Text: H.R.3180 — 102nd Congress (1991-1992)All Information (Except Text)

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HR 3180 IH
102d CONGRESS
1st Session
 H. R. 3180
To amend title XVIII of the Social Security Act to provide protection against
expenses of long-term home care under the medicare program.
IN THE HOUSE OF REPRESENTATIVES
August 1, 1991
Mr. ROYBAL introduced the following bill; which was referred jointly to the
Committees on Ways and Means and Energy and Commerce
A BILL
To amend title XVIII of the Social Security Act to provide protection against
expenses of long-term home care 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; REFERENCES IN ACT.
  (a) SHORT TITLE- This Act may be cited as the `Long-Term Home Care Act
  of 1991'.
  (b) AMENDMENTS TO THE SOCIAL SECURITY ACT- Except as otherwise specifically
  provided, whenever in this Act an amendment is expressed in terms of an
  amendment to or repeal of, a section or other provision, the reference
  shall be considered to be made to that section or other provision of the
  Social Security Act.
SEC. 2. COVERAGE OF LONG-TERM HOME CARE FOR CHRONICALLY ILL INDIVIDUALS AND
CHILDREN UNDER MEDICARE.
  (a) COVERAGE OF LONG-TERM HOME CARE-
  (1) FOR CHRONICALLY ILL INDIVIDUALS GENERALLY- Section 1812(a) (42
  U.S.C. 1395d(a)) is amended--
  (A) by striking `and' at the end of paragraph (3);
  (B) by striking the period at the end of paragraph (4) and inserting `;
  and', and
  (C) by adding at the end the following:
  `(5) long-term home care for a chronically ill individual;
except that an individual who is entitled to benefits under this part only
because of section 226(h) is only entitled to benefits with respect to
long-term home care.'.
  (2) FOR CHRONICALLY ILL CHILDREN AND OTHER INDIVIDUALS 65 YEARS OF AGE
  OR OLDER-
  (A) Section 226 (42 U.S.C. 426) is amended--
  (i) by redesignating subsection (h) as subsection (j), and
  (ii) by inserting after subsection (g) the following new subsections:
  `(h) Every individual who--
  `(1)(A) is under 19 years of age and (B) is (i) a citizen of the United
  States, or (ii) an alien lawfully admitted for permanent residence who has
  resided in the United States continuously during the 5 years immediately
  preceding the month involved,
  `(2) has been certified by a trained case management team of a long-term
  care management agency in consultation with the individual's attending
  physician (or, in the absence of such a physician, any physician)--
  `(A) to be chronically ill or disabled and to be unable to perform (without
  human assistance or supervision) due to the individual's chronic illness
  or disability at least 2 age-appropriate activities of daily living (as
  defined in section 1861(kk)(3)), or
  `(B) to require both a medical device to compensate for the loss of a
  vital body function necessary to avert death or major loss of bodily
  functional capacity and substantial and ongoing nursing care to avert
  death or further disability,
  `(3) has filed an application for benefits under this subsection, and
  `(4) is not otherwise eligible for benefits under part A of title XVIII,
shall be entitled to benefits for long-term home care under part A of title
XVIII for each month beginning with the first month the individual meets
the requirements of this subsection and ending with the month following the
month in which the individual no longer meets such requirements.
  `(i) Every individual who--
  `(1)(A) is 65 years of age or older and (B) is (i) a citizen of the United
  States, or (ii) an alien lawfully admitted for permanent residence who has
  resided in the United States continuously during the 5 years immediately
  preceding the month involved,
  `(2) has been certified by a trained case management team of a long-term
  care management agency in consultation with the individual's attending
  physician (or, in the absence of such a physician, any physician) to be
  chronically ill or disabled and to be unable to perform (without human
  assistance or supervision) at least 2 activities of daily living (as
  defined in section 1861(kk)(3)),
  `(3) has filed an application for benefits under this subsection, and
  `(4) is not otherwise eligible for benefits under part A of title XVIII,
shall be entitled to benefits for long-term home care under part A of title
XVIII for each month beginning with the first month the individual meets
the requirements of this subsection and ending with the month following the
month in which the individual no longer meets such requirements.'.
  (B) Section 1811 (42 U.S.C. 1395c) is amended by adding at the end the
  following new sentence: `The program also provides protection for long-term
  home care for certain chronically ill or disabled children and certain
  chronically ill or disabled elderly individuals.'.
  (C) Section 1836(a)(1) (42 U.S.C. 1395o(a)(1)) is amended by inserting
  `(other than as an individual described in section 226(h) or 226(i))'
  after `benefits under part A'.
  (D) Section 1902(p)(1)(A) (42 U.S.C. 1396a(p)(1)(A)) is amended by inserting
  `, but excluding an individual who is entitled to benefits under such part
  only because of section 226(h) or 226(i)' after `section 1818'.
  (b) DEFINITIONS OF LONG-TERM HOME CARE, CASE MANAGEMENT SERVICES, CHRONICALLY
  ILL INDIVIDUAL, AND LONG-TERM CARE MANAGEMENT AGENCY- Section 1861 (42
  U.S.C. 1395x) is amended by inserting after subsection (jj) the following
  new subsection:
`Long-Term Home Care; Chronically Ill Individual; Long-Term Care Management
Agency
  `(kk)(1) The term `long-term home care' means the case management services
  (as defined in paragraph (2)) furnished by a long-term care management
  agency (as defined in paragraph (5)) and the following items and services
  furnished to an individual, who is under the care of a physician, by a
  qualified home health agency (or, with respect to items and services not
  described in subparagraph (A), (B), or (F), by such an agency or by others
  under arrangements with them made by the agency) under arrangements with
  it made by the long-term care management agency, under a written plan of
  care (for furnishing such items and services and other related items and
  services to such individual) established and periodically reviewed by a
  trained case management team of a long-term care management agency and
  approved by the individual's attending physician (or, in the absence
  of an attending physician, any physician) and the individual or the
  individual's representative, which items and services are, except as
  provided in subparagraph (D), provided in a place of residence (other
  than a nursing facility) used as such individual's home (including, for
  a chronically ill individual described in paragraph (3)(B), a foster home)--
  `(A) nursing care provided by or under the supervision of a registered
  professional nurse;
  `(B) services of a homemaker/home health or personal care aide who has
  successfully met the training requirements of section 1893(b)(1)(C),
  including such services provided as a limited respite for family caregivers;
  `(C) medical social services under the direction of a physician;
  `(D) physical, occupational, respiratory, or corrective therapy or
  speech-language pathology;
  `(E) medical supplies (other than drugs and biologicals) and durable
  medical equipment, while under such a plan;
  `(F) patient and caregiver (including family caregiver) education, training,
  and counseling aimed at continuing and enhancing the care and assistance
  provided to the patient by the patient or caregiver, respectively; and
  `(G) in the case of an individual described in section 226(h)(2)(B) or
  section 226(i)(2)(B), any of the foregoing items and service which are
  provided on an outpatient basis, under arrangements made by the home health
  agency, at a hospital or skilled nursing facility, or at a rehabilitation
  center which meets such standards as may be prescribed in regulations, and--
  `(i) the furnishing of which involves the use of equipment of such a
  nature that the items and services cannot readily be made available to
  the individual in such place of residence, or
  `(ii) which are furnished at such facility while the individual is there
  to receive any such item or service described in clause (i).
  `(2) The term `case management services' means on-going services provided
  to ensure effective, efficient, and coordinated delivery of long-term home
  care, including--
  `(A) making initial and periodic certifications under section 1814(a)(8)(A)
  respecting whether an individual is eligible to receive long-term home
  care services;
  `(B) for individuals certified as so eligible, developing individual plans
  of care which (i) are based on an in-person assessment of the individual's
  health status, functional capacity, and social and family support system
  (including the need for limited respite for family caregivers) and on a
  review of home health services and extended care services provided to the
  individual under this title, (ii) provide the most comprehensive services,
  as necessary to the needs of the individual, as is feasible taking into
  account payment limits established under section 1814(m), and (iii) identify
  the specific amount, duration, and scope of services, consistent with the
  limitations on payment established under section 1814(m), to be provided
  and do not include services or care to which the individual has objected;
  `(C) periodic review and revision of such plans, in accordance with
  regulations promulgated under section 1893(c)(7)(C);
  `(D) making (in consultation with the individual or individual's
  representative) arrangements with one or more qualified home health agencies
  for the provision of care and services prescribed under the individual's
  plan of care;
  `(E) promptly providing the fiscal intermediary with a copy of the plan of
  care developed under subparagraph (B) and appropriate identifying information
  for each qualified home health agency with which arrangements have been
  made for providing the long-term home care under the plan of care; and
  `(F) followup and ongoing monitoring of patient and services delivery in
  accordance with regulations promulgated under section 1893(c)(7)(D).
The certifications under subparagraph (A) and the assessments under
subparagraph (B)(i) shall follow national standard protocols established by
the Secretary in consultation with the Long-Term Care Advisory Council. Such
protocols shall include a standard, reproducible assessment instrument and
methodology. The Secretary shall develop such protocol by not later than 9
months after the date of the enactment of this section, but the failure of
the Secretary to do so shall not relieve any long-term home care management
agency of its responsibilities under this section.
  `(3) The term `chronically ill individual' means an individual who--
  `(A) has been certified by a trained case management team of a long-term
  care management agency, in consultation with the individual's attending
  physician (or, in the absence of such a physician, any physician), as
  (i) being unable to perform (without human assistance or supervision)
  at least 2 activities of daily living (as defined in paragraph (4)) or
  (ii) having a similar level of disability due to cognitive impairment, as
  prescribed in regulations by the Secretary (in consultation with experts in
  the field of geriatric psychiatry and other appropriate health professionals
  and representatives of individuals afflicted with brain disorders including
  Alzheimer's disease and Parkinson's disease), and as not being a terminally
  ill individual (as defined in subsection (dd)(3)(A)) or as being such an
  individual who has exhausted benefits for hospice care under this part;
  `(B) is described in section 226(h); or
  `(C) is described in section 226(i).
  `(4) For purposes of paragraph (3), each of the following is an activity
  of daily living:
  `(A) BATHING- The overall complex behavior of getting water and cleansing
  the whole body, including turning on the water for a bath, shower, or
  sponge bath, getting to, in, and out of a tub or shower, and washing and
  drying oneself.
  `(B) DRESSING- The overall complex behavior of getting clothes from closets
  and drawers and then getting dressed.
  `(C) TOILETING- The act of going to the toilet room for bowel and bladder
  function, transferring on and off the toilet, cleaning after elimination,
  and arranging clothes.
  `(D) TRANSFER- The process of getting in and out of bed or in and out of
  a chair or wheelchair.
  `(E) EATING- The process of getting food from a plate or its equivalent
  into the mouth.
  `(5) The term `long-term care management agency' means a agency or
  organization, or a subdivision of such an agency or organization, which--
  `(A) is a government agency; except that the agency or organization may be
  a private, nonprofit agency or organization with respect to a service area
  if there is no government long-term care management agency serving the area;
  `(B) demonstrates expertise in managing health and social services for
  chronically ill individuals and is capable of completing the assessment
  and plan of care and arranging for services under paragraph (2) within a
  reasonable time period following referral to the agency or organization;
  `(C) provides only case management services under this title and makes
  arrangements with qualified home health agencies (with which it does
  not have a direct or indirect ownership or control interest) to provide
  long-term home care the agency or organization prescribes;
  `(D) has policies, established by a group of professionals (associated
  with the agency or organization) including one or more registered nurses,
  one or more physicians, and one or more social workers, to govern the
  services described in subparagraph (B) which it provides;
  `(E) maintains a sufficient number of professional case management teams
  which (i) are trained in the process of determining eligibility for long-term
  home care and in assessing the needs of chronically ill individuals and
  (ii)(I) include at least a registered professional nurse and a licensed
  social worker, (II) include, in the case of an individual under the age
  of 19, a physician, and (III) include such other health professionals
  (including rehabilitation professionals) as is appropriate;
  `(F) in the case of an agency or organization in any State in which State or
  applicable local law provides for the licensing of agencies or organization
  of this nature, (i) is licensed pursuant to such law, or (ii) is approved,
  by the agency of such State or locality responsible for licensing agencies
  or organizations of this nature, as meeting the standards established for
  such licensing;
  `(G) has in effect an overall plan and budget that meets the requirements
  of subsection (z) (other than paragraph (2) thereof);
  `(H) has been designated by the Secretary to perform the functions of such
  an agency with respect to residents of a State or specified subdivision
  thereof; and
  `(I) meets the additional conditions of participation specified in section
  1893(c) and such other conditions of participation as the Secretary, in
  consultation with the Long-Term Care Advisory Council (established under
  section 1893(h)), may find necessary in the interest of the health and safety
  of individuals who are furnished services by such agency or organization and
  for the effective and efficient operation of the program. The Secretary may
  provide for a temporary waiver of any of the requirements any subparagraph
  (other than subparagraph (A) or (B)) of this paragraph for such period
  (not to exceed one year, but subject to renewal) as the Secretary deems
  appropriate in the case of an agency or organization serving an area that is
  a rural area or that is designated as a health manpower shortage area under
  section 332 of the Public Health Service Act if (i) failure to waive such
  requirements would significantly limit access to long-term home care services
  to beneficiaries residing in the area, (ii) the agency or organization has
  made and continues to make good faith efforts to meet such requirements, and
  (iii) waiver of such requirements does not jeopardize the health, safety,
  or well-being of beneficiaries receiving long-term home care services.
  `(6) The term `qualified home health agency' means a home health agency
  which--
  `(A) provides directly the items and services described in subparagraphs
  (A), (B), and (F) of paragraph (1), and
  `(B) either provides directly or has made arrangements for providing
  physical therapy and speech-language pathology.'.
  (c) CERTIFICATION OF NEED AND STANDARD FOR COVERAGE-
  (1) CERTIFICATION OF NEED- Section 1814(a) (42 U.S.C. 1395f(a)) is amended--
  (A) by striking `and' at the end of paragraph (6),
  (B) by striking the period at the end of paragraph (7) and inserting `;
  and', and
  (C) by inserting after paragraph (7) the following new paragraph:
  `(8) in the case of long-term home care provided to an individual--
  `(A) a long-term care management agency certifies (and recertifies,
  where such care is furnished over a period of time, such frequency as
  may be provided in regulations) that the individual is a chronically ill
  individual, and
  `(B) with respect to other than case management services, the care
  is approved by the agency furnishing case management services to the
  individual.'.
  (2) STANDARD OF COVERAGE- Section 1862(a) (42 U.S.C. 1395y(a)) is amended--
  (A) in paragraph (1)--
  (i) by striking `and' at the end of subparagraph (E),
  (ii) by adding `and' at the end of subparagraph (F), and
  (iii) by adding at the end the following new subparagraph:
  `(G) in the case of long-term home care, which is not reasonable
  and necessary (i) for the care and management of chronic illness,
  (ii) to assist with activities of daily living, or (iii) to prevent
  institutionalization;'; and
  (B) in paragraph (6), by inserting `and except, in the case of long-term
  home care, as is otherwise permitted under paragraph (1)(H)' after `paragraph
  (1)(C)'.
  (d) PAYMENT BASIS AND LIMIT FOR LONG-TERM HOME CARE-
  (1) PAYMENT BASIS AND LIMIT- Section 1814 (42 U.S.C. 1395f) is amended by
  adding at the end the following new subsection:
`Payment for Long-Term Home Care
  `(m)(1) PAYMENT BASIS-
  `(A) IN GENERAL- Subject to the succeeding provisions of this subsection,
  there shall be paid from the Federal Hospital Insurance Trust Fund, in the
  case of expenses determined payable under this part for long-term home care,
  amounts determined under a fee schedule (or other prospectively determined
  reimbursement mechanism) established and annually adjusted by the Secretary
  under subparagraph (B).
  `(B) PROSPECTIVE PAYMENT METHODOLOGY- The Secretary shall establish a
  fee schedule (or other prospectively determined reimbursement mechanism)
  consistent with the following:
  `(i) NATIONAL SCHEDULE- Except as adjusted under clause (iii), the schedule
  or mechanism shall provide for uniform national payment rates.
  `(ii) ANNUAL ADJUSTMENT- The Secretary shall provide for an annual adjustment
  in the rates under such schedule or mechanism based on the Secretary's
  estimate, before the beginning of the year involved, of the percentage by
  which the cost of the mix of goods and services comprising long-term home
  care (based on an index of appropriately weighted indicators of changes in
  wages and prices which are representative of the mix of goods and services
  included in long-term home care) for the year will exceed the cost of such
  mix of goods and services for the preceding year.
  `(iii) AREA WAGE ADJUSTMENT- The Secretary shall adjust the proportion
  (as estimated by the Secretary from time to time) of payment amounts which
  are attributable to wages and wage-related costs of long-term home care for
  area differences in wage levels by a factor (established by the Secretary)
  reflecting the relative wage level for such care in the geographic area
  in which the care is provided compared to the national average wage level
  for such care. At least every 36 months, the Secretary shall update the
  factor under the preceding sentence on the basis of a survey conducted by
  the Secretary (and updated as appropriate) of the wages and wage-related
  costs for long-term home care in the United States. To the extent determined
  feasible by the Secretary, such survey shall measure the earnings and paid
  hours of employment by occupational category.
  `(2) LIMITATION ON PAYMENT- The maximum amount of payment that may be made
  with respect to long-term home care provided--
  `(A) a chronically ill individual (other than one described in section
  226(h)(2)(B)) residing in a State in a month is an amount that the Secretary
  estimates is equal to the product of--
  `(i) 50 percent of the average per diem payment rate for nursing facility
  care in the State on a full-time basis (determined under paragraph (3)) for
  days in the month, in the case of an individual determined by a long-term
  care management agency to have a moderate impairment, or
  `(ii) 65 percent of the average per diem payment rate for nursing facility
  care in the State on a full-time basis (determined under paragraph (3)) for
  days in the month, in the case of an individual determined by a long-term
  care management agency to have a severe impairment,
and the number of days in the month over which the individual is provided
such care; or
  `(B) a chronically ill individual described in section 226(h)(2)(B) residing
  in a State in a month is an amount that the Secretary estimates is equal
  to the product of (i) 100 percent of the per diem amount that would be
  payable, under the plan of the State approved under title XIX, during the
  month if the individual were provided appropriate care in an appropriate
  institutional setting if no limit on amount, duration, or scope of covered
  institutional services applied other than medical necessity, and (ii) the
  number of days in the month over which the individual is provided such care.
The monthly payment limitations established under the previous sentence
shall be applied on an average basis with respect to long-term home care
furnished over any period of 4 consecutive months.
  `(3) DETERMINATION OF AVERAGE PER DIEM PAYMENT RATE FOR NURSING FACILITY
  CARE IN DIFFERENT STATES- Before the beginning of each calendar year, the
  Secretary shall estimate, for nursing facilities located in each State,
  the State average per diem payment rates that would apply (under paragraph
  (1)) for nursing facility care in the State on a full-time basis in the
  year if there were no reduction for coinsurance under this part.'.
  (2) ASSURING SELF-FINANCING- For additional amendments assuring
  self-financing of this Act, see section 3(c).
  (e) ADJUSTMENTS OF AAPCC'S AND CONTRACTS FOR RISK-BASED ELIGIBLE
  ORGANIZATIONS- The Secretary of Health and Human Services shall--
  (1) take into account the amendments made by this Act in estimating the
  adjusted average per capita cost under section 1876(a) of the Social
  Security Act for eligible organizations with risk-sharing contracts under
  that section for portions of contract years occurring after the effective
  date provided under subsection (h);
  (2) modify such contracts, for such portions of contract years, to reflect
  any adjustments made under paragraph (1); and
  (3) require such organizations to make appropriate adjustments (including
  adjustments in premiums and benefits) in the terms of their agreements with
  medicare beneficiaries to take into account the amendments made by this Act.
  (f) CONFORMING AMENDMENTS- (1) Section 1861(o)(1) (42 U.S.C. 1395x(o)(1)) is
  amended by inserting `and provides long-term home care' before the semicolon.
  (2) Section 1861(u) (42 U.S.C. 1395x(u)) is amended by inserting `long-term
  care management agency,' after `home health agency,'.
  (3) Section 1121(a) (42 U.S.C. 1320a(a)) is amended by inserting `long-term
  care management agencies,' after `home health agencies,'.
  (g) COORDINATION OF LONG-TERM HOME CARE AND HOME HEALTH SERVICES- The
  Secretary of Health and Human Services, in consultation with the Long-Term
  Care Advisory Council, shall develop policies and protocols to assure
  the appropriate coordination in payments, and identification of benefits,
  for long-term home care and home health services under title XVIII of the
  Social Security Act. Such coordination shall assure that long-term home
  care benefits supplement, and not replace, home health service benefits and
  that receipt of long-term home care, by itself, is not taken into account in
  determining coverage and benefits for home health services under such title.
  (h) EFFECTIVE DATE- The amendments made by this section shall apply to
  long-term home care furnished on and after the first day of the first
  month beginning one year after the date of the enactment of this Act,
  and the amendment made by subsection (f)(1) shall apply to home health
  agencies as of such date.
SEC. 3. ASSURING SELF-FINANCING OF BENEFITS UNDER THIS ACT.
  (a) STATEMENT OF PURPOSE- The purpose of this section is to assure that
  all the additional costs to the Federal Government resulting from the
  enactment of this Act do not exceed the additional revenues derived from
  the amendments made by this Act.
  (b) STRUCTURE OF LIMITATION ON EXCESS EXPENDITURES- In order to carry
  out subsection (a), the amendment made by subsection (c) provides for
  the following:
  (1) Each year the Secretary of Health and Human Services will estimate
  whether additional anticipated revenues for the succeeding period exceed,
  or are less than, additional expenditures under this Act for the period
  involved.
  (2) If there is a deficit estimated for a year, the following adjustments
  will be made to eliminate any such deficit:
  (A) First, (i) a copayment (not to exceed 5 percent of average daily payment
  rate for long-term home care) is imposed on long-term home care, and (ii)
  the limits on payments for long-term home care are proportionally reduced
  to achieve net savings equal to the savings achieved through the copayment.
  (B) Next, if a deficit was projected for the second previous year, any
  surplus resulting for that second previous year is applied against the
  deficit.
  (C) Next, up to 10 percent of any previous accumulated surplus, plus the
  annual interest on the previous accumulated surplus, is applied against
  the deficit.
  (D) Lastly, any remaining deficit is eliminated by further proportional
  reductions in the limits on payments for long-term home care.
  (c) ASSURING SELF-FINANCING OF BENEFITS- Section 1813 (42 U.S.C. 1395c)
  is amended by adding at the end the following new subsection:
  `(c)(1) Not later than 3 months before the effective date for 1992 and not
  later than October 1 of 1992 (and of each succeeding year), the Secretary
  shall, in close consultation with the Director of the Congressional Budget
  Office, estimate the amount (if any) for transition period or for the
  succeeding year, respectively, by which--
  `(A) the additional amounts of revenues to be transferable into the Federal
  Hospital Insurance Trust Fund in that period or succeeding year because
  of the amendments made by section 7 of the Long-Term Home Care Act of 1991,
exceeds or is less than--
  `(B) the sum of--
  `(i) the amount to be expended during that period or succeeding year under
  section 1893,
  `(ii) the amount of claims expected to be received during that period or
  succeeding year under this part because of the amendments made by section
  2 of the Long-Term Home Care Act of 1991,
  `(iii) any additional administrative costs to be expended during that
  period or succeeding year under this title, or under part B of title XI,
  as a result of the enactment of such Act, and
  `(iv) any expenditures to be made during that period or succeeding year
  under section 5 of such Act (relating to demonstration projects).
In this paragraph, the term `effective date' means the first day of the first
month beginning 1 year after the date of the enactment of this subsection
and the term `transition period' means the period beginning on the effective
date and ending with the last day of the calendar year in which the effective
date occurs.
  `(2) If the Secretary estimates under paragraph (1), with respect to a
  period or year, that a deficit exists, then--
  `(A) the amount that is payable for long-term home care furnished to any
  individual on each day in the period or year shall be reduced, subject to
  the limit established in paragraph (3), by such a copayment amount as the
  Secretary estimates to be necessary to reduce by  1/2  the amount of such
  deficit, and
  `(B) the payment limits established under section 1814(m) for months in
  such period or year shall be proportionally reduced--
  `(i) by such a percentage as the Secretary estimates to be necessary to
  achieve the same savings as are achieved from the application of subparagraph
  (A), and
  `(ii) to the extent necessary after taking into account the application of
  any annual or cumulative surplus under paragraph (4)(C), by such additional
  percentage as the Secretary estimates to be necessary (in conjunction with
  savings achieved under subparagraph (A) and clause (i) and the application
  of any such surplus) to eliminate any remaining deficit.
  `(3) Any copayment amount established under paragraph (2)(A) may not exceed
  5 percent of the Secretary's estimate of the national average daily payment
  rate for long-term home care under this title for the period in which the
  copayment amount will be applied.
  `(4)(A) Before each October 1 following a transition period or year the
  Secretary shall estimate, the amount (if any) by which--
  `(i) the additional amount of revenues actually transferable into the Federal
  Hospital Insurance Trust Fund in the period or year involved because of
  the amendments made by section 7 of the Long-Term Home Care Act of 1991,
exceeds or is less than--
  `(ii) the sum of--
  `(I) the amount actually expended under section 1893 during that period
  or year,
  `(II) the amount of claims actually received during the period or year
  under this part because of the amendments made by section 2 of the Long-Term
  Home Care Act of 1991,
  `(III) any additional administrative costs actually paid during the period
  or year under this title, or under part B of title XI, as a result of the
  enactment of such Act, and
  `(IV) any expenditures made during the period or year under section 5 of
  such Act (relating to demonstration projects).
Such estimate shall be subject to adjustment from time to time to take into
account the best available data.
  `(B) There shall be established and maintained in the Federal Hospital
  Insurance Trust Fund a separate cumulative account of the amount of surpluses
  and deficits estimated under this paragraph. The amount in the account shall
  be increased in any period or year by the amount of any surplus estimated
  under subparagraph (A) for the period or year and shall be decreased in any
  period or year by the amount of any deficit estimated under subparagraph (A)
  for the period or year and by the amount of any reduction effected under
  subparagraph (C). The Board of Trustees of the Trust Fund shall provide
  for the imputation of annual interest each period or year to the balance
  in the account at a rate that reflects the rate of interest received on
  funds in the Trust Fund during the period or year involved.
  `(C) If the savings achieved under subparagraphs (A) and (B)(i) of paragraph
  (2) are insufficient to eliminate a deficit for a year, the remainder of
  such deficit shall be reduced or eliminated, to the extent necessary--
  `(i) first, by the amount of any surplus added to the cumulative account
  established and maintained under subparagraph (B) for the second previous
  year if, for that year, there was any adjustment made for that year under
  paragraph (2), and
  `(ii) next, by applying up to 10 percent of any remaining surplus accumulated
  in the cumulative account, plus the amount of any interest imputed (under
  the last sentence of subparagraph (B)) to the account during the year.
  `(D) For purposes of this subsection, revenues to be transferable or
  actually transferable in 1991 because of the amendments made by section 7
  of the Long-Term Home Care Act of 1991 shall be deemed to be transferable
  in the transition period.'.
SEC. 4. ASSURING QUALITY OF LONG-TERM HOME CARE.
  (a) IN GENERAL- Title XVIII is amended by adding at the end the following
  new section:
`LONG-TERM HOME CARE QUALITY ASSURANCE
  `SEC. 1893. (a) LONG-TERM HOME CARE CONSUMERS' BILL OF RIGHTS- The Secretary
  shall promulgate, by regulation, a long-term home care consumers' bill of
  rights, which shall recognize the following as rights of long-term home
  care consumers which may be asserted by the home care consumer or the
  consumer's representative or guardian:
  `(1) To be treated with courtesy, respect, and full recognition of one's
  dignity, individuality, and right to control one's own household and
  lifestyle.
  `(2) To be fully and promptly informed orally and in writing--
  `(A) of services to be provided and any limits regarding availability of
  services from the home health agency or home care provider;
  `(B) of whether services may be provided under this title or are covered
  by other sources, and whether uncompensated care may be available;
  `(C) of charges for services and billing procedures, including an itemized
  copy of each bill submitted to any payor;
  `(D) of changes in services or charges; and
  `(E) of the procedures to follow if rights are violated or services are
  not satisfactory, including the right to a hearing before an entity other
  than a home health agency or a long-term care management agency.
  `(3) To take an active part in creating and changing the plan of care.
  `(4) To take an active part in selecting and evaluating the home health
  agency and the home care provider, and in selecting and evaluating treatment,
  care, and services.
  `(5) To be served by individuals who are properly trained and competent
  to perform their duties.
  `(6) To be fully informed by a home care provider of the provider's
  assessment of the home care consumer's condition, unless contraindicated
  by documentation provided by a professional practitioner in the home care
  consumer's record.
  `(7) To refuse all or part of any treatment, care, or service, and to be
  informed of the likely consequences of such refusal.
  `(8) To receive treatment, care, and services in compliance with all State
  and local laws and regulations without discrimination in the provision or
  quality of services based on race, religion, gender, age, or creed (except
  as provided under the Age Discrimination Act of 1975 (Public Law 94-135;
  42 U.S.C. 6101 et seq.)), or because of a change in the source of payment.
  `(9) To be free from mental and physical abuse, neglect, and exploitation,
  and to be free from chemical and physical restraints.
  `(10) To receive respect and privacy in the home care consumer's treatment,
  care, and services in caring for personal needs, in communications, and
  in all daily activities.
  `(11) To be assured respect for the home care consumer's property rights.
  `(12) To be assured confidential treatment of personal, financial, and
  medical records and to approve or refuse their release to any individuals
  outside the agency except as otherwise required by law or third-party
  payment contract.
  `(13) To voice grievances and recommend changes in policies and services
  to staff or outside representatives of the consumer's choice and to be
  assisted in doing so when assistance is needed, free from restraint,
  interference, coercion, discrimination, or reprisal by the long-term care
  management agency, by the home health agency, or by the home care provider.
  `(14) To be free to fully exercise the consumer's civil rights and to be
  assisted in doing so when assistance is needed.
  `(15) To receive promptly written notice from the long-term care management
  agency if treatment, care or services are to be reduced or terminated,
  and assistance to assure a smooth transition in services consistent with
  the welfare of the home care consumer.
  `(16) To be promptly notified by the home health agency of acceptance or
  denial of services and the reasons for such denial.
  `(b) HOME HEALTH AGENCY QUALITY ASSURANCE REQUIREMENTS- (1) In addition
  to such other requirements as may apply, the Secretary shall promulgate
  regulations requiring that to receive funding for the provision of long-term
  home care services under this title, a home health agency must within 6
  months after the date of the publication of such regulations--
  `(A)(i) comply with the home care consumer's bill of rights promulgated
  under subsection (a); and
  `(ii) provide a written copy of such bill of rights to each long-term home
  care consumer (or the consumer's representative or guardian) who receives
  long-term home care services from the home health agency or other providers
  under this title;
  `(B)(i) implement procedures for promptly reviewing and resolving grievances
  of long-term home care consumers regarding the provision of long-term home
  care services; and
  `(ii) provide a written copy of such procedures to each long-term home
  care consumer (or the consumer's representative or guardian) who receives
  long-term home care services from the home health agency;
  `(C) ensure that each long-term home care provider employed by or under
  contract with the home health agency receives training--
  `(i) sufficient to meet a level of proficiency established by the Secretary
  in regulations (in consultation with representatives of the elderly,
  disabled, and children, home health agencies, and experts in the fields
  of geriatric nursing, pediatric nursing, geriatric social work, pediatric
  social work, mental health, rehabilitation, and other appropriate health
  care professionals) to be appropriate in content and amount;
  `(ii) which develops separate levels of proficiency in and is reflective
  of the range of skills required of long-term home care providers providing
  different levels of long-term home care services; and
  `(iii) the extent of which shall be made available on request to each
  long-term home care consumer with respect to the amount of training or
  level of certification achieved by each long-term home care provider;
  `(D) supervise all long-term home care providers employed by or under
  contract to the home health agency in accordance with regulations promulgated
  by the Secretary (including regular random onsite supervisory visits by
  registered nurses or other appropriate health care professionals); and
  `(E) perform annual evaluations of quality of services rendered by long-term
  home care providers employed by or under contract to the home health agency
  which includes and documents long-term home care consumer involvement.
  `(2) In addition to such other requirements as may apply, to receive funding
  for the provision of durable medical equipment services under this title,
  a home health agency or long-term home care provider shall in each case
  of a long-term home care consumer to which such services are provided--
  `(A) issue written instructions for the operation of such equipment;
  `(B) provide sufficient training to the long-term home care consumer,
  the long-term home care consumer's family, and staff to allow correct,
  safe operation of all such equipment; and
  `(C) formulate an emergency plan appropriate to the services provided to
  the long-term home care consumer.
In the previous sentence, the term `durable medical equipment services' means
supply, maintenance, or training in the operation of durable medical equipment.
  `(c) LONG-TERM CARE MANAGEMENT AGENCY QUALITY ASSURANCE REQUIREMENTS-
  In addition to such other requirements as may apply, the Secretary shall
  promulgate regulations requiring that to receive funding for the provision
  of case management services (as defined in section 1861(kk)(2)) under this
  title, a long-term care management agency must within 6 months after the
  date of the publication of such regulations--
  `(1)(A) comply with the long-term home care consumers' bill of rights
  promulgated under subsection (a); and
  `(B) provide a written copy of such bill of rights to each long-term home
  care consumer (or the consumer's representative or guardian) who receives
  long-term home care services from the home health agency under this title;
  `(2)(A) implement procedures for promptly reviewing and resolving grievances
  of long-term home care consumers; and
  `(B) provide a written copy of such procedures to each long-term home
  care consumer (or the consumer's representative or guardian) who receives
  long-term home care services from the home health agency;
  `(3) provide to each long-term home care consumer (or the consumer's
  representative or guardian) a written statement of the services to be
  provided to the long-term home care consumer and the schedule for provision
  of such services, as agreed upon by the long-term home care consumer;
  `(4) provide to each long-term home care consumer a clear written statement
  as to how the consumer, or the consumer's representative or guardian,
  may appeal benefit and level decisions made by the agency;
  `(5) maintain procedures that assure prompt access to long-term home care
  services for eligible long-term home care consumers;
  `(6) ensure that personnel providing case management services to long-term
  home care consumer have received adequate training as prescribed in
  regulations by the Secretary, in consultation with the Long-Term Care
  Advisory Council; and
  `(7) establish and implement care management processes which include--
  `(A) a plan of care which states reasonable and measurable client objectives
  and long-term home care services to be provided to meet the objectives;
  `(B) a plan of care that employs outcome measures care insofar as they
  are appropriate and available for each long-term home care consumer served;
  `(C) methods for periodic review of--
  `(i) a long-term home care consumer's needs; and
  `(ii) the plan of care for a long-term home care consumer;
  `(D) methods for follow-up and on-going monitoring of patient and services
  delivery; and
  `(E) a statement of criteria and procedures for discharge or transfer to
  another agency, program, or service.
  `(d) SURVEY REQUIREMENTS- (1) The Secretary shall, in consultation with the
  Long-Term Care Advisory Council, promulgate regulations which establish
  procedures for surveying long-term care management agencies regarding
  compliance with conditions of participation established by this section.
  `(2) Regulations promulgated under paragraph (1) shall include--
  `(A) survey methodologies which include--
  `(i) patient-oriented assessment techniques;
  `(ii) process and outcome criteria for measuring the compliance of
  long-term care management agencies with conditions of participation under
  this title; and
  `(iii) randomized, onsite review of a representative sample of long-term
  home care consumers to evaluate compliance with applicable conditions
  of participation;
  `(B) a graduated schedule of unannounced surveys that provides surveys--
  `(i) not less than every 9 months for long-term care management agencies
  that are determined by the Secretary to have a substandard record of
  compliance with applicable conditions of participation;
  `(ii) not less than every 15 months for long-term care management agencies
  that are determined by the Secretary to have consistently satisfactory
  records of compliance with the applicable conditions of participation; and
  `(iii) not less than every 12 months for other such agencies.
  `(3) The results of surveys performed under this subsection shall be
  provided to the Long-Term Care Advisory Council and community advisory
  boards established under subsection (e)(1) and shall be made available to
  others in accordance with this title.
  `(4)(A) The Secretary may enter into a contract with a State under which
  a State, which has survey and enforcement procedures which are determined
  by the Secretary to be at least equivalent to the survey and enforcement
  procedures which the Secretary would otherwise apply under this section,
  shall conduct surveys of compliance of long-term care management agencies
  (other than those owned or operated by a State) with the requirements of
  this section and provide for the annual transmittal to the Secretary of
  the results of such State surveys.
  `(B) The Secretary shall develop and implement procedures for annually
  validating a representative sample of surveys of long-term care management
  agencies performed by States under subparagraph (A).
  `(C) Procedures developed under subparagraph (B) shall provide for review
  of such surveys within 1 month after the performance of such a survey.
  `(e) QUALITY ASSURANCE SYSTEM THROUGH PEER REVIEW ORGANIZATIONS- (1)(A) The
  Secretary shall promulgate regulations under which peer review organizations
  shall monitor the provision of home health services and long-term home care.
  `(B) In awarding, administering, and evaluating contracts entered into
  with peer review organizations of the performance of monitoring under this
  subsection, the Secretary shall--
  `(i) take into consideration information contained in reports issued by
  Consumer Boards under paragraph (2)(C)(iii);
  `(ii) require that at least  3/4  of the level of effort of a peer review
  organization shall be for the purpose of monitoring the quality of home
  health services and long-term home care provided;
  `(iii) require that the remainder of the effort of a peer review
  organization shall be for the purpose of review, on the basis of exceptional
  circumstances and on the health and safety of the home care consumer,
  of the appropriateness and necessity of care denied under this title;
  `(iv) require that any review by a peer review organization of a home health
  agency or a home care management agency include a representative sample
  of documentary reviews and personal interviews of home care consumers and
  home care providers;
  `(v) require that if any portion of a peer review organization's
  responsibilities are provided by a third party under contract with the
  peer review organization the fulfillment of such responsibilities are
  fully integrated with other functions of such peer review organization; and
  `(vi) require that the membership of a peer review organization board
  include representatives of all types of home care providers reviewed by
  the peer review organization and consumers under section 9353(b) of the
  Omnibus Budget Reconciliation Act of 1986.
  `(C) A peer review organization performing monitoring functions under this
  subsection may not be--
  `(i) a home health agency;
  `(ii) a home care management agency;
  `(iii) a home care provider; or
  `(iv) a fiscal intermediary.
  `(D) The Secretary shall make available to a peer review organization such
  information as may be necessary for it to carry out its responsibilities
  under this paragraph.
  `(E) A peer review organization may recommend to the Secretary sanctions to
  be applied to home health agencies and to home care management agencies who
  have been found to have not met professionally recognized standards of care.
  `(2)(A) The Secretary shall establish a Consumer Board in each State within
  1 year after the date of the enactment of this section.
  `(B)(i) A Consumer Board shall be composed of at least 5 and not more
  than 7 members appointed by the Secretary based on recommendations
  from organizations in each State representing home care consumers who
  are entitled to benefits under this title. Members must be entitled to
  benefits under this title or be representatives of organizations which
  represent home care consumers who are entitled to such benefits.
  `(ii) Limited staff support and training shall be provided to a Consumer
  Board by the Secretary as is necessary to carry out its functions.
  `(C) A Consumer Board shall--
  `(i) monitor the review activities of peer review organizations by--
  `(I) providing input into the awarding of contracts to peer review
  organizations; and
  `(II) evaluating the contracts of peer review organizations and the
  mechanisms established to monitor home health agencies and home care
  management agencies;
  `(ii) have access to--
  `(I) information of peer review organizations,
  `(II) results of State surveys conducted under subsection (d)(4)(A), and
  `(III) information from toll-free hotlines (established under paragraph
  (4)), after protection of the identities of individual health care providers
  and consumers; and
  `(iii) file an annual report with the Secretary and the chief executive
  officer of the State on October 1 of each year regarding the performance
  during the previous year of peer review organizations.
  `(D) A Consumer Board shall not be involved in the day-to-day operation
  of peer review organizations.
  `(3)(A) The Secretary shall develop methods for monitoring the continuity
  of care provided to home care consumers throughout episodes of illness
  and across care settings.
  `(B) The Secretary shall develop outcome-oriented criteria for use in
  determining quality assurance in home care.
  `(4) Peer review organizations shall establish and operate statewide
  toll-free hot-lines for receiving questions and complaints from home care
  consumers, home care providers, and other interested persons concerning
  home care quality issues.
  `(5) The Secretary shall require peer review organizations to assist home
  care consumers in the resolution of problems related to the quality of
  home care services and case management services.
  `(6) Consumer Boards established under paragraph (2) and peer review
  organizations shall coordinate with State and local government officials
  to educate home care consumers regarding quality assurance programs and
  the various forms of assistance available to home care consumers with
  quality assurance problems under this title.
  `(f) COMMUNITY ADVISORY BOARDS AND ADDITIONAL QUALITY ASSURANCE- (1) Each
  State shall establish and appoint (based on the recommendations of long-term
  home care consumers, their representatives, and organizations representing
  these individuals and pursuant to regulations of the Secretary) members to
  a community advisory board (in this subsection referred to as the `board')
  for each long-term care management agency. Each board shall be composed
  of long-term home care consumers and their families, representatives of
  agencies and organizations representing long-term home care consumers and
  professionals providing services to chronically ill individuals. Long-term
  home care consumers, their families, or their representatives shall form a
  majority of the members of each board. The Secretary shall provide limited
  staff support to each board as is necessary to carry out its functions.
  `(2) Each board shall--
  `(A) monitor the activities of the long-term care management agencies,
  `(B) provide input in the selection of long-term care management agencies,
  `(C) file a report with the Secretary on the findings of its monitoring
  not less frequently than annually, and
  `(D) have prompt access to results of surveys and of investigations of
  complaints of the long-term care management agency with respect to which
  it was established and home health agencies providing long-term home care
  services to individuals in the area served by the agency.
Each report under subparagraph (C) shall be reviewed and its findings
incorporated into the survey of long-term care management agencies under
subsection (d).
  `(3)(A) The Secretary shall develop and implement methods for monitoring
  the continuity of care provided to long-term home care consumers throughout
  episodes of illness and across care settings.
  `(B) The Secretary shall develop and implement outcome-oriented criteria
  for use in determining quality assurance in long-term home care services.
  `(g) SANCTIONS- (1) The Secretary shall develop and implement a range of
  intermediate sanctions and procedures implementing such sanctions to be
  applied to long-term care management agencies providing case management
  services under this title for failing to comply with this section.
  `(2) Sanctions and procedures established under paragraph (1) shall--
  `(A) include civil monetary penalties (under the procedures described in
  section 1128A), a ban on admissions, receivership, and emergency authority
  to decertify home health agencies and long-term care management agencies;
  `(B) include specific criteria as to when and how each sanction is to be
  applied and the amounts of any fines and penalties;
  `(C) be designed so as to minimize the time between the identification of
  violations and final imposition of the sanctions;
  `(D) provide for a plan and schedule for corrective action by home health
  agencies found to be out of compliance with conditions of participation; and
  `(E) require public disclosure of failures of home health agencies and
  long-term care management agencies to meet professionally recognized
  standards of care, and the sanctions imposed for such failures.
  `(3) The Secretary shall file an annual report with the Congress on January
  1 of each year regarding the availability, adequacy, and use of sanctions
  to correct failures of long-term care management agencies to meet the
  requirements of this title.
  `(h) DEVELOPMENT OF LICENSING POLICIES- The Secretary shall--
  `(1) encourage States to develop policies and procedures for the licensing
  of home health agencies;
  `(2) gather information relating to activities of States in implementing
  licensing policies and procedures; and
  `(3) issue a biannual report which summarizes information gathered under
  paragraph (2).
  `(i) LONG-TERM CARE ADVISORY COUNCIL- (1)(A) There shall be established,
  no later than 60 days after the date of the enactment of this section,
  an independent body to be known as the Long-Term Care Advisory Council
  (in this subsection referred to as the `Council').
  `(B) The Council shall be composed of 13 individuals appointed by the
  Director of the Office of Technology Assessment and shall include,
  to the greatest extent possible, individuals with expertise in
  pediatrics, geriatrics, gerontology, disability, case management of
  home and community-based services and payment for such services, home
  and community-based care consumers and their representatives, home and
  community-based care providers and their representatives, professionals with
  expertise in long-term care (including nurses, social workers, and discharge
  planners and physicians), third-party payors, long-term care ombudsmen,
  peer review organizations, and State and local health and social service
  agency representatives. Appointments to the Council shall be for a term
  of not to exceed 4 years.
  `(2) The purposes of the Council are--
  `(A) to assist the Secretary in assuring the prompt and efficient
  implementation of the provisions of the Long-Term Home Care Act of 1991,
  `(B) to review regularly the implementation of such provisions, and
  `(C) to recommend to the Secretary and the Congress any needed changes
  or refinements to such provisions or regulations promulgated to implement
  such provisions.
The Secretary shall regularly and closely consult with the Council in the
implementation and administration of the provisions of such Act, including
the issuance of regulations to carry out such provisions. The Secretary (or
the Secretary's designee) shall meet with the Council at least once every
month during the 24-month period beginning two months after the date of the
enactment of such Act, and at least quarterly thereafter, for these purposes.
  `(j) TRAINING GRANTS- (1) The Secretary shall issue guidelines and provide
  funding for grants for training programs for home health agencies, long-term
  care management agencies, and long-term home care providers.
  `(2) In awarding grants under paragraph (1), the Secretary shall give
  special consideration to--
  `(A) the training of paraprofessionals (including homemakers, home health
  aides, and family care givers) and professionals providing case management
  services;
  `(B) the training of long-term home care providers who are members of
  minorities and ethnic groups;
  `(C) training programs for high technology long-term home care services (as
  defined by the Secretary) that assist professional health care providers
  in adapting their services to high technology therapies to be provided as
  long-term home care services; and
  `(D) training of long-term home care providers who will provide long-term
  home care services to chronically ill or disabled children.
  `(3) Training materials shall be provided by the Secretary to States and home
  health agencies, long-term care management agencies, and home care providers.
  `(4) The Secretary shall encourage States to work with home health agencies,
  long-term home care providers, and educational institutions, especially
  those with a demonstrated expertise in geriatrics, pediatrics, gerontology,
  and disability to provide training to long-term home care providers.
  `(k) STUDIES- (1)(A) The Secretary shall conduct studies on quality assurance
  measures for long-term home care services provided under this title.
  `(B) Studies referred to in subparagraph (A) shall include examination of--
  `(i) methodologies which develop and evaluate outcome standards in the
  provision of long-term home care services;
  `(ii) mechanisms for ensuring and monitoring long-term home care quality
  by episode of care;
  `(iii) the role of case management for ensuring quality in provision of
  long-term home care services;
  `(iv) the differing approaches to and responsibility for the development
  of a plan of long-term home care services; and
  `(v) the impact on quality of care of--
  `(I) the separate reimbursement for supply of durable medical equipment
  to long-term home care consumers; and
  `(II) the training of long-term home care consumers and their families in
  the operation of such equipment.
  `(2) The Secretary shall report to Congress, by not later than 2 years
  after the date of the enactment of this Act, on the findings of studies
  funded under paragraph (1).
  `(l) REPORTS ON QUALITY ASSURANCE SYSTEM- (1) The Secretary shall prepare
  (in consultation with the Long-Term Care Advisory Council) and file an
  annual report with the Congress on January 1 of each year regarding the
  nature and performance during the preceding fiscal year of the home care
  quality assurance system established under subsection (e).
  `(2) Each report required by paragraph (1) shall include information
  regarding--
  `(A) the number of individuals served by long-term home care providers
  subject to the provisions of this section;
  `(B) the amount of Federal funds expended for long-term home care services
  under this title;
  `(C) examination of noncompliance with the provisions of this section by
  long-term home care providers who received funds under this title and the
  sanctions imposed;
  `(D) the economic impact on home health agencies of requiring them to
  comply with the requirements of this section;
  `(E) the impact of the requirements of this section on availability of
  long-term home care services in rural areas and to members of minority
  and ethnic groups;
  `(F) the concerns and recommendations of community advisory boards and
  Consumer Boards;
  `(G) training and grants awarded under subsection (i); and
  `(H) the status of studies undertaken under subsection (j).
  `(m) DEFINITIONS- For purposes of this section:
  `(1) The term `long-term home care consumer' means a chronically ill
  individual who is provided long-term home care services.
  `(2) The term `long-term home care provider' means an individual who
  provides long-term home care services directly to a home care consumer.
  `(3) The term `long-term home care services' means home health services
  and long-term home care.
  `(4) The term `Consumer Board' means a Consumer Board established under
  subsection (e)(2).
  `(n) AUTHORIZATION OF APPROPRIATIONS- There are authorized to be appropriated
  from the Federal Hospital Insurance Trust Fund $100,000,000 for each of
  fiscal years 1992 and 1993 and $15,000,000 for each succeeding fiscal
  year to carry out subsection (i) (at least two-thirds of which is made
  available for training related to the provision of long-term home care
  and case management services) and such sums as may be necessary in each
  fiscal year to carry out the remaining provisions of this section.'.
  (b) SURVEYS OF HOME HEALTH AGENCIES PROVIDING LONG-TERM HOME CARE
  SERVICES TO INCLUDE REVIEW OF ADDITIONAL REQUIREMENTS- Section 1891(c)(1)
  (42 U.S.C. 13995bbb(c)(1)) is amended by adding at the end the following
  new subparagraph:
  `(F) A standard survey conducted under this paragraph with respect to a
  home health agency that provides long-term home care services (as defined
  in section 1893(l)(3)) shall include review of whether the agency meets the
  requirements imposed under section 1893(c) with respect to the provision
  of such services.'.
  (c) PROMULGATION OF REGULATIONS- The Secretary of Health and Human Services
  shall promulgate regulations by not later than 6 months after the date of
  the enactment of this Act, to implement section 1893 of the Social Security
  Act, to be effective for home care services furnished on or after 12 months
  after the date of the enactment of this Act.
  (d) APPOINTMENT OF LONG-TERM CARE ADVISORY COUNCIL- The Director of the
  Office of Technology Assessment shall complete appointments to the Long-Term
  Care Advisory Council under section 1893(h) of the Social Security Act
  within 1 month after the date of the enactment of this Act.
SEC. 5. DEMONSTRATION PROJECTS.
  (a) CASE MANAGEMENT DEMONSTRATION PROJECTS-
  (1) The Secretary of Health and Human Services (in this section referred
  to as the `Secretary') shall conduct at least 5 (but not more than 10)
  demonstration projects to determine the relative effectiveness, cost,
  and impact on quality of long-term home care of using different models of
  providing and reimbursing of case management services under title XVIII
  of the Social Security Act.
  (2) Demonstration projects under this subsection shall--
  (A) each be conducted over a period of 3 years;
  (B) be conducted in sites which are chosen to be geographically diverse
  and include at least one rural site;
  (C) include testing the use of different types of agencies (including home
  health agencies) as long-term care management agencies and provide for
  selection of such types of agencies in consultation with the Comptroller
  General;
  (D) include case management services provided to the elderly, the disabled,
  and children;
  (E) include testing payment for case management services on a capitated
  basis; and
  (F) include testing methods of minimizing variation among case management
  teams and long-term care management agencies in eligibility and coverage
  determinations under title XVIII of the Social Security Act.
  (3) The Secretary shall provide for the evaluation of the projects on
  a concurrent basis and shall submit to the Congress, not later than 18
  months after the initiation of the projects and upon the completion of the
  projects, a report on the findings of the evaluation. The Secretary shall
  include in such reports recommendations for appropriate legislative changes.
  (4) There are authorized to be appropriated from the Federal Hospital
  Insurance Trust Fund for the 3-fiscal year period beginning with fiscal year
  1992, not to exceed $10,000,000 to carry out demonstration projects under
  this subsection and not to exceed $1,000,000 to carry out the evaluation
  of such projects under this subsection.
  (b) DEMONSTRATION PROJECTS FOR SERIOUSLY MENTALLY ILL INDIVIDUALS-
  (1) The Secretary shall conduct at least 5 (but not more than 10)
  demonstration projects to determine the relative effectiveness, cost,
  and impact on quality of long-term home care of using different models
  of providing and reimbursing long-term home care services for seriously
  mentally ill individuals and family caregivers.
  (2) In this subsection, the term `seriously mentally ill individual' means
  an individual who a licensed mental health professional in the individual's
  State of residence certifies--
  (A) has schizophrenia, bipolar or unipolar disorder or other significant
  mental illness which restricts the individual's ability to function in
  activities of daily living, employment, and social interaction,
  (B) has been previously institutionalized or is at risk of being
  institutionalized in the absence of the services provided under this
  subsection, and
  (C) is not institutionalized at the time of the certification.
  (3) Demonstration projects under this subsection shall--
  (A) each be conducted over a period of 3 years;
  (B) be conducted in sites which are chosen to be geographically diverse
  and include at least one rural site;
  (C) be sensitive to the needs of racial and ethnic minorities;
  (D) include outreach and case management activities;
  (E) be responsive to family needs and concerns and appropriately involve
  and consult with family members regarding the provision of services under
  this subsection;
  (F) specify, at the time of application, specific outcome expectations to
  be met by the project and identify appropriate mechanisms for measuring
  outcomes; and
  (G) include testing the use of different agencies (including home health
  agencies) as long-term care management agencies and provide for selection
  of such agencies in consultation with the Comptroller General.
  (4) Demonstration projects under this subsection may--
  (A) provide services or reimbursement for nursing care, homemaker/home
  health aide services; psychosocial services; medical services, including
  the provision, monitoring, and testing of necessary medications; client
  and family education, training, and counseling; respite care; crisis
  intervention; information and referral services; and rehabilitation; and
  (B) provide services to seriously mentally ill individuals or provide
  services to home caregivers (including family members) when such service
  augment and support home caregivers in the care of seriously mentally
  ill individuals.
  (5) The Secretary shall provide for the evaluation of the projects on
  a concurrent basis and shall submit to the Congress, not later than 18
  months after the initiation of the projects and upon the completion of the
  projects, a report on the findings of the evaluation. Such evaluation shall
  measure the cost and effectiveness of funded projects against the outcome
  expectations identified in the initial applications and include relevant
  data on client and family satisfaction and received benefits, together
  with such additional information as the Secretary may deem appropriate.
  (6) There are authorized to be appropriated from the Federal Hospital
  Insurance Trust Fund for each of fiscal years 1992, 1993, and 1994,
  not to exceed $10,000,000 to carry out demonstration projects under this
  subsection and not to exceed $1,000,000 to carry out the evaluation of
  such projects under this subsection.
  (c) DEMONSTRATION PROJECTS FOR WORKING AGE INDIVIDUALS WITH SEVERE
  FUNCTIONAL LIMITATIONS-
  (1)(A) The Secretary shall conduct at least 5 (and no more than 10)
  demonstration projects to determine the feasibility of providing long-term
  home care benefits under the medicare program for working-age individuals
  with severe functional limitations (as defined in paragraph (2)).
  (B) In this subsection, the term `working-age individual with severe
  functional limitations' means an individual over 18 years of age, but
  under 65 years of age, who is not entitled to benefits under title XVIII
  of the Social Security Act but is a chronically ill individual, within
  the meaning of section 1861(kk)(1)(A)(i) of such Act.
  (2) Demonstration projects under this subsection--
  (A) shall include, in the items and services covered under long-term home
  care, personal care services, short-term respite, and emergency assistance
  and shall permit coverage of items and services provided either by home
  health agencies or by other qualified persons;
  (B) may provide for limited cost-sharing for long-term home care;
  (C) shall provide that payment rates for long-term home care provided by
  persons other than home health agencies shall be comparable to the payment
  rates for such care provided by home health agencies;
  (D) shall provide that each individual's plan of care shall take into account
  the individual's capability to direct the individual's own long-term home
  care and to train persons in providing that care;
  (E) shall test the effectiveness of consumer-directed living centers that
  are primarily engaged in assisting working age individuals with severe
  functional limitations in maximizing their independence;
  (F) shall, to the maximum extent practicable, cover working age
  individuals with severe functional limitations who (i) are at imminent
  risk of institutionalization within 30 days without long-term home care,
  (ii) are institutionalized but who, if provided long-term home care, could
  be discharged from the institution, or (iii) need long-term home care to
  secure or continue employment, to increase independence, to enable present
  caregivers to secure or continue employment, or to stabilize families;
  (G) shall include projects under which personal care services are made
  available away from an individual's primary residence, as well as at that
  residence; and
  (H) shall include projects under which family members may be employed as
  caregivers if the family members would be employed if not providing such
  care or if the individual requires more than 20 hours a week of long-term
  home care.
  (3)(A) In designing and evaluating the projects, the Secretary shall
  consult with experts in the field of disability policy and independent
  living and with groups representing working age individuals with severe
  functional limitations.
  (B) The Secretary shall provide for the evaluation of the projects on a
  concurrent basis. Such evaluation shall include an evaluation of the size
  of the demand, cost, relative effectiveness, and impact on quality of life,
  of providing long-term home care to working age individuals with severe
  functional limitations.
  (C) The Secretary shall submit to the Congress, not later than 18 months
  after the initiation of the projects and upon the completion of the
  projects, a report on the findings of the evaluation under subparagraph
  (B). The Secretary shall include in such reports recommendations for
  appropriate legislative changes.
  (4) There are authorized to be appropriated from the Federal Hospital
  Insurance Trust Fund--
  (A) for each of fiscal years 1992, 1993, and 1994 not to exceed $10,000,000
  to carry out demonstration projects under this subsection, and
  (B) for the 3-fiscal-year period beginning with fiscal year 1992 not
  to exceed $1,000,000 to carry out the evaluation of such projects under
  this subsection.
  (d) DEMONSTRATION PROJECTS FOR ADULT DAY CARE-
  (1) The Secretary shall conduct at least 5 (and no more than 10)
  demonstration projects to test the feasibility of including adult day care
  among the items and services covered under long-term home care under the
  medicare program.
  (2) Demonstration projects under this subsection--
  (A) each be conducted and completed within 18 months of the date of the
  enactment of this Act;
  (B) be conducted in sites which are chosen to be geographically diverse
  and include at least one rural site;
  (C) be designed and conducted so as to produce reliable comparative data
  on the cost of long-term home care under the medicare program with and
  without the addition of adult day care;
  (D) be designed and conducted so as to develop reliable information on
  the adequacy of quality controls in the provision of adult day care;
  (E) test the impact of providing adult day care on the amount and quality
  of informal care provided; and
  (F) include the measurement of beneficiary and caregiver satisfaction with
  adult day care received.
  (3) In this subsection:
  (A) The term `adult day care' means the following items and services provided
  to a chronically ill individual (described in section 1861(kk)(2)(A)
  of the Social Security Act) by an adult day care program under a plan of
  care described in section 1861(kk)(1) of such Act:
  (i) Nursing care provided by or under the supervision of a registered
  professional nurse.
  (ii) Physical or occupational therapy or speech-language pathology.
  (iii) Medical social services.
  (iv) Personal care services under the supervision of a registered nurse.
  (v) Planned therapeutic, social, physical, and educational activities.
  (vi) Transportation services from the adult's home to and from the program.
  (vii) Nutritional services, including at least one meal daily and nutritional
  counseling and education.
  (B) The term `adult day care program' means a public agency or private
  organization (or a subdivision thereof) which--
  (i) is primarily engaged in providing services described in subparagraph
  (A) to chronically ill adults in a group setting outside their homes on
  a less than 24-hour-a-day basis;
  (ii) provides for such services directly or under arrangements made by
  the agency or organization;
  (iii) maintains a multidisciplinary group of personnel, including at least
  a physician, registered nurse, professional social worker, appropriate
  rehabilitation professionals, and, as needed, a dietitian, which provides
  (or supervises the provision of) such services and which establishes
  policies governing the provision of such services;
  (iv) maintains appropriate records on all individuals provided such services;
  (v) utilizes volunteers in its provision of such services;
  (vi) in the case or an agency or organization in any State in which State
  or applicable local law provides for the licensing of such agencies or
  organizations, is licensed pursuant to such law;
  (vii) has procedures for obtaining appropriate aid in medical emergencies;
  and
  (viii) meets other requirements as the Secretary may find necessary in
  the interest of the health and safety of individuals receiving services
  described in subparagraph (A) from such agency or organization.
  (4)(A) The Secretary shall provide for the evaluation of the projects on a
  concurrent basis and shall submit to the Congress and the Long-Term Care
  Advisory Council an interim report on the findings of the evaluation one
  year after the date of the enactment of this Act and a final report on
  the finding of the evaluation upon the completion of the projects. Such
  evaluation shall include an analysis of the costs or cost savings, and
  the impact on quality of long-term home care, of adding adult day care
  to the items and services included under long-term home care under the
  medicare program.
  (B) Based on such evaluation and in close consultation with the Long-Term
  Care Advisory Council, the Secretary, within 90 days of the submission
  of the final report under subparagraph (A), shall determine whether, as a
  result of the addition of adult day care to the items and services included
  under long-term home care under title XVIII of the Social Security Act,
  the expenditures for adult day care under such title will not exceed the
  savings in other long-term home care resulting from the addition of such
  services, and whether there will be any decline in quality of long-term
  home care under such title. If the Secretary determines that the addition
  of adult day care to the items and services included under long-term home
  care under such title will not result in expenditures for adult day care
  exceeding savings in other long-term health care and will maintain the
  quality of long-term home care under such title, then--
  (i) within 6 months after the date of such determination, the Secretary
  shall, by regulation, establish requirements for adult day care programs
  (as defined in paragraph (3)(B)); and
  (ii) within 3 months after the day of issuing in final form such regulations,
  the Secretary shall by regulation provide, for purposes of title XVIII of
  the Social Security Act, for the inclusion of adult day care within the
  items and services described in section 1861(kk)(1) of such Act.
  (5) There are authorized to be appropriated from the Federal Hospital
  Insurance Trust Fund for the 2-fiscal year period beginning with fiscal year
  1992, not to exceed $5,000,000 to carry out demonstration projects under
  this subsection and not to exceed $1,000,000 to carry out the evaluation
  of such projects under this subsection.
  (6) The conduct or results of the projects under this subsection shall not
  affect any other studies or activities concerning the provision of adult
  day care under the medicare program.
  (e) GENERAL AUTHORITY-
  (1) Payments under demonstration projects under this section may be made in
  advance or by way of reimbursement, as may be determined by the Secretary,
  and shall be made in such installments and on such conditions as the
  Secretary finds necessary to carry out the purpose of this section.
  (2) The Secretary may waive such requirements of title XVIII of the Social
  Security Act as may be required to carry out demonstration projects under
  this section.
SEC. 6. PERMITTING DISABLED INDIVIDUALS TO PURCHASE MEDICARE COVERAGE DURING
THE 24-MONTH WAITING PERIOD FOR MEDICARE ENTITLEMENT; PERMITTING DISABLED
INDIVIDUALS NOT ENTITLED TO LONG-TERM HOME CARE BENEFITS TO BUY-IN TO MEDICARE
TO OBTAIN SUCH BENEFITS.
  (a) DISABLED BUY-IN- Section 1818(a) (42 U.S.C. 1395i-2(a)) is amended--
  (1) by amending paragraph (1) to read as follows:
  `(1) has not attained the age of 65 and would be described in section
  226(b)(2) if the phrases `, and has for 24 calendar months been entitled
  to,' `, and has been for not less than 24 months,' and `including the
  requirement that he has been entitled to the specified benefits for 24
  months,' were deleted from subparagraphs (A), (B), and (C)(ii), respectively,
  of such section,';
  (2) by striking paragraph (2), and
  (3) by redesignating paragraphs (3) and (4) as paragraphs (2) and (3),
  respectively.
  (b) LIMITED BUY-IN FOR LONG-TERM HOME CARE BENEFITS- Section 1818(a)
  (42 U.S.C. 1395i-2(a)) is amended by adding at the end the following:
  `In enrolling under this section, for months beginning with the first
  month that begins 1 year after the date of the enactment of this sentence,
  an individual has the option of enrolling for all benefits under this part
  (other than long-term home care benefits described in section 1812(a)(2)),
  for long-term home care benefits described in section 1812(a)(2), or
  for both.'.
  (b) PREMIUMS- Section 1818(d) (42 U.S.C. 1395i-2(d)) is amended--
  (1) in the first sentence of paragraph (2), by striking `for months
  occurring in the following calendar year' and inserting before the period
  the following: `for benefits (other than for long-term home care benefits
  described in section 1812(a)(2)) for months occurring in the following
  calendar year for individuals described in subsection (a)(1)(A)', and
  (2) by adding at the end the following new paragraphs:
  `(4) The Secretary shall, during the next to last calendar quarter of each
  year, determine and promulgate the dollar amount which shall be applicable
  for premiums (other than for long-term home care benefits described
  in section 1812(a)(2)) for months occurring in the following year for
  individuals described in subsection (a)(1)(B). Such amount shall be equal
  to the amount the Secretary estimates to be necessary so that the aggregate
  amount for such calendar year with respect to such individuals will equal
  100 percent of the total of the benefits and administrative costs which he
  estimates will be payable from the Federal Hospital Insurance Trust Fund
  for services performed and related administrative costs incurred in such
  calendar year with respect to such individuals (other than with respect to
  long-term home care benefits). In calculating such amount the Secretary
  shall include an appropriate amount for a contingency margin. Any amount
  determined under the preceding sentence which is not a multiple of $1
  shall be rounded to the nearest multiple of $1, or, if a multiple of 50
  cents but not a multiple of $1, to the next higher multiple of $1.
  `(5) The Secretary shall, during the first calendar quarter of 1992 and
  during the next to last calendar quarter of each year (beginning with 1992),
  determine and promulgate the dollar amount which shall be applicable for
  premiums for individuals enrolled for long-term home care benefits under
  this section for months occurring in 1992 or in the following year,
  respectively. Such amount shall be equal to the amount the Secretary
  estimates to be necessary so that the aggregate amount for such period
  or calendar year with respect to individuals so enrolled will equal 100
  percent of the benefits and administrative costs which will be payable
  from the Federal Hospital Insurance Trust Fund for long-term home care
  benefits provided and related administrative costs incurred in the period
  or year with respect to individuals so enrolled under this section. In
  calculating such amount the Secretary shall include an appropriate amount
  for a contingency margin. Any amount determined under the preceding sentence
  which is not a multiple of $1 shall be rounded to the nearest multiple of
  $1 (or, if it is a multiple of 50 cents but not a multiple of $1, to the
  next higher multiple of $1).'.
  (c) EFFECTIVE DATE- The amendments made by this section shall apply to
  months beginning with January 1, 1992.
SEC. 7. FINANCING BY REPEALING DOLLAR LIMITATION ON AMOUNT OF WAGES SUBJECT
TO HOSPITAL INSURANCE AND DISABILITY INSURANCE TAXES.
  (a) EMPLOYMENT TAXES-
  (1) IN GENERAL- Paragraph (1) of section 3121(a) of the Internal Revenue
  Code of 1986 (defining wages) is amended--
  (A) by inserting `in the case of OASI taxes (as defined in subsection
  (x)),' after `(1)',
  (B) by striking `applicable contribution base (as determined under subsection
  (x))' and inserting `contribution and benefit base (as determined under
  section 230 of the Social Security Act)' each place it appears, and
  (C) by striking `such applicable contribution base' and inserting `such
  contribution and benefit base'.
  (2) OASI TAXES- Subsection (x) of section 3121 of such Code is amended to
  read as follows:
  `(x) OASI TAXES- For purposes of subsection (a)(1), the term `OASI taxes'
  means the taxes imposed by sections 3101(a) and 3111(a) to the extent such
  taxes are determined at a rate in excess of the applicable rate specified
  in section 201(b)(1)(A) of the Social Security Act.'
  (b) SELF-EMPLOYMENT TAX-
  (1) IN GENERAL- Paragraph (1) of section 1402(b) of such Code is amended--
  (A) by inserting `in the case of the OASI tax (as defined in subsection
  (k)),' after `(1)', and
  (B) by striking `applicable contribution base (as determined under subsection
  (k))' and inserting `contribution and benefit base (as determined under
  section 230 of the Social Security Act)'.
  (2) OASI TAX- Subsection (k) of section 1402 of such Code is amended to
  read as follows:
  `(k) OASI TAX- For purposes of subsection (b)(1), the term `OASI tax' means
  the tax imposed by section 1401(a) to the extent such tax is determined at
  a rate in excess of the applicable rate specified in section 201(b)(1)(B)
  of the Social Security Act.'
  (c) RAILROAD RETIREMENT TAXES-
  (1) IN GENERAL- Subparagraph (A) of section 3231(e)(2) of such Code is
  amended by adding at the end thereof the following new clause:
  `(iii) LIMITATION NOT TO APPLY TO TAXES EQUIVALENT TO HOSPITAL INSURANCE
  AND DISABILITY INSURANCE TAXES- Clause (i) shall not apply to--
  `(I) so much of the rate applicable under section 3201(a) or 3221(a)
  (as the case may be) as exceeds the rate of the OASI tax (as determined
  under section 3121(x)) in effect, and
  `(II) so much of the rate of tax applicable under section 3211(a)(1) as
  exceeds the rate of the OASI tax (as determined under section 1401(k))
  in effect.'
  (2) TECHNICAL AMENDMENT- Clause (i) of section 3231(e)(2)(B) of such Code
  is amended to read as follows:
  `(i) TIER 1 TAXES- Except as provided in clause (ii), the term `applicable
  base' means for any calendar year the contribution and benefit base
  determined under section 230 of the Social Security Act for such calendar
  year.'
  (d) DEPOSITS INTO TRUST FUNDS REDUCED BY DECREASES IN INCOME TAX REVENUES-
  (1) FEDERAL DISABILITY INSURANCE TRUST FUND- Subsection (b) of section
  201 is amended by adding at the end thereof the following new sentence:
`The amounts determined under paragraphs (1) and (2) shall be reduced by
the decrease in the tax imposed by chapter 1 of the Internal Revenue Code
of 1986 resulting from the amendments made by section 7 of the Long-Term
Home Care Act of 1991.'
  (2) HOSPITAL INSURANCE TRUST FUND- Subsection (a) of section 1817 is
  amended by adding at the end thereof the following new sentence:
`The amounts determined under paragraphs (1) and (2) shall be reduced by
the decrease in the tax imposed by chapter 1 of the Internal Revenue Code
of 1986 resulting from the amendments made by section 7 of the Long-Term
Home Care Act of 1991.'
  (e) OTHER TECHNICAL AMENDMENTS-
  (1) Paragraph (3) of section 6413(c) of such Code is amended to read
  as follows:
  `(3) REFUNDS NOT ALLOWED FOR HOSPITAL INSURANCE AND DISABILITY TAXES-
  Paragraphs (1) and (2) shall apply only to so much of the taxes imposed by
  sections 3101(a) (or any amount equivalent to such tax) and 3201(a) which
  do not apply to remuneration in excess of the contribution and benefit base
  (as determined under section 230 of the Social Security Act).'
  (2) Sections 3122 and 3125 of such Code are each amended--
  (A) by striking `section 3111' each place it appears and inserting `section
  3111(a)', and
  (B) by striking `applicable contribution base limitation' and inserting
  `contribution and benefit base limitation'.
  (f) EFFECTIVE DATE- The amendments made by this section shall apply to
  1991 and later calendar years.

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