established
under section 1834(m);’’, and
(ii) by adding at the end the following
new subsection:
‘‘(u)(1) Payment may be made under this title for
home health case manager services in the case of an indi-
vidual only—
‘‘(A) for the initial development of the home
health case management plan for the individual, and
‘‘(B) for the subsequent review and modifica-
tion of such plan, as provided by the Secretary in
regulations.’’.
(3) ESTABLISHMENT
OF FEE SCHEDULE.—
Section 1834 of such Act (42 U.S.C. 1395m) is
amended by adding at the end the following new sec-
tion:
‘‘(m) ESTABLISHMENT
OF FEE SCHEDULE
FOR
HOME HEALTH CASE MANAGER SERVICES.—
‘‘(1) IN GENERAL.—The Secretary shall estab-
lish a fee schedule for payment for home health case
manager services. Such schedule may provide for
rates that differ for such services that comprise the
establishment of a home health case management
plan and that comprise review and modification of
such a plan.
‘‘(2) CONSIDERATIONS.—In establishing such
fee schedule, the Secretary shall consider appro-
priate regional and operational differences and ad-
justments to payment rates to account for inflation
and other relevant factors.
‘‘(3) CONSULTATION.—In establishing the fee
schedule for home health case manager services
under this subsection, the Secretary shall consult
with appropriate organizations representing individ-
uals and entities who furnish referral services for
home health services and share with such organiza-
tions relevant data in establishing such schedule.’’.
(c) EFFECTIVE DATES.—
(1) REQUIREMENT
OF
CASE
MANAGEMENT
PLAN.—The amendment made by subsection (a)(1)
applies with respect to home health services fur-
nished on or after October 1, 2000.
(2) PAYMENT FOR CASE MANAGER SERVICES.—
The amendments made by subsection (b) apply to
home health case manager services furnished on or
after 6 months before the effective date specified in
paragraph (1).
SEC. 3. REPORT TO CONGRESS ON FEASIBILITY OF CASE
MANAGERS WITH RESPECT TO OTHER MEDI-
CARE SERVICES.
(a) STUDY.—The Secretary of Health and Human
Services shall conduct a study of the types of services con-
sisting of post-acute hospital care furnished under the
Medicare program under title XVIII of the Social Security
Act to determine whether use of case managers and case
management plans similar to home health case managers
(as defined in section 1861(uu)(1)) and home health case
management plans (as defined in section 1861(uu)(2)) is
feasible and appropriate for each such type of service. In
conducting the study, the Secretary shall also determine
whether such case managers and case management plans
may improve quality of care and patient outcomes under
the medicare program, may result in cost savings to the
program, and may reduce incidents of waste, fraud and
abuse against the program.
(b) REPORT.—Not later than January 1, 2001, the
Secretary shall submit to Congress a report containing the
determinations made pursuant to the study conducted
under subsection (a) and any recommendations for legisla-
tive and administrative action the Secretary deems appro-
priate.
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