[Congressional Bills 103th Congress]
[From the U.S. Government Publishing Office]
[S. 484 Introduced in Senate (IS)]
103d CONGRESS
1st Session
S. 484
To amend title XIX of the Social Security Act to provide for coverage
of alcoholism and drug dependency residential treatment services for
pregnant women and certain family members under the medicaid program,
and for other purposes.
_______________________________________________________________________
IN THE SENATE OF THE UNITED STATES
March 3, 1993
Mr. Daschle (for himself, Mr. Bradley, Mr. Kennedy, Mr. Chafee, Mr.
Murkowski, Mr. Conrad, Mr. Simon, Ms. Kassebaum, Mr. DeConcini, and Mr.
Akaka) introduced the following bill; which was read twice and referred
to the Committee on Finance
_______________________________________________________________________
A BILL
To amend title XIX of the Social Security Act to provide for coverage
of alcoholism and drug dependency residential treatment services for
pregnant women and certain family members under the medicaid program,
and for other purposes.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Medicaid Substance Abuse Treatment
Act of 1993''.
SEC. 2. FINDINGS AND PURPOSE.
(a) Findings.--The Congress finds that--
(1) a woman's ability to bear healthy children is
threatened by the consequences of alcoholism and drug
addiction;
(2) an estimated 375,000 infants each year are born drug-
exposed, at least 5,000 infants are born each year with fetal
alcohol syndrome, and another 35,000 are born each year with
fetal alcohol effect, a less severe version of fetal alcohol
syndrome;
(3) drug use during pregnancy can result in low
birthweight, physical deformities, mental retardation, learning
disabilities, and heightened nervousness and irritability in
newborns;
(4) fetal alcohol syndrome is the leading identifiable
cause of mental retardation in the United States and the only
cause that is 100 percent preventable;
(5) drug-impaired individuals pose extraordinary societal
costs in terms of medical, educational, foster care,
residential, and support services over the lifetimes of such
individuals;
(6) women, in general, are underrepresented in drug and
alcohol treatment programs;
(7) due to fears among service providers concerning the
risks pregnancies pose, pregnant women face more obstacles to
substance abuse treatment than do other addicts and many
substance abuse treatment programs, in fact, exclude pregnant
women or women with children;
(8) alcohol and drug treatment is an important prevention
strategy to prevent low birthweight, transmission of AIDS, and
chronic physical, mental, and emotional disabilities associated
with prenatal exposure to alcohol and other drugs;
(9) effective substance abuse treatment must address the
special needs of pregnant women who are alcohol or drug
dependent, including substance-abusing women who may often face
such problems as domestic violence, incest and other sexual
abuse, poor housing, poverty, unemployment, lack of education
and job skills, lack of access to health care, emotional
problems, chemical dependency in their family backgrounds,
single parenthood, and the need to ensure child care for
existing children while undergoing substance abuse treatment;
(10) nonhospital residential treatment is an important
component of comprehensive and effective substance abuse
treatment for pregnant addicted women, many of whom need long-
term, intensive habilitation outside of their communities to
recover from their addiction and take care of themselves and
their families; and
(11) a gap exists under the medicaid program for the
financing of comprehensive residential care in the existing
continuum of medicaid-covered alcoholism and drug abuse
treatment services for low-income pregnant addicted women.
(b) Purposes.--The purposes of this Act are--
(1) to increase the ability of pregnant women who are
substance abusers to participate in alcohol and drug treatment;
(2) to ensure the availability of comprehensive and
effective treatment programs for pregnant women, thus promoting
a woman's ability to bear healthy children;
(3) to ensure that nonhospital residential treatment is
available to those low-income pregnant addicted women who need
long-term, intensive habilitation to recover from their
addiction;
(4) to create a new optional medicaid residential treatment
service for alcoholism and drug dependency treatment; and
(5) to define the core services that must be provided by
treatment providers to ensure that needed services will be
available and appropriate.
SEC. 3. MEDICAID COVERAGE OF ALCOHOLISM AND DRUG DEPENDENCY RESIDENTIAL
TREATMENT SERVICES FOR PREGNANT WOMEN, CARETAKER PARENTS,
AND THEIR CHILDREN.
(a) Coverage of Alcoholism and Drug Dependency Residential
Treatment Services.--
(1) Optional coverage.--Section 1905 of the Social Security
Act (42 U.S.C. 1396d) is amended--
(A) in subsection (a)--
(i) by striking ``and'' at the end of
paragraph (21);
(ii) in paragraph (24), by striking the
period at the end and inserting a semicolon;
(iii) by redesignating paragraphs (22),
(23), and (24) as paragraphs (25), (22), and
(23), respectively, and by transferring and
inserting paragraph (25) after paragraph (23),
as so redesignated; and
(iv) by inserting after paragraph (23) the
following new paragraph:
``(24) alcoholism and drug dependency residential treatment
services (to the extent allowed and as defined in section
1931); and''; and
(B) in the sentence following paragraph (25), as so
redesignated--
(i) in subdivision (A), by striking ``or''
at the end;
(ii) in subdivision (B), by inserting ``,
who is not receiving alcoholism and drug
dependency residential treatment services,''
after ``65 years of age''; and
(iii) by inserting after subdivision (B)
the following:
``(C) any such payments with respect to alcoholism and drug
dependency residential treatment services under paragraph (24)
for individuals not described in section 1931(d).''.
(2) Alcoholism and drug dependency residential treatment
services defined.--Title XIX of the Social Security Act (42
U.S.C. 1396 et seq.) is amended by adding at the end the
following new section:
``alcoholism and drug dependency residential treatment services
``Sec. 1931. (a) Alcoholism and Drug Dependency Residential
Treatment Services.--The term `alcoholism and drug dependency
residential treatment services' means all the required services
described in subsection (b) which are provided--
``(1) in a coordinated manner by a residential treatment
facility that meets the requirements of subsection (c) either
directly or through arrangements with--
``(A) public and nonprofit private entities;
``(B) licensed practitioners or federally qualified
health centers with respect to medical services; or
``(C) the Indian Health Service or a tribal or
Indian organization that has entered into a contract
with the Secretary under section 102 of the Indian
Self-Determination Act (25 U.S.C. 450f) or section 502
of the Indian Health Care Improvement Act (25 U.S.C.
1652) with respect to such services provided to women
eligible to receive services in Indian Health
Facilities; and
``(2) pursuant to a written individualized treatment plan
prepared for each individual, which plan--
``(A) states specific objectives necessary to meet
the individual's needs;
``(B) describes the services to be provided to the
individual to achieve those objectives;
``(C) is established in consultation with the
individual;
``(D) is periodically reviewed and (as appropriate)
revised by the staff of the facility in consultation
with the individual;
``(E) reflects the preferences of the individual;
and
``(F) is established in a manner which promotes the
active involvement of the individual in the development
of the plan and its objectives.
``(b) Required Services Defined.--
``(1) In general.--The required services described in this
subsection are as follows:
``(A) Counseling, addiction education, and
treatment provided on an individual, group, and family
basis and provided pursuant to individualized treatment
plans, including the opportunity for involvement in
Alcoholics Anonymous and Narcotics Anonymous.
``(B) Parenting skills training.
``(C) Education concerning prevention of HIV
infection.
``(D) Assessment of each individual's need for
domestic violence counseling and sexual abuse
counseling and provision of such counseling where
needed.
``(E) Room and board in a structured environment
with on-site supervision 24 hours-a-day.
``(F) Therapeutic child care or counseling for
children of individuals in treatment.
``(G) Assisting parents in obtaining access to--
``(i) developmental services (to the extent
available) for their preschool children;
``(ii) public education for their school-
age children, including assistance in enrolling
them in school; and
``(iii) public education for parents who
have not completed high school.
``(H) Facilitating access to prenatal and
postpartum health care for women, to pediatric health
care for infants and children, and to other health and
social services where appropriate and to the extent
available, including services under title V, services
and nutritional supplements provided under the special
supplemental food program for women, infants, and
children (WIC) under section 17 of the Child Nutrition
Act of 1966, services provided by federally qualified
health centers, outpatient pediatric services, well-
baby care, and early and periodic screening,
diagnostic, and treatment services (as defined in
section 1905(r)).
``(I) Ensuring supervision of children during times
their mother is in therapy or engaged in other
necessary health or rehabilitative activities,
including facilitating access to child care services
under title IV and title XX.
``(J) Planning for and counseling to assist reentry
into society, including appropriate outpatient
treatment and counseling after discharge (which may be
provided by the same program, if available and
appropriate) to assist in preventing relapses,
assistance in obtaining suitable affordable housing and
employment upon discharge, and referrals to appropriate
educational, vocational, and other employment-related
programs (to the extent available).
``(K) Continuing specialized training for staff in
the special needs of residents and their children,
designed to enable such staff to stay abreast of the
latest and most effective treatment techniques.
``(2) Requirement for certain services.--Services under
subparagraphs (A), (B), (C), and (D), of paragraph (1) shall be
provided in a cultural context that is appropriate to the
individuals and in a manner that ensures that the individuals
can communicate effectively, either directly or through
interpreters, with persons providing services.
``(3) Limitations on coverage.--
``(A) In general.--Subject to subparagraph (B),
services described in paragraph (1) shall be covered in
the amount, duration, and scope therapeutically
required for each eligible individual in need of such
services.
``(B) Restrictions on limiting coverage.--A State
plan shall not limit coverage of alcoholism and drug
dependency residential treatment services for any
period of less than 12 months per individual, except in
those instances where a finding is made that such
services are no longer therapeutically necessary for an
individual.
``(c) Facility Requirements.--The requirements of this subsection
with respect to a facility are as follows:
``(1) The agency designated by the chief executive officer
of the State to administer the State's alcohol and drug abuse
prevention and treatment activities and programs has certified
to the single State agency under section 1902(a)(5) that the
facility--
``(A) is able to provide all the services described
in subsection (b) either directly or through
arrangements with--
``(i) public and nonprofit private
entities;
``(ii) licensed practitioners or federally
qualified health centers with respect to
medical services; or
``(iii) the Indian Health Service or with a
tribal or Indian organization that has entered
into a contract with the Secretary under
section 102 of the Indian Self-Determination
Act (25 U.S.C. 450f) or section 502 of the
Indian Health Care Improvement Act (25 U.S.C.
1652) with respect to such services provided to
women eligible to receive services in Indian
Health Facilities; and
``(B) except for Indian Health Facilities, meets
all applicable State licensure or certification
requirements for a facility of that type.
``(2)(A) The facility or a distinct part of the facility
provides room and board, except that--
``(i) subject to subparagraph (B), the facility
shall have no more than 40 beds; and
``(ii) subject to subparagraph (C), the facility
shall not be licensed as a hospital.
``(B) The single State agency may waive the bed limit under
subparagraph (A)(i) for one or more facilities subject to
review by the Secretary. Waivers, where granted, must be made
pursuant to standards and procedures set out in the State plan
and must require the facility seeking a waiver to demonstrate
that--
``(i) the facility will be able to maintain a
therapeutic, family-like environment;
``(ii) the facility can provide quality care in the
delivery of each of the services identified in
subsection (b);
``(iii) the size of the facility will be
appropriate to the surrounding community; and
``(iv) the development of smaller facilities is not
feasible in that geographic area.
``(C) The Secretary may waive the requirement under
subparagraph (A)(ii) that a facility not be a hospital, if the
Secretary finds that such facility is located in an Indian
Health Service area and that such facility is the only or one
of the only facilities available in such area to provide
services under this section.
``(3) With respect to a facility providing the services
described in subsection (b) to an individual eligible to
receive services in Indian Health Facilities, such a facility
demonstrates (as required by the Secretary) an ability to meet
the special needs of Indian and Native Alaskan women.
``(d) Eligible Individuals.--
``(1) In general.--A State plan shall limit coverage of
alcoholism and drug dependency residential treatment services
under section 1905(a)(24) to the following individuals
otherwise eligible for medical assistance under this title:
``(A) Women during pregnancy, and until the end of
the 12th month following the termination of the
pregnancy.
``(B) Children of a woman described in subparagraph
(A).
``(C) At the option of a State, a caretaker parent
or parents and children of such a parent.
``(2) Initial assessment of eligible individuals.--An
initial assessment of eligible individuals specified in
paragraph (1) seeking alcoholism and drug dependency
residential treatment services shall be performed by the agency
designated by the chief executive officer of the State to
administer the State's alcohol and drug abuse treatment
activities (or its designee). Such assessment shall determine
whether such individuals are in need of alcoholism or drug
dependency treatment services and, if so, the treatment setting
(such as inpatient hospital, nonhospital residential, or
outpatient) that is most appropriate in meeting such
individual's health and therapeutic needs and the needs of such
individual's dependent children, if any.
``(e) Overall Cap on Medical Assistance and Allocation of Beds.--
``(1) Total amount of services as medical assistance.--
``(A) In general.--The total amount of services
provided under this section as medical assistance for
which payment may be made available under section 1903
shall be limited to the total number of beds allowed to
be allocated for such services in any given year as
specified under subparagraph (B).
``(B) Total number of beds.--The total number of
beds allowed to be allocated under this subparagraph
(subject to paragraph (2)(C)) for the furnishing of
services under this section and for which Federal
medical assistance may be made available under section
1903 is for calendar year--
``(i) 1994, 1,080 beds;
``(ii) 1995, 2,000 beds;
``(iii) 1996, 3,500 beds;
``(iv) 1997, 5,000 beds;
``(v) 1998, 6,000 beds; and
``(vi) 1999 and for calendar years
thereafter, a number of beds determined
appropriate by the Secretary.
``(2) Allocation of beds.--
``(A) Initial allocation formula.--For each
calendar year, a State exercising the option to provide
the services described in this section shall be
allocated from the total number of beds available under
paragraph (1)(B)--
``(i) in calendar years 1994 and 1995, 20
beds;
``(ii) in calendar years 1996, 1997, and
1998, 40 beds; and
``(iii) in calendar year 1999 and for each
calendar year thereafter, a number of beds
determined based on a formula (as provided by
the Secretary) distributing beds to States on
the basis of the relative percentage of women
of childbearing age in a State.
``(B) Reallocation of beds.--The Secretary shall
provide that in allocating the number of beds made
available to a State for the furnishing of services
under this section that, to the extent not all States
are exercising the option of providing services under
this section and there are beds available that have not
been allocated in a year as provided in paragraph
(1)(B), that such beds shall be reallocated among
States which are furnishing services under this section
based on a formula (as provided by the Secretary)
distributing beds to States on the basis of the
relative percentage of women of childbearing age in a
State.
``(C) Indian health service areas.--In addition to
the beds allowed to be allocated under paragraph (1)(B)
there shall be an additional 20 beds allocated in any
calendar year to States for each Indian Health Service
area within the State to be utilized by Indian Health
Facilities within such an area and, to the extent such
beds are not utilized by a State, the beds shall be
reapportioned to Indian Health Service areas in other
States.''.
(3) Maintenance of state financial effort and 100 percent
federal matching for services for indian and native alaskan
women in indian health services areas.--Section 1903 of the
Social Security Act (42 U.S.C. 1396b) is amended by adding at
the end the following new subsections:
``(x) No payment shall be made to a State under this section in a
State fiscal year for alcoholism and drug dependency residential
treatment services (described in section 1931) unless the State
provides assurances satisfactory to the Secretary that the State is
maintaining State expenditures for such services at a level that is not
less than the average annual level maintained by the State for such
services for the 2-year period preceding such fiscal year.
``(y) Notwithstanding the preceding provisions of this section, the
Federal medical assistance percentage for purposes of payment under
this section for services described in section 1931 provided to
individuals residing on or receiving services in an Indian Health
Service area shall be 100 percent.''.
(b) Payment on a Cost-Related Basis.--Section 1902(a)(13) of the
Social Security Act (42 U.S.C. 1396a(a)(13)) is amended--
(1) by striking ``and'' at the end of subparagraph (E);
(2) by adding ``and'' at the end of subparagraph (F); and
(3) by adding at the end the following new subparagraph:
``(G) for payment for alcoholism and drug
dependency residential treatment services which the
State finds, and makes assurances satisfactory to the
Secretary, are reasonable and adequate to meet the
costs which must be incurred by efficiently and
economically operated facilities in order to provide
all the services listed in section 1931(b) in
conformity with applicable Federal and State laws,
regulations, and quality and safety standards and to
assure that individuals eligible for such services have
reasonable access to such services;''.
(c) Conforming Amendments.--
(1) Clarification of optional coverage for specified
individuals.--Section 1902(a)(10) of the Social Security Act
(42 U.S.C. 1396a(a)(10)) is amended, in the matter following
subparagraph (F)--
(A) by striking ``; and (XI)'' and inserting ``,
(XI)'';
(B) by striking ``, and (XI)'' and inserting ``,
and (XII)''; and
(C) by inserting before the semicolon at the end
the following: ``, and (XIII) the making available of
alcoholism and drug dependency residential treatment
services to individuals described in section 1931(d)
shall not, by reason of this paragraph, require the
making of such services available to other
individuals''.
(2) Continuation of eligibility for alcoholism and drug
dependency treatment for pregnant women for 12 months following
end of pregnancy.--Section 1902 of the Social Security Act (42
U.S.C. 1396a) is amended in subsection (e)(5) by striking
``under the plan,'' and all through the period at the end and
inserting ``under the plan--
``(A) as though she were pregnant, for all pregnancy-
related and postpartum medical assistance under the plan,
through the end of the month in which the 60-day period
(beginning on the last day of her pregnancy) ends; and
``(B) for alcoholism and drug dependency residential
treatment services under section 1931 through the end of the 1-
year period beginning on the last day of her pregnancy.''.
(3) Redesignations.--Section 1902 of the Social Security
Act (42 U.S.C. 1396a) is further amended--
(A) in subsection (a)(10)(C)(iv), by striking
``(21)'' and inserting ``(24)''; and
(B) in subsection (j), by striking ``(22)'' and
inserting ``(25)''.
(d) Annual Education and Training in Indian Health Service Areas.--
The Secretary of Health and Human Services in cooperation with the
Indian Health Service shall conduct on at least an annual basis
training and education in each of the 12 Indian Health Service areas
for tribes, Indian organizations, residential treatment providers, and
State health care workers regarding the availability and nature of
residential treatment services available in such areas under the
provisions of this Act.
(e) Effective Date; Transition.--(1) The amendments made by this
section apply to alcoholism and drug dependency residential treatment
services furnished on or after July 1, 1994, without regard to whether
or not final regulations to carry out such amendments have been
promulgated by such date.
(2) The Secretary of Health and Human Services shall not take any
compliance, disallowance, penalty, or other regulatory action against a
State under title XIX of the Social Security Act with regard to
alcoholism and drug dependency residential treatment services (as
defined in section 1931(a) of such Act) made available under such title
on or after July 1, 1994, before the date the Secretary issues final
regulations to carry out the amendments made by this section, if the
services are provided under its plan in good faith compliance with such
amendments.
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