[Congressional Bills 111th Congress]
[From the U.S. Government Publishing Office]
[H.R. 4787 Introduced in House (IH)]
111th CONGRESS
2d Session
H. R. 4787
To amend title XIX of the Social Security Act to improve and protect
rehabilitative services and case management services provided under
Medicaid to improve the health and welfare of the Nation's most
vulnerable seniors and children.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
March 9, 2010
Ms. Baldwin (for herself and Mr. Sullivan) introduced the following
bill; which was referred to the Committee on Energy and Commerce
_______________________________________________________________________
A BILL
To amend title XIX of the Social Security Act to improve and protect
rehabilitative services and case management services provided under
Medicaid to improve the health and welfare of the Nation's most
vulnerable seniors and children.
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) Short Title.--This Act may be cited as the ``Medicaid Services
Restoration Act of 2010''.
(b) Table of Contents.--The table of contents of this Act is as
follows:
Sec. 1. Short title; table of contents.
TITLE I--REHABILITATIVE SERVICES PROTECTIONS
Sec. 101. Inclusion of therapeutic foster care as medical assistance.
Sec. 102. Inclusion of attainment and retention of functional status in
rehabilitative services.
Sec. 103. Reasonable and efficient payment methodologies for
rehabilitative services.
Sec. 104. Clarification of coverage of EPSDT services for children
receiving inpatient psychiatric hospital
services.
Sec. 105. Third party liability clarification relating to diagnostic,
screening, preventive, and rehabilitative
services.
TITLE II--CASE MANAGEMENT AND TARGETED CASE MANAGEMENT PROTECTIONS
Sec. 201. Third party liability clarification relating to case
management and targeted case management.
Sec. 202. Reasonable and efficient payment methodologies for case
management services.
Sec. 203. Protecting health and safety.
Sec. 204. Codification of Olmstead standard; protecting children.
Sec. 205. Assuring appropriate case management.
TITLE I--REHABILITATIVE SERVICES PROTECTIONS
SEC. 101. INCLUSION OF THERAPEUTIC FOSTER CARE AS MEDICAL ASSISTANCE.
Section 1905 of the Social Security Act (42 U.S.C. 1396d) is
amended--
(1) in subsection (a)--
(A) in paragraph (27), by striking ``and'' at the
end;
(B) by redesignating paragraph (28) as paragraph
(29); and
(C) by inserting after paragraph (27) the following
new paragraph:
``(28) therapeutic foster care services described in
subsection (y); and''; and
(2) by adding at the end the following new subsection:
``(y)(1) For purposes of subsection (a)(28), subject to
subparagraph (C), therapeutic foster care services described in this
subsection are services provided for children who have not attained age
21, and who, as a result of mental illness, other emotional or
behavioral disorders, medically fragile conditions, or developmental
disabilities, need the level of care provided in an institution
(including a psychiatric residential treatment facility) or nursing
facility the cost of which could be reimbursed under the State plan but
who can be cared for or maintained in a community placement, through
therapeutic foster care programs that--
``(A) are licensed by the State and accredited by the Joint
Commission on Accreditation of Healthcare Organizations, the
Commission on Accreditation of Rehabilitation Facilities, the
Council on Accreditation, or by another equivalent
accreditation agency (or agencies) as the Secretary may
recognize;
``(B) provide structured daily activities, including the
development, improvement, monitoring, and reinforcing of age-
appropriate social, communication and behavioral skills, crisis
intervention and crisis support services, medication
monitoring, counseling, and case management, and may furnish
other intensive community services; and
``(C) provide foster care parents with specialized training
and consultation in the management of children with mental
illness, other emotional or behavioral disorders, medically
fragile conditions, or developmental disabilities, and specific
additional training on the needs of each child provided such
services.
``(2) In making coverage determinations under paragraph (1), a
State may employ medical necessity criteria that are similar to the
medical necessity criteria applied to coverage determinations for other
services and supports under this title.
``(3) The services described in this subsection do not include the
training referred to in paragraph (1)(C).''.
SEC. 102. INCLUSION OF ATTAINMENT AND RETENTION OF FUNCTIONAL STATUS IN
REHABILITATIVE SERVICES.
Section 1905(a)(13) of the Social Security Act (42 U.S.C.
1396d(a)(13)) is amended by striking ``and restoration of an individual
to the best possible functional level'' and inserting ``, restoration
of an individual to the best possible functional level, or attainment
or retention of the individual's best possible functional status''.
SEC. 103. REASONABLE AND EFFICIENT PAYMENT METHODOLOGIES FOR
REHABILITATIVE SERVICES.
Section 1905(a)(13) of the Social Security Act (42 U.S.C.
1396d(a)(13)), as amended by section 102, is amended by inserting
``(and which reimbursement for, in the case of rehabilitative services,
may be made through the establishment of reasonable and efficient
payment methodologies, including fee-for-service payments, case rates,
daily rates, or other forms of capitated payment'' after ``status''.
SEC. 104. CLARIFICATION OF COVERAGE OF EPSDT SERVICES FOR CHILDREN
RECEIVING INPATIENT PSYCHIATRIC HOSPITAL SERVICES.
Section 1905(h)(1) of the Social Security Act (42 U.S.C.
1396d(h)(1)) is amended--
(1) in subparagraph (B), by striking ``and'' at the end;
(2) in subparagraph (C), by adding ``and'' after the
semicolon; and
(3) by inserting after subparagraph (C), the following new
subparagraph:
``(D) services described in subsection (r) which are
provided on an inpatient or outpatient basis to an individual
receiving inpatient services described in subparagraph (A),
(B), or (C).''.
SEC. 105. THIRD PARTY LIABILITY CLARIFICATION RELATING TO DIAGNOSTIC,
SCREENING, PREVENTIVE, AND REHABILITATIVE SERVICES.
Section 1903(c) of the Social Security Act (42 U.S.C. 1396b(c)) is
amended--
(1) by inserting ``(1)'' after ``(c)''; and
(2) by adding at the end the following new paragraph:
``(2) Nothing in this title shall be construed as prohibiting or
restricting, or authorizing the Secretary to prohibit or restrict,
payment under subsection (a) for medical assistance for services
provided under section 1905(a)(13) to eligible individuals furnished by
qualified providers under non-medical programs, provided, however, a
State or local agency administering such plan shall comply with section
1902(a)(25).''.
TITLE II--CASE MANAGEMENT AND TARGETED CASE MANAGEMENT PROTECTIONS
SEC. 201. THIRD PARTY LIABILITY CLARIFICATION RELATING TO CASE
MANAGEMENT AND TARGETED CASE MANAGEMENT.
Section 1903(c) of the Social Security Act (42 U.S.C. 1396b(c)), as
amended by section 105, is amended by adding at the end the following
new paragraph:
``(3) Nothing in this title shall be construed as prohibiting or
restricting, or authorizing the Secretary to prohibit or restrict
payment under subsection (a) for medical assistance for services
provided under section 1915(g) to eligible individuals furnished by
qualified providers under non-medical programs, provided, however, a
State or local agency administering such plan shall comply with section
1902(a)(25).''.
SEC. 202. REASONABLE AND EFFICIENT PAYMENT METHODOLOGIES FOR CASE
MANAGEMENT SERVICES.
Section 1915(g)(4) of the Social Security Act (42 U.S.C.
1396n(g)(4)) is amended by adding at the end the following new
subparagraph:
``(C) Reimbursement for case management and targeted case
management services may be made through the establishment of reasonable
and efficient payment methodologies including fee-for-service payments,
case rates, daily rates, or other forms of capitated payment.''.
SEC. 203. PROTECTING HEALTH AND SAFETY.
Section 1915(c)(4) of the Social Security Act (42 U.S.C.
1396n(c)(4)) is amended by adding after the second sentence the
following new sentence: ``For the purpose of developing and monitoring
the implementation of the written plan of care required under paragraph
(1), and to assure the health and welfare of individuals, the State may
require case management services for each beneficiary and may limit the
case managers available with respect to case management services for
eligible individuals in order to ensure that the case managers for such
individuals are capable of ensuring that such individuals receive
needed services.''.
SEC. 204. CODIFICATION OF OLMSTEAD STANDARD; PROTECTING CHILDREN.
Section 1915(g)(2)(A) of the Social Security Act (42 U.S.C.
1396n(g)(2)(A)) is amended--
(1) in clause (i), by striking ``services which will'' and
all that follows through the period and inserting ``services
furnished to assist individuals, eligible under the State plan
who reside in a community setting or are transitioning to a
community setting, in gaining access to needed medical, social,
educational, and other services. Such services may be offered
by staff of non-medical programs or those who contract with
non-medical programs, so long as such individuals are qualified
providers under the State plan under this title and the case
management services are distinct from the direct services of
the non-medical program.'';
(2) by redesignating clause (ii) as clause (iii); and
(3) by inserting after clause (i) (as amended by paragraph
(1)), the following new clause:
``(ii) For purposes of providing case management services,
individuals (other than individuals who have attained age 22
but not attained age 65 and are patients in an institution for
mental diseases or individuals who are inmates of public
institutions) may be considered to be transitioning to a
community setting for up to the last 180 days of an
institutional stay.''.
SEC. 205. ASSURING APPROPRIATE CASE MANAGEMENT.
Section 1915(g)(4) of the Social Security Act (42 U.S.C.
1396n(g)(4)), as amended by section 202, is amended by adding at the
end the following:
``(D) Nothing in this subsection shall be construed as prohibiting
a State from providing case management or targeted case management
services, as defined in subparagraphs (A) and (B), respectively, of
paragraph (2), through multiple case managers to any individual who
qualifies for medical assistance under the State plan, or to specific
classes of individuals, or to individuals who reside in specified
areas, selected by the State pursuant to this subsection.''.
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