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

H.R. 3421 · 118th Congress · May 17, 2023 · 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 and medical devices, including outpatient prescription drugs, medical devices, and biological products, and all contraceptive items approved by the Food and Drug Administration.
(5)
Mental health and substance use treatment services, including inpatient care.
(6)
Laboratory and diagnostic services.
(7)
Comprehensive reproductive care, including abortion, contraception, and assistive reproductive technology.
(8)
Maternity and newborn care.
(9)
Comprehensive gender affirming health care.
(10)
Oral health, audiology, and vision services.
(11)
Rehabilitative and habilitative services and devices.
(12)
Emergency services and transportation.
(13)
Early and periodic screening, diagnostic, and treatment services, as described in sections 1902(a)(10)(A), 1902(a)(43), 1905(a)(4)(B), and 1905(r) of the Social Security Act (42 U.S.C. 1396a(a)(10)(A); 1396a(a)(43); 1396d(a)(4)(B); 1396d(r)).
(14)
Necessary transportation to receive health care services for persons with disabilities, older individuals with functional limitations, or low-income individuals (as determined by the Secretary).
(15)
Long-term care services and support (as described in section 204).
(16)
Hospice care.
(17)
Services provided by a licensed marriage and family therapist or a licensed mental health counselor.
(18)
Any service described in a preceding paragraph that is furnished via telehealth, to the extent practical.
(b)
Revision— The Secretary shall, at least annually, and on a regular basis, evaluate whether the benefits package should be improved 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. Such recommendations may not include a recommendation to eliminate any benefit.
(c)
Hearings—
(1)
In general— The Committee on Energy and Commerce and the Committee on Ways and Means of the House of Representatives shall, not less frequently than annually, hold a hearing on the recommendations submitted by the Secretary under subsection (b).
(2)
Exercise of rulemaking authority— Paragraph (1) is enacted—
(A)
as an exercise of rulemaking power of the House of Representatives, and, as such, shall be considered as part of the rules of the House, and such rules shall supersede any other rule of the House only to the extent that rule is inconsistent therewith; and
(B)
with full recognition of the constitutional right of either House to change such rules (so far as relating to the procedure in such House) at any time, in the same manner, and to the same extent as in the case of any other rule of the House.
(d)
Complementary and Integrative Medicine—
(1)
In general— In carrying out subsection (b), the Secretary shall consult with the persons described in paragraph (2) with respect to—
(A)
identifying specific complementary and integrative medicine practices that 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 alternative 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.
(e)
States may provide additional benefits— Individual States may provide additional benefits for the residents of such States, as determined by such State, and may provide benefits to individuals not eligible for benefits under this Act, at the expense of the State, subject to the requirements specified in section 1102.

Sec. 202 No cost-sharing; other limitations

(a)
In general— The Secretary shall ensure that no cost-sharing, including deductibles, coinsurance, copayments, or similar charges, is imposed on an individual for any benefits provided under this Act.
(b)
No balance billing— No provider may impose a charge to an enrolled individual for covered services for which benefits are provided under this Act.
(c)
No prior authorization— Benefits provided under this Act shall be covered without any need for any prior authorization determination and without any limitation applied through the use of step therapy protocols.

Sec. 203 Exclusions and limitations

(a)
In general— Benefits for items and services are not available under this Act unless the items and services meet the standards developed by the Secretary pursuant to section 201(a).
(b)
Treatment of experimental items and services and drugs—
(1)
In general— In applying subsection (a), the Secretary shall make national coverage determinations with respect to items and 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 the 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—
(1)
In general— In the case of items and services for which the Department of Health and Human Services has recognized a national practice guideline, such items and services shall be deemed to meet the standards specified in section 201(a) if they have been provided in accordance with such guideline. For purposes of this subsection, an item or service not provided in accordance with a practice guideline shall be deemed to have been provided in accordance with the guideline if the health care provider providing the item or service—
(A)
exercised appropriate professional judgment in accordance with the laws and requirements of the State in which such item or service is furnished in deviating from the guideline;
(B)
acted in the best interest of the individual receiving the item or service; and
(C)
acted in a manner consistent with the individual’s wishes.
(2)
Override of standards—
(A)
In general— An individual’s treating physician or other health care professional authorized to exercise independent professional judgment in implementing a patient’s medical or nursing care plan in accordance with the scope of practice, licensure, and other law of the State where items and services are to be furnished may override practice standards established pursuant to section 201(a) or practice guidelines described in paragraph (1), including such standards and guidelines that are implemented by a provider through the use of health information technology, such as electronic health record technology, clinical decision support technology, and computerized order entry programs.
(B)
Limitation— An override described in subparagraph (A) shall, in the professional judgment of such physician, nurse, or health care professional, be—
(i)
consistent with such physician’s, nurse’s, or health care professional’s determination of medical necessity and appropriateness or nursing assessment;
(ii)
in the best interests of the individual; and
(iii)
consistent with the individual’s wishes.

Sec. 204 Coverage of long-term care services

(a)
In general— Subject to the other provisions of this Act, individuals enrolled for benefits under this Act are entitled to the following long-term services and supports and to have payment made by the Secretary to an eligible provider for such services and supports if medically necessary and appropriate and in accordance with the standards established in this Act, for maintenance of health or for care, services, diagnosis, treatment, or rehabilitation that is related to a medically determinable condition, whether physical or mental, of health, injury, or age that—
(1)
causes a functional limitation in performing one or more activities of daily living; or
(2)
requires a similar need of assistance in performing instrumental activities of daily living.
(b)
Eligibility— An individual shall be eligible for services and supports described in this section if such individual has one or more medically determinable conditions described in subsection (a).
(c)
Services and supports— Long-term services and supports under this section shall be tailored to an individual’s needs, as determined through assessment, and shall be defined by the Secretary to—
(1)
include any long-term nursing services for the enrollee, whether provided in an institution or in a home and community-based setting;
(2)
provide coverage for a broad spectrum of long-term services and supports, including for home and community-based services and other care provided through non-institutional settings;
(3)
provide coverage that meets the physical, mental, and social needs of recipients while allowing recipients their maximum possible autonomy and their maximum possible civic, social, and economic participation;
(4)
prioritize delivery of long-term services and supports through home and community-based services over institutionalization;
(5)
unless an individual elects otherwise, ensure that recipients will receive home and community based long-term services and supports (as defined in subsection (f)(4)), regardless of the individuals’s type or level of disability, service need, or age;
(6)
be provided with the goal of enabling persons with disabilities to receive services in the least restrictive and most integrated setting appropriate to the individual’s needs;
(7)
be provided in such a manner that allows persons with disabilities to maintain their independence, self-determination, and dignity;
(8)
provide long-term services and supports that are of equal quality and equally accessible across geographic regions; and
(9)
ensure that long-term services and supports provide recipient’s the option of self-direction of services from either the recipient or care coordinators of the recipient’s choosing.
(d)
Public consultation— In developing regulations to implement this section, the Secretary shall consult with an advisory commission on long-term services and supports that includes—
(1)
people with disabilities who use long-term services and supports and older adults who use long-term services and supports;
(2)
representatives of people with disabilities and representatives of older adults;
(3)
groups that represent the diversity of the population of people living with disabilities, including racial, ethnic, national origin, primary language use, age, sex, including gender identity and sexual orientation, geographical, and socioeconomic diversity;
(4)
providers of long-term services and supports, including family attendants and family caregivers, and members of organized labor;
(5)
disability rights organizations; and
(6)
relevant academic institutions and researchers.
(e)
Budgeting and payments— Budgeting and payments for long-term services and supports provided under this section shall be made in accordance with the provisions under title VI.
(f)
Definitions— In this section:
(1)
The term long-term services and supports means long-term care, treatment, maintenance, or services needed to support the activities of daily living and instrumental activities of daily living, including home and community-based services and any additional services and supports identified by the Secretary to support people with disabilities to live, work, and participate in their communities.
(2)
The term activities of daily living means basic personal everyday activities, including tasks such as eating, toileting, grooming, dressing, bathing, and transferring.
(3)
The term instrumental activities of daily living means activities related to living independently in the community, including meal planning and preparation, managing finances, shopping for food, clothing, and other essential items, performing essential household chores, communicating by phone or other media, and traveling around and participating in the community.
(4)
The term home and community-based services means the home and community-based services that are coverable under subsections (c), (d), (i), and (k) of section 1915 of the Social Security Act (42 U.S.C. 1396n), and as defined by the Secretary, including as defined in the home and community-based services settings rule in sections 441.530 and 441.710 of title 42, Code of Federal Regulations (or a successor regulation).