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Title II — Comprehensive Benefits, Including Preventive Benefits and Benefits for Long-Term Care

S. 1129 · 116th Congress · Apr 10, 2019 · Lineage

II Comprehensive Benefits, Including Preventive Benefits and Benefits for Long-Term Care

Sec. 201 Comprehensive benefits

(a)
In general— Subject to the other provisions of this title and titles IV through IX, individuals enrolled for benefits under this Act are entitled to have payment made by the Secretary to an eligible provider for the following items and services if medically necessary or appropriate for the maintenance of health or for the diagnosis, treatment, or rehabilitation of a health condition:
(1)
Hospital services, including inpatient and outpatient hospital care, including 24-hour-a-day emergency services and inpatient prescription drugs.
(2)
Ambulatory patient services.
(3)
Primary and preventive services, including chronic disease management.
(4)
Prescription drugs, medical devices, biological products, including outpatient prescription drugs, medical devices, and biological products.
(5)
Mental health and substance abuse treatment services, including inpatient care.
(6)
Laboratory and diagnostic services.
(7)
Comprehensive reproductive, maternity, and newborn care.
(8)
Pediatrics, including early and periodic screening, diagnostic, and treatment services (as defined in section 1905(r) of the Social Security Act (42 U.S.C. 1396d(r))).
(9)
Oral health, audiology, and vision services.
(10)
Short-term rehabilitative and habilitative services and devices.
(11)
Emergency services and transportation.
(12)
Necessary transportation to receive health care services for individuals with disabilities and low-income individuals.
(13)
Home and community-based long-term services and supports (to be provided in accordance with the requirements for home and community-based settings under sections 441.530 and 441.710 of title 42, Code of Federal Regulations), including—
(A)
services described in paragraphs (7), (8), (13), (19), and (24) of section 1905(a) of the Social Security Act (42 U.S.C. 1396d(a));
(B)
home and community-based services described in subsection (c)(4)(B) of section 1915 of the Social Security Act (including habilitation services defined in subsection (c)(5) of such section);
(C)
self-directed home and community-based services described in subsection (i) of section 1915 of the Social Security Act;
(D)
self-directed personal assistance services (as defined in subsection (j)(4)(A) of section 1915 of the Social Security Act); and
(E)
home and community-based attendant services and supports described in subsection (k) of section 1915 of the Social Security Act.
(b)
Revision and adjustment— The Secretary shall, on a regular basis, evaluate whether the benefits package should be improved or adjusted to promote the health of beneficiaries, account for changes in medical practice or new information from medical research, or respond to other relevant developments in health science, and shall make recommendations to Congress regarding any such improvements or adjustments.
(c)
Complementary and integrative medicine—
(1)
In general— In carrying out subsection (b), the Secretary shall consult with the persons described in paragraph (1) with respect to—
(A)
identifying specific complementary and integrative medicine practices that, on the basis of research findings or promising clinical interventions, are appropriate to include in the benefits package; and
(B)
identifying barriers to the effective provision and integration of such practices into the delivery of health care, and identifying mechanisms for overcoming such barriers.
(2)
Consultation— In accordance with paragraph (1), the Secretary shall consult with—
(A)
the Director of the National Center for Complementary and Integrative Health;
(B)
the Commissioner of Food and Drugs;
(C)
institutions of higher education, private research institutes, and individual researchers with extensive experience in complementary and integrative medicine and the integration of such practices into the delivery of health care;
(D)
nationally recognized providers of complementary and integrative medicine; and
(E)
such other officials, entities, and individuals with expertise on complementary and integrative medicine as the Secretary determines appropriate.
(d)
States may provide additional benefits— Individual States may provide additional benefits for the residents of such States at the expense of the State.

Sec. 202 No cost-sharing

(a)
In general— The Secretary shall ensure that no cost-sharing, including deductibles, coinsurance, copayments, or similar charges, be imposed on an individual for any benefits provided under this Act, except as described in subsection (b).
(b)
Exceptions— The Secretary may set a cost-sharing schedule for prescription drugs and biological products—
(1)
provided that—
(A)
such schedule is evidence-based and encourages the use of generic drugs;
(B)
such cost-sharing does not apply to preventive drugs;
(C)
such cost-sharing does not exceed $200 annually per individual, adjusted annually for inflation; and
(D)
such cost-sharing is not imposed on individuals with a household income equal to or below 200 percent of the poverty line for a family of the size involved; and
(2)
under which the Secretary may exempt brand-name drugs from consideration in determining whether an individual has reached any out-of-pocket limit if a generic version of such drug is available.
(c)
No balance billing— Notwithstanding contracts in accordance with section 303, no provider may impose a charge to an enrolled individual for covered services for which benefits are provided under this Act.

Sec. 203 Exclusions and limitations

(a)
In general— Benefits for services are not available under this Act unless the services meet the standards specified in section 201(a), as defined by the Secretary.
(b)
Treatment of experimental services and drugs—
(1)
In general— In applying subsection (a), the Secretary shall make national coverage determinations with respect to services that are experimental in nature. Such determinations shall be consistent with the national coverage determination process as defined in section 1869(f)(1)(B) of the Social Security Act (42 U.S.C. 1395ff(f)(1)(B)).
(2)
Appeals process— The Secretary shall establish a process by which individuals can appeal coverage decisions. The process shall, as much as is feasible, follow process for appeals under the Medicare program described in section 1869 of the Social Security Act (42 U.S.C. 1395ff).
(c)
Application of practice guidelines— In the case of services for which the Department of Health and Human Services has recognized a national practice guideline, the services are considered to meet the standards specified in section 201(a) if they have been provided in accordance with such guideline. For purposes of this subsection, a service shall be considered to have been provided in accordance with a practice guideline if the health care provider providing the service exercised appropriate professional discretion to deviate from the guideline in a manner authorized or anticipated by the guideline.

Sec. 204 Coverage of institutional long-term care services under Medicaid

Title XIX of the Social Security Act (42 U.S.C. 1396 et seq.) is amended by inserting the following section after section 1946:

“1947. State Plan for Providing Institutional Long-Term Care Services

“(a) In general—For quarters beginning on or after date on which benefits are first available under section 106(a) of the Medicare for All Act of 2019, notwithstanding any other provision of this title—

“(1) a State plan for medical assistance shall provide for making medical assistance available for services that are institutional long-term care services in a manner consistent with this section; and

“(2) no payment to a State shall be made under this title with respect to expenditures incurred by the State in providing medical assistance on or after such date for services that are not—

“(A) institutional long-term care services; or

“(B) other services for which benefits are not available under the Medicare for All Act of 2019 and which are furnished under a State plan for medical assistance which provided for medical assistance for such services on September 1, 2018.

“(b) Institutional long-Term care services defined—In this section, the term institutional long-term care services means the following:

“(1) Nursing facility services for individuals 21 years of age or over described in subparagraph (A) of section 1905(a)(4).

“(2) Inpatient services for individuals 65 years of age or over provided in an institution for mental disease described in section 1905(a)(14).

“(3) Intermediate care facility services described in section 1905(a)(15).

“(4) Inpatient psychiatric hospital services for individuals under age 21 described in section 1905(a)(16).

“(5) Nursing facility services described in section 1905(a)(29).

“(c) Maintenance of effort

“(1) Eligibility standards

“(A) In general—Beginning on the date described in subsection (a), no payment may be made under section 1903 with respect to medical assistance provided under a State plan for medical assistance if the State adopts income, resource, or other standards and methodologies for purposes of determining an individual's eligibility for medical assistance under the State plan that are more restrictive than those applied as of January 1, 2019.

“(B) Indexing of amounts of income and resource standards—In determining whether a State has adopted income or resource standards that are more restrictive than the standards which applied as of January 1, 2019, the Secretary shall deem the amount of any such standard that was applied as of such date to be increased by the percentage increase in the medical care component of the consumer price index for all urban consumers (U.S. city average) from September of 2018 to September of the fiscal year for which the Secretary is making such determination.

“(2) Expenditures

“(A) In general—For each fiscal year or portion of a fiscal year that occurs during the period that begins on the first day of the first fiscal quarter that begins on or after the date on which benefits are first available under section 106(a) of the Medicare for All Act of 2019, as a condition of receiving payments under section 1903(a), a State shall make expenditures for medical assistance for services that are institutional long-term care services in an amount that is not less than the expenditure floor determined for the State and fiscal year (or portion of a fiscal year) under subparagraph (B).

“(B) Expenditure floor

“(i) In general—For each fiscal year or portion of a fiscal year described in subparagraph (A), the Secretary shall determine for each State an expenditure floor that shall be equal to—

“(I) the amount of the State's expenditures for fiscal year 2018 on medical assistance for institutional long-term care services; increased by

“(II) the growth factor determined under subclause (ii).

“(ii) Growth factor—For each fiscal year or portion of a fiscal year described in subparagraph (A), the Secretary shall, not later than September 1 of the fiscal year preceding such fiscal year or portion of a fiscal year, determine a growth factor for each State that takes into account—

“(I) the percentage increase in health care costs in the State;

“(II) the total amount expended by the State for the previous fiscal year on medical assistance for institutional long-term care services;

“(III) the increase, if any, in the total population of the State from July of 2018 to July of the fiscal year preceding the fiscal year involved;

“(IV) the increase, if any, in the population of individuals aged 65 and older of the State from July of 2018 to July of the fiscal year preceding the fiscal year involved; and

“(V) the decrease, if any, in the population of the State that requires medical assistance for institutional long-term care services that is attributable to the availability of coverage for the services described in section 201(a)(13) of the Medicare for All Act of 2019.

“(iii) Proration rule—Any amount determined under this subparagraph for a portion of a fiscal year shall be prorated based on the length of such portion of a fiscal year relative to a complete fiscal year.

“(d) Nonapplication of certain requirements—Beginning on the date described in subsection (a), any provision of this title requiring a State plan for medical assistance to make available medical assistance for services that are not institutional long-term care services or services described in section 901(a)(3)(A)(ii) of the Medicare for All Act of 2019 shall have no effect.”

Sec. 205 Prohibiting recovery of correctly paid Medicaid benefits

Section 1917 of the Social Security Act (42 U.S.C. 1396p) is amended—
(1)
by amending subsection (a) to read as follows:

“(a) No lien may be imposed against the property of any individual prior to his death on account of medical assistance paid or to be paid on his behalf under the State plan, except pursuant to the judgment of a court on account of benefits incorrectly paid on behalf of such individual.”

(2)
by amending subsection (b) to read as follows:

“(b) No adjustment or recovery of any medical assistance correctly paid on behalf of an individual under the State plan may be made.”

Sec. 206 State standards

(a)
In general— Nothing in this Act shall prohibit individual States from setting additional standards, with respect to eligibility, benefits, and minimum provider standards, consistent with the purposes of this Act, provided that such standards do not restrict eligibility or reduce access to benefits or services.
(b)
Restrictions on providers— With respect to any individuals or entities certified to provide services covered under section 201(a)(7), a State may not prohibit an individual or entity from participating in the program under this Act, for reasons other than the ability of the individual or entity to provide such services.