Summary: H.R.5300 — 101st Congress (1989-1990)All Information (Except Text)

There is one summary for H.R.5300. Bill summaries are authored by CRS.

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Introduced in House (07/18/1990)

Mediplan Act of 1990 - Title I: Health Care Eligibility and Benefits - Adds a new title XXI to the Social Security Act entitled "Mediplan Health Benefits." Makes all U.S. residents eligible for Mediplan benefits. Requires the development of a Mediplan enrollment mechanism that includes automatic enrollment at birth and the issuance of Mediplan cards for identification and claims processing purposes. Provides the same benefits under the Mediplan program as are provided under title XVIII (Medicare) of the Social Security Act to individuals who are entitled to benefits under part A (Hospital Insurance) and enrolled under part B (Supplementary Medical Insurance) of the Medicare program. Imposes a $500 annual deductible on Mediplan beneficiaries, but limits an individual's annual out-of-pocket costs for deductibles, coinsurance, and copayments to $2,500.

Provides additional Mediplan coverage to children under age 23, pregnant women, and low-income individuals. Imposes no coinsurance, deductible, or copayment for benefits provided to such children, to individuals whose income is below the Federal poverty level, or for pregnancy-related services provided to pregnant women. Charges individuals whose income is above the Federal poverty level but does not exceed twice that level with a proportion of cost-sharing amounts equal to the extent to which their income spans such limits. Provides children with preventive health care services, and children and individals whose income is below the Federal poverty level with outpatient prescription drugs and biologicals, eyeglasses and hearing aids and examinations therefor, and inpatient hospital services without durational limitations. Includes postnatal family planning services among covered pregnancy-related services.

Requires that payments under the Mediplan program be made only on an assignment-related basis. Requires payments for obstetrical services to be made on the basis of a global fee for the group of obstetrical services typical during the course of pregnancy, with slightly greater payments for prenatal care services begun in a women's first trimester of pregnancy and for non-caesarean deliveries. Requires the Secretary of Health and Human Services to establish a prospective payment methodology for outpatient prescription drugs and biologicals.

Establishes the Mediplan Trust Fund which shall consist of revenues raised by this Act's financing mechanisms and amounts States save under their Medicaid (title XIX of the Social Security Act) programs due to the Mediplan program.

Requires the modification of Medicaid and other Federal health programs to avoid their duplication of Mediplan coverage. Applies various administrative provisions of the Medicare program to the Mediplan program.

Requires group health plans which provide their current beneficiaries with benefits which are in addition to Mediplan benefits to continue to provide such benefits to such individuals, though they needn't provide such additional benefits to individuals who are not entitled to them before this Act's enactment.

Title II: Long-Term Care Eligibility and Benefits - Amends the Medicare program to eliminate the requirement that covered extended care services follow hospitalization, and extend such coverage to 180 days per year, rather than the current 100 days of extended care coverage for each spell of illness. Requires that the coinsurance amount, charged for each of the first eight days of extended care, represent 20 percent of the national average per diem cost of such care.

Covers nursing care and home health aide services as home health services if such services are needed less than seven days each week or are needed for up to 180 consecutive days.

Adds a new title XXII to the Social Security Act entitled "Mediplan Long-Term Care Benefits." Covers nursing facility services and long-term home and community-based care for chronically ill individuals under title XXII, but limits such services, until 1997, to individuals who are age 65 or older.

Defines a chronically ill individual as an individual who has been certified by a case manager pursuant to an eligibility assessment as: (1) being unable to perform three activities of daily living, for purposes of the provision of this Act's nursing facility services; (2) being unable to perform two activities of daily living, for purposes of the provision of this Act's long-term home and community-based care; or (3) having a similar level of disability due to cognitive impairment such that without supervision the individual would be a danger to, or unable to care for, himself or herself. Requires a case manager to conduct a comprehensive needs assessment of chronically ill individuals and develop a written plan of care for such individuals on the basis of such assessment. Provides for the regular review and appropriate revision of such assessment and plans of care.

Directs the Secretary of Health and Human Services to: (1) develop, by July 1, 1991, a uniform instrument for use in conducting eligibility and needs assessments; (2) annually survey assessment and case management agencies to ensure their compliance with this Act's requirements; and (3) establish standards for case manager training programs.

Requires that covered long-term care services be reasonable and necessary for the maintenance of the physical, mental, and psychosocial well-being of the beneficiary.

Makes the title XXII program the secondary payor for benefits which an individual is also eligible to receive under the Medicare program.

Requires that payments for nursing facility services and long-term home and community-based care for chronically ill individuals be based on a prospective payment system that takes into account variations in case mix and area wages. Limits payments for long-term home and community-based care to 90 percent of the median payment amounts for nursing facility services in the same wage area if a physician certifies that the individual requires skilled nursing and rehabilitation care and to 70 percent of such amounts if such certification is not made.

Requires individuals to have received nursing facility services for at least 12 of the preceding 24 months before title XXII benefits will be payable for services furnished during 1993 and 1994 and to have received such services for at least two of the preceding 3 months before such benefits will be payable for services furnished thereafter. Sets the coinsurance amount for nursing facility services and long-term home and community-based care at 20 percent of the national average per diem payment amounts for such respective services. Makes such deductible and coinsurance provisions inapplicable to individuals whose income is below 200 percent of the Federal poverty level.

Makes the Mediplan Trust Fund provisions of title XXI applicable under title XXII as well.

Gives individuals the right to appeal title XXII eligibility or benefit determinations.

Applies various administrative provisions of the Medicare program to the Mediplan Long-Term Care Benefits program.

Requires the Secretary to report to the Congress by 1992 on how Medicare health maintenance organization provisions might be adapted to Mediplan long-term care benefits.

Directs States to pay to the Mediplan Trust Fund amounts they save under their Medicaid programs due to this Act's long-term care coverage. Prohibits Medicaid duplication of Mediplan long-term care benefits.

Title III: Financing Provisions - Amends the Internal Revenue Code to impose an additional income tax on individuals, a tax on every taxpayer other than an individual, and a tax on the wages paid by employers to finance Mediplan health and long-term care benefits.