S 646 IS
108th CONGRESS
1st Session
S. 646
To amend title XVIII of the Social Security Act to expand and improve
coverage of mental health services under the medicare program.
IN THE SENATE OF THE UNITED STATES
March 18, 2003
Mr. CORZINE (for himself, Mr. DASCHLE, Mr. BINGAMAN, Ms. MIKULSKI, Mr.
JOHNSON, and Mr. SARBANES) introduced the following bill; which was read twice
and referred to the Committee on Finance
A BILL
To amend title XVIII of the Social Security Act to expand and improve
coverage of mental health services under the medicare program.
Be it enacted by the Senate and House of Representatives of the United
States of America in Congress assembled,
SECTION 1. SHORT TITLE; TABLE OF CONTENTS.
(a) IN GENERAL- This Act may be cited as the `Medicare Mental Health
Modernization Act of 2003'.
(b) TABLE OF CONTENTS- The table of contents of this Act is as follows:
Sec. 1. Short title; table of contents.
TITLE I--ESTABLISHING PARITY FOR MENTAL HEALTH SERVICES
Sec. 101. Elimination of lifetime limit on inpatient mental health
services.
Sec. 102. Parity in treatment for outpatient mental health
services.
TITLE II--EXPANDING COVERAGE OF COMMUNITY-BASED MENTAL HEALTH SERVICES
Sec. 201. Coverage of intensive residential services.
Sec. 202. Coverage of intensive outpatient services.
TITLE III--IMPROVING BENEFICIARY ACCESS TO MEDICARE-COVERED SERVICES
Sec. 301. Excluding clinical social worker services from coverage under
the medicare skilled nursing facility prospective payment system and
consolidated payment.
Sec. 302. Coverage of marriage and family therapist services.
Sec. 303. Coverage of mental health counselor services.
Sec. 304. Study of coverage criteria for Alzheimer's disease and related
mental illnesses.
SEC. 2. FINDINGS.
Congress finds the following:
(1) Older people have the highest rate of suicide of any population in
the United States, and the suicide rate of that population increases with
age, with individuals 65 and older accounting for 20 percent of all suicide
deaths in the United States, while comprising only 13 percent of the
population of the United States.
(2) Disability due to mental illness in individuals over 65 years old
will become a major public health problem in the near future because of
demographic changes. In particular, dementia, depression, schizophrenia,
among other conditions, will all present special problems for this age
group.
(3) Major depression is strikingly prevalent among older people, with
between 8 and 20 percent of older people in community studies and up to 37
percent of those seen in primary care settings experiencing symptoms of
depression.
(4) Almost 20 percent of the population of individuals age 55 and older,
experience specific mental disorders that are not part of normal
aging.
(5) Unrecognized and untreated depression, Alzheimer's disease, anxiety,
late-life schizophrenia, and other mental conditions can be severely
impairing and may even be fatal.
(6) Substance abuse, particularly the abuse of alcohol and prescription
drugs, among adults 65 and older is one of the fastest growing health
problems in the United States, with 17 percent of this age group suffering
from addiction or substance abuse. While addiction often goes undetected and
untreated among older adults, aging and disability makes the body more
vulnerable to the effects of alcohol and drugs, further exacerbating other
age-related health problems. Medicare coverage for addiction treatment of
the elderly needs to recognize these special vulnerabilities.
(7) The disabled are another population receiving inadequate mental
health care through medicare. According to the Health Care Financing
Administration, medicare is the primary health care coverage for the
5,000,000 nonelderly, disabled people on Social Security Disability
Insurance. Up to 40 percent of these individuals have a diagnosis of mental
illness.
(8) The current medicare benefit structure discriminates against the
millions of Americans who suffer from mental illness and maintains an
outdated bias toward institutionally based service delivery. According to
the report of the Surgeon General on mental health for 1999, intensive
outpatient services, such as psychiatric rehabilitation and assertive
community treatment, represent state-of-the-art mental health services.
These evidence-based community support services help people with psychiatric
disabilities improve their ability to function in the community and reduce
hospitalization rates by 30 to 60 percent, even for people with the most
severe mental illnesses.
TITLE I--ESTABLISHING PARITY FOR MENTAL HEALTH SERVICES
SEC. 101. ELIMINATION OF LIFETIME LIMIT ON INPATIENT MENTAL HEALTH
SERVICES.
(a) IN GENERAL- Section 1812 of the Social Security Act (42 U.S.C. 1395d)
is amended--
(A) in paragraph (1), by adding `and' at the end;
(B) in paragraph (2), by striking `; and' at the end; and
(C) by striking paragraph (3); and
(2) by striking subsection (c).
(b) EFFECTIVE DATE- The amendments made by subsection (a) shall apply to
items and services furnished on or after January 1, 2004.
SEC. 102. PARITY IN TREATMENT FOR OUTPATIENT MENTAL HEALTH SERVICES.
(a) IN GENERAL- Section 1833 of the Social Security Act (42 U.S.C.
1395l) is amended by striking subsection (c).
(b) EFFECTIVE DATE- The amendment made by subsection (a) shall apply to
items and services furnished on or after January 1, 2004.
TITLE II--EXPANDING COVERAGE OF COMMUNITY-BASED MENTAL HEALTH
SERVICES
SEC. 201. COVERAGE OF INTENSIVE RESIDENTIAL SERVICES.
(a) COVERAGE UNDER PART A- Section 1812(a) of the Social Security Act (42
U.S.C. 1395d(a)) is amended--
(1) in paragraph (3), by striking `and' at the end;
(2) in paragraph (4), by striking the period at the end and inserting `;
and'; and
(3) by adding at the end the following new paragraph:
`(5) intensive residential services (as defined in section 1861(ww))
furnished to an individual for up to 120 days during any calendar year,
except that such services may be furnished to the individual for additional
days (not to exceed 20 days) during the year if necessary for the individual
to complete a course of treatment.'.
(b) SERVICES DESCRIBED- Section 1861 of the Social Security Act (42 U.S.C.
1395x) is amended by adding at the end the following new subsection:
`Intensive Residential Services
`(ww)(1) Subject to paragraphs (3) and (4), the term `intensive
residential services' means a program of residential services (described in
paragraph (2)) that is--
`(A) prescribed by a physician for an individual entitled to, or
enrolled for, benefits under part A who is under the care of the physician;
and
`(B) furnished under the supervision of a physician pursuant to an
individualized, written plan of treatment established and periodically
reviewed by a physician (in consultation with appropriate staff
participating in such services), which plan sets forth--
`(i) the individual's diagnosis,
`(ii) the type, amount, frequency, and duration of the items and
services provided under the plan, and
`(iii) the goals for treatment under the plan.
In the case of such an individual who is receiving qualified
psychologist services (as defined in subsection (ii)), the individual may be
under the care of the clinical psychologist with respect to such services
under this subsection to the extent permitted under State law.
`(2) The program of residential services described in this paragraph is a
nonhospital-based community residential program that furnishes acute mental
health services or substance abuse services, or both, on a 24-hour basis. Such
services shall include treatment planning and development, medication
management, case management, crisis intervention, individual therapy, group
therapy, and detoxification services. Such services shall be furnished in any
of the following facilities:
`(A) Crisis residential programs or mental illness residential treatment
programs.
`(B) Therapeutic family or group treatment homes.
`(C) Residential detoxification centers.
`(D) Residential centers for substance abuse treatment.
`(3) No service may be treated as an intensive residential service under
paragraph (1) unless the facility at which the service is provided--
`(A) is legally authorized to provide such service under the law of the
State (or under a State regulatory mechanism provided by State law) in which
the facility is located or meets such certification requirements that the
Secretary may impose; and
`(B) meets such other requirements as the Secretary may impose to assure
the quality of the intensive residential services provided.
`(4) No service may be treated as an intensive residential service under
paragraph (1) unless the service is furnished in accordance with standards
established by the Secretary for the management of such services.'.
(c) AMOUNT OF PAYMENT- Section 1814 of the Social Security Act (42 U.S.C.
1395f) is amended--
(1) in subsection (b), in the matter preceding paragraph (1), by
inserting `other than intensive residential services,' after `hospice
care,'; and
(2) by adding at the end the following new subsection:
`Payment for Intensive Residential Services
`(m)(1) The amount of payment under this part for intensive residential
services under section 1812(a)(5) shall be equal to an amount specified under
a prospective payment system established by the Secretary, taking into account
the prospective payment system established for psychiatric hospitals pursuant
to section 124 of the Medicare, Medicaid, and SCHIP Balanced Budget
Refinement
Act of 1999 (113 Stat. 1501A-332), as enacted into law by section 1000(a)(6)
of Public Law 106-113.
`(2) Prior to the date on which the Secretary implements the prospective
payment system established under paragraph (1), the amount of payment under
this part for such intensive residential services is the reasonable costs of
providing such services.'.
(d) EFFECTIVE DATE- The amendments made by this section shall apply to
items and services furnished on or after January 1, 2004.
SEC. 202. COVERAGE OF INTENSIVE OUTPATIENT SERVICES.
(a) COVERAGE- Section 1832(a)(2) of the Social Security Act (42 U.S.C.
1395k(a)(2)) is amended--
(1) in subparagraph (I), by striking `and' at the end;
(2) in subparagraph (J), by striking the period at the end and inserting
`; and'; and
(3) by adding at the end the following new subparagraph:
`(K) intensive outpatient services (as described in section
1861(xx)).'.
(b) SERVICES DESCRIBED- Section 1861 of the Social Security Act (42 U.S.C.
1395x), as amended by section 201(b), is amended by adding at the end the
following new subsection:
`Intensive Outpatient Services
`(xx)(1) The term `intensive outpatient services' means the items and
services described in paragraph (2) prescribed by a physician and provided
within the context described in paragraph (3) under the supervision of a
physician (or, to the extent permitted under the law of the State in which the
services are furnished, a non-physician mental health professional) pursuant
to an individualized, written plan of treatment that is established by a
physician and periodically reviewed by a physician or, to the extent permitted
under the laws of the State in which the services are furnished, a
non-physician mental health professional (in consultation with appropriate
staff participating in such services), which plan sets forth the patient's
diagnosis, the type, amount, frequency, and duration of the items and services
provided under the plan, and the goals for treatment under the plan.
`(2)(A) The items and services described in this paragraph are the items
and services described in subparagraph (B) that are reasonable and necessary
for the diagnosis or treatment of the individual's condition, reasonably
expected to improve or maintain the individual's condition and functional
level and to prevent relapse or hospitalization, and furnished pursuant to
such guidelines relating to frequency and duration of services as the
Secretary shall by regulation establish (taking into account accepted norms of
clinical practice).
`(B) For purposes of subparagraph (A), the items and services described in
this paragraph are as follows:
`(i) Psychiatric rehabilitation.
`(ii) Assertive community treatment.
`(iii) Intensive case management.
`(iv) Day treatment for individuals under 21 years of age.
`(v) Ambulatory detoxification.
`(vi) Such other items and services as the Secretary may provide (but in
no event to include meals and transportation).
`(3) The context described in this paragraph for the provision of
intensive outpatient services is as follows:
`(A) Such services are furnished in a facility, home, or community
setting.
`(B) Such services are furnished--
`(i) to assist the individual to compensate for, or eliminate,
functional deficits and interpersonal and environmental barriers created
by the disability; and
`(ii) to restore skills to the individual for independent living,
socialization, and effective life management.
`(C) Such services are furnished by an individual or entity that--
`(i) is legally authorized to furnish such services under State law
(or the State regulatory mechanism provided by State law) or meets such
certification requirements that the Secretary may impose; and
`(ii) meets such other requirements as the Secretary may impose to
assure the quality of the intensive outpatient services
provided.'.
(1) IN GENERAL- With respect to intensive outpatient services (as
defined in section 1861(xx)(1) of the Social Security Act (as added by
subsection (b)) furnished under the medicare program, the amount of payment
under such Act for such services shall be 80 percent of--
(A) during 2004 and 2005, the reasonable costs of furnishing such
services; and
(B) on or after January 1, 2006, the amount of payment established for
such services under the prospective payment system established by the
Secretary under paragraph (2) for such services.
(2) ESTABLISHMENT OF PPS-
(A) IN GENERAL- With respect to intensive outpatient services (as
defined in section 1861(xx)(1) of the Social Security Act (as added by
subsection (b)) furnished under the medicare program on or after January
1, 2006, the Secretary of Health and Human Services (in this paragraph
referred to as the `Secretary') shall establish a prospective payment
system for payment for such services. Such system shall include an
adequate patient classification system that reflects the differences in
patient resource use and costs and shall provide for an annual update to
the rates of payment established under the system.
(B) ADJUSTMENTS- In establishing the system under subparagraph (A),
the Secretary shall provide for adjustments in the prospective payment
amount for variations in wage and wage-related costs, case mix, and such
other factors as the Secretary determines appropriate.
(C) COLLECTION OF DATA AND EVALUATION- In developing the system
described in subparagraph (A), the Secretary may require
providers of services under the medicare program to submit such information
to the Secretary as the Secretary may require to develop the system, including
the most recently available data.
(D) REPORTS TO CONGRESS- Not later than October 1 of each of 2004 and
2005, the Secretary shall submit to Congress a report on the progress of
the Secretary in establishing the prospective payment system under this
paragraph.
(d) CONFORMING AMENDMENTS- (1) Section 1835(a)(2) of the Social Security
Act (42 U.S.C. 1395n(a)(2)) is amended--
(A) in subparagraph (E), by striking `and' at the end;
(B) in subparagraph (F), by striking the period at the end and inserting
`; and'; and
(C) by inserting after subparagraph (F) the following new
subparagraph:
`(G) in the case of intensive outpatient services, (i) that those
services are reasonably expected to improve or maintain the individual's
condition and functional level and to prevent relapse or hospitalization,
(ii) an individualized, written plan for furnishing such services has been
established by a physician and is reviewed
periodically by a physician or, to the extent permitted under the laws of the
State in which the services are furnished, a non-physician mental health
professional, and (iii) such services are or were furnished while the individual
is or was under the care of a physician or, to the extent permitted under the
law of the State in which the services are furnished, a non-physician mental
health professional.'.
(2) Section 1861(s)(2)(B) of the Social Security Act (42 U.S.C.
1395x(s)(2)(B)) is amended by inserting `and intensive outpatient services'
after `partial hospitalization services'.
(3) Section 1861(ff)(1) of the Social Security Act (42 U.S.C.
1395x(ff)(1)) is amended--
(A) by inserting `or, to the extent permitted under the law of the State
in which the services are furnished, a non-physician mental health
professional,' after `under the supervision of a physician' and after
`periodically reviewed by a physician'; and
(B) by striking `physician's' and inserting `patient's'.
(4) Section 1861(cc) of the Social Security Act (42 U.S.C. 1395x(cc)) is
amended--
(A) in paragraph (1), in the matter preceding subparagraph (A), by
striking `physician--' and inserting `physician or, to the extent permitted
under the law of the State in which the services are furnished, a
non-physician mental health professional--'; and
(B) in paragraph (2)(E), by inserting before the semicolon at the end
the following: `, except that a patient receiving social and psychological
services under paragraph (1)(D) may be under the care of a non-physician
mental health professional with respect to such services to the extent
permitted under the law of the State in which the services are
furnished'.
(e) EFFECTIVE DATE- The amendments made by this section shall apply to
items and services furnished on or after January 1, 2004.
TITLE III--IMPROVING BENEFICIARY ACCESS TO MEDICARE-COVERED
SERVICES
SEC. 301. EXCLUDING CLINICAL SOCIAL WORKER SERVICES FROM COVERAGE UNDER THE
MEDICARE SKILLED NURSING FACILITY PROSPECTIVE PAYMENT SYSTEM AND CONSOLIDATED
PAYMENT.
(a) IN GENERAL- Section 1888(e)(2)(A)(ii) of the Social Security Act (42
U.S.C. 1395yy(e)(2)(A)(ii)) is amended by inserting `clinical social worker
services,' after `qualified psychologist services,'.
(b) CONFORMING AMENDMENT- Section 1861(hh)(2) of the Social Security Act
(42 U.S.C. 1395x(hh)(2)) is amended by striking `and other than services
furnished to an inpatient of a skilled nursing facility which the facility is
required to provide as a requirement for participation'.
(c) EFFECTIVE DATE- The amendments made by this section shall apply to
items and services furnished on or after January 1, 2004.
SEC. 302. COVERAGE OF MARRIAGE AND FAMILY THERAPIST SERVICES.
(a) COVERAGE OF SERVICES- Section 1861(s)(2) of the Social Security Act
(42 U.S.C. 1395x(s)(2)) is amended--
(1) in subparagraph (U), by striking `and' at the end;
(2) in subparagraph (V), by adding `and' at the end; and
(3) by adding at the end the following new subparagraph:
`(W) marriage and family therapist services (as defined in subsection
(yy));'.
(b) DEFINITION- Section 1861 of the Social Security Act (42 U.S.C. 1395x),
as amended by sections 201(b) and 202(b), is amended by adding at the end the
following new subsection:
`Marriage and Family Therapist Services
`(yy)(1) The term `marriage and family therapist services' means services
performed by a marriage and family therapist (as defined in paragraph (2)) for
the diagnosis and treatment of mental illnesses, which the marriage and family
therapist is legally authorized to perform under State law (or the State
regulatory mechanism provided by State law) of the State in which such
services are performed, provided such services are covered under this title,
as would otherwise be covered if furnished by a physician or as incident to a
physician's professional service, but only if no facility or other provider
charges or is paid any amounts with respect to the furnishing of such
services.
`(2) The term `marriage and family therapist' means an individual who--
`(A) possesses a master's or doctoral degree which qualifies for
licensure or certification as a marriage and family therapist pursuant to
State law;
`(B) after obtaining such degree has performed at least 2 years of
clinical supervised experience in marriage and family therapy; and
`(C) is licensed or certified as a marriage and family therapist in the
State in which marriage and family therapist services are performed.'.
(c) PROVISION FOR PAYMENT UNDER PART B- Section 1832(a)(2)(B) of the
Social Security Act (42 U.S.C. 1395k(a)(2)(B)) is amended by adding at the end
the following new clause:
`(v) marriage and family therapist services;'.
(1) IN GENERAL- Section 1833(a)(1) of the Social Security Act (42 U.S.C.
1395l(a)(1)) is amended--
(A) by striking `and' before `(U)'; and
(B) by inserting before the semicolon at the end the following: `, and
(V) with respect to marriage and family therapist services under section
1861(s)(2)(W), the amounts paid shall be 80 percent of the lesser of (i)
the actual charge for the services or (ii) 75 percent of the amount
determined for payment of a psychologist under subparagraph (L)'.
(2) DEVELOPMENT OF CRITERIA WITH RESPECT TO CONSULTATION WITH A
PHYSICIAN- The Secretary of Health and Human Services shall, taking into
consideration concerns for patient confidentiality, develop criteria with
respect to payment for marriage and family therapist services for which
payment may be made directly to the marriage and family therapist under part
B of title XVIII of the Social Security Act under which such a therapist
must agree to consult with a patient's attending or primary care physician
in accordance with such criteria.
(e) EXCLUSION OF MARRIAGE AND FAMILY THERAPIST SERVICES FROM SKILLED
NURSING FACILITY PROSPECTIVE PAYMENT SYSTEM- Section 1888(e)(2)(A)(ii) of the
Social Security Act (42 U.S.C. 1395yy(e)(2)(A)(ii)), as amended in section
301(a), is amended by inserting `marriage and family therapist services (as
defined in subsection (yy)(1)),' after `clinical social worker services,'.
(f) COVERAGE OF MARRIAGE AND FAMILY THERAPIST SERVICES PROVIDED IN RURAL
HEALTH CLINICS AND FEDERALLY QUALIFIED HEALTH CENTERS- Section 1861(aa)(1)(B)
of the Social Security Act (42 U.S.C. 1395x(aa)(1)(B)) is amended by striking
`or by a clinical social worker (as defined in subsection (hh)(1)),,' and
inserting `, by a clinical social worker (as defined in subsection (hh)(1)),
or by a marriage and family therapist (as defined in subsection (yy)(2)),'.
(g) INCLUSION OF MARRIAGE AND FAMILY THERAPISTS AS PRACTITIONERS FOR
ASSIGNMENT OF CLAIMS- Section 1842(b)(18)(C) of the Social Security Act (42
U.S.C. 1395u(b)(18)(C)) is amended by adding at the end the following new
clause:
`(vii) A marriage and family therapist (as defined in section
1861(yy)(2)).'.
(h) EFFECTIVE DATE- The amendments made by this section shall apply to
items and services furnished on or after January 1, 2004.
SEC. 303. COVERAGE OF MENTAL HEALTH COUNSELOR SERVICES.
(a) COVERAGE OF SERVICES- Section 1861(s)(2) of the Social Security Act
(42 U.S.C. 1395x(s)(2)), as amended in section 302(a), is amended--
(1) in subparagraph (V), by striking `and' at the end;
(2) in subparagraph (W), by inserting `and' at the end; and
(3) by adding at the end the following new subparagraph:
`(X) mental health counselor services (as defined in subsection
(zz)(2));'.
(b) DEFINITION- Section 1861 of the Social Security Act (42 U.S.C. 1395x),
as amended by sections 201(b), 202(b), and 302(b), is amended by adding at the
end the following new subsection:
`Mental Health Counselor; Mental Health Counselor Services
`(zz)(1) The term `mental health counselor' means an individual who--
`(A) possesses a master's or doctor's degree in mental health counseling
or a related field;
`(B) after obtaining such a degree has performed at least 2 years of
supervised mental health counselor practice; and
`(C) is licensed or certified as a mental health counselor or
professional counselor by the State in which the services are
performed.
`(2) The term `mental health counselor services' means services performed
by a mental health counselor (as defined in paragraph (1)) for the diagnosis
and treatment of mental illnesses which the mental health counselor is legally
authorized to perform under State law (or the State regulatory mechanism
provided by the State law) of the State in which such services are performed,
provided such services are covered under this title, as would otherwise be
covered if furnished by a physician or as incident to a physician's
professional service, but only if no facility or other provider charges or is
paid any amounts with respect to the furnishing of such services.'.
(1) IN GENERAL- Section 1833(a)(1) of the Social Security Act (42 U.S.C.
1395l(a)(1)), as amended by section 302(d), is amended--
(A) by striking `and' before `(V)'; and
(B) by inserting before the semicolon at the end the following: `, and
(W) with respect to mental health counselor services under section
1861(s)(2)(X), the amounts paid shall be 80 percent of the lesser of (i)
the actual charge for the services or (ii) 75 percent of the amount
determined for payment of a psychologist under subparagraph (L)'.
(2) DEVELOPMENT OF CRITERIA WITH RESPECT TO CONSULTATION WITH A
PHYSICIAN- The Secretary of Health and Human Services shall, taking into
consideration concerns for patient confidentiality, develop criteria with
respect to payment for mental health counselor services for which payment
may be made directly to the mental health counselor under part B of title
XVIII of the Social Security Act under which such a counselor must agree to
consult with a patient's attending or primary care physician in accordance
with such criteria.
(d) EXCLUSION OF MENTAL HEALTH COUNSELOR SERVICES FROM SKILLED NURSING
FACILITY PROSPECTIVE PAYMENT SYSTEM- Section 1888(e)(2)(A)(ii) of the Social
Security Act (42 U.S.C. 1395yy(e)(2)(A)(ii)), as amended by sections 301(a)
and 302(e), is amended by inserting `mental health counselor services (as
defined
in section 1861(zz)(2)),' after `marriage and family therapist services (as
defined in subsection (yy)(1)),'.
(e) COVERAGE OF MENTAL HEALTH COUNSELOR SERVICES PROVIDED IN RURAL HEALTH
CLINICS AND FEDERALLY QUALIFIED HEALTH CENTERS- Section 1861(aa)(1)(B) of the
Social Security Act (42 U.S.C. 1395x(aa)(1)(B)), as amended by section 302(f),
is amended--
(1) by striking `or by a marriage' and inserting `by a marriage';
and
(2) by inserting `or a mental health counselor (as defined in subsection
(zz)(1)),' after `marriage and family therapist (as defined in subsection
(yy)(2)),'.
(f) INCLUSION OF MENTAL HEALTH COUNSELORS AS PRACTITIONERS FOR ASSIGNMENT
OF CLAIMS- Section 1842(b)(18)(C) of the Social Security Act (42 U.S.C.
1395u(b)(18)(C)), as amended by section 302(g), is amended by adding at the
end the following new clause:
`(viii) A mental health counselor (as defined in section
1861(zz)(1)).'.
(g) EFFECTIVE DATE- The amendments made by this section shall apply to
items and services furnished on or after January 1, 2004.
SEC. 304. STUDY OF COVERAGE CRITERIA FOR ALZHEIMER'S DISEASE AND RELATED
MENTAL ILLNESSES.
(1) IN GENERAL- The Secretary of Health and Human Services (in this
section referred to as the `Secretary') shall conduct a study to determine
whether the criteria for coverage of any therapy service (including
occupational therapy services and physical therapy services) or any
outpatient mental health care service under the medicare program under title
XVIII of the Social Security Act unduly restricts the access of any medicare
beneficiary who has been diagnosed with Alzheimer's disease or a related
mental illness to such a service because the coverage criteria requires the
medicare beneficiary to display continuing clinical improvement to continue
to receive the service.
(2) DETERMINATION OF NEW COVERAGE CRITERIA- If the Secretary determines
that the coverage criteria described in paragraph (1) unduly restricts the
access of any medicare beneficiary to the services described in such
paragraph, the Secretary shall identify alternative coverage criteria that
would permit a medicare beneficiary who has been diagnosed with Alzheimer's
disease or a related mental illness to receive coverage for health care
services under the medicare program that are designed to control symptoms,
maintain functional capabilities, reduce or deter deterioration, and prevent
or reduce hospitalization of the beneficiary.
(b) REPORT- Not later than 1 year after the date of enactment of this Act,
the Secretary shall submit to the committees of jurisdiction of Congress a
report on the study conducted under subsection (a) together with such
recommendations for legislative and administrative action as the Secretary
determines appropriate.
END