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Education and Labor [2]
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Jennifer Klein's Files
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F:\HSA\EDLABOR\SUB\MILLER.004
H.L.C.
AMENDMENT To COMMITTEE PRINT (H.R. 3600)
OFFERED BY MR. MILLER OF CALIFORNIA
Page 30, strike lines 16 through 19 and insert the
following:
1 (which are subject to section 1115), except-
2
(1) medical detoxification as required for the
3
management of medical conditions associated with
4
withdrawal from alcohol or drugs (which is not cov-
5
ered under such section); and
6
(2) treatment of a substance abuse disorder
7
that is necessary in order to ensure continuity of
8
care for an individual receiving hospital services
9
other than such treatment, where the individual was
10
receiving substance abuse treatment covered under
11
section 1115 prior to receiving such other hospital
12
services.
Page 41, strike line 25 and insert "(c)), including
case management.".
Page 42, line 1, strike "nonresidential" and insert
"community services for".
Page 42, strike line 3 and insert "(d)), including
case management.".
May 10, 1994
F:\HSA\EDLABOR\SUB\MILLER.004
H.L.C.
2
Page 42, line 11, strike "NONRESIDENTIAL, and in-
sert "INTENSIVE COMMUNITY SERVICES,".
Page 42, line 14, strike "nonresidential" and insert
"community services for".
Page 42, line 17, strike "management" and insert
"management, screening and assessment, crisis serv-
ices,".
Page 42, line 22, strike "disorder;" and insert "dis-
order or, in the case of an individual 5 years of age or
less than 5 years of age, is at risk for such a mental dis-
order;
Page 43, strike lines 8 through 19 and insert the
following:
1
(2) CASE MANAGEMENT.-An eligible individual
2
who is receiving an item or service described in this
3
section that does not consist of case management is
4
eligible to receive coverage for case management in
5
addition to coverage for such item or service.
Page 44, line 8, strike "nonresidential" and insert
"community services for".
Beginning on page 44, strike line 19 through page
45, line 2, and insert the following:
May 10, 1994
F:\HSAVEDLABOR\SUB\MILLER.004
H.L.C.
3
1
(A) an inpatient of a hospital or a psy-
2
chiatric hospital; or
3
(B) a resident of a residential treatment
4
center, residential detoxification center, crisis
5
residential program, mental illness residential
6
treatment program, therapeutic family home,
7
group treatment home, community residential
8
treatment program, or recovery center for sub-
9
stance abuse.
Beginning on page 45, strike line 21 through page
46, line 5 (and redesignate provisions accordingly).
Beginning on page 46, strike line 15 through page
47, line 5 (and redesignate provisions accordingly).
Page 47, after line 18, insert the following:
10
(E) ANNUAL AND LIFETIME LIMIT ON
11
HOSPITAL TREATMENT.-Prior to January 1,
12
2001, such treatment, when furnished to an in-
13
patient of a hospital that is not a psychiatric
14
hospital, is subject to an aggregate annual limit
15
of 90 days. Such treatment, when furnished to
16
an inpatient of a psychiatric hospital, is subject
17
to an aggregate annual limit of 45 days and an
18
aggregate lifetime limit of 190 days per individ-
19
ual.
May 10, 1994
F:\HSA\EDLABOR\SUB\MILLER.004
H.L.C.
4
1
(F) ANNUAL LIMIT ON RESIDENTIAL
2
TREATMENT.-Prior to January 1, 2001, such
3
treatment, when furnished in a setting other
4
than a hospital or psychiatric hospital, is sub-
5
ject to an aggregate annual limit of 135 days.
6
The number of covered days of inpatient mental
7
illness and substance abuse treatment that are
8
available to an individual under the annual and
9
lifetime limits described in subparagraph (E)
10
shall be reduced by 1 day for each 3 covered
11
days of residential mental illness and substance
12
abuse treatment that are provided to the indi-
13
vidual.
Page 47, line 19, strike "NONRESIDENTIAL TREAT-
MENT.-" and insert "COMMUNITY SERVICES.-".
Page 47, line 21, strike "nonresidential" and insert
"community services for".
Page 48, line 14, strike "nonresidential" and insert
"community services for".
Page 48, strike lines 16 through 22 (and redesignate
provisions accordingly).
Beginning on page 49, strike line 16 through page
50, line 14, and insert the following:
May 10, 1994
F:/HSAVEDLABOR\SUB\MILLER.004
H.L.C.
5
1
(B) ANNUAL LIMIT.-Prior to January 1,
2
2001, such treatment is subject to an aggregate
3
annual limit of 90 days, except with respect to
4
individuals less than 22 years of age such an-
5
nual limit shall be 180 days.
Page 50, line 16, strike "nonresidential" and insert
"community services for".
Page 50, line 22, strike "nonresidential" and insert
"community services for".
Page 51, strike lines 5 through 8 and insert "this
subtitle.".
Beginning on page 52, strike line 8 through page
54, line 23 (and redesignate provisions accordingly).
Page 55, after line 12, insert the following (and re-
designate provisions accordingly):
6
(f) UTILIZATION REVIEW REQUIREMENT.-
7
(1) IN GENERAL.-The mental illness and sub-
8
stance abuse services that are described in this sec-
9
tion are not covered for an individual, after each ap-
10
plicable set of visits or set of treatment days de-
11
scribed in paragraph (2) has been provided to the
12
individual, unless the health plan in which the indi-
13
vidual is enrolled determines, based on a utilization
May 10, 1994
F:\HSA\EDLABOR\SUB\MILLER.004
H.L.C.
6
1
review, that such services continue to be medically
2
necessary or appropriate.
3
(2) SETS OF VISITS AND TREATMENT DAYS.-
4
(A) SETS OF VISITS.-The sets of visits re-
5
ferred to in paragraph (1) are-
6
(i) 1 initial set of 10 consecutive regu-
7
larly-scheduled outpatient psychotherapy
8
visits provided to an individual during a
9
period that does not exceed 12 months;
10
and
11
(ii) each subsequent set of 15 con-
12
secutive regularly-scheduled outpatient
13
psychotherapy visits provided to the indi-
14
vidual that immediately follows the initial
15
set of visits described in clause (i) or an-
16
other set of visits described in this clause.
17
(B) SETS OF TREATMENT DAYS.-The sets
18
of treatment days referred to in paragraph (1)
19
are-
20
(i) 1 initial set of 10 consecutive days
21
of inpatient and residential mental illness
22
and substance abuse treatment; and
23
(ii) each subsequent set of 15 con-
24
secutive days of inpatient and residential
25
mental illness and substance abuse treat-
May 10, 1994
F:\HSAVEDLABOR\SUB\MILLER.004
H.L.C.
7
1
ment provided to the individual that imme-
2
diately follows the initial set of treatment
3
days described in clause (i) or another set
4
of treatment days described in this clause.
5
(3) MODIFICATION OF NUMERICAL SETS BY
6
BOARD.-The National Health Board may by regu-
7
lation modify the number of visits or days that con-
8
stitute a set referred to in paragraph (1).
9
(4) MODIFICATION OF NUMERICAL SETS BY
10
STATES.-With respect to mental illness and sub-
11
stance abuse services that are provided in a State,
12
the State may modify the number of visits or days
13
that constitute a set referred to in paragraph (1), if
14
the modification decreases such number below the
15
number specified in paragraph (2) or specified by
16
the Board under paragraph (3).
Page 86, strike the items relating to intensive
nonresidential mental illness and substance abuse treat-
ment, outpatient mental illness and substance abuse
treatment, and outpatient psychotherapy and insert the
following:
Intensive community services
for mental illness and sub-
stance abuse treatment
1115 No copayment
20 percent of applicable
payment rate
May 10, 1994
F:\HSAVEDLABOR\SUB\MILLER.004
H.L.C.
8
Outpatient mental illness
and substance abuse treat-
ment (except psycho-
therapy for individuals at
least 22 years of age, col-
lateral services, and case
management)
1115
$10 per visit
20 percent of applicable
payment rate
Outpatient psychotherapy
for individuals at least 22
years of age and collateral
services
1115
$25 per visit
50 percent of applicable
until January
payment rate until
1, 2001, and
January 1, 2001, and
$10 per visit
20 percent thereafter
thereafter
Page 97, after line 22, insert the following (and re-
designate provisions accordingly):
1
(7) CONTINUITY OF CARE FOR MENTAL AND
2
SUBSTANCE ABUSE DISORDERS.-Ensuring con-
3
tinuity of care for individuals who require mental ill-
4
ness and substance abuse services described in sec-
5
tion 1115, but are not covered for such services be-
6
cause of annual or lifetime limits described in such
7
section, by contracting with providers who provide
8
mental illness and substance abuse services de-
9
scribed in such section, unless suitable agreements
10
with such providers cannot be reached.
Page 224, beginning on line 11, strike "Each car-
rier" through line 17 and insert the following:
11
(1) IN GENERAL.-Each carrier providing a
12
health plan with an integrated health network (as
May 10, 1994
F:\HSAVEDLABOR\SUB\MILLER.004
H.L.C.
9
1
defined in section 1902(25)) shall enter into such
2
agreements with health care providers or have such
3
other arrangements as may be necessary to assure
4
the provision of all services covered by the com-
5
prehensive benefit package to eligible individuals en-
6
rolled with the plan through such a network.
7
(2) SPECIAL REQUIREMENTS FOR MENTAL ILL-
8
NESS AND SUBSTANCE ABUSE SERVICES.-Each car-
9
rier providing a health plan with an integrated
10
health network shall enter into such agreements with
11
health care providers or have such other arrange-
12
ments as may be necessary-
13
(A) to demonstrate specifically that the
14
carrier has the ability to provide, through such
15
network, to individuals who have severe mental
16
illness, serious emotional disturbance, or a sub-
17
stance abuse disorder, medically necessary or
18
appropriate-
19
(i) inpatient and residential mental ill-
20
ness and substance abuse treatment (de-
21
scribed in section 1115(c)) with respect to
22
a diagnosable substance abuse disorder in
23
a setting that is not a hospital or psy-
24
chiatric hospital;
May 10, 1994
F:\HSAVEDLABOR\SUB\MILLER.004
H.L.C.
10
1
(ii) intensive community services for
2
mental illness and substance abuse treat-
3
ment (described in section 1115(d)); and
4
(iii) outpatient mental illness and sub-
5
stance abuse treatment consisting of case
6
management (described in section
7
1115(e)(1)(H);
8
(B) to ensure that the items and services
9
described in subparagraph (A) are provided to
10
all individuals enrolled under the plan by pro-
11
viders who have a demonstrated ability to iden-
12
tify individuals who require such treatment and
13
to deliver such treatment within a reasonable
14
distance from the residence of an individual;
15
(C) to ensure continuity of care for individ-
16
uals who require mental illness and substance
17
abuse services described in section 1115, but
18
are not covered for such services because of an-
19
nual or lifetime limits described in such section,
20
by developing appropriate plans and linkages
21
with public agencies that may provide such
22
services; and
23
(D) to ensure that the carrier has estab-
24
lished, or is establishing, linkages with existing
25
mental illness and substance abuse service de-
May 10, 1994
F:\HSAVEDLABOR\SUB\MILLER.004
H.L.C.
11
1
livery programs in the plan service area for
2
services that are required under section 1115(g)
3
to be provided through an organized system of
4
care.
5
(3) SPECIAL REQUIREMENT TO CONTRACT WITH
6
STATE-DESIGNATED PROVIDERS.-In the case of a
7
carrier with respect to which a State has made a
8
finding that the carrier has not satisfied the require-
9
ment in subparagraph (A) or (B) of paragraph (2),
10
the carrier, if directed by the State, shall contract
11
with providers designated by the State as having
12
demonstrated experience in providing the services
13
described in paragraph (2)(A).
May 10, 1994
F:\HSAVEDLABOR\SUB\MILLER.002
H.L.C.
AMENDMENT To COMMITTEE PRINT (H.R. 3600)
OFFERED By MR. MILLER OF CALIFORNIA
Beginning on page 55, strike "The" on line 16
through page 56, line 10, and insert the following (and
redesignate provisions accordingly):
1
A health plan sponsor shall ensure that mental ill-
2
ness and substance abuse services described in this
3
section are furnished through an organized system
4
of care, as described in paragraph (2), if-
5
(A) the services are provided to an individ-
6
ual less than 22 years of age;
7
(B) the individual has a serious emotional
8
disturbance or a substance abuse disorder; and
9
(C) the individual is, or is at imminent risk
10
of being, subject to the authority of, or in need
11
of the services of-
12
(i) a public agency that serves the
13
needs of children, such as an agency in-
14
volved with child welfare or special edu-
15
cation;
16
(ii) the juvenile justice system; or
17
(iii) the criminal justice system.
18
(2) REQUIREMENTS FOR SYSTEM OF CARE.-In
19
this subsection, an "organized system of care" is a
May 10, 1994
F:\HSAVEDLABOR\SUB\MILLER.002
H.L.C.
2
1
community-based service delivery network, which
shall
2
may consist of public and private providers, that
A
3
meets the following requirements:
Page 56, beginning on line 11, after "participation"
insert "and coordination".
Page 56, beginning on line 13, strike "area (includ-
ing" and insert "area, including".
Page 56, line 15, after "justice" insert "criminal
justice".
Page 56, line 17, strike "treatment)." and insert
"treatment.".
Page 56, line 25, strike "through" and insert "by".
Page 56, line 25, strike "or" and insert "and".
Page 57, line 1, strike "teams that" and insert
"teams, which".
Page 57, line 6, strike "children" and insert "indi-
viduals".
Page 57, line 7, after "age" insert "who have a seri-
ous emotional disturbance or a substance abuse dis-
order".
May 10, 1994
EDLABOR SUB\ MILLER.003
AMENDMENT TO COMMITTEE PRINT (H.R. 3600)
OFFERED BY MR. MILLER OF CALIFORNIA
Page 564, strike lines 1 through 24 (and conform
line 8 on page 560 and the table of contents accordingly).
Page 565, strike line 1 and all that follows through
page 567, line 23, and insert the following part (and con-
form the table of contents accordingly):
1 PART 3 - -ASSISTANCE FOR STATE MANAGED MEN-
2
TAL HEALTH AND SUBSTANCE ABUSE PRO-
3
GRAMS
4 SEC. 3531. AVAILABILITY OF ASSISTANCE.
5
(a) IN GENERAL.-The Secretary may make grants
6 to States for the development and operation of comprehen-
7 sive managed mental health and substance abuse pro-
8 grams that are integrated with the delivery of items and
9 services covered under the comprehensive benefits pack-
10 age. Such programs shall-
11
(1) promote the development of integrated de-
12
livery systems for the management of the mental
13
health and substance abuse services provided under
14
the comprehensive benefit package;
15
(2) give priority initially to providing services to
16
low-income adults with serious mental illness or sub-
17
stance abuse disorders and children with serious
May 9, 1994 (3:29 p.m.)
F:\HSAVEDLABOR\SUB\MILLER.003
2
1
emotional disturbance or substance abuse disorders
2
and provide for the phase-in of such services for all
3
eligible persons within 5 years;
4
(3) ensure that individuals participating in the
5
program have access to all medically necessary men-
6
tal health and substance abuse services;
7
(4) promote the linkage of mental health and
8
substance abuse services with primary and preven-
9
tive health care services; and
10
(5) meet such other requirements as the Sec-
11
retary may impose.
12
(b) EXCEPTION.-Nothing in this part shall be con-
13 strued as preventing States that have separate administra-
14 tive entities for mental health and for substance abuse
15 services from establishing separate comprehensive man-
16 aged care programs for such services and receiving assist-
17 ance under this part for either or both programs.
18 SEC. 3532. REQUIREMENTS FOR A PLAN.
19
In order to receive a grant under this part, a State
20 must have a plan for a comprehensive managed mental
21 health and substance abuse program, which is approved
22 by the Secretary. Such plan shall-
23
(1) describe the management, access, and refer-
24
ral structure that the State will use to promote and
25
achieve integration of mental health and substance
May 9, 1994 (3:29 p.m.)
F:\HSAVEDLABOR\SUB\MILLER.003
3
1
abuse services with the delivery of items and services
2
covered under the comprehensive benefits package
3
for eligible individuals in the State;
4
(2) describe how the State will ensure that pro-
5
viders of specialized services will meet appropriate
6
standards and provide assurances that the State has
7
complied with section 1201(a)(7) as it affects mental
8
health and substance abuse services;
9
(3) describe payment, utilization review, and
10
other mechanisms that the State will use to encour-
11
age appropriate service delivery and management of
12
costs;
13
(4) describe uniform patient placement criteria
14
that the State will use to ensure placement in appro-
15
priate substance abuse treatment;
16
(5) describe the process the State will use to
17
ensure that individuals will continue to have access
18
to treatment through referrals from nonhealth public
19
entities, such as the juvenile or criminal justice sys-
20
tems, or social service systems;
21
(6) specify the methods the State will use to en-
22
sure that individuals receiving services under the
23
program have access to all medically necessary and
24
appropriate mental health and substance abuse serv-
25
ices;
May 9, 1994 (3:29 p.m.)
:\HSA\EDLABOR\SUB\MILLER.003
4
1
(7) define terms that will be used by the State
2
in determining the eligibility of individuals for serv-
3
ices under the program;
4
(8) describe how health plans will use services
5
under the comprehensive managed mental health
6
and substance abuse programs established under
7
this part;
8
(9) describe the sources of funding, including
9
the medicaid program and the block grants author-
10
ized by title XIX of the Public Health Service Act,
11
that will be used by the State, other than the grant
12
received under this part, to operate the program,
13
and provide the status of any request for a medicaid
14
waiver relating to the delivery of mental health and
15
substance abuse services submitted by the State to
16
the Secretary;
17
(10) describe how the State provided for broad-
18
based public input in the development of the plan,
19
and the mechanism that will be used for ongoing
20
public comment on and review of amendments to the
21
plan; and
22
(11) describe grievance procedures that will be
23
available for individuals dissatisfied with their health
24
plan's participation in the comprehensive managed
25
mental health and substance abuse program, and
May 9, 1994 (3:29 p.m.)
F:\HSAVEDLABOR\SUB\MILLER.003
5
1
mechanisms that will be available to review the per-
2
formance of health plans and fee-for-service arrange-
3
ments to ensure against undertreatment.
4 SEC. 3533. MAINTENANCE OF EFFORT.
5
States receiving assistance under this part shall
6 maintain expenditures of non-Federal funds, including
7 State medicaid expenditures and State substance abuse
8 treatment expenditures required by title XIX of the Public
9 Health Services Act, for all covered services for covered
10 persons provided under the comprehensive managed men-
11 tal health and substance abuse program at the level of
12 such expenditures for the fiscal year preceding the first
13 fiscal year for which the State receives such a grant. Such
14 level must be adjusted annually for inflation in accordance
15 with the general health care inflation factor (as defined
16 in section 6001(a)(3)), but may be reduced in proportion
17 to reductions in the State population.
18 SEC. 3534. ADDITIONAL FEDERAL RESPONSIBILITIES.
19
The Secretary shall, upon the submission of a State's
20 plan--
21
(1) ensure the timely consideration of any re-
22
quest for a medicaid waiver relating to the delivery
23
of mental health and substance abuse services sub-
24
mitted by the State to the Secretary,
May 9, 1994 (3:29 p.m.)
F:VHSAVEDLABOR\SUB\MILLER.003
6
1
(2) affirm that the State has met the respon-
2
sibilities required under section 1201(a)(7), and
3
(3) affirm that carriers providing health plans
4
in the State meet the requirements of paragraphs
5
(2) and (3) of section 1407(a).
6 SEC. 3535. AUTHORIZATION OF APPROPRIATIONS.
7
There are authorized to be appropriated for grants
8 under this part $100,000,000 for each of the fiscal years
9 1996 through 2000.
May 9, 1994 (3:29 p.m.)
Amendment To Committee Print (H.R. 3600)
Offered By Mr. Green of Texas
Page 10, line 13, before the period insert "or
making payment on the individual's own behalf (or
on behalf of a relative or other individual) for such
services directly to a health care provider that is
legally authorized to provide the services, subject to
the balance billing requirements of this Act".
MAY-13-1994 09:39 FROM ACTUARIAL RESEARCH
TO
2024562878 P.01
Actuarial Research Corporation
6928 Little River Turnpike, Suite E
Annandale, Virginia 22003
(703) 941-7400
FAX (703) 941-3951
Date: 5/13/94
Please Deliver Immediately
To:
Jennifer Klein
From:
Gardon Trapnell
Re:
Memo:
Revised estemate 7 Miller Dental
2.20% premission
17.6 Billion over 5 years
)
( Around $ $7.3 bellions in 1994 dollars for EN Plans)
We are transmitting
pages (including this transmittal sheet).
MAY-12-1994 15:09 FROM ACTUARIAL RESEARCH
TO
12022255350
P.02
a:\dental.wq1
05/12/94
rgm
MILLER DENTAL AMENDMENT
NO ANNUAL LIMIT
Aggregates
HCFA
GRT
CBO
Contract
GRT
CBO
Counts
Increment
Premium
%
Type
Increment
Premium
(Millions)
(Millions)
(Millions)
Increase
Assumes
Single
$65.84
$2,100
41.9
$2,758.70
$87,990
3.14%
Couple
18
132.82
4,200
17.5
2,324.35
73,500
3.16%
One Adult
83.56
4,095
6.9
576.56
28,256
2.04%
Two Adults
151.78
5,560
25.8
3,915.92
143,448
2.73%
Total
/
adolt
92.1
$9,575.53
$333,194
2.87%
2 adults
1.9
2 kids
ANNUAL LIMIT
10% of people
Aggregates
HCFA
GRT
CBO
Contract
GRT
CBO
Counts
Increment
Premium
%
Type
Increment
Premium
(Millions)
(Millions)
(Millions)
Increase
Single
$59.85
$2,100
41.9
$2,507.91
$87,990
2.85%
Couple
120.75
4,200
17.5
2,113.05
73,500
2.87%
One Adult
75.96
4,095
6.9
524.15
28,256
1.86%
Two Adults
137.98
5,560
25.8
3,559.93
143,448
2.48%
Total
92.1
$8,705.03
$333,194
2.61%
Cost Estimates Relate to 1994
1994 cost
issity emented
Adult
66.41
Increase increase
Child
9.03
TOTAL P.02
Station High Cost Sharing
DENTAL SERVICES
Clief Dental Officer- PHS
Large Employers
Marge
High CIB Plan
(ADULT)
pop 158,732,000
Line
Per
%
Unit
Per
%
Unit
Per
*
Preq
Part
Cost
Capits
Cor
C8M
Freq
Cost
Capital
Car
CSM
Freq
Part
Cost
Capita
Cov
CSW
Copay
Ded
Colo
Bane
12022255350 P.02
A. Presention and Diagnosis
$42.08
30.00
$44.40
$0.00
660.41
$68.41
$88.41
TOTAL P.02
Assessments
626.27
$0.00
$21.68
$0.00
$41.45
$41.45
WE
Clinical oral examinations
1021
70%
$20.00
$14.32
0%
00.00
0.528
$16.27
$6.64
OK
$0.00
1.812
70%
$20.00
$22.00
100%
$82.00
$0
1.00
1.00
$22.00
Rediographs
0.258
TO%
$17.01
$11.94
0%
40.00
0.580
$20.41
$12.04
0%
$0.00
1.512
70%
817.81
$18.84
100%
$16.04
$0
1.00
1 00
$18.84
2. Dental securits
10
1.00
1.00
$0.00
3. Fluoride
$2.39
$0.00
$0.00
$0.00
$3.77
$3.77
$3.77
Professionally applied
0.182
70%
$17.80
$2.38
0%
$000
6
$0.00
0.302
70%
$17.91
$3.77
100%
$3.77
00
1.00
1.00
$3.77
Supplements
0%
$0.00
0%
$0.00
0%
$0.00
00
1.00
1.00
$0.00
4. Clarrial prophylars
0.481
70%
$14.02
$13.43
0%
10.00
0.587
$38.76
$22.75
0%
$0.00
0.000
70%
$44.52
$21.20
100%
821.20
$0
1.00
1.00
$21.20
a TREATMENT
$90.62
$7.07
$245.04
$1.28
$208.27
1501
$2.45
TO
1. Energencias
$3.62
$0.02
$0.83
$0.83
$3.92
$3.92
$1.60
Emergency EXPIRE
0150
100%
$24.71
$4.01
100%
$4.01
100%
$0.00
0.105
100%
$26.71
1280
100%
$2.00
$0
0.51
0.00
$1.18
Sedable tilling
0.020
100%
$95.62
$0.71
100%
$0.71
100%
$0.00
0.014
100%
$30.82
40.50
100%
$0.50
$0
0.51
0.80
1020
Pallative
0.015
100%
$38.96
$0.59
100%
$0.50
0.018
$35.50
$063
100%
$0.63
0.011
100%
638.98
10.41
100%
$0.41
$0
0.51
0.80
$0.17
Traumalic recurds
0.005
100%
$61.22
$0.31
100%
$0.31
100%
$0.00
0.003
100%
$61.22
4021
100%
$0.21
$0
0.81
0.80
$010
2 Routine Filings
1256
70%
$41.20
$45.01
0%
10.00
0911
$58.14
$53.88
0%
$0.00
0.937
70%
$57.00
$53.17
0%
$0.00
10
034
0.80
$0.00
a Proalhodostics
$1.50
$1.58
$152.52
$0.63
$107.15
$1.09
$0.83
I
Dentures
$
$0.00
0.031
$647.53
$20 20
6
$0.00
0.031
70%
$847.53
$1410
0%
$0.00
to
1.00
0.80
$0.00
ACTUARIAL RESEARCH
Crowns
0%
$0.00
0.183
$474.72
687.67
6
$0.00
0.184
10%
$474.72
$61.13
0%
$0.00
80
1.00
0.80
$0.00
Bridge walk
0%
$0.00
0.075
$541.11
$40.39
O%
$0.00
0.074
70%
$541.11
$20 19
0%
$0.00
10
100
0.80
$0.00
Integral
0%
$0.00
0.004
$438.11
$1.58
0%
$0.00
0.004
70%
$438.11
$1.10
0%
$0.00
to
1.00
080
$0.00
Feesthebe for genetal defects
0.002
70%
$1 393.51
$1.56
100%
$1.56
0.003
$193.25
$0.83
100%
$0.63
0.001
70%
$1,363.51
$1.09
500%
$1.00
10
0.94
0.80
$0.85
General anoxthesia
0%
$0.00
0.018
$125.70
$2.05
(6)
$0.00
0.018
70%
$12570
$1.43
2
$0.00
R
1.00
080
$0.00
4. Periodentics
$24.09
$0.00
$16.00
$0.00
$27.94
$0.00
$0.00
Pericdortic surgery
0%
$0.00
0 044
$280.97
$11.49
0%
$0.00
0.044
70%
$260.97
$0.02
0%
$0.00
$0
1.00
0.00
$0.00
Periodontel maintenance
0.517
70%
$87.89
82459
0%
$0.00
0017
$70.96
$1.23
0%
$0.00
0361
FO%
$67.09
$17.45
0%
$0.00
DI
0.51
0.00
$0.00
Other perfodantal
0%
$0.00
0011
$07.44
$1.95
%
$0.00
0.040
TO%
$97.44
$2.78
0%
$0.00
$0
1.00
0.00
$0.00
5 Eedodontic services Ireal canall
0.388
70%
$51.80
$13.65
0%
$0.00
0 061
$377.97
123.13
0%
$0.00
0.061
70%
$377.87
$16.14
0%
$0.00
$0
0.91
0.00
$0.00
FROM
c. ORTHODOHTICS
$0.00
$0.00
$27.50
$0.00
$27.58
$0.00
$0.00
Spece maintenance (ages 8.40
0%
$0.00
0%
$0.00
0.000
0%
$0.00
$0.00
0%
$0.00
$0
1.00
0.60
$0.00
Severe Nateoclusion lages 6 141
0%
$0.00
0%
$0.00
0.000
0%
$0.00
$0.00
O%
50.00
a
1.00
0.00
$0.00
Other orthodonium
0%
$0.00
$27.58
0%
$0 00
$27.58
O%
$0.00
a
1.00
040
40.00
D. CIRCUL SURGERY BY DENTISTS
$6.19
$0.86
$12.60
$7.06
$0.93
$0.98
$0.07
MAY-12-1994 15:12
1. Extractions
0.100
100%
$02.31
$023
0%
$0.00
0.121
$46.25
$5.59
0%
20 00
0.013
100%
$5231
$0.70
O%
1000
to
0.38
0.00
$0.00
2. Surgice* extractions
0.010
100%
$85.77
$0.98
100%
$0.80
0.000
$141.77
$7.06
100%
$7.04
0.001
100%
$95.72
$0.13
100%
$0.56
30
0.85
0.80
$0.07
TOTAL
$136.90
$1.53
$331.50
$6.32
$903.10
$72.38
$68.93
Section A Scaler:
1,576
Section 8 Scaler:
0.695
Section D Scaler:
0.134
MAY-12-1994 13:14 FROM ACTUARIAL RESEARCH
TO
12022255350
P.02
For Official Use Only
Estimated Cost of Oral Health Benefits Package .. Total U.S Population
Description of Proposed Oral Health Benefits for Children, Adolescents, & Adults (Under the age of 65)
freek
Participation
ESTIMATED
PROJECTED
rate
TARGET
the
an
SERVICE
UTILIZATION
TOTAL
PER CAPITA
SERVICE
POPULATION
FREQ/YR
MODIFIER
RATE
COST/UNIT
ANNUAL COST
COST($)/YR
(1995)
ORAL HEALTH ASSESSMENT
ORAL EXAMINATION (INI./PER.)
220,875,947
1
100%
70%
$18
$2,841,789,939
$12.87
DENTAL RADIOGRAPHS (2 BW)
214,277,530
1
100%
70%
$16
$2,399,908,338
$11.20
DENTAL SEALANTS
DENTAL SEALANTS (6-17 Y/O)
37,954,200
0.17
8.00
50%
$19
$490,368,264
$12.92
PROFESSIONAL APPLIED TOPICAL FLUORIDE
CHILD TF/HIGH RISK (2-18 Y/O)
64,143,947
2
(45%
85%
$16
$785,121,916
$12.24
CHILD TF/NON-FL COMM (2-18 Y/O
64,143,947
2
(55%
25%
$16
$282,233,368
$4.40
ADULT TF/HIGH RISK (19-64 Y/O)
150,133,583
2
10%
70%
$16
$336,299,225
$2.24
ORAL PROPHYLAXIS
ORAL PROPHY (CHILD 2-14 Y/O)
47,678,263
1
60%
70%
$29
$580,721,245
$12.18
ORAL PROPHY (ADULT 15-64 Y/O)
164,765,583
1
45%
70%
$40
$2,076,046,343
$12.60
FLUORIDE SUPPLEMENTS
DENTAL EMERGENCY
EMERGENCY EXAM
226,374,000
1
15%
100%
$24
$814,946,400
$3.60
SEDATIVE FILLING
220,875,947
1
2%
100%
$32
$141,360,606
$0.64
EMERGENCY TX OF PAIN
226,374,000
1
1.5%
100%
$35.
$118,846,350
$0.53
EXTRACTION (SINGLE)
220,875,947
1
10%
100%
$47
$1,038,116,953
$4.70
EXTRACTION (SURGICAL)
219,043,263
1
1%
100%
$86
$188,377,206
$0.86
TRAUMATIC WOUND TX
226,374,000
1
0.5%
100%
$55
$62,252,850
$0.28
ROUTINE RESTORATIVE SERVICES
PRIMARY REST. (CHILD 3-10 Y/O)
29,446,000
1
1.1
70%
$45
$1,020,303,900
$34.65
PERM. REST. (CHILD 6-18 Y/O)
48,121,000
1
0.4
70%
$46
$625,188,032
$12.99
CORONAL REST. (ADULT 19-64 Y/O)
150,133,583
1
1.3
70%
$46
$6,339,240,400
$42.22
ROOT REST. (ADULT 19-64 Y/O)
150,133,583
1
0.4
70%
$46
$1,950,535,508
$12.99
PERIODIC MAINTENANCE CARE (S&RP)
CHILD (15-18 Y/O)
14,632,000
1
10.0%
70%
$61
$62,478,640
$4.27
ADULT (19-64 Y/O)
150,133,583
1
54.0%
70%
$61
$3,461,780,152
$23.06
INTERCEPTIVE ORTHODONTICS (6-11 Y/O)
SPACE MAINTENANCE (3-10 Y/O)
29,446,000
0.125
39.0%
70%
$166
$166,804,229
$5.66
CHILD (6-11 Y/O)
22,326,000
0.17
14.2%
70%
$3,130
$1,180,838,661
$52.89
ENDOONTIC SERVICES
CHILD/ADOLESCENT (6-18 Y/O)
48,121,000
1
0.0256
70%
$400
$344,931,328
$7.17
MEDICALLY NECESSARY CARE (Specific Conditions)
DENTAL PROSTHETIC SERVICES
1,250,000
0.2
---
70%
$1,252
$219,100,000
$175.28
DOC:ORBP1A.WK1
LJF
(15APR93)
Estimated Total Cost
$27,527,589,854
Annual per capita cost/Targ. Pop
$121.60
Monthly per capita cost/Targ. Po
$10.13
Annual per capita cost/U.S. Pop.
$105.82
Monthly per capita cost/U.S. Pop
$8.82
Preliminary Staff Working Paper - For Illustrative Purposes Only
TOTAL P.02
703 941 3951
Estimated Cost of Oral Health Benefits Package -- Total U.S Population
Description of Proposed Oral Health Benefits for Adults (18 to 64 years of age)
(Estimate Utilization Rate of 60 percent / 1994 adjusted dental fees)
ESTIMATED
PROJECTED
TARGET
SERVICE
UTILIZATION
TOTAL
PER CAPITA
SERVICE
POPULATION
FREQ/YR
MODIFIER
RATE
COST/UNIT
ANNUAL COST
COST($)/YR
(1995)
ORAL HEALTH ASSESSMENT
ORAL EXAMINATION (INI./PER.)
160,402,000
1
100%
60%
$20.03
$1,927,711,236
$8.52
DENTAL RADIOGRAPHS
153,649,076
1
100%
60%
$17.81
$1,641,894,024*
$7.25
PROFESSIONAL APPLIED TOPICAL FLUORIDE
ADULT TF/HIGH RISK (18-64 Y/O)
153,649,076
2
10%
60%
$17.81
$328,378,805
$1.45
ORAL PROPHYLAXIS
ORAL PROPHY (ADULT 18-64 Y/O)
153,649,076
1
45%
60%
$44.52
$1,846,923,351
$8.16
DENTAL EMERGENCY
already
EMERGENCY EXAM
160,402,000
1
15%
100%
$26.71
$642,650,613
$2.84
SEDATIVE FILLING
153,649,076
1
2%
100%
$35.62
$109,459,602
$0.48
EMERGENCY TX OF PAIN
160,402,000
1
1.5%
100%
$38.96
$93,738,929
$0.41
HSA
EXTRACTION (SINGLE)
153,649,076
1
10%
100%
$52.31
$803,738,316
$3.55
EXTRACTION (SURGICAL)
153,649,076
1
1%
100%
$95.72
$147,072,895
$0.65
TRAUMATIC WOUND TX
160,402,000
1
0.5%
100%
$61.22
$49,099,052
$0.22
ROUTINE RESTORATIVE SERVICES
CORONAL REST. (ADULT 18-64 Y/O)
153,649,076
1
1.3
60%
$51.20
$6,136,129,491
$27.11
ROOT REST.
(ADULT 18-64 Y/O)
153,649,076
1
0.4
60%
$51.20
$1,888,039,843
$8.34
PERIO MAINTENANCE CARE (S&RP)
ADULT (18-64 Y/O)
153,649,076
1
54.0%
60%
$67.89
$3,379,720,385
$14.93
MEDICALLY NECESSARY CARE (Specific Conditions)
DENTAL PROSTHETIC SERVICES
933,000
0.125
...
60%
$1,393.51
$97,510,862
$0.43
DOC:OHC18-64.WK1
LJF
(10NOV93)
Revised cost est. using ARC info.
OHC-Requested
Estimated Total Cost
$19,092,067,404
Annual per capita cost/Targ. Pop
$84.34
Monthly per capita cost/Targ. Po
$7.03
Annual per capita cost/U.S. Pop.
$73.39
Monthly per capita cost/U.S. Pop
$6.12
limited to 1 set of
Bite-wings per 2yr. or
1 Full mouth sires
per Syr.
therefore costs is reduced
by 50 percent:
05/24/94 17:17
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->
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NO. 600 P002
F:\HSA\EDLABOR\SUB\WILLIA.003
H.L.C.
AMENDMENT To COMMITTEE PRINT (H.R. 3600)
OFFERED BY MR. WILLIAMS
Page 39, after line 18, insert the following:
1
(D) Annual fecal-occult blood tests for the
2
purpose of early detection of colon cancer.
3
(E) Flexible sigmoidoscopies for the pur-
4
pose of early detection of colon cancer every 3
5
years.
Page 40, after line 15, insert the following:
6
(D) Annual fecal-occult blood tests for the
7
purpose of early detection of colon cancer.
8
(E) Flexible sigmoidoscopies for the pur-
9
pose of early detection of colon cancer every 3
10
years.
May 20, 1994
DRAFT 5/12/94
MENTAL ILLNESS AND SUBSTANCE ABUSE BENEFITS COMPARISON
Service
Clinton Health Security Act
Stark - Ways and Means
Inpatient
Before January 1, 2001, 30 days
90 days general
hospital
plus an additional 30 days under
hospitals.
certain circumstances.¹
45 days psychiatric
and
hospitals with a 190
Cost sharing:
day lifetime limit on
Residential
Lower - no copayment
psychiatric hospitals.
Services
Higher - one day deductible, 20%
coinsurance (expenses apply to o-
Up to 135 days per
o-p max)
year intensive
residential services²,
inpatient psychiatric
benefits reduced by one
day of inpatient care
for every three days of
residential. (The
provision regarding the
trade off needs
clarification as to
which of the annual
inpatient limits is
traded.) Secretary
directed to develop
standards for the
appropriate management
of these services.
Cost sharing:
Hospitals no
coinsurance.
General plan deductible
of $500 individual/$750
per family applies.
Cost sharing for
residential not clearly
specified.
'Includes general and psychiatric hospital, residential
treatment centers, residential detoxification centers, crisis
residential programs, mental health residential treatment
programs, therapeutic family or group treatment homes, community
residential treatment or recovery centers for substance abuse.
²Includes residential detoxification centers, crisis
residential programs or mental illness residential treatment
programs, therapeutic family or group treatment homes, community
residential treatment centers, and recovery centers for substance
abuse.
Service
Clinton Health Security Act
Stark - Ways and Means
Intensive
Before January 1, 2001, two to
Partial hospitalization
Non-
one substitute with inpatient
covered for individuals
Residential
treatment plus maximum of 60
who would otherwise
Treatment
additional days at plan
require inpatient
discretion (partial
psychiatric care.
hospitalization, day treatment,
psychiatric rehabilitation, home-
Covers 90 days per year
based services, ambulatory
of additional intensive
detoxification, behavioral aide
community services
services).
(psychiatric
rehabilitation, day
Cost sharing:
treatment services for
Lower - no copayment, except $25
children, behavioral
per visit for additional 60 days.
aide services, in-home
Higher - one day deductible, 20%
services, case
coinsurance, except 50%
management services,
coinsurance for additional 60
and ambulatory
days.
detoxification
Before 1/1/2001, expenses do not
services
apply to o-o-p if for substance
abuse, or for additional 60 days.
Cost sharing:
20% coinsurance
Service
Clinton Health Security Act
Stark - Ways and Means
Outpatient
Annual limit on some services
Based on Medicare
mental
before January 1, 2001
No limits
illness and
Psychotherapy
substance
-30 visits for psychotherapy
Cost sharing:
abuse
and collateral services.
20% coinsurance for
services
-four to one substitution at
medication management
discretion of plan.
brief office visits,
Substance abuse counseling and
and initial diagnosis,
relapse prevention
20% coinsurance for
-four to one substitution at
outpatient
discretion of plan.
psychotherapy services
-30 group therapy visits if
for children through
received inpatient/residential or
age 18.
intensive non-residential
50% coinsurance for
treatment within 12 months.
other treatment
-outpatient detoxification
services.
covered only in context of
treatment program.
Services without specified limit
-screening and assessment,
diagnosis, medical management,
crisis services, somatic
treatments, case management.
Cost sharing:
Lower - $10 copayment, except
$25 for psychotherapy and
collateral services (before
1/1/2001) and no copayment for
case management.
Higher - 20%, except 50% for
psychotherapy and collateral
services (before 1/2001) and none
for case management.
Before 1/1/2001 expenses do not
apply to o-o-p max.
X
miller amendment uses 22
Clinton Health Security
Stark - Ways and Means
Service
Act
Other mental health
By October 1, 1998
States given broad
provisions
States required to
flexibility to
submit plans for
establish comprehensive
integration.
managed mental health
programs for low-income
adults and children
with serious mental
illness or emotional
disturbance. Programs
allow individuals to
receive benefit package
without limits and , at
state option, with
reduced copayments.
Federal coverment
establish standards for
program eligibility.
State submit plan
including additional
Federal, State, and
local funds to be used
to finance the program.
NO.246 P002
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4
002/020
F:\HSAVEDLABOR\SUB\MILLER.004
H.L.C.
AMENDMENT To COMMITTEE PRINT (H.R. 3600)
OFFERED BY MR. MILLER OF CALIFORNIA
Page 30, strike lines 16 through 19 and insert the
following:
1 (which are subject to section 1115), except-
2
(1) medical detoxification as required for the
3
management of medical conditions associated with
4
withdrawal from alcohol or drugs (which is not COV-
5
ered under such section); and
6
(2) treatment of a substance abuse disorder
7
that is necessary in order to ensure continuity of
8
care for an individual receiving hospital services
9
other than such treatment, where the individual was
10
receiving substance abuse treatment covered under
11
section 1115 prior to receiving such other hospital
12
services.
Page 41, strike line 25 and insert "(c)), including
case management.".
Page 42, line 1, strike "nonresidential" and insert
"community services for".
Page 42, strike line 3 and insert "(d)), including
case management.".
May 10, 1994
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4
003/020
F:\HSAVEDLABOR\SUB\MILLER.004
H.L.C.
2
Page 42, line 11, strike "NONRESIDENTLAL, and in-
sert "INTENSIVE COMMUNITY SERVICES,".
Page 42, line 14, strike "nonresidential" and insert
"community services for".
Page 42, line 17, strike "management" and insert
"management, screening and assessment, crisis serv-
ices,".
Page 42, line 22, strike "disorder;" and insert "dis-
order or, in the case of an individual 5 years of age or
less than 5 years of age, is at risk for such a mental dis-
order;
Page 43, strike lines 8 through 19 and insert the
following:
1
(2) CASE MANAGEMENT.-An eligible individual
2
who is receiving an item or service described in this
3
section that does not consist of case management is
4
eligible to receive coverage for case management in
5
addition to coverage for such item or service.
Page 44, line 8, strike "nonresidential" and insert
"community services for".
Beginning on page 44, strike line 19 through page
45, line 2, and insert the following:
May 10, 1994
NO. 246 P004
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4
004/020
F:\HSAVEDLABOR\SUB\MILLER004
H.L.C.
3
1
(A) an inpatient of a hospital or a psy-
2
chiatric hospital; or
3
(B) a resident of a residential treatment
4
center, residential detoxification center, crisis
5
residential program, mental illness residential
6
treatment program, therapeutic family home,
7
group treatment home, community residential
8
treatment program, or recovery center for sub-
9
stance abuse.
Beginning on page 45, strike line 21 through page
46, line 5 (and redesignate provisions accordingly).
Beginning on page 46, strike line 15 through page
47, line 5 (and redesignate provisions accordingly).
Page 47, after line 18, insert the following:
10
(E) ANNUAL AND LIFETIME LIMIT ON
11
HOSPITAL TREATMENT.-Prior to January 1,
12
2001, such treatment, when furnished to an in-
13
patient of a hospital that is not a psychiatric
14
hospital, is subject to an aggregate annual limit
15
of 90 days. Such treatment, when furnished to
16
an inpatient of a psychiatric hospital, is subject
17
to an aggregate annual limit of 45 days and an
18
aggregate lifetime limit of 190 days per individ-
19
ual.
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1
(F) ANNUAL LIMIT ON RESIDENTIAL
2
TREATMENT.-Prior to January 1, 2001, such
3
treatment, when furnished in a setting other
4
than a hospital or psychiatric hospital, is sub-
5
ject to an aggregate annual limit of 135 days.
6
The number of covered days of inpatient mental
7
illness and substance abuse treatment that are
8
available to an individual under the annual and
9
lifetime limits described in subparagraph (E)
10
shall be reduced by 1 day for each 3 covered
11
days of residential mental illness and substance
12
abuse treatment that are provided to the indi-
13
vidual.
Page 47, line 19, strike "NONRESIDENTIAL TREAT-
MENT.-" and insert "COMMUNITY SERVICES.-".
Page 47, line 21, strike "nonresidential" and insert
"community services for".
Page 48, line 14, strike "nonresidential" and insert
"community services for".
Page 48, strike lines 16 through 22 (and redesignate
provisions accordingly).
Beginning on page 49, strike line 16 through page
50, line 14, and insert the following:
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5
1
(B) ANNUAL LIMIT.-Prior to January 1,
2
2001, such treatment is subject to an aggregate
3
annual limit of 90 days, except with respect to
4
individuals less than 22 years of age such an-
5
nual limit shall be 180 days.
Page 50, line 16, strike "nonresidential" and insert
"community services for".
Page 50, line 22, strike "nonresidential" and insert
"community services for".
Page 51, strike lines 5 through 8 and insert "this
subtitle.".
Beginning on page 52, strike line 8 through page
54, line 23 (and redesignate provisions accordingly).
Page 55, after line 12, insert the following (and re-
designate provisions accordingly):
6
(f) UTILIZATION REVIEW REQUIREMENT.-
7
(1) IN GENERAL-The mental illness and sub-
8
stance abuse services that are described in this sec-
9
tion are not covered for an individual, after each ap-
10
plicable set of visits or set of treatment days de-
11
scribed in paragraph (2) has been provided to the
12
individual, unless the health plan in which the indi-
13
vidual is enrolled determines, based on a utilization
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6
1
review, that such services continue to be medically
2
necessary or appropriate.
3
(2) SETS OF VISITS AND TREATMENT DAYS.-
4
(A) SETS OF VISITS.-The sets of visits re-
5
ferred to in paragraph (1) are-
6
(i) 1 initial set of 10 consecutive regu-
7
larly-scheduled outpatient psychotherapy
8
visits provided to an individual during a
9
period that does not exceed 12 months;
10
and
11
(ii) each subsequent set of 15 con-
12
secutive regularly-scheduled outpatient
13
psychotherapy visits provided to the índi-
14
vidual that immediately follows the initial
15
set of visits described in clause (i) or an-
16
other set of visits described in this clause.
17
(B) SETS OF TREATMENT DAYS.-The sets
18
of treatment days referred to in paragraph (1)
19
are-
20
(i) 1 initial set of 10 consecutive days
21
of inpatient and residential mental illness
22
and substance abuse treatment; and
23
(ii) each subsequent set of 15 con-
24
secutive days of inpatient and residential
25
mental illness and substance abuse treat-
May 10. 1994
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7
1
ment provided to the individual that imme-
2
diately follows the initial set of treatment
3
days described in clause (i) or another set
4
of treatment days described in this clause.
5
(3) MODIFICATION OF NUMERICAL SETS BY
6
BOARD.-The National Health Board may by regu-
7
lation modify the number of visits or days that con-
8
stitute a set referred to in paragraph (1).
9
(4) MODIFICATION OF NUMERICAL SETS BY
10
STATES.-With respect to mental illness and sub-
11
stance abuse services that are provided in a State,
12
the State may modify the number of visits or days
13
that constitute a set referred to in paragraph (1), if
14
the modification decreases such number below the
15
number specified in paragraph (2) or specified by
16
the Board under paragraph (3).
Page 86, strike the items relating to intensive
nonresidential mental illness and substance abuse treat-
ment, outpatient mental illness and substance abuse
treatment, and outpatient psychotherapy and insert the
following:
Intensive community services
for mental illness and sub-
stance abuse treatment
1115 No copayment
20 percent of applicable
payment rate
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Outpatient mental illness
and substance abose treat-
ment (except psycho-
therapy for individuals at
least 22 years of age, col-
lateral services, and case
management)
1115 $10 per visit
20 percent of applicable
payment rate
Outpatient psychotherapy
for individuals at least 22
years of age and collateral
services
1115 $25 per visit
50 percent of applicable
until January
payment rate until
1, 2001, and
January 1, 2001, and
$10 per visit
20 percent thereafter
thereafter
Page 97, after line 22, insert the following (and re-
designate provisions accordingly):
1
(7) CONTINUITY OF CARE FOR MENTAL AND
2
SUBSTANCE ABUSE DISORDERS-Ensuring con-
3
tinuity of care for individuals who require mental ill-
4
ness and substance abuse services described in sec-
5
tion 1115, but are not covered for such services be-
6
cause of annual or lifetime limits described in such
7
section, by contracting with providers who provide
8
mental illness and substance abuse services de-
9
scribed in such section, unless suitable agreements
10
with such providers cannot be reached.
Page 224, beginning on line 11, strike "Each car-
rier" through line 17 and insert the following:
11
(1) IN GENERAL-Each carrier providing a
12
health plan with an integrated health network (as
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9
1
defined in section 1902(25)) shall enter into such
2
agreements with health care providers or have such
3
other arrangements as may be necessary to assure
4
the provision of all services covered by the com-
5
prehensive benefit package to eligible individuals en-
6
rolled with the plan through such a network.
7
(2) SPECIAL REQUIREMENTS FOR MENTAL ILL-
8
NESS AND SUBSTANCE ABUSE SERVICES.-Each car-
9
rier providing a health plan with an integrated
10
health network shall enter into such agreements with
11
health care providers or have such other arrange-
12
ments as may be necessary-
13
(A) to demonstrate specifically that the
14
carrier has the ability to provide, through such
15
network, to individuals who have severe mental
16
illness, serious emotional disturbance, or a sub-
17
stance abuse disorder, medically necessary or
18
appropriate-
19
(i) inpatient and residential mental ill-
20
ness and substance abuse treatment (de-
21
scribed in section 1115(c)) with respect to
22
a diagnosable substance abuse disorder in
23
a setting that is not a hospital or psy-
24
chiatric hospital;
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1
(ii) intensive community services for
2
mental illness and substance abuse treat-
3
ment (described in section 1115(d)); and
4
(iii) outpatient mental illness and sub-
5
stance abuse treatment consisting of case
6
management (described in section
7
1115(e)(1)(H);
8
(B) to ensure that the items and services
9
described in subparagraph (A) are provided to
10
all individuals enrolled under the plan by pro-
11
viders who have a demonstrated ability to iden-
12
tify individuals who require such treatment and
13
to deliver such treatment within a reasonable
14
distance from the residence of an individual;
15
(C) to ensure continuity of care for individ-
16
uals who require mental illness and substance
17
abuse services described in section 1115, but
18
are not covered for such services because of an-
19
nual or lifetime limits described in such section,
20
by developing appropriate plans and linkages
21
with public agencies that may provide such
22
services; and
23
(D) to ensure that the carrier has estab-
24
lished, or is establishing, linkages with existing
25
mental illness and substance abuse service de-
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1
livery programs in the plan service area for
2
services that are required under section 1115(g)
3
to be provided through an organized system of
4
care.
5
(3) SPECIAL REQUIREMENT TO CONTRACT WITH
6
STATE-DESIGNATED PROVIDERS.-In the case of a
7
carrier with respect to which a State has made a
8
finding that the carrier has not satisfied the require-
9
ment in subparagraph (A) or (B) of paragraph (2),
10
the carrier, if directed by the State, shall contract
11
with providers designated by the State as having
12
demonstrated experience in providing the services
13
described in paragraph (2)(A).
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H.L.C.
AMENDMENT To COMMITTEE PRINT (H.R. 3600)
OFFERED BY MR. MILLER OF CALIFORNIA
Beginning on page 55, strike "The" on line 16
through page 56, line 10, and insert the following (and
redesignate provisions accordingly):
1
A health plan sponsor shall ensure that mental ill-
2
ness and substance abuse services described in this
3
section are furnished through an organized system
4
of care, as described in paragraph (2), if-
5
(A) the services are provided to an individ-
6
ual less than 22 years of age;
7
(B) the individual has a serious emotional
8
disturbance or a substance abuse disorder; and
9
(C) the individual is, or is at imminent risk
10
of being, subject to the authority of, or in need
11
of the services of-
12
(i) a public agency that serves the
13
needs of children, such as an agency in-
14
volved with child welfare or special edu-
15
cation;
16
(ii) the juvenile justice system; or
17
(iii) the criminal justice system.
18
(2) REQUIREMENTS FOR SYSTEM OF CARE.-In
19
this subsection, an "organized system of care" is a
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1
community-based service delivery network, which
2
may consist of public and private providers, that
3
meets the following requirements:
Page 56, beginning on line 11, after "participation"
insert "and coordination".
Page 56, beginning on line 13, strike "area (includ-
ing" and insert "area, including".
Page 56, line 15, after "justice" insert "criminal
justice".
Page 56, line 17, strike "treatment)." and insert
"treatment.".
Page 56, line 25, strike "through" and insert "by".
Page 56, line 25, strike "or" and insert "and".
Page 57, line 1, strike "teams that" and insert
"teams, which".
Page 57, line 6, strike "children" and insert "indi-
viduals".
Page 57, line 7, after "age" insert "who have a seri-
ous emotional disturbance or a substance abuse dis-
order".
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AMENDMENT TO COMMITTEE PRINT (H.R. 3600)
OFFERED BY MR. MILLER OF CALIFORNIA
Page 564, strike lines 1 through 24 (and conform
line 8 on page 560 and the table of contents accordingly).
Page 565, strike line 1 and all that follows through
page 567, line 23, and insert the following part (and con-
form the table of contents accordingly):
1 PART 3-ASSISTANCE FOR STATE MANAGED MEN-
2
TAL HEALTH AND SUBSTANCE ABUSE PRO-
3
GRAMS
4 SEC. 3531. AVAILABILITY OF ASSISTANCE.
5
(a) IN GENERAL.-The Secretary may make grants
6 to States for the development and operation of comprehen-
7 sive managed mental health and substance abuse pro-
8 grams that are integrated with the delivery of items and
9 services covered under the comprehensive benefits pack-
10 age. Such programs shall-
11
(1) promote the development of integrated de-
12
livery systems for the management of the mental
13
health and substance abuse services provided under
14
the comprehensive benefit package;
15
(2) give priority initially to providing services to
16
low-income adults with serious mental illness or sub-
17
stance abuse disorders and children with serious
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2
1
emotional disturbance or substance abuse disorders
2
and provide for the phase-in of such services for all
3
eligible persons within 5 years;
4
(3) ensure that individuals participating in the
5
program have access to all medically necessary men-
6
tal health and substance abuse services;
7
(4) promote the linkage of mental health and
8
substance abuse services with primary and preven-
9
tive health care services; and
10
(5) meet such other requirements as the Sec-
11
retary may impose.
12
(b) EXCEPTION.-Nothing in this part shall be con-
13 strued as preventing States that have separate administra-
14 tive entities for mental health and for substance abuse
15 services from establishing separate comprehensive man-
16 aged care programs for such services and receiving assist-
17 ance under this part for either or both programs.
18 SEC. 3532. REQUIREMENTS FOR A PLAN.
19
In order to receive a grant under this part, a State
20 must have a plan for a comprehensive managed mental
21 health and substance abuse program, which is approved
22 by the Secretary. Such plan shall-
23
(1) describe the management, access, and refer-
24
ral structure that the State will use to promote and
25
achieve integration of mental health and substance
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3
1
abuse services with the delivery of items and services
2
covered under the comprehensive benefits package
3
for eligible individuals in the State;
4
(2) describe how the State will ensure that pro-
5
viders of specialized services will meet appropriate
6
standards and provide assurances that the State has
7
complied with section 1201(a)(7) as it affects mental
8
health and substance abuse services;
9
(3) describe payment, utilization review, and
10
other mechanisms that the State will use to encour-
11
age appropriate service delivery and management of
12
costs;
13
(4) describe uniform patient placement criteria
14
that the State will use to ensure placement in appro-
15
priate substance abuse treatment;
16
(5) describe the process the State will use to
17
ensure that individuals will continue to have access
18
to treatment through referrals from nonhealth public
19
entities, such as the juvenile or criminal justice sys-
20
tems, or social service systems;
21
(6) specify the methods the State will use to en-
22
sure that individuals receiving services under the
23
program have access to all medically necessary and
24
appropriate mental health and substance abuse serv-
25
ices;
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4
1
(7) define terms that will be used by the State
2
in determining the eligibility of individuals for serv-
3
ices under the program;
4
(8) describe how health plans will use services
5
under the comprehensive managed mental health
6
and substance abuse programs established under
7
this part;
8
(9) describe the sources of funding, including
9
the medicaid program and the block grants author-
10
ized by title XIX of the Public Health Service Act,
11
that will be used by the State, other than the grant
12
received under this part, to operate the program,
13
and provide the status of any request for a medicaid
14
waiver relating to the delivery of mental health and
15
substance abuse services submitted by the State to
16
the Secretary;
17
(10) describe how the State provided for broad-
18
based public input in the development of the plan,
19
and the mechanism that will be used for ongoing
20
public comment on and review of amendments to the
21
plan; and
22
(11) describe grievance procedures that will be
23
available for individuals dissatisfied with their health
24
plan's participation in the comprehensive managed
25
mental health and substance abuse program, and
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5
1
mechanisms that will be available to review the per
2
formance of health plans and fee-for-service arrange-
3
ments to ensure against undertreatment.
4 SEC. 3533. MAINTENANCE OF EFFORT.
5
States receiving assistance under this part shall
6 maintain expenditures of non-Federal funds, including
7 State medicaid expenditures and State substance abuse
8 treatment expenditures required by title XIX of the Public
9 Health Services Act, for all covered services for covered
10 persons provided under the comprehensive managed men-
11 tal health and substance abuse program at the level of
12 such expenditures for the fiscal year preceding the first
13 fiscal year for which the State receives such a grant. Such
14 level must be adjusted annually for inflation in accordance
15 with the general health care inflation factor (as defined
16 in section 6001(a)(3)), but may be reduced in proportion
17 to reductions in the State population.
18 SEC. 3534. ADDITIONAL FEDERAL RESPONSIBILITIES.
19
The Secretary shall, upon the submission of a State's
20 plan-
21
(1) ensure the timely consideration of any re-
22
quest for a medicaid waiver relating to the delivery
23
of mental health and substance abuse services sub-
24
mitted by the State to the Secretary,
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6
1
(2) affirm that the State has met the respon-
2
sibilities required under section 1201(a)(7), and
3
(3) affirm that carriers providing health plans
4
in the State meet the requirements of paragraphs
5
(2) and (3) of section 1407(a).
6 SEC. 3535. AUTHORIZATION OF APPROPRIATIONS
Health
7
There are authorized to be appropriated Bener
face grants
THE
8 under this part $100,000,000 for each of the fiscal years
9 1996 through 2000.
10} store UOURSE <<<
date.
-
Ex
May 9, 1994 (3:29 p.m.)
05/11/94 18:01 LMR 94017321
NO. 245 P001
COMMITTEE ON EDUCATION AND LABOR
Subcommittee on Labor-Management Relations
U.S. House of Representatives
320 Cannon House Office Building
Washington, DC 20515
phone: (202) 225-5768
fax: (202) 225-3614
FACSIMILE TRANSMISSION SHEET
DATE:
5/11
TO:
SHARMAN
FROM: Jon Weintraub
Fred Feinstein
Phyllis Borzi
Rick Jerue
Gail Brown
Susie Ringel Allison Hogue
Tony Guiles
8
NUMBER OF PAGES TO FOLLOW:
MESSAGE: Here's the rest of William's
mental health pager
- let me know if you
need any thing else -
Susie
40
41
I
(1) IMMUNIZATIONS.-The immunizations spec-
1
(4) Targeted health advice and counseling, in-
2
ified in this subsection are as follows:
NO.245 P002
2
cluding nutrition counseling.
3
(A) Booster immunizations against tetanus
3
(5) The administration of age-appropriate im-
4
and diphtheria every 10 years.
4
munizations and tests specified in subsections (b)
5
(B) Age-appropriate immunizations for the
5
through (b).
6
following illnesses:
6
(k) IMMUNIZATIONS AND TESTS NOT ADMINISTERED
7
(i) Influenza.
7 DURING CLINICIAN VISIT-Notwithstanding subsection
8
(ii) Pneumococcal invasive disease.
8 (j)(5), the clinical preventive services described in this sec-
9
(2) TESTS.-The tests specified in this sub-
9 tion include an immunization or test described in this sec-
10
section are as follows:
10 tion that is administered to an individual consistent with
11
(A) Annual Papanicolaou smears, pelvic
11 any periodicity schedule for the immunization or test dur-
12
exams, and clinical breast examinations for fe-
12 ing the age range specified for the immunization or test,
13
males.
13 and any administration fee for such immunization or test,
14
(B) Annual mammograms for females.
14 even if the immunization or test is not administered dur-
15
(C) Cholesterol every 5 years.
15 ing a clinician visit.
16
(3) CLINICIAN VISITS.-The clinician visits
16 SEC. 1115. MENTAL ILLNESS AND SUBSTANCE ABUSE SERV.
17
specified in this subsection are 1 clinician visit every
17
ICES.
18
year.
05/11/94 18:01 LMR 94017321
18
(a) COVERAGE.-The mental illness and substance
19
(j) CLINICIAN VISIT.-For purposes of this section,
19 abuse services that are described in this section are the
20 the term "clinician visit" includes the following health pro-
20 following items and services for eligible individuals, as de-
21 fessional services (as defined in section 1112(c)):
21 fined in section 1001(c), who satisfy the eligibility require-
22
(1) A complete medical history.
22 ments in subsection (b):
23
(2) An appropriate physical examination.
23
(1) Inpatient and residential mental illness and
24
(3) Risk assessment.
24
substance abuse treatment (described in subsection
25
(c)).
Tue 1. submite
42
43
1
(2) Intensive nonresidential mental illness and
I
For purposes of this paragraph, an individual who
NO.245 P003
2
substance abuse treatment (described in subsection
2
has a diagnosable mental disorder or a diagnosable
3
(d)).
3
substance abuse disorder, is receiving treatment for
4
(3) Outpatient mental illness and substance
4
such disorder, but does not satisfy the functional im-
5
abuse treatment (described in subsection (e)), in-
5
pairment criterion in subparagraph (B) shall he
6
cluding case management, screening and assessment,
6
treated as satisfying such criterion if the individual
7
crisis services, and collateral services.
7
would satisfy such criterion without such treatment.
8
(b) ELIGIBILITY.-The eligibility requirements re-
8
(2) CASE MANAGEMENT.-An eligible individual
9 ferred to in subsection (a) are as follows:
9
is eligible to receive coverage for case management
10
(1)
INPATIENT,
RESIDENTIAL,
10
if-
11
NONRESIDENTIAL, AND OUTPATIENT TREATMENT.-
11
(A) a health professional designated by the
12
An eligible individual is eligible to receive coverage
12
health plan in which the individual is enrolled
13
for inpatient and residential mental illness and sub-
13
determines that the individual should receive
14
stance abuse treatment, intensive nonresidential
14
such services; and
15
mental illness and substance abuse treatment, or
15
(B) the individual is eligible to receive cov-
16
outpatient mental illness and substance abuse treat-
16
erage for, and is receiving, outpatient mental
94817321 +
17
ment (except case management and collateral serv-
17
illness and substance abuse treatment with re-
18
ices) if the individual-
18
spect to a diagnosable mental disorder or a
19
(A) has, or has had during the 1-year pe-
19
diagnosable substance abuse disorder.
05/11/94 18:01 LMR
20
riod preceding the date of such treatment, a
20
(3) SCREENING AND ASSESSMENT AND CRISIS
21
diagnosable mental disorder or a diagnosable
21
SERVICES.-All eligible individuals enrolled under a
22
substance abuse disorder; and
22
health plan are eligible to receive coverage for out-
23
(B) is experiencing, or is at significant risk
23
patient mental illness and substance abuse treat-
24
of experiencing, functional impairment in fam-
24
ment consisting of screening and assessment and
25
ily, work, school, or community activities.
25
crisis services.
Title 1, Bubtitle B
44
45
1
(4) COLLATERAL SERVICES.-An eligible indi-
I
treatment and recovery center for substance
NO.245 P004
2
vidual is eligible to receive coverage for outpatient
2
abuse.
3
mental illness and substance abuse treatment con-
3
The National Health Board shall specify those
4
sisting of collateral services if the individual is a
4
health professional services described in section 1112
5
family member (described in section 1011(b)) of an
5
that shall be treated as inpatient and residential
6
individual who is receiving inpatient and residential
6
mental illness and substance abuse treatment when
7
mental illness and substance abuse treatment, inten-
7
provided to such an inpatient or resident.
8
sive nonresidential mental illness and substance
8
(2) LMITATIONS.-Coverage for inpatient and
9
abuse treatment, or outpatient mental illness and
9
residential mental illness and substance abuse treat-
10
substance abuse treatment.
10
ment is subject to the following limitations:
11
(c) INPATIENT AND RESIDENTIAL TREATMENT.-
11
(A) RESIDENTIAL MENTAL ILLNESS
12
(1) DEFINITION.-For purposes of this subtitle,
12
TREATMENT.-Such treatment, when provided
13
the term "inpatient and residential mental illness
13
with respect to a diagnosable mental disorder in
14
and substance abuse treatment" means the items
14
a setting that is not a hospital or a psychiatric
15
and services described in paragraphs (1) through (3)
15
hospital, is covered only to avert the need for,
16
of section 1861(b) of the Social Security Act when
16
or as an alternative to, treatment in a hospital
17
18:01 LMR 94017321
provided with respect to a diagnosable mental dis-
17
or a psychiatric hospital, as determined by a
18
order or a diagnosable substance abuse disorder to-
18
health professional designated by the health
19
(A) an inpatient of a hospital, psychiatric
19
plan in which the individual receiving such
20
hospital, residential treatment center, residen-
20
treatment is enrolled.
21
tial detoxification center, crisis residential pro-
21
(B) RESIDENTIAL SUBSTANCE ABUSE
22
gram, or mental illness residential treatment
22
TREATMENT.-Such treatment, when provided
05/11/94
23
program; or
23
with respect to a diagnosable substance abuse
24
(B) a resident of a therapeutic family or
24
disorder in a setting that is not a hospital or
25
group treatment home or community residential
25
a psychiatric hospital, is covered only if a
46
I
health professional designated by the health
1
(ii) the medical condition of the indi-
2
plan in which the individual receiving such
2
vidual requires inpatient treatment in a
NO.245 P005
3
treatment is enrolled determines (based on cri-
3
hospital or a psychiatric hospital in order
4
teria that the plau may choose to employ) that
4
to initiate, change, or adjust pharma-
5
the individual should receive such treatment.
5
cological or somatic therapy.
6
(C) LEAST RESTRICTIVE SETTING.-Such
6
(E) INPATIENT HOSPITAL TREATMENT
7
treatment is covered only when-
7
FOR SUBSTANCE ABUSE.-Such treatment,
8
(i) provided to an individual in the
8
when provided in a hospital or a psychiatric
9
least restrictive inpatient or residential set-
9
hospital with respect to a diagnosable substance
10
ting that is effective and appropriate for
10
abuse disorder, is covered under this section
11
the individual; and
11
only for detoxification requiring the manage-
12
(ii) less restrictive intensive
12
ment of psychiatric conditions associated with
13
nonresidential or outpatient treatment
13
withdrawal from alcohol or drugs. The items
14
would be ineffective or inappropriate.
14
and services described in this section do not in-
15
(D) ANNUAL LIMIT.-Prior to January 1,
15
clude medical detoxification as required for the
16
2001, such treatment is subject to an aggregate
16
management of medical conditions associated
17
-> 94017321
annual limit of 30 days. A maximum of 30 ad-
17
with withdrawal from alcohol or drugs (which is
18
ditional days of such treatment shall be covered
18
covered under section 1111).
19
for an individual if a health professional des-
19
(d) INTENSIVE NONRESIDENTIAL TREATMENT.-
20
ignated by the health plan in which the individ-
20
(1) DEFINITION.-For purposes of this subtitle,
05/11/94 18:01 LMR
21
ual is enrolled determines in advance that-
21
the term "intensive nonresidential mental illness and
22
(i) the individual poses a threat to his
22
substance abuse treatment" means diagnostic or
23
or her own life or the life of another indi-
23
therapeutic items or services provided with respect
24
vidual; or
24
to a diagnosable mental disorder or a diagnosable
25
substance abuse disorder to an individual-
THE s, D
48
49
I
(A) participating in a partial hospitaliza-
1
(i) to avert the need for, or as an al-
NO.245 P006
2
tion program, a day treatment program, a psy-
2
ternative to, treatment in residential or in-
3
chiatric rehabilitation program, or an ambula-
3
patient settings;
4
tory detoxification program; or
4
(ii) to facilitate the earlier discharge
5
(B) receiving home-based mental illness
5
of an individual receiving inpatient or resi-
6
services or behavioral aide mental illness serv-
6
dential care;
7
ices.
7
(iii) to restore the functioning of an
8
The National Health Board shall specify those
8
individual with a diagnosable mental dis-
9
health professional services described in section 1112
9
order or a diagnosable substance abuse
10
that shall be treated as intensive nonresidential men-
10
disorder; or
11
tal illness and substance abuse treatment when pro-
11
(iv) to assist such an individual to de-
12
vided to such an individual.
12
velop the skills and gain access to the sup-
13
(2) LIMITATIONS.-Coverage for intensive
13
port services the individual needs to
14
nonresidential mental illness and substance abuse
14
achieve the maximum level of functioning
15
treatment is subject to the following limitations:
15
of the individual within the community.
16
(A) DISCRETION OF PLAN-An individual
16
(C) ANNUAL LIMIT.-
-> 94017321
17
shall receive coverage for such treatment if a
17
(i) IN GENERAL-Prior to January 1,
18
health professional designated by the health
18
2001, the number of covered days of inpa-
19
plan in which the individual is enrolled deter-
19
tient and residential mental illness and
20
mines (based on criteria that the plan may
20
substance abuse treatment that are avail-
05/11/94 18:01 LMR
21
choose to employ) that the individual should re-
21
able to an individual under the 30-day
22
ceive such treatment.
22
limit described in the first sentence of sub-
23
(B) TREATMENT PURPOSES.-Such treat-
23
section (c)(2)(D) shall be reduced by 1 day
24
ment is covered only when provided-
24
for each 2 covered days of intensive
25
nonresidential mental illness and substance
Title I, Subtitle B
Title I. Subtitle B
50
51
1
NO.245 P007
abuse treatment that are provided to the
1
paid by or on behalf of the individual for such
2
individual, until such number is reduced to
2
treatment, may not be applied toward any an-
3
zero.
3
nual out-of-pocket limit on cost sharing under
4
(ii) ADDITIONAL DAYS.-After the
4
any cost sharing schedule described in part 3 of
5
number of covered days referred to in
5
this subtitle if such treatment is provided-
6
clause (i) has been reduced to zero with re-
6
(i) with respect to a diagnosable sub-
7
spect to an individual, the individual shall
7
stance abuse disorder; or
8
receive coverage for a maximum of 60 days
8
(ii) pursuant to subparagraph (C)(ii).
9
of intensive nonresidential mental illness
9
(e) OUTPATIENT TREATMENT.-
10
and substance abuse treatment if a health
10
(1) DEFINITION.-For purposes of this subtitle,
11
professional designated by the health plan
11
the term "outpatient mental illness and substance
12
in which the individual is enrolled deter-
12
abuse treatment" means the following services pro-
13
mines that the individual should receive
13
vided with respect to a diagnosable mental disorder
14
such treatment.
14
or a diagnosable substance abuse disorder in an out-
15
(D)
DETOXIFICATION.-Intensive
15
patient setting:
94817321 r
16
nonresidential mental illness and substance
16
(A) Screening and assessment.
17
abuse treatment consisting of detoxification is
17
(B) Diagnosis.
18
covered only if it is provided in the context of
18
(C) Medical management.
19
a treatment program.
19
(D) Substance abuse counseling and re-
05/11/94 18:02 LMR
20
(E) OUT-OF-POCKET MAXIMUM.-Prior to
20
lapse prevention.
21
January 1, 2001, expenses for intensive
21
(E) Crisis services.
22
nonresidential mental illness and substance
22
(F) Somatic treatment services.
23
abuse treatment that an individual incurs prior
23
(G) Psychotherapy.
24
to satisfying a deductible applicable to such
24
(H) Case management.
25
treatment, and copayments and coinsurance
25
(I) Collateral services.
Title 1. Subtitle B
Title I, Subtitle B
53
52
I
(2) LIMITATIONS.-Coverage for outpatient
health plan in which the individual receiv-
NO.245 P008
1
2
mental illness and substance abuse treatment is sub-
ing treatment is enrolled, to prevent has-
2
3
pitalization or to facilitate earlier hospital
3
ject to the following limitations:
4
release, for which the number of covered
4
(A) HEALTH PROFESSIONAL SERVICES.-
5
Such treatment is covered only when it con-
days of inpatient and residential mental ill-
5
6
ness and substance abuse treatment that
6
stitutes health professional services (as defined
7
are available to an individual under the 30-
7
in section 1112(c)(2)).
8
8
(B) DISCRETION OF PLAN.-An individual
day limit described in the first sentence of
9
9
shall receive coverage for outpatient mental ill-
subsection (c)(2)(D) shall be reduced by 1
10
10
ness and substance abuse treatment consisting
day for each 4 visits. After such number
11
of substance abuse counseling and relapse pre-
has been reduced to zero, no additional vis-
11
12
vention if a health professional designated by
its under the preceding sentence may be
12
13
covered.
13
the health plan in which the individual is en-
14
rolled determines (based on criteria that the
(ii) SUBSTANCE ABUSE COUNSELING
14
15
AND RELAPSE PREVENTION.-
15
plan may choose to employ) that the individual
16
94017321
16
should receive such treatment. This subpara-
(I) IN GENERAL.-Except as pro-
17
17
graph does not apply to group therapy covered
vided in subclause (II), the number of
18
18
pursuant to subparagraph (C)(ii)(II).
covered days of inpatient and residen-
19
tial mental illness and substance
05/11/94 18:02 LMR ->
19
(C) ANNUAL LIMITS.-
20
abuse treatment that are available to
20
(i) PSYCHOTHERAPY AND COLLAT-
21
21
ERAL SERVICES.-Prior to January 1,
an individual under the 30-day limit
22
described in the first sentence of sub-
22
2001, psychotherapy and collateral services
23
23
are subject to an aggregate annual limit of
section (c)(2)(D) shall be reduced by
24
30 visits per individual. Additional visits
1 day for each 4 visits for substance
24
25
may be covered, at the discretion of the
abuse counseling and relapse preven-
25
Title I, Subtitle B
Title 1. Subtitle B
54
55
I
tion that are covered for the individ-
I
ing of detoxification is covered only if it is pro-
NO.245 P009
2
ual under subparagraph (B). After
2
vided in the context of a treatment program.
3
such number has been reduced to
3
(E) OUT-OF-POCKET MAXIMUM.-Prior to
4
zero, no visits for substance abuse
4
January 1, 2001, expenses for outpatient men-
5
counseling and relapse prevention may
5
tal illness and substance abuse treatment that
6
be covered, except as provided in
6
an individual incurs prior to satisfying a de-
7
subclause (II).
7
ductible applicable to such treatment, and
8
(II) GROUP THERAPY.-Prior to
8
copayments and coinsurance paid by or on be-
9
January 1, 2001, substance abuse
9
half of the individual for such treatment, may
10
counseling and relapse prevention con-
10
not be applied toward any annual out-of-pocket
11
sisting of group therapy is subject to
11
limit on cost sharing under any cost sharing
12
a separate aggregate annual limit of
12
schedule described in part 3 of this subtitle.
13
30 visits, if such therapy occurs with-
13
(f) SPECIAL DELIVERY REQUIREMENTS FOR SERV.
14
in 12 months after the individual has
14 ICES PROVIDED TO CHILDREN.-
15
received, with respect to a diagnosable
15
(1) REQUIRING SERVICES TO BE PROVIDED
16
substance abuse disorder, inpatient
16
THROUGH ORGANIZED SYSTEMS OF CARE.-The
17
and residential mental illness and sub-
17
mental illness and substance abuse services de-
05/11/94 18:02 LMR 94017321
18
stance abuse treatment or intensive
18
scribed in this section shall be included in the com-
19
nonresidential mental illness and sub-
19
prehensive benefit package with respect to an eligible
20
stance abuse treatment. The provi-
20
individual under 22 years of age only if such services
21
sions of clause (i) and subclause (I)
21
are provided through an organized system of care
22
do not apply to therapy that is de-
22
described in paragraph (2).
23
scribed in the preceding sentence.
23
(2) REQUIREMENTS FOR SYSTEMS OF CARE.-
24
(D) DETOXIFICATION.-Outpatient mental
24
In this subsection, an "organized system of care" is
25
illness and substance abuse treatment consist-
25
a community-based system established by an appli-
05/11/94 17:22
LMR
94017321
NO.237 P001
COMMITTEE ON EDUCATION AND LABOR
Subcommittee on Labor-Management Relations
U.S. House of Representatives
320 Cannon House Office Building
Washington, DC 20515
phone: (202) 225-5768
fax: (202) 225-3614
FACSIMILE TRANSMISSION SHEET
DATE:
5/11
SHARMAN
TO:
FROM: Jon Weintraub
Fred Feinstein
Phyllis Borzi
Rick Jerue
Gail Brown
Susie Ringel X Allison Hogue
Tony Guiles
NUMBER OF PAGES TO FOLLOW:
7
MESSAGE:
Here are mental health pageson
the 2 programs- I'll fax the benefits
section next
- let me know if you need more,
Title I, Subtitle B
Title 1. Subtitle B
54
55
I
tion that are covered for the individ-
1
ing of detoxification is covered only if it is pro-
2
ual under subparagraph (B). After
2
vided in the context of a treatment program.
3
such number has been reduced to
3
(E) OUT-OF-POCKET MAXIMUM.-Prior to
05/11/94 17:22
4
zero, no visits for substance abuse
4
January 1, 2001, expenses for outpatient men-
5
counseling and relapse prevention may
5
tal illness and substance abuse treatment that
6
be covered, except as provided in
6
an individual incurs prior to satisfying a de-
7
subclause (II).
7
ductible applicable to such treatment, and
8
(II) GROUP THERAPY.-Prior to
8
copayments and coinsurance paid by or on be-
LMR 94017321
9
January 1, 2001, substance abuse
9
half of the individual for such treatment, may
10
counseling and relapse prevention con-
10
not be applied toward any annual out-of-pocket
11
sisting of group therapy is subject to
11
limit on cost sharing under any cost sharing
12
a separate aggregate annual limit of
12
schedule described in part 3 of this subtitle.
13
30 visits, if such therapy occurs with-
13
(f) SPECIAL DELIVERY REQUIREMENTS FOR SERV-
14
in 12 months after the individual has
14 ICES PROVIDED TO CHILDREN.-
15
received, with respect to a diagnosable
15
(1) REQUIRING SERVICES TO BE PROVIDED
16
substance abuse disorder, inpatient
16
THROUGH ORGANIZED SYSTEMS OF CARE.-The
17
and residential mental illness and sub-
17
mental illness and substance abuse services de-
18
stance abuse treatment or intensive
18
scribed in this section shall be included in the com-
19
nonresidential mental illness and sub-
19
prehensive benefit package with respect to an eligible
20
stance abuse treatment. The provi-
20
individual under 22 years of age only if such services
21
sions of clause (i) and subclause (I)
21
are provided through an organized system of care
22
do not apply to therapy that is de-
22
described in paragraph (2).
23
scribed in the preceding sentence.
23
(2) REQUIREMENTS FOR SYSTEMS OF CARE.-
NO.237 P002
24
(D) DETOXIFICATION.-Outpatient mental
24
In this subsection, an "organized system of care" is
25
illness and substance abuse treatment consist-
25
a community-based system established by an appli-
56
57
I
cable health plan for the provision of mental illness
I
multiagency teams that are recognized and fol-
2
and substance abuse services described in this sec-
2
lowed by the applicable agencies and providers
3
tion that meets the following requirements:
3
in the area.
4
(A) The system has established linkages
4
(E) The system ensures the delivery and
5
with existing mental illness and substance
5
coordination of the range of mental illness and
6
abuse service delivery programs in the plan
6
substance abuse services required by children
7
service area (or is in the process of developing
7
under 22 years of age.
8
or operating a system with appropriate public
8
(F) The system provides for the manage-
05/11/94 17:22 LMR 94017321
+
9
agencies in the area to coordinate the delivery
9
ment of the individualized treatment plans de-
10
of such services to individuals in the area).
10
scribed in subparagraph (D) and for a flexible
11
(B) The system provides for the participa-
11
response to changes in treatment needs over
12
tion of multiple agencies and providers that
12
time.
13
serve the needs of children in the area (includ-
13
(g) OTHER DEFINITIONS.-For purposes of this sub-
14
ing agencies and providers involved with child
14 title:
15
welfare, education, juvenile justice, health care,
15
(1) CASE MANAGEMENT.-The term "case man-
16
mental health, and substance abuse prevention
16
agement" means services that assist individuals in
17
and treatment).
17
gaining access to needed medical, social, educational,
18
(C) The system provides for the involve-
18
and other services.
19
ment of the families of children to whom mental
19
(2) DIAGNOSABLE MENTAL DISORDER AND
20
illness and substance abuse services are pro-
20
DIAGNOSABLE SUBSTANCE ABUSE DISORDER.-The
21
vided in the planning of treatment and the de-
21
terms "diagnosable mental disorder" and
22
livery of services.
22
"diagnosable substance abuse disorder" mean a dis-
23
(D) The system provides for the develop-
23
order that-
24
ment and implementation of individualized
24
(A) is listed in the Diagnostic and Statis-
NO.237 NO. P003
25
treatment plans through multidisciplinary or
25
tical Manual of Mental Disorders, Third Edi-
Title I, Subtitle B
Title 1, Bubtitle B
58
59
1
tion, Revised or a revised version of such man-
1
(B) in the case of an item or service pro-
2
ual (except V Codes for Conditions Not Attrib-
2
vided to an individual whose applicable health
3
utable to a Mental Disorder That Are a Focus
05/11/94 17:23
3
plan is specified pursuant to section 1004(b)(2),
4
of Attention or Treatment);
4
a facility operated by the Department of Veter-
5
(B) is the equivalent of a disorder de-
5
ans Affairs that is engaged in providing services
6
scribed in subparagraph (A), but is listed in the
6
to inpatients that are equivalent to the services
7
International Classification of Diseases, 9th Re-
7
provided by a psychiatric hospital; and
8
vision, Clinical Modification, Third Edition or a
LMR 94017321
8
(C) in the case of an item or service pro-
9
revised version of such text; or
9
vided to an individual whose applicable health
10
(C) is listed in any authoritative text speci-
10
plan is specified pursuant to section 1004(b)(3),
11
fying diagnostic criteria for mental disorders or
11
a facility operated by the Indian Health Service
12
substance abuse disorders that is identified by
12
that is engaged in providing services to inpa-
13
the National Health Board.
13
tients that are equivalent to the services pro-
14
(3) PSYCHIATRIC HOSPITAL-The term "psy-
14
vided by a psychiatric hospital.
15
chiatric hospital" has the meaning given such term
15 SEC. 1116. FAMILY PLANNING SERVICES AND SERVICES
16
in section 1861(f) of the Social Security Act, except
16
FOR PREGNANT WOMEN.
17
that such term shall include—
17
The services described in this section are the follow-
18
(A) in the case of an item or service pro-
19
18 ing items and services:
vided to an individual whose applicable health
19
20
(1) Voluntary family planning services.
plan is specified pursuant to section 1004(b)(1),
20
21
(2) Contraceptive devices that-
a facility of the uniformed services under title
21
22
(A) may only be dispensed upon prescrip-
10, United States Code, that is engaged in pro-
22
23
tion; and
viding services to inpatients that are equivalent
NO.237 P004
23
24
(B) are subject to approval by the Sec-
to the services provided by a psychiatric hos-
24
25
retary of Health and Human Services under the
pital;
25
Federal Food, Drug, and Cosmetic Act.
Title III, Subtitle
Title UI, Subtitle F
560
561
1 except to the extent incousistent with the purpose de-
I
(1) Information on the number of individuals
2 scribed in subsection (a), subpart C of part 2 of subtitle
2
served by or through mental illness and substance
3 E applies to such assistance to the same extent and in
3
abuse programs administered by State and local
4 the same manner as such subpart applies to loans and
4
agencies and the proportion who are eligible persons
5 loan guarantees under section 3441.
5
under title I.
6
PART 2-AUTHORITIES REGARDING
6
(2) The following information on services fur-
05/11/94 17:23 LMR 94017321
7
PARTICIPATING STATES
7
nished to eligible persons:
8
Subpart A-Report
8
(A) Each type of benefit furnished.
9 SEC. 3511. REPORT ON INTEGRATION OF MENTAL HEALTH
9
(B) The mental illness diagnoses for which
10
SYSTEMS.
10
each type of benefit is covered, the amount, du-
11
(a) IN GENERAL.-As a condition of being a partici-
11
ration and scope of coverage for each covered
12 pating State under title I, each State shall, not later than
12
benefit, and any applicable limits on benefits.
13 October 1, 1998, submit to the Secretary a report on (in-
13
(C) Cost sharing rules that apply.
14 cluding a plan for) the measures to be implemented by
14
(3) Information on the extent to which each
15 the State to achieve the integration of the mental illness
15
health provider furnishing mental illness and sub-
16 and substance abuse services of the State and its political
16
stance abuse services under a State program partici-
17 subdivisions with the mental illness and substance abuse
17
pates in one or more regional or corporate alliance
18 services that are included in the comprehensive benefit
18
health plans, and, in the case of providers that do
19 package under title I. The plan required in the preceding
19
not so participate, the reasons for the lack of par-
20 sentence shall meet the conditions described in section
20
ticipation.
21 3074(b).
21
(4) The amount of revenues from health plans
22
(b) REQUIRED CONTENTS.-With respect to the pro-
22
received by mental illness and substance abuse pro-
NO.237 P005
23 vision of items and services relating to mental illness and
23
viders that are participating in such health plans
24 substance abuse, the report of a State under subsection
24
and are funded under one or more State programs.
25 (a) shall. at a minimum. coutain the following information:
Title IIL, Subtitle F
Title III, Subtitle F
562
563
1
(5) With respect to the two years preceding the
1
fit package will continue to be furnished to such en-
2
year in which the State becomes a participating
2
rollees.
3
State under title I-
3
(8) A description of the conditions under which
4
(A) the amount of funds expended by the
4
the integration of mental illness and substance abuse
5
State and its political subdivisions for each of
5
providers into regional and corporate alliances can
6
such years for items and services that are in-
6
be achieved, and an identification of changes in par-
7
cluded in the comprehensive benefit package
05/11/94 17:23 LMR -> 94017321
7
ticipation and certification requirements that are
8
under such title;
8
needed to achieve the integration of such. programs
9
(B) the amount of funds expended for
9
and providers into health plans.
10
medically necessary and appropriate items and
10
(9) If the integration of mental illness and sub-
11
services not included in such benefit package,
11
stance abuse programs operated by the State into
12
including medical care, other health care, and
12
one or more health plans is not medically appro-
13
supportive services related to the provision of
13
priate or feasible for one or more groups of individ-
14
health care.
14
nais treated under State programs, a description of
IS
(6) An estimate of the amount that the State
15
the reasons that integration is not feasible or appro-
16
will expend to furnish items and services not in-
16
priate and a plan for assuring the coordination for
17
cluded in such package once the expansion of cov-
17
such individuals of the care and services covered
18
erage for mental illness and substance abuse services
18
under the comprehensive benefit package with the
19
is implemented in the year 2001.
19
additional items and services furnished by such pro-
20
(7) A description of how the State will assure
20
grams.
1
that all individuals served by mental illness and sub-
21
(c) GENERAL PROVISIONS.-Reports under sub-
22
stance abuse programs funded by the State will be
22 section (a) shall be provided at the time and in the manner
23
enrolled in a health plan and how mental illness and
23 prescribed by the Secretary.
NO.237 P006
24
substance abuse services not covered under the bene-
Title III, Subtitle F
564
565
1
1
Subpart B-Pilot Program
PART 3-ASSISTANCE FOR STATE MANAGED
2
2 SEC. 3521. PILOT PROGRAM.
MENTAL HEALTH PROGRAMS
3
(a) IN GENERAL-The Secretary shall establish a
3 SEC. 3531. AVAILABILITY OF ASSISTANCE.
4
4 pilot program to demonstrate model methods of achieving
(a) IN GENERAL-The Secretary may make grants
5 the integration of the mental illness and substance abuse
5 to States for the development and operation of comprehen-
6 services of the States with the mental illness and sub-
6 sive managed mental health programs that meet the re-
05/11/94 17:23 LMR 94017321
+
7 stance abuse services that are included in the comprehen-
7 quirements of section 3532
8
8 sive benefit package under title I.
(b) ELIGIBILITY OF STATE.-In order to receive a
9
(b) CERTAIN CONSIDERATIONS,-Witb respect to the
9 grant under this part, a State shall submit to the Sec-
10 provision of items and services relating to mental illness
10 retary (at such time and in such form as the Secretary
11 and substance abuse, the Secretary, in carrying out sub-
11 may require) an application containing such information
12 section (a), shall consider the following:
12 and assurances as the Secretary may require.
13
(1) The types of items and services needed in
13 SEC. 3532. REQUIREMENTS FOR PROGRAM.
addition to the items and services included in the
14
14
A State comprehensive managed mental health pro-
15
comprehensive benefits package under title I.
15 gram meets the requirements of this section if the
16
(2) The optimal methods of treatment for indi-
16 program-
17
17
viduals with long-term conditions.
(1) promotes the development of integrated de-
18
(3) The capacity of alliance health plans to fur-
18
livery systems for the management of the mental
19
19
nish such treatment.
health services provided under the comprehensive
(4) The modifications that should be made in
20
20
benefit package;
the items and services furnished by such health
21
21
(2) gives priority in providing assistance on be-
22
22
plans.
half of low-income individuals who are adults with
NO.237 P007
23
(5) The role of publicly-funded health providers
23
serious mental illness or children with severe emo-
24
24
in the integration of acute and long-term treatment.
tional disturbance (in accordance with standards of
25
the Secretary promulgated under section 3533)
Title III, Subtitle F
Title III, Subtitle Q
566
567
1
(3) ensures that individuals participating in the
1 gram, the State shall submit a report to the Secretary con-
2
program have access to all medically necessary men-
2 taining the following information with respect to the year:
05/11/94 17:23
3
tal health services; and
3
(1) The management, access, and referral
4
(4) meets such other requirements as the Sec-
4
structure which the State uses under the program to
5
retary may impose.
5
promote and achieve integration of mental health
6 SEC. 3533. STANDARDS RELATING TO DETERMINATIONS OF
6
services provided to residents of the State.
7
INCOME AND SEVERITY OF ILLNESS.
7
(2) Detailed specifications of the methods used
LMR 94017321
8
(a) IN GENERAL-The Secretary shall promulgate
8
by the State under the program to ensure that indi-
9 standards to be used by States to determine whether an
9
viduals receiving services under. the program have
10 individual is a low-income individual who is an adult with
10
access to all medically necessary and appropriate
11 a serious mental illness or a child with a severe emotional
11
mental health services.
12 disturbance for purposes of section 3532(2).
12
(3) The definition of an adult with a serious
13
(b) SEVERITY OF ILLNESS OR DISTURBANCE.—
13
mental illness and a child with a severe emotional
14 Under the standards promulgated pursuant to subsection
14
disturbance used by the State in determining the eli-
15 (a), the determination of whether an adult has a serious
15
gibility of individuals for services under the pro-
16 mental illness or a child has a severe emotional disturb-
16
gram.
17 ance shall be based on the individual's anticipated need
17
(4) A description of sources of funding used by
18 for services (as determined on the basis of the individual's
18
the State (other than the grant received under this
19 medical history or a prediction of future medical needs)
19
part) to operate the program during the year.
20 and on whether the individual is expected to need mental
20 SEC. 3535. AUTHORIZATION OF APPROPRIATIONS.
21 health services for a period of at least 1 year.
21
There are authorized to be appropriated for grants
22 SEC. 3534. REPORTING REQUIREMENTS.
22 under this part $100,000,000 for each of the fiscal years
NO.237 P008
23
With respect to each year for which a State is receiv-
23 1996 through 2000.
24 ing a grant under this part for the establishment and op-
25 eration of a comprehensive managed mental health pro-
F:\HSA\EDLABOR\SUB\UNSOEL.002
H.L.C.
AMENDMENT To COMMITTEE PRINT (H.R. 3600)
OFFERED By MRS. UNSOELD
Page 72, line 16, strike "discretion." and insert
"discretion, except that the plan shall offer smoking ces-
sation classes to pregnant women enrolled in the plan.".
May 4, 1994
MAY-13-1994 17:59 FROM ACTUARIAL RESEARCH
TO
2024562878 P.01
Actuarial Research Corporation
6928 Little River Turnpike, Suite E
Annandale, Virginia 22003
(703) 941-7400
FAX (703) 941-3951
Date:
5/13
Please Deliver Immediately
To:
Jennifer Klein
From:
Gordon
Re:
Memo:
with Miller dental limited to one exam/year
with radiographs ( but no prophylaxis) and:
30 % COINSURANCE
$10 capayment / visit
Average premium increase is 0.77% ( I.e. 2 little
less than 1%).
We are transmitting
pages (including this transmittal sheet).
Memo to Danny Weiss
May 11, 1994
Page 2
Cost Estimate Information:
Emergency Care
Already in the Williams' Substitute
Preventive and Diagnostic Care
Limits:
Costs (in Billions):
Oral exams
1/yr
$1,928
Radiographs
1/2yr BW* or 1/5yr FMS**
821
Sealants
no adults
Fluorides
High Risk ONLY
328
Cleanings
1 @/yr
1,847
Treatment
no restorative, prosthetics,
orthodontics for adults
Special Needs Patients:
Orthodontics
Severe Malocclusions ONLY for
children age 6-12
Dentures
Special needs patients ONLY
1.530
Medically Necessary Oral
Patient population as defined
Health Care
in amendment
TOTAL:
$6.454
A study just prepared
for Hay Huggrns (last
* BW = Bite Wing Radiographs
week) will show the
** FMS = Full Mouth Series
special needs patient
Costs to equal $1.558 B.
The result is an
increase in Cost of
$28 Million largely due
to rates. use of 65% utilization
05/13/94 15:04
202 225 5609
GEORGE MILLER
001/012
U.S. HOUSE OF
FAX TRANSMISSION
ALPRESENTATIVES
FROM
CONGRESSMAN GEORGE MILLER
(D-CALIFORNIA)
TO:
Jennifer Klein / Jack Lew
FR:
Daniel Weiss
TOTAL NUMBER OF PAGES INCLUDING THIS ONE: 12
DATE: 5/13/94 TIME: 3:30 pm
MESSAGE: If you need the legislative language,
let came know.
Rep. George Miller, 2205 Rayburn Bldg., Washington, DC 20515 (202)225-2095
05/13/94
15:05
202 225 5609
GEORGE MILLER
002/012
May 13, 1994
TO:
Daniel Weiss
FROM:
Marty Liggett
SUBJECT: Dental Amendment Cost Estimates
Coalition for
Oral Health
Per our conversation earlier today, here are the details
underlying our estimates. The chart below summarizes the
costs of medically necessary oral health care and special
needs patients. Specific numbers and assumptions are
1625 Massachusetts
Ave., NW, Suite 502
spelled out in detail in the attached letters from the
Washington DC
American Association of Hospital Dentists. Please note
20036-2212
that their estimates are comprised of two subtotals.
Page 2 of this memo describes the proposed preventive
benefits for adults (ages 18-64) included in the amendment,
with detailed assumptions listed.
Our amendment would never cover cast restorations (caps,
gold crowns, bridge work), or cosmetic services.
President
Medically Necessary Oral Health Care
John McFarland,
Cost Projections Summary Sheet
NNOHA
Vice President
Category
# Patients
Costs (in
Hermine McLeran,
AAPHD
Millions)
Treasurer
Chemotherapy
174,556
$
71
Nik Petrovic,
Diabetes
809,200
349
ADTA
Heart Defects
22,320
9
Secretary
Hemophilia
11,560
4
Gene Bartlow,
HIV
289,200
118
AADR
Orphan Diseases
346,800
149
Radiation
14,450
6
Director
Martha Liggett,
Renal Dialysis
171,088
72
AADS
Transplantation
13,838
5
Dev & Acq MXF Def*
17,480
46
Dev Disabilities
1,676,200
723
TOTAL PROJECTED ANNUAL COSTS:
$1,552
*
Dev & Acq MSF Def - Developmental and Acquired
Maxillofacial Defects
Phone: (202) 667-9433
Fax: (202) 667-0642
May 12, 1994
Pertinent data for Dental Amendment
Description of Proposed Oral Health Benefits for Adults (18-64 years of age)
Estimated utilization rate of 60 percent/1994 adjusted dental fees
05/13/94
Service
Estimated
Frequency/
Service
Projected
Cost/
Total First Year
Target
Year
Modifier
Utilization
Unit
Projected
15:05
Population
Rate
Cost (in Billions)
Preventive and Diagnostic Care:
Oral Exams
160,402,000
1 x/yr
none
60%
$20.03
1.928
Radiographs
153,649,076
1 x/2yr or 5yr
none
60%
17.81
.821
Sealants
NA
NA
NA
NA
NA
NA
5609 225 20202
Fluorides
153,649,076
2 x/yr
10%
60%
17.81
.328
Cleanings
153,649,076
I x/yr
45%
60%
44.52
1.847
TOTAL:
$ 4.924
ASSUMPTIONS:
I.
Targer population: There are two different population numbers used because there are 160 million adults ages 18 - 64, of whom 153 million have teeth; every one of the 160
million require oral exams, while only those with leeth get cleanings, x-rays, and fluoride treatments.
2.
Frequency per year: This figure refers to limitations on the number of times per year the service will be provided. Most services are only covered annually. This is a more severe
limitation than is coinonly seen in the private sector, where 2 exams and cleanings may be covered each year. Radiographs are subject to the following limitations: not more
then one set of bitewing x-rays every 2 years or one full mouth series of x-rays (or panographic x-ray) every s years.
GEORGE MILLER
3.
Service modifier: A service modifier is an adjustment to reflect the need for doe service. Fluorides: An estimate of 10 percent. was used in the model to project the proportion
of adults at increased risk of active dental disease and who would benefit from professionally applied fluoride treatments. The National Institute of Dental Research (NIDR)
conducted a 1985.86 National Survey of Oral Health in U.S. Employed Adults and Seniors and reported that the decayed component (D) of caries scores (unrestored tooth
surfaces) comprised approximately 8 percent in employed adults and 9 percent in seniors of the decayed and filled tooth soares (DFT). Cleanings. Approximately 89 percent
of the adult population aged 18 and older is classified as dentate (with some teeth). The preportion of dentate adults requiring "oral prophylaxis" (cleanings) is estimated at 45
percent. The projection is based on data from the 1985-86 NIDR National Survey of Oral Health in U.S. Employed Adults and Seniors - 43.6 persent of employed adults
(dentate) aged 18-64+ years were reported with gingiva bleeding in at least one site.
4.
Utilization rate: National dental care utilization data (NHIS, 1989) reports an animal utilization rate of approximately 50% for adults. Because this amendment would bring
preventive dental care to individuals currently without it, 8 significant number of those newly eligible for coverage will be low income adults. For these people. finances are
not the only barrier to access, and their Wilization rates are significantly below the overall adult average. Adult utilization of Medicaid dental benefits, for example, averages
35%, as reported by the Department of Health Policy and Epidemiology, Harvard School of Dermal Medicine. A 60 percent utilization rate for busic services was used, which
provides quite a large "custion".
4
003/012
5.
Cost/unit: Cost estimates for individual clinical-based services are based on 1985 median fees (Sorb percentile of general proctitioner fees) from the most recent
rehensive
survey of dentists conducted by the American Dental Association and adjusted Ю 1994 dollars.
6.
Only first year cost projections are given. The out years should be costed at the Consumer Price Index rate, using whatever assumptions are being applied to the bill generalty.
Growth in the price of dental services continues to be lower than the CPI for physician and hospital services. The preventive services proposed are least subject to upward
inflation. Thus are annual increase at the CPI rate should be used.
15:06
5609 225 20202
GEORGE MILLER
004/012
05/13/94
15:06
202 225 5609
GEORGE MILLER
005/012
- insuration
of Hospital Dentists
:1.
ddll, you
April 29, 1994
Mr. Mike Carter
Hay Huggins Co, Inc.
1500 K st., N.W.
Suite 1000
AAHD
Washington, DC 20005
Dear Mr. Carter:
on behalf of the American Association of Hospital Dentists,
I would like to thank you for this opportunity to assist you in
costing out a "medically necessary oral health care" add-on to
Mr. Dingell's proposal. We currently define medically necessary
oral health care as "a direct result of, or having direct impact
on a medical condition". The provision of this care provides for
elimination of infection, pain and reestablishment of function.
Examples of various medical conditions which require
adequate and appropriate medically necessary oral health care
include diabetes, cancer, heart defects, hemophilia, HIV disease,
organ transplantation, renal dialysis, congenital and heredity
disorders and those diseases we consider orphan diseases such as
sjogren's Syndrome.
The enclosed cost-out for medically necessary oral health
care includes the disease entities which I have mentioned above
and defines the critical services that must be provided to effect
optimal health outcomes. We have made a number of assumptions in
the calculations which include:
The total number of cases documented under each disease
entity is the calculated total of individuals between
18 and 65. That is, we have made the assumption that
those under 18 would be covered under the Health
Security Act and those over 65 would be considered
under any future proposed Medicare changes. Our
calculation is based on 1990 census data.
We have made the assumption that utilization for these
services would be on the order of 65%. The Public
Health Service currently estimates that utilization for
the population at large currently is between 55% and
60%.
The cost estimates and disease category definitions
assume that this is an add-on to the existing Health
Security Act.
05/13/94
15:06
6202 225 5609
GEORGE MILLER
006/012
Mr. Mike Carter
April 29, 1994
Page Two
The chemotherapy category is a "catch-all" for all
those receiving chemotherapy including patients with
leukemia.
The patients in the HIV category include those on
disease-related therapies, i.e., not including those
who are asymptomatic. These patients will necessitate
approximately two exams per year or more due to their
suppressed immune status and continually changing oral
health status.
Under the orphan disease category we must note that
Sjogren's Syndrome patients may have an increased need
for cleanings and fluoride treatment. This population
will require more regular and routine protection of
their hard and soft tissues due to the nature of the
disease process.
The estimates for the developmental and acquired
maxillofacial defects include patients with ectodermal
dysplasia as well as those receiving surgical resection
for head and neck cancers. This group is covered under
the radiation and/or orphan disease categories for the
Initial Workup and Treatment as well as the Primary
Care Maintenance. However, this group does necessitate
the additional services of functional restorations.
Elimination of infection has been estimated by a non-
random survey to approximate the cost of extracting six
teeth. Clearly there are some individuals who present
with no need for extractions and others who present for
extraction of entire sets of teeth. This estimate is
anecdotally accurate and appropriate.
The Dental Fees used for the respective calculations
were taken from the 1993 ADA Survey of Dental Fees with
the exception of functional restorations for
Developmental and Acquired Maxillofacial Defects.
Frequencies were gathered from the Journal of
Prosthetic Dentistry and the cost from personal
communication.
The restorative component under Primary Care
Maintenance was calculated for cavities on the crown
and root surfaces, respectively. The Public Health
Service has estimated that a factor of 1.3 surfaces is
restored on the crown in the general population and 0.4
surfaces restored on the root structure. The average
restoration cost of $51.20 was used to compute the
final cost.
05/13/94
15:07
202 225 5609
GEORGE MILLER
007/012
Mr. Mike Carter
April 29, 1994
Page Three
Fluoride treatment will apply only to patients at high
risk for cavities. Therefore although we have assigned
fluoride treatment to all medically compromised groups,
most treatment will be limited to chemotherapy, HIV,
orphan diseases, and radiation.
There are special needs patient populations which include
children with baby bottle syndrome and those with handicapping
malocclusions which have not been included in this cost out.
Baby bottle syndrome is assumed to be covered under the existing
Health Security Act. However, handicapping malocclusions due to
malformed Jaws is an issue and condition which should be
addressed for adults as well as children. The reestablishment of
function for these individuals is critical for their day-to-day
existence.
As a final note, we made some estimates on the potential
cost of not providing the medically necessary dental care. For
example it is estimated that between 10-15% (personal
communication) of all patients undergoing head and neck radiation
for malignancy will develop a condition called osteoradionecrosis
without appropriate oral care. Osteoradionecrosis occurs when
blood vessels in the path of the radiation beam become thicker
causing impaired circulation to the jaw bone resulting in bone
death. Individuals in poor dental health frequently develop
osteoradionecrosis due to tooth and gum-related infections. In
20% of these cases, patients must undergo extensive and expensive
hyperbaric oxygen therapy. This estimate alone is in excess of
60% higher than the total cost of care provided to the entire
radiation patient population!
Please feel free to contact me if you have any questions or
comments concerning these figures. We feel our estimates are
sound. Again, anecdotal evidence indicates that not providing
the medically necessary oral health care can ultimately cost the
system magnitudes higher in terms of adverse health outcomes and
real dollars. Thank you very much for this opportunity.
sincerely yours,
DAS
John 5. Rutkauskas, MS, DDS
Executive Director
JSR/bw
CC: Ms. Dorothy Moss, ADA Washington office
Mr. Craig Palmer, ADA Washington office
Federation Board of Directors
Medically Necessary Oral Realth Care
65% OR
Chemotherapy
Diabetes
Heart Defects
Memophilla
HIV
(174,556)
(809,200)
(21,320)
(11,560)
(289,200)
Initial Workup and
Treatment
05/13/84 15:07
a. Exam
3,971,149
18,409,300
507,700
262,990
6,579,300
b. Radiograph
5,105,763
23,669,100
652,860
338,130
8,459,100
c. Periodontal Scaling
7,601,914
35,240,660
972,036
503,438
12,594,660
to Reduce Inflammation
d. Fluoride Treatment
1,701,921
7,889,700
217,620
112,710
2,819,700
e. Ellmination of
34,492,266
159,897,920
4,410,432
2,204,256
57,145,920
6202 225 5609
Infection
Subtatal
52,871,019
245,106,600
6,760,728
3,501,524
87,598,680
Primary Care
Naintenance
a. Periodic
1,928,844
8,941,660
246,636
127,738
9,586,900
Exam 1x/yr
b. Bitewings
1,015,382
6,415,680
232,128
120,224
3,007,680
1n/yc
C. Prophylaxis 2x/yr
864,990
41,026,440
1,131,624
506,092
1,466,240
GEORGE MILLER
d. Restorative
I. Coronal Caries
11,618,447
35,009,228
965,653
500,132
12,511,940
II. Root Caries
2,323,664
10,772,070
297,124
153,887
3,849,830
Punctional Restoration
Subtotal
18,571,347
104,165,078
2,873,165
1,688,073
30,422,670
Total
71,444,360
349,271,758
9,633,893
4,989,597
110,021,358
008/012
Medically Madessary Oral I
Ith Care
65% OR
Orphan Diseases
Radiation
Renal
Transplantation
Developmental
(346,800)
(14,450)
Dialysis
(13,838)
and Acquired
(171,008)
Maxillofacial
Defecta
(17,480)
Initial Norkup and
Treatment
ST:21 РЕБТ-ЕЙ-ЛЬШ
05/13/94 15:07
a. Exam
7,009,700
328,736
3,892,252
314,815
b. Radiograph
10,143,900
422,663
5,004,324
404,762
0. Periodental Scaling
15,103,140
629,290
7,450,802
602,645
to Reduce Inflammation
d. Fluoride Treatment
3,381,300
140,088
166,811
134,921
20202 225 5609
e. Elimination of
60,527,680
2,855,320
11,806,988
2,734,369
Infection
Subtotal
105,045,720
4,376,907
50,321,257
4,191,532
Primary Care
Maintenance
a. Periodic Exam In/yc
3,832,140
159,673
1,690,522
152,910
b. eltewings 1n/yr
3,606,720
150,280
1,779,315
143,915
C. Prophylawis 2n/yr
17,502,760
732,616
0,674,162
701,506
GEORGE MILLER
d. Restorative
I. Coronal Carles
15,003,955
625,165
7,401,951
598,607
II. Root Ceries
4,616,602
295,936
2,277,523
184,211
Functional Restoration
46,550,000
Subtotal
64,642,177
1,963,670
22,023,473
1,781,309
66,558,000
Total
149,687,897
6,340,577
73,344,730
5,972,841
46,558,000
1.00/00
} ,
0099012
05/13/94
15:08
6202 225 5609
GEORGE MILLER
0
010/012
of Hospital genilsis
Chicago, :! N)611
312.420 2019
May 4, 1994
Mr. Mike Carter
Hay Huggins Co, Inc.
1500 K st., N.W.
Suite 1000
Washington, DC 20005
Dear Mr. carter:
It's been a pleasure to continue to work with you on the
important issue of medically necessary oral health care. As I had
mentioned to you over the phone, one population which we neglected to
AAHD
include is that of the profoundly and severely developmentally
disabled. I have enclosed the spread sheet for this medical category.
Please find below a sample calculation for the group of radiation
patients.
Radiation Therapy Patients
Those receiving radiation therapy of the head and neck,
including those with Hodgkins Disease - -- 25,000 per year for
all ages.
Approximately 57.8% of the population is in the 18-65 age
group based on 1990 census data.
14,450 therefore would potentially be covered under the
proposed plan. with a 65% utilization rate, approximately
9392.5 individuals would access services.
Fees: these estimates are taken from the 1993 ADA survey of
dental fees at the 50th percentile. The only exceptions are
those for examinations under initial workup and treatment
which were calculated at the 80th percentile due to the
extensive nature of the exams and estimates for restorations
which were calculated at $51.20 by the Public Health
Service.
a.
Examination
$ 35.00
x
9392.5
-
$ 328,738
b. Radiograph
$ 45.00
X
9392.5
=
$ 422,663
C. Periodontal
$ 67.00
X
9392.5
=
$ 629,298
d. Fluoride
Treatment
$ 15.00
x
9392.5
=
$ 140,888
8. Elimination
of Infection
$304.00
X
9392.5
-
$2,855,320
$1,376,907
a. Periodic Exam
$ 17.00
X
9392.5
-
$ 159,673
b. Bitewings
$ 16.00
X
9392.5
e
$ 150,280
C. Prophylaxis
($ 39x2)
X
9392.5
A
$ 732,616
d. Restorative
Coronal
$ 51.20
X
9392.5
#
$ 625,165
x 1.3 surfaces
Root
$51.20
X
9392.5
=
$ 192,358
X 0.4 surfaces
$1,860,092
Total
$6,236,999
05/13/94
15:08
202 225 5609
GEORGE MILLER
011/012
Mr. Mike Carter
May 4, 1994
Page Two
cost of treatment for osteoradionecrosis as a result of not
providing care:
10-15% of 14,450 will develop osteoradionecrosis due to
inadequate oral care.
Additionally, 20% of 1445 will necessitate hyperbaric oxygen
therapy to treat the problem at a cost of $35,000 per case.
289 cases of hyperbaric oxygen therapy X $35,000 = $10,115,000
This is in excess of 50% of the $6,236,999 of total care provided
to all radiation patients.
Please let me know if there are any further questions.
Sincerely,
SA
John S. Rutkauskas, MS, DDS
Executive Director
JSR/bw
CC: Ms. Dorothy Moss, ADA Washington Office
Mr. Craig Palmer, ADA Washington office
Federation Board of Directors
Medically Nacessary Oral Health Care
65% UR
Developmental Disabilities
(1,676,200)
05/13/84
Initial Markup and
Treatment
a. Exam
38,133,550
15:09
b. Radiograph
49,028,850
C. Periodontal Scaling to Reduce Inflammation
72,998,510
d. Fluoride Treatment
16,342,950
e. Elimination of Infection
331,217,120
Subtotal
507,753,980
6202 225 5609
Primary Care
Maintenance
a. Periodic
Bwam 1M/YE
18,522,010
b. Bitewings
1x/yr
17,432,480
C. Prophylasla 2n/yr
84,983,340
d. Restorative
GEORGE MILLER
I. Coronal Caries
72,519,117
IT. Root Carles
22,313,574
Punctional Restoration
Subtotal
215,770,521
Total
723,524,501
TOTAL P.04
012/012