The Bazelon Center for Mental Health Law

The Administration's Proposed Language Revising Medicaid's Rehabilitation and Targeted Case Management Options

 

SEC. __. CLARIFICATION OF DEFINITION OF REHABILITATION SERVICES.

(a) IN GENERAL.-Section 1905 of the Social Security Act (42 U.S.C. 1396d) is amended-

(1) in subsection (a), in the matter following paragraph (27)-

(A) by striking "or" after subparagraph (A);

(B) by striking the period after subparagraph (B) and inserting "; or" and

(C) by inserting after subparagraph (B) the following new subparagraph:

"(C) any payment with respect to rehabilitation services for purposes of paragraphs (9), (13), or other any other provision of this subsection if such services do not meet the requirements of subsection (x).".

(2) by adding after subsection (w) the following new subsection:

"(x) the term "rehabilitation services" means services which-

"( 1) are intended for the maximum reduction of physical or mental disability and restoration of an individual to the best possible functional level;

"(2) are necessary for the achievement of specific, measurable outcomes related to the purposes described in paragraph (1);

"(3) are prescribed by a physician or other licensed practitioner of the healing arts within the scope of his or her practice under State law;

"(4) are provided by, or under the direction of, a physician or other licensed practitioner of the healing arts within the scope of his or her practice under State law;

"(5) are provided consistent with the requirements of section 1902(a)(23) (with respect to freedom of choice of provider); and

"(6) are not allowable services or an administrative function under any other Federal, State, or local program, including programs under-

"(A) title IV of this Act; or

"(B) any other Federal, State, or local authority governing provision of services pertaining to education, mental health, job training, housing, parole and probation, juvenile justice, public guardianship, foster care, or child welfare.".

(b) CONFORMING STATE PLAN REQUIREMENTS.-Section 1902(a) of the Social Security Act (42 U.S.C. 1396a(a)) is amended-

(1) in paragraph (66) by striking "and" at the end;

(2) in paragraph (67) by striking the period at the end and inserting "; and" and

(3) by adding after paragraph (67), as so amended, the following new paragraph:

"(68) provide, with respect to rehabilitation services described in section 1905(x), such information and assurances as the Secretary determines appropriate to demonstrate that the State furnished such services in accordance with the requirements of such section.".

(c) PAYMENT EXCLUSION.-Section 1903(i) of the Social Security Act (42 U.S.C. 1396b(i)) is amended by inserting immediately after paragraph (8) the following new paragraph:

"(9) with respect to any amount expended for rehabilitation services (as described in section 1905(x)), to the extent the Secretary determines that such services-

"(A) are furnished without charge to individuals in the State irrespective of such individuals' eligibility for medical assistance;

"(B) are not billed under a fee schedule; or

"(C) are not provided with respect to a specific individual.".

(           d) ENF0RCEMENT.- Section 1903 of the Social Security Act (42 U.S.C. 1396b) is amended by adding at the end the following new subsection:

"(x) ENFORCEMENT OF LIMITATIONS ON PAYMENT FOR REHABILITATION SERVICES .-

"(1) STATE PLAN AUDITS.- If the Secretary determines that information submitted by a State pursuant to this title is insufficient to demonstrate that the State's report of its estimated or actual quarterly expenditures (pursuant to subsection (d)(l)(A)) excludes expenditures of the type for which Federal matching payments are not permitted under subsection (i)(9), the Secretary shall audit, at such times and to the extent determined necessary and appropriate by the Secretary, the program under the State plan under this title, including any demonstration or waiver programs.

"(2) ACTIONS BY SECRETARY .- If information obtained by the Secretary in accordance with this subsection (or otherwise under this title) demonstrates to the Secretary that the State report described in paragraph (1) includes expenditures for which Federal matching is barred under subsection (i)(9), or that any existing State plan methodology would result in such expenditures, the Secretary shall reduce, defer, or disallow such expenditures.".

(e) EFFECTIVE DATE.-The provisions of this section shall take effect October 1 , 2006.

 

SEC.___ . CLARIFICATION OF DEFINITION OF CASE MANAGEMENT SERVICES.

(a) IN GENERAL.-Section 1915(g) of the Social Security Act (42 U.S.C. 1396n(g)(2)) is amended by amending paragraph (2) to read as follows:

"(2) For purposes of this subsection, the term 'case management services' means services which-

"(A) will assist individuals eligible under the plan in gaining access to needed medical, social, educational, and other services;

"(B) are distinct from such medical, social, education, and other services;

"(C) are used to achieve specific, measurable outcomes for specific individuals in accordance with subparagraph (A); and

"(D) subject to paragraph (3), are not allowable services or an administrative function under any other Federal, State, or local program, including programs under-

"(i) title IV of this Act; or

"(ii) any other Federal, State, or local authority governing provision of services pertaining to education, mental health, job training, housing, parole and probation, juvenile justice, public guardianship, foster care, or child welfare.

"(3) Subparagraph (2)(D) shall not apply with respect to case management services (as otherwise defined under paragraph (2)) furnished to an infant or toddler with a disability pursuant to the child's individualized family service plan under part C of the Individuals with Disabilities Education Act.".

(b) CONFORMING STATE PLAN REQUIREMENTS.-Section 1902(a) (42 U.S.C. 1396a(a)) is amended-

(1) in paragraph (66) by striking "and" at the end;

(2) in paragraph (67) by striking the period at the end and inserting "; and"

(3) by adding after paragraph (67), as so amended, the following new paragraph:

"(68) provide, with respect to case management services as described in section 1915(g), such information and assurances as the Secretary determines appropriate to demonstrate that the State has furnished such services in accordance with the requirements of such section.".

(c) PAYMENT EXCLUSION.-Section 1903(i) (42 U.S.C. 1396b(i)) is amended by inserting immediately after paragraph (8) the following new paragraph:

"(9) notwithstanding section 8435 of the Technical and Miscellaneous Revenue Act of 1988 (P.L. 100-647), with respect to any amount expended for case management services (as described in section 1915(g)), to the extent the Secretary determines that such services-

"(A) are furnished without charge to individuals in the State irrespective of such individuals' eligibility for medical assistance;

"(B) are not billed under a fee schedule; or

"(C) are not provided with respect to a specific individual.".

(d) ENFORCEMENT.- Section 1903 of the Social Security Act (42 U.S.C. 1396b) is amended by adding at the end the following new subsection:

"(x) ENFORCEMENT OF LIMITATIONS ON PAYMENT FOR CASE MANAGEMENT SERVICES.-

"(1) STATE PLAN AUDITS.- If the Secretary determines that information submitted by a State pursuant to this title is insufficient to demonstrate that the State's report of its estimated or actual quarterly expenditures (pursuant to subsection (d)( l)(A)) excludes expenditures of the type for which Federal matching payments are not permitted under subsection (i)(9), the Secretary shall audit, at such times and to the extent

determined necessary and appropriate by the Secretary, the program under the State plan under this title, including any demonstration or waiver programs.

"(2) ACTIONS BY SECRETARY.- If information obtained by the Secretary in accordance with this subsection (or otherwise under this title) demonstrates to the Secretary that the State report described in paragraph (1) includes expenditures for which Federal matching is not permitted under subsection (i)(9), or that any existing State plan methodology would result in such expenditures, the Secretary shall reduce, defer, or disallow such expenditures-".

(e) EFFECTIVE DATE.-The provisions of this section shall take effect October 1, 2006.

 

SEC. ___. FEDERAL MATCHING RATE FOR CASE MANAGEMENT SERVICES.

(a) IN GENERAL.-Section 1903(a) of the Social Security Act (42 U.S.C. 1396b(a)) is Amended-

(1) in paragraph (l), by inserting before the semicolon "(other than for services specified in paragraph (8))";

(2) by striking the period at the end of paragraph (7) and inserting "; plus"; and

(3) by inserting after paragraph (7) the following new paragraph:

"(8) 50 per centum of the sums expended during such quarter for case management services, as described in subsections (c)(4)(B) and (g)(2) of section 1915, and 50 per centum of any administrative expenditures related to providing such services.".

(b) EFFECTIVE DATE.- This section shall be effective with respect to calendar quarters beginning on or after October 1,2005.

 

SEC. ___. ALLOTMENT LIMITS FOR MEDICAID ADMINISTRATIVE COSTS.

(a) IN GENERAL.-Section 1903 of the Social Security Act (42 U.S.C. 1396b) is amended-

(1) in subsection (a), in the matter preceding paragraph (1), by inserting "(subject, except with respect to medical assistance expenditures under paragraph (1), to the allotment limits under subsection (x))" after "under this title"; and

(2) by adding at the end the following new subsection:

"(x) STATE ADMINISTRATIVE COST LIMITAT10N.-

"(1) IN GENERAL.-Payments to a State under paragraphs (2) through (7) of subsection (a) for calendar quarters in fiscal year 2006 or any succeeding fiscal year shall not exceed, in the aggregate, an amount equal to the State's administrative cost allotment, as determined under this subsection.

"(2) ALLOTMENT FORMULA.-The administrative allotment for a State-

"(A)(i) for fiscal year 2006 shall be an amount equal to the Federal share of total allowable costs claimed by the State under paragraphs (2) through (7) of subsection (a) for calendar quarters in fiscal year 2003, determined as of September 30,2004, adjusted in accordance with clause (ii).

"(ii) the amount specified in clause (i) shall be increased by a percentage equal to the sum of the percentages described in clause (iii).

"(iii) the percentages described in this clause are, with respect to each consecutive 12-month period in the 36-month period ending March 30, 2006, the percentage change in the consumer price index (for all urban consumers; U.S. city average) plus 4.5 percentage points; and

"(B)(i) for each succeeding fiscal year, shall be the State's administrative allotment for the preceding fiscal year, increased by the percentage described in clause (ii).

"(ii) the percentage described in this paragraph is the percentage change in the consumer price index (for all urban consumers; U.S. city average) for the 12-month period ending on March 30 of such fiscal year, plus 4.5 percentage points.".

(b) EFFECTIVE DATE.-The amendments made by this section shall be effective with respect to calendar quarters beginning on or after October 1, 2006.