S 1640 ISCommentsClose CommentsPermalink

To amend title XVIII of the Social Security Act to provide coverage of intensive lifestyle treatment.CommentsClose CommentsPermalink

August 6, 2009CommentsClose CommentsPermalink

Mr. WYDEN (for himself, Mr. CORNYN, and Mr. HARKIN) introduced the following bill; which was read twice and referred to the Committee on FinanceCommentsClose CommentsPermalink

To amend title XVIII of the Social Security Act to provide coverage of intensive lifestyle treatment.CommentsClose CommentsPermalink

Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled,CommentsClose CommentsPermalink

SECTION 1. SHORT TITLE.

This Act may be cited as the ‘Take Back Your Health Act of 2009’.CommentsClose CommentsPermalink

SEC. 2. COVERAGE OF INTENSIVE LIFESTYLE TREATMENT.

(a) Intensive Lifestyle Treatment Program-CommentsClose CommentsPermalink





(1) IN GENERAL- Section 1861 of the Social Security Act (42 U.S.C. 1395x) is amended--CommentsClose CommentsPermalink





(A) in subsection (s)(2)--CommentsClose CommentsPermalink





(i) in subparagraph (DD) by striking ‘and’ at the end;CommentsClose CommentsPermalink





(ii) in subparagraph (EE) by inserting ‘and’ at the end; andCommentsClose CommentsPermalink





(iii) by adding at the end the following new subparagraph:CommentsClose CommentsPermalink





‘(FF) items and services furnished under an intensive lifestyle treatment program (as defined in paragraph (hhh)(1)) to eligible beneficiaries (as defined in paragraph (hhh)(4));’; andCommentsClose CommentsPermalink





(B) by adding at the end the following new subsection:CommentsClose CommentsPermalink

‘Intensive Lifestyle Treatment Program

‘(hhh)(1) The term ‘intensive lifestyle treatment program’ means a physician-supervised program (as defined in paragraph (2)) that furnishes the items and services described in paragraph (3) intended to beneficially affect the progression of chronic diseases to eligible beneficiaries (as defined in paragraph (4)).CommentsClose CommentsPermalink





‘(2) A program described in this paragraph is a program under which--CommentsClose CommentsPermalink





‘(A) items and services under the program are delivered--CommentsClose CommentsPermalink





‘(i) in a physician’s office or clinic;CommentsClose CommentsPermalink





‘(ii) in a hospital on an outpatient basis; orCommentsClose CommentsPermalink





‘(iii) in other settings determined appropriate by the Secretary;CommentsClose CommentsPermalink





‘(B) a physician (as defined in section 1861(r)(1)) is immediately available and accessible for medical consultation and medical emergencies at all times items and services are being furnished under the program, except that, in the case of items and services furnished under such a program in a hospital, such availability shall be presumed;CommentsClose CommentsPermalink





‘(C) individualized treatment is furnished under a written plan established and designed by a physician (as so defined) in advance of the start of the program and reviewed and signed by a physician every 60 days that describes--CommentsClose CommentsPermalink





‘(i) the individual’s diagnosis;CommentsClose CommentsPermalink





‘(ii) the type, amount, frequency, and duration of the items and services furnished under the plan; andCommentsClose CommentsPermalink





‘(iii) the goals set for the individual under the plan;CommentsClose CommentsPermalink





‘(D) items and services may be provided in a series of 72 one-hour sessions (as defined in section 1848(b)(6)), up to 6 sessions per day, over a period of 18 weeks, and may include group sessions with up to 15 other eligible beneficiaries; andCommentsClose CommentsPermalink





‘(E) items and services may be provided--CommentsClose CommentsPermalink





‘(i) by an intensive lifestyle team;CommentsClose CommentsPermalink





‘(ii) under the direction of a physician (as so defined); andCommentsClose CommentsPermalink





‘(iii) if determined appropriate by the Secretary, in the case of such items and services provided in underserved areas, by a physician assistant, nurse practitioner, or clinical nurse specialist as provided under State law.CommentsClose CommentsPermalink





‘(3) The items and services described in this paragraph are--CommentsClose CommentsPermalink





‘(A) exercise;CommentsClose CommentsPermalink





‘(B) risk factor modification, including education, counseling, and behavioral intervention (to the extent such education, counseling, and behavioral intervention is closely related to the individual’s care and treatment and is tailored to the individual’s needs);CommentsClose CommentsPermalink





‘(C) psychosocial assessment;CommentsClose CommentsPermalink





‘(D) provider consultation;CommentsClose CommentsPermalink





‘(E) care coordination;CommentsClose CommentsPermalink





‘(F) medication management;CommentsClose CommentsPermalink





‘(G) medical nutritional therapy;CommentsClose CommentsPermalink





‘(H) tobacco cessation;CommentsClose CommentsPermalink





‘(I) outcomes assessment; andCommentsClose CommentsPermalink





‘(J) such other items and services as the Secretary determines appropriate, but only if such items and services are--CommentsClose CommentsPermalink





‘(i) reasonable and necessary for the diagnosis or active treatment of the individual’s condition;CommentsClose CommentsPermalink





‘(ii) reasonably expected to improve or maintain the individual’s condition and functional level; andCommentsClose CommentsPermalink





‘(iii) furnished under such guidelines relating to the frequency and duration of such items and services as the Secretary shall establish, taking into account accepted norms of medical practice and the reasonable expectation of improvement of the individual.CommentsClose CommentsPermalink





‘(4) The term ‘eligible beneficiary’ means an individual who is entitled to, or enrolled for, benefits under part A and enrolled under this part and who has been diagnosed with 1 or more of the following conditions:CommentsClose CommentsPermalink





‘(A) Coronary heart disease.CommentsClose CommentsPermalink





‘(B) Type 2 diabetes.CommentsClose CommentsPermalink





‘(C) Metabolic syndrome.CommentsClose CommentsPermalink





‘(D) Prostate cancer.CommentsClose CommentsPermalink





‘(E) Breast cancer.’.CommentsClose CommentsPermalink





(2) PAYMENT FOR INTENSIVE LIFESTYLE TREATMENT PROGRAMS-CommentsClose CommentsPermalink





(A) INCLUSION IN PHYSICIANS’ SERVICES- Section 1848(j)(3) of the Social Security Act (42 U.S.C. 1395w-4(j)(3)) is amended by inserting ‘(2)(FF),’ after ‘(2)(EE).’.CommentsClose CommentsPermalink





(B) CONFORMING AMENDMENT- Section 1848(b) of the Social Security Act (42 U.S.C. 1395w-4(b)) is amended by adding at the end the following new paragraph:CommentsClose CommentsPermalink





‘(6) TREATMENT OF INTENSIVE LIFESTYLE TREATMENT PROGRAM-CommentsClose CommentsPermalink





‘(A) IN GENERAL- In the case of an intensive lifestyle treatment program described in section 1861(hhh)(2), the Secretary shall establish an aggregate payment for items and services furnished under such program (as described in section 1861(hhh)(3)) not to exceed the cost to the program under this title for a hospitalization for a similarly situated eligible beneficiary, subject to the limitation under subparagraph (C).CommentsClose CommentsPermalink





‘(B) PAYMENT SCHEDULE- The Secretary shall--CommentsClose CommentsPermalink





‘(i) make a payment to such a program in an amount that is equal to 50 percent of the amount established under subparagraph (A) upon completion of the initial consultation under the program; andCommentsClose CommentsPermalink





‘(ii) subject to the limitation described in subparagraph (C), make a second payment to a program for the balance of the amount defined in subparagraph (A) upon completion of treatment under the program.CommentsClose CommentsPermalink





‘(C) LIMITATION-CommentsClose CommentsPermalink





‘(i) IN GENERAL- Notwithstanding the provisions of subparagraph (B), an intensive lifestyle treatment program shall not receive the payment described in subparagraph (B)(ii) unless it documents, upon the completion of the program by an eligible beneficiary, that services provided to such beneficiary under the program are beneficially affecting the progression of chronic disease or diseases in the beneficiary, as measured under clause (ii) with respect to 2 or more of the following measures:CommentsClose CommentsPermalink





‘(I) Measures described in subclauses (I) through (V) of section 1861(eee)(4)(A)(ii).CommentsClose CommentsPermalink





‘(II) High density lipoprotein.CommentsClose CommentsPermalink





‘(III) Hemoglobin A1C.CommentsClose CommentsPermalink





‘(IV) C-reactive protein.CommentsClose CommentsPermalink





‘(V) Waist size.CommentsClose CommentsPermalink





‘(VI) Elimination of cotinine level as evidence that the eligible beneficiary no longer uses tobacco.CommentsClose CommentsPermalink





‘(VII) Prostate specific antigen or other prognostic biomarkers of prostate cancer.CommentsClose CommentsPermalink





‘(VIII) Prognostic biomarkers of breast cancer.CommentsClose CommentsPermalink





‘(ii) MEASUREMENT- The Secretary shall determine the beneficial progression of chronic disease or diseases under clause (i), using the level of 2 or more of the measures described in subclause (i) before receiving services under such program and such levels after completion of treatment under the program--CommentsClose CommentsPermalink





‘(I) by normalization (as defined by the Secretary); andCommentsClose CommentsPermalink





‘(II) in the case of--CommentsClose CommentsPermalink

‘(aa) measures described in subclauses (I) through (V), (VII), and (VIII), by at least 10 percent reduction; orCommentsClose CommentsPermalink

‘(bb) the measure described in subclause (VI), by elimination.CommentsClose CommentsPermalink

‘(iii) REFUND OF PAYMENTS OR COSTS IN CERTAIN CIRCUMSTANCES- In the case of an eligible beneficiary who, within 1 year of receiving an initial consultation under the program, receives any other treatment covered under part A or this part for any condition that relates to the initial diagnosis resulting in eligibility for the intensive lifestyle treatment program, except for a physician office visit for the purpose of making adjustments to medication prescribed to the eligible beneficiary, such program shall refund to the Secretary the lesser of--CommentsClose CommentsPermalink





‘(I) any payments made under paragraph (B) for services provided to the eligible beneficiary under the program; orCommentsClose CommentsPermalink





‘(II) the cost of such other treatment covered under part A or this part such condition.CommentsClose CommentsPermalink





‘(D) COVERAGE OF SESSIONS-CommentsClose CommentsPermalink





‘(i) IN GENERAL- Items and services provided under the program in a series of 72 one-hour sessions (as defined in clause (ii)), up to 6 sessions per day, over a period of 18 weeks shall, subject to the limitation under subparagraph (C), be eligible for the aggregate payment established under subparagraph (A).CommentsClose CommentsPermalink





‘(ii) DEFINITION OF SESSION- Each of the services described in subparagraphs (A) through (J) of section 1861(hhh)(3), when furnished for 1 hour, is a separate session under an intensive lifestyle treatment program.’.CommentsClose CommentsPermalink





(b) Copayments for Intensive Lifestyle Treatment Items and Services- Section 1833(a)(1) of the Social Security Act (42 U.S.C. 1395l(a)(1)) is amended--CommentsClose CommentsPermalink





(1) by striking ‘and’ before (W);CommentsClose CommentsPermalink





(2) by inserting before the semicolon at the end the following: ‘, and (X) with respect to items and services furnished under an intensive lifestyle treatment program (as defined in section 1861(hhh)(2)), the amount paid shall be 100 percent of the lesser of the actual charge for the services or the amount determined under section 1848(b)(6)(A)’.CommentsClose CommentsPermalink





(c) Lifestyle Rewards Program- Title XVIII of the Social Security Act is amended by adding at the end the following new section:CommentsClose CommentsPermalink

‘SEC. 1899. LIFESTYLE REWARDS PROGRAMS.

‘(a) Establishment- The Secretary shall establish a Lifestyle Rewards Program (in this section referred to as the ‘program’) for eligible beneficiaries (as defined in section 1861(s)(2)(hhh)(4)) who have successfully completed an intensive lifestyle treatment program (as defined in section 1861(hhh)(2)) and meet the requirements described in subsection (b).CommentsClose CommentsPermalink





‘(b) Requirements- In order to receive an award under the program, an eligible beneficiary must--CommentsClose CommentsPermalink





‘(1) demonstrate that the program has beneficially affected the progression of chronic disease or diseases in the beneficiary upon completion of the program, as measured under clause (ii) of section 1848(b)(6)(C) with respect to 2 or more of the measures described in clause (i) of such section; andCommentsClose CommentsPermalink





‘(2) during the 1 year period beginning on the date of an initial consultation under the lifestyle treatment program, receive no other treatment under part A or this part for any condition that relates to the initial diagnosis resulting in eligibility for the intensive lifestyle treatment program, except for a physician office visit for the purpose of making adjustments to medication prescribed to the eligible beneficiary.CommentsClose CommentsPermalink





‘(c) Form of Reward- The Secretary shall make such award to eligible beneficiaries described in subsection (a) in such form and manner as the Secretary, by regulation, shall prescribe.CommentsClose CommentsPermalink





‘(d) Amount of Reward- The amount of such award for each such eligible beneficiary shall be $200.’.CommentsClose CommentsPermalink





(d) Effective Date- The amendments made by this section shall apply to items and services furnished on or after January 1, 2010.CommentsClose CommentsPermalink

SEC. 3. SENSE OF THE CONGRESS.

It is the sense of the Congress that the services provided under a intensive lifestyle treatment program (as defined in section 1861(hhh)(2) of the Social Security Act, as added by section 2(a))--CommentsClose CommentsPermalink





(1) would benefit individuals with chronic diseases who are not enrolled in the Medicare Program under title XVIII of the Social Security Act; andCommentsClose CommentsPermalink





(2) should be covered by all public and private payers.CommentsClose CommentsPermalink