Section 1 Short title
This Act may be cited as the “Health Outcomes, Planning, and Education (HOPE) for Alzheimer’s Act of 2015”.
Health Outcomes, Planning, and Education (HOPE) for Alzheimer’s Act of 2015
A BILL
To amend title XVIII of the Social Security Act to provide for coverage under the Medicare program of an initial comprehensive care plan for Medicare beneficiaries newly diagnosed with Alzheimer’s disease and related dementias, and for other purposes.
Sec. 2 Findings and purpose
Findings— Congress makes the following findings:
As many as half of the estimated 5,100,000 American seniors with Alzheimer’s disease and other dementias have never received a diagnosis.
An early and documented diagnosis and access to care planning services leads to better outcomes for individuals with Alzheimer’s disease and other dementias and their caregivers.
Building upon the existing Medicare benefit of a diagnostic evaluation to add comprehensive care planning services would help ensure that beneficiaries and their families receive critical information about the disease and available care options, which leads to better outcomes.
An accurate, timely, and documented diagnosis allows for better management of other known chronic conditions and more efficient utilization of medical resources, including reducing complications and the number of costly emergency room visits and hospitalizations.
A formal and documented diagnosis and care planning services allow individuals and their caregivers to have access to available medical and non-medical treatments, build a care team, participate in support services, and enroll in clinical trials.
Purpose— The purpose of this Act is to provide better care and outcomes for Medicare beneficiaries living with Alzheimer’s disease and related dementias by building upon existing Medicare coverage of a diagnostic evaluation for Alzheimer’s disease and related dementias to add coverage of initial comprehensive care planning services for Medicare beneficiaries who are first diagnosed with Alzheimer’s disease or related dementias on or after the date of the enactment of this Act and whose medical records contain the documented diagnosis of the disease.
Sec. 3 Medicare coverage of comprehensive alzheimer’s disease care planning services
in subsection (s)(2)—
by striking “and” at the end of subparagraph (EE);
by adding “and” at the end of subparagraph (FF); and
by adding at the end the following new subparagraph:
“(GG) comprehensive Alzheimer’s disease care planning services (as defined in subsection (iii));”
by adding at the end the following new subsection:
“(iii) Comprehensive Alzheimer’s disease care planning services
“(1)
“(A) Subject to subparagraph (B), the term comprehensive Alzheimer’s disease care planning services means the services described in paragraph (2) furnished by a physician or non-physician practitioner to any or all of the following:
“(i) An eligible individual.
“(ii) The personal representative of such eligible individual, with or without the presence of the eligible individual.
“(iii) One or more family caregivers of such eligible individual, with or without the presence of the eligible individual.
“(B) The Secretary shall establish guidelines for the furnishing of Comprehensive Alzheimer’s disease care planning services to individuals described in clauses (i), (ii), and (iii) of subparagraph (A).
“(2)
“(A) Subject to the succeeding provisions of this paragraph, the services described in this paragraph are the development and furnishing of an initial comprehensive care plan to an eligible individual that provides such information and services as the Secretary may specify (in consultation with stakeholders as provided in paragraph (5)), which—
“(i) includes—
“(I) assistance understanding the diagnosis;
“(II) assistance understanding medical and non-medical options for ongoing treatment, services, and supports; and
“(III) information about how to obtain the treatments, services, and supports described in subclause (II); and
“(ii) takes into account the eligible individual’s other co-morbid chronic conditions.
“(B) The services described in this paragraph shall also include comprehensive medical record documentation, with respect to the eligible individual of the care planning services under subparagraph (A), by the physician or non-physician practitioner furnishing the services.
“(3) Subject to paragraph (5), the Secretary shall periodically update requirements under this subsection to reflect advances in science and technology.
“(4)
“(A) Comprehensive Alzheimer’s disease care planning services may only be furnished once with respect to each eligible individual.
“(B) Nothing in this subsection shall be construed as prohibiting an update of any initial comprehensive care plan furnished under this subsection to an eligible individual under physicians’ services that are covered under other provisions of this title, such as care planning under personalized prevention plan services (as defined in subsection (hhh)(1)).
“(5) The Secretary shall consult with stakeholders, such as physicians, non-physician practitioners, and organizations that represent individuals (including individuals under this title) with Alzheimer’s disease, with respect to each of the following:
“(A) The scope of, and requirements for, services described in paragraph (2).
“(B) The periodic updates of requirements under paragraph (3).
“(6) In this subsection:
“(A) The term Alzheimers disease’ means Alzheimer’s disease and related dementias.
“(B) The term eligible individual means an individual who—
“(i) has a documented diagnosis of Alzheimer’s disease in the medical record; and
“(ii) was first diagnosed as having Alzheimer's disease on or after the date of the enactment of this subsection.
“(C) The term non-physician practitioner means a practitioner described in clause (i), (iv), or (v) of section 1842(b)(18)(C).
“(D) The term personal representative means, with respect to an individual, a person legally authorized to make health care decisions on such individual’s behalf.
“(E) The term physician has the meaning given that term in subsection (r)(1).”
Payment—
by striking “and” before “(Z)”; and
by inserting before the semicolon at the end the following: “, and (AA) with respect to comprehensive Alzheimer’s disease care planning services (as defined in section 1861(iii)(2)), the amount paid shall be an amount equal to 80 percent of the lesser of the actual charge for the services or the amount determined under the payment basis determined under section 1848.”.
Payment under physician fee schedule— Section 1848(j)(3) of the Social Security Act (42 U.S.C. 1395w–4(j)(3)) is amended by inserting “(2)(GG),” after “(2)(FF) (including administration of the health risk assessment),”.
Frequency limitation— Section 1862(a)(1) of the Social Security Act (42 U.S.C. 1395y(a)(1)) is amended—
in subparagraph (O), by striking “and” at the end;
in subparagraph (P), by striking the semicolon at the end and inserting “, and”; and
by adding at the end the following new subparagraph:
“(Q) in the case of comprehensive Alzheimer's disease care planning services (as defined in section 1861(iii)(1)), which are performed more frequently than is covered under such section;”
Provider outreach and reporting on care planning services—
Outreach— The Secretary of Health and Human Services (in this subsection referred to as the “Secretary”) shall conduct outreach to physicians and appropriate non-physician practitioners participating under the Medicare program with respect to the amendments made by subsections (a) and (b). Such outreach shall include a comprehensive, one-time education initiative to inform such physicians and practitioners of the addition of comprehensive Alzheimer’s disease care planning services as a covered benefit under the Medicare program, including materials on appropriate diagnostic evaluations and explanations of the requirements for eligibility for such services.
Reports to Congress—
Provider outreach— Not later than one year after the effective date of the amendments made by subsections (a) and (b) (as described in subsection (d)), the Secretary shall submit to the Committee on Ways and Means and the Committee on Energy and Commerce of the House of Representatives and the Committee on Finance of the Senate a report on the outreach conducted under paragraph (1). Such report shall include a description of the methods used for such outreach.
Utilization rates— Not later than 18 months after the effective date of the amendments made by subsections (a) and (b) (as described in subsection (d)) and annually thereafter for the succeeding five years, the Secretary shall submit to the Committee on Ways and Means and the Committee on Energy and Commerce of the House of Representatives and the Committee on Finance of the Senate a report on the number of Medicare beneficiaries who, during the preceding year, were furnished comprehensive Alzheimer’s disease care planning services for which payment was made under title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.). Each such report shall include information on any barriers Medicare beneficiaries face to access such services and the Secretary’s recommendations to eliminate any such barriers.
Copy of each report— On the same day that a report is submitted under subparagraph (A) or (B) of paragraph (2), the Secretary shall transmit a copy of such report to the Advisory Council on Alzheimer’s Research, Care, and Services (established under section 2(e) of the National Alzheimer’s Project Act (Public Law 111–375).
Effective date— The amendments made by subsections (a) and (b) shall apply to services furnished on or after January 1 of the year following the year which includes the date of the enactment of this Act.