[Congressional Bills 112th Congress]
[From the U.S. Government Publishing Office]
[H.R. 6476 Introduced in House (IH)]
112th CONGRESS
2d Session
H. R. 6476
To amend title XVIII of the Social Security Act to provide for coverage
of certified adult day services under the Medicare program.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
September 20, 2012
Ms. Linda T. Sanchez of California introduced the following bill; which
was referred to the Committee on Ways and Means, and in addition to the
Committee on Energy and Commerce, for a period to be subsequently
determined by the Speaker, in each case for consideration of such
provisions as fall within the jurisdiction of the committee concerned
_______________________________________________________________________
A BILL
To amend title XVIII of the Social Security Act to provide for coverage
of certified adult day services under the Medicare program.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Medicare Adult Day Services Act of
2012''.
SEC. 2. FINDINGS.
Congress makes the following findings:
(1) Adult day care can offer services, including medical
care, rehabilitation therapies, dignified assistance with
activities of daily living, nutrition therapy, health
monitoring, social interaction, stimulating activities, and
transportation, to seniors and people with disabilities at no
extra cost to the Medicare program.
(2) The care given at adult day services centers under an
interdisciplinary team provides seniors, people with
disabilities, and their familial caregivers with more care
hours and additional services that are critical to keeping
patients healthier and in the homes of the patients instead of
in a nursing home, and reduces the risk of hospital admission
or readmission.
SEC. 3. MEDICARE COVERAGE OF CERTIFIED ADULT DAY SERVICES.
(a) Medicare Certified Adult Day Services Benefit.--
(1) Definition.--Section 1861 of the Social Security Act
(42 U.S.C. 1395x) is amended by adding at the end the following
new subsection:
``(iii) Certified Adult Day Services; Adult Day Services Provider;
Certified Adult Day Services Center; Post-Institutional Certified Adult
Day Services; Certified Adult Day Services Spell of Illness.--(1)(A)
The term `certified adult day services' means, subject to paragraph
(4), the items and services described in subparagraph (B) that are
furnished to an individual who is under the care of a physician--
``(i) by an adult day services provider (as defined
in paragraph (2)) or by another entity under an
arrangement with such an adult day services provider to
provide such services;
``(ii) in accordance with a plan (for furnishing
such items and services to such individual) approved
and periodically reviewed by such physician; and
``(iii) in a certified adult day services center
(as defined in paragraph (3)).
``(B) For purposes of subparagraph (A), the items and services
described in this subparagraph are the following:
``(i) Part-time or intermittent services (as defined in
subparagraph (C)(i)) provided by or under the supervision of a
registered professional nurse.
``(ii) Physical or occupational therapy or speech-language
pathology services, or any combination of such services.
``(iii) Medical social services under the direction of a
physician.
``(iv) Nutritional meals, including special diets, as
ordered by a physician.
``(v) A program of supervised activities (that meets such
criteria as the Secretary determines appropriate) designed to
promote physical and mental health that are furnished in a
group setting for a period of not fewer than 4 and not greater
than 8 hours per day.
``(vi) A medication management program (as defined in
subparagraph (C)(ii)).
``(vii) Medical supplies (including catheters, catheter
supplies, ostomy bags, and supplies related to ostomy care, and
a covered osteoporosis drug (as defined in subsection (kk)),
but excluding other drugs and biologicals) and durable medical
equipment.
``(viii) Transportation of the individual described in
subparagraph (A) to and from a certified adult day services
center in connection with the provision of an item or service
described in a previous provision of this subparagraph.
``(C)(i) For purposes of subparagraph (B)(i), the term `part-time
or intermittent services' means certified adult day services furnished
any number of days per week as long as such services are furnished
fewer than 8 hours each day. For purposes of sections 1814(a)(2)(C) and
1835(a)(2)(A), insofar as such respective section relates to certified
adult day services, `intermittent' means certified adult day services
that are either provided or needed on fewer than 7 days each week, or
less than 8 hours of each day for periods of 21 days or less (with
extensions in exceptional circumstances when the need for additional
care is finite and predictable).
``(ii) For purposes of subparagraph (B)(vi), the term `medication
management program' means a program of education and services (that
meets such criteria as the Secretary determines appropriate) to
minimize--
``(I) unnecessary or inappropriate use of prescription
drugs; and
``(II) adverse events due to unintended prescription drug-
to-drug interactions.
``(2) The term `adult day services provider' means a provider of
home and community based services that is approved in the applicable
State to provide long-term services and supports, which may include
nursing care, physical therapy, occupational therapy, social work
services, transportation, and personal care services.
``(3) The term `certified adult day services center' means a
facility--
``(A) of a public agency or private organization, or a
subdivision of such an agency or organization, that--
``(i) is primarily engaged in providing an
interdisciplinary approach that includes skilled
nursing services and other therapeutic services
directly;
``(ii) has policies, established by a group of
professional personnel (associated with the agency or
organization), including one or more physicians and one
or more registered professional nurses, to govern the
services (referred to in subparagraph (A)) which it
provides, and provides for supervision of such
services;
``(iii) maintains clinical records on all patients;
``(iv) in the case of an agency or organization in
any State in which State or applicable local law
provides for the licensing or certification of agencies
or organizations of this nature, (i) is licensed or
certified pursuant to such law, or (ii) is approved, by
the agency of such State or locality responsible for
licensing or certifying agencies or organizations of
this nature, as meeting the standards established for
such licensing or certification;
``(v) is licensed or certified by the State
involved or accredited as meeting requirements,
including under section 1865, through a nationally
recognized accrediting agency that is recognized by the
Secretary;
``(vi) has in effect an overall plan and budget
that meets the requirements of subsection (z);
``(vii) meets applicable conditions of
participation under section 1891(a) (or similar
conditions specified by the Secretary as applicable to
such an agency or organization) and such other
conditions of participation as the Secretary may find
necessary in the interest of the health and safety of
individuals who are furnished services by such agency
or organization; and
``(viii) meets such additional requirements
(including conditions relating to bonding or
establishing of escrow accounts as the Secretary finds
necessary for the financial security of the program) as
the Secretary finds necessary for the effective and
efficient operation of the program;
``(B) at which such agency or organization provides for
items and services described in paragraph (1)(B); and
``(C) that complies with all applicable State and local
building codes, fire codes, zoning laws, and State licensing
building standards that apply to a State licensed or certified
or nationally accredited adult day center, and in States where
there are no State licensing building standards for adult day
centers, building standards based on the standards adopted by a
nationally recognized accrediting agency that is recognized by
the Secretary and applies to such a center standards that are
comparable to the requirements applied to a skilled nursing
facility pursuant to section 1819(d)(2)(B).
``(4) For purposes of paragraph (1)(A), an item or service
furnished to an individual, with respect to a period, shall not be
considered an adult day service if--
``(A) the individual is--
``(i) concurrently receiving similar skilled
services under a State plan under section 1905(a) or
under a home and community-based waiver authorized for
a State under section 1115, under subsection (c) or (d)
of section 1915, under a State plan amendment under
subsection (i) of section 1915, or under section
1902(a)(10)(D); and
``(ii) receiving such item or service during such
period under such State plan, waiver, amendment, or
respective section; or
``(B) the individual is receiving such item or service
during such period pursuant to a plan of care from a home
health agency under section 1861(m).
``(5) Nothing in this subsection shall be construed as prohibiting
a home health agency from--
``(A) establishing a State licensed or certified or
nationally accredited certified adult day services center and
furnishing certified adult day services; or
``(B) providing services under arrangements with such a
center.
``(6) The term `post-institutional certified adult day services'
means certified adult day services furnished to an individual--
``(A) after discharge from a hospital or critical access
hospital in which the individual was an inpatient for not less
than 3 consecutive days before such discharge if such certified
adult day services were initiated within 14 days after the date
of such discharge; or
``(B) after discharge from a skilled nursing facility in
which the individual was provided post-hospital extended care
services if such certified adult day services were initiated
within 14 days after the date of such discharge.
``(7) The term `certified adult day services spell of illness' with
respect to any individual means a period of consecutive days--
``(A) beginning with the first day (not included in a
previous certified adult day services spell of illness)--
``(i) on which such individual is furnished post-
institutional certified adult day services, and
``(ii) which occurs in a month for which the
individual is entitled to benefits under part A; and
``(B) ending with the close of the first period of 60
consecutive days thereafter on each of which the individual is
neither an inpatient of a hospital or critical access hospital
nor an inpatient of a facility described in section 1819(a)(1)
or subsection (y)(1) nor provided home health services or
certified adult day services.''.
(2) Inclusion under part b benefit.--Section 1832(a)(2) of
the Social Security Act (42 U.S.C. 1395k(a)(2)) is amended--
(A) in subparagraph (I), by striking at the end
``and'';
(B) in subparagraph (J), by striking at the end the
period and inserting ``; and''; and
(C) by adding at the end the following new
subparagraph:
``(K) certified adult day services (as defined in
section 1861(iii)(1)(A)).''.
(3) Inclusion under part a benefit.--Section 1812(a) of the
Social Security Act is amended--
(A) in paragraph (4), by striking at the end
``and'';
(B) in paragraph (5), by striking the period at the
end and inserting ``; and''; and
(C) by adding at the end the following new
paragraph:
``(6) in the case of individuals not enrolled in part B,
certified adult day services (as defined in paragraph (1)(A) of
section 1861(iii)), and in the case of individuals so enrolled,
post-institutional certified adult day services (as defined in
paragraph (6) of such section) furnished during a certified
adult day services spell of illness (as defined in paragraph
(7) of such section) for up to 100 visits during such spell of
illness.''.
(b) Payment of Claims Requirements for Home Health Services Applied
to Certified Adult Day Services.--
(1) Part a.--Section 1814(a)(2)(C) of the Social Security
Act (42 U.S.C. 1395f(a)(2)(C)) is amended by inserting ``or
certified adult day services'' after each occurrence of ``home
health services''.
(2) Part b.--Section 1835(a)(2)(A) of the Social Security
Act (42 U.S.C. 1395n(a)(2)(A)) is amended--
(A) in the matter preceding clause (i), by
inserting ``or certified adult day services (as defined
in section 1861(iii)(1)(A))'' after ``home health
services''; and
(B) in clause (i), by inserting ``or certified
adult day services'' after ``home health services''.
(c) Conforming Amendments.--
(1) Interaction with coverage of home health services.--
Section 1861(m) of the Social Security Act (42 U.S.C. 1395x(m))
is amended by adding at the end the following new sentence:
``An individual described in this subsection, with respect to
home health services furnished during a period, shall not
include an individual who is receiving comparable certified
adult day services (as defined in section 1861(iii)(1)) during
such period.''.
(2) Intermittent services.--Section 1861(m) of the Social
Security Act (42 U.S.C. 1395x(m)) is amended in the last
sentence by inserting ``insofar as such respective section
relates to home health services,'' after ``section
1835(a)(2)(A),''.
(3) Institutional planning requirement.--Section 1861(z) of
the Social Security Act (42 U.S.C. 1395x(z)) is amended in the
matter preceding paragraph (1), by striking ``or home health
agency'' and inserting ``home health agency, or certified adult
day services center''.
(4) Inclusion as provider of services.--Section 1861(u) of
the Social Security Act (42 U.S.C. 1395x(u)) is amended by
inserting ``certified adult day services center,'' after ``home
health agency,''.
(d) Payment for Certified Adult Day Services Under the Home Health
Prospective Payment System.--Section 1895 of the Social Security Act
(42 U.S.C. 1395fff) is amended by adding at the end the following new
subsection:
``(f) Application of Home Health Prospective Payment System to
Certified Adult Day Services.--
``(1) In general.--The Secretary shall, in accordance with
this subsection, develop a methodology under which the fee
schedule and provisions under this section shall apply to
certified adult day services (as defined in section
1861(iii)(1)) in a similar manner to which such schedule and
provisions apply to home health services.
``(2) Payment rate determination and limitations.--Under
such methodology, the following shall apply, with respect to
certified adult day services furnished to an individual during
a period specified by the Secretary under a plan of care
established under section 1861(iii) for which payment may be
made under this title:
``(A) Determination of components.--The Secretary
shall determine each component (as defined by the
Secretary) of such certified adult day services.
``(B) Estimation of payment amount.--The Secretary
shall estimate the amount that would otherwise be
payable under this section for the components of
services determined under subparagraph (A) if such
services were furnished by a home health agency (or, if
such component or service would not otherwise be so
payable under this section if so furnished, the amount
that would be payable under this section for a
comparable home health service furnished by a home
health agency) during such period.
``(C) Amount of payment.--The total amount payable
under this section for such certified adult day
services furnished to such individual during such
period shall be 98 percent of the amount estimated to
be payable for such services (or comparable services)
under subparagraph (B) for such period.
``(D) Limitation.--No payment may be made under
this section for certified adult day services described
in clauses (iv) through (vi) and (ix) of section
1861(iii)(1)(A).
``(3) Limitation on balance billing.--A certified adult day
services center shall accept as payment in full for certified
adult day services described in clauses (i) through (iii),
(vii) through (viii), and (x) through (xii) of section
1861(iii)(1)(A) furnished by the center to an individual
entitled to benefits under this title the amount of payment
provided under this section for home health services consisting
of items and services described in such respective clauses.''.
(e) Consolidated Billing.--Section 1862(a) of the Social Security
Act (42 U.S.C. 1395y(a)) is amended--
(1) by striking ``or'' at the end of paragraph (23);
(2) by striking the period at the end of paragraph (24) and
inserting, ``or''; and
(3) by inserting after paragraph (24) the following new
paragraph:
``(25) which are certified adult day services for which
payment may be made under section 1895(f) and which are
furnished to an individual by a State licensed or certified or
nationally accredited certified adult day services center
pursuant to a plan of care established under section 1861(iii)
with respect to such services, by an entity other than such
facility, unless the services are furnished under arrangements
(as defined in section 1861(w)(1)) with the entity made by such
facility.''.
(f) Temporary Increase for Certified Adult Day Services Furnished
in a Rural Area.--
(1) In general.--With respect to episodes and visits ending
on or after January 1, 2011, and before January 1, 2016, in the
case of certified adult day services (as defined in section
1861(iii)(1)(A) of the Social Security Act, as added by
subsection (a)), furnished in a rural area (as defined in
section 1886(d)(2)(D) of such Act (42 U.S.C. 1395ww(d)(2)(D))),
the Secretary of Health and Human Services shall increase the
payment amount otherwise made under section 1895 of such Act
(42 U.S.C. 1395fff) for such services by 3 percent.
(2) Waiving budget neutrality.--The Secretary shall not
reduce the standard prospective payment amount (or amounts)
under section 1895 of the Social Security Act (42 U.S.C.
1395fff) applicable to such certified adult day services
furnished during a period to offset the increase in payments
resulting from the application of paragraph (1).
(3) No effect on subsequent periods.--The payment increase
provided under paragraph (1) for a period under such
paragraph--
(A) shall not apply to episodes and visits ending
after such period; and
(B) shall not be taken into account in calculating
the payment amounts applicable for episodes and visits
occurring after such period.
(g) Adult Day Services Provider Technical Assistance.--In order to
facilitate the development of certified adult day services under title
XVIII of the Social Security Act, the Secretary of Health and Human
Services shall, as deemed necessary by the Secretary, provide adult day
services providers (as defined in section 1861(iii)(2) of such Act)
with technical assistance, consultation, tools, and other resources to
assist them with the application process and implementation of
certified adult day services (as defined in such section).
(h) Effective Date.--The amendments made by this section shall
apply to items and services furnished on or after January 1, 2013.
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