[Congressional Bills 108th Congress]
[From the U.S. Government Publishing Office]
[S. 1227 Introduced in Senate (IS)]







108th CONGRESS
  1st Session
                                S. 1227

To amend title XVIII of the Social Security Act to provide for coverage 
      of substitute adult day services under the medicare program.


_______________________________________________________________________


                   IN THE SENATE OF THE UNITED STATES

                             June 10, 2003

 Mr. Santorum (for himself and Mrs. Lincoln) introduced the following 
  bill; which was read twice and referred to the Committee on Finance

_______________________________________________________________________

                                 A BILL


 
To amend title XVIII of the Social Security Act to provide for coverage 
      of substitute 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 
Alternative Act of 2003''.

SEC. 2. FINDINGS.

    Congress finds that--
            (1) adult day services offers services, including medical 
        care, rehabilitation therapies, dignified assistance with 
        activities of daily living, social interaction, and stimulating 
        activities, to seniors who are frail, physically challenged, or 
        cognitively impaired;
            (2) access to adult day services provides seniors and their 
        familial caregivers support that is critical to keeping the 
        senior in the family home;
            (3) more than 22,000,000 families in the United States 
        serve as caregivers for aging or ailing seniors, nearly 1 in 4 
        American families, providing close to 80 percent of the care to 
        individuals requiring long-term care;
            (4) nearly 75 percent of those actively providing such care 
        are women who also maintain other responsibilities, such as 
        working outside of the home and raising young children;
            (5) the average loss of income to these caregivers has been 
        shown to be $659,130 in wages, pension, and Social Security 
        benefits;
            (6) the loss in productivity in United States businesses 
        ranges from $11,000,000,000 to $29,000,000,000 annually;
            (7) the services offered in adult day services facilities 
        provide continuity of care and an important sense of community 
        for both the senior and the caregiver;
            (8) there are adult day services facilities in every State 
        in the United States and the District of Columbia;
            (9) these centers generally offer transportation, meals, 
        personal care, and counseling in addition to the medical 
        services and socialization benefits offered; and
            (10) with the need for quality options in how to best care 
        for our senior population about to dramatically increase with 
        the aging of the baby boomer generation, the time to address 
        these issues is now.

SEC. 3. MEDICARE COVERAGE OF SUBSTITUTE ADULT DAY SERVICES.

    (a) Substitute Adult Day Services Benefit.--
            (1) In general.--Section 1861(m) of the Social Security Act 
        (42 U.S.C. 1395x(m)) is amended--
                    (A) in the matter preceding paragraph (1), by 
                inserting ``or (8)'' after ``paragraph (7)'';
                    (B) in paragraph (6), by striking ``and'' at the 
                end;
                    (C) in paragraph (7), by adding ``and'' at the end; 
                and
                    (D) by inserting after paragraph (7), the following 
                new paragraph:
            ``(8) substitute adult day services (as defined in 
        subsection (ww));''.
            (2) Substitute adult day services defined.--Section 1861 of 
        the Social Security Act (42 U.S.C. 1395x) is amended by adding 
        at the end the following new subsection:

      ``Substitute Adult Day Services; Adult Day Services Facility

    ``(ww)(1)(A) The term `substitute adult day services' means the 
items and services described in subparagraph (B) that are furnished to 
an individual by an adult day services facility as a part of a plan 
under subsection (m) that substitutes such services for some or all of 
the items and services described in subparagraph (B)(i) furnished by a 
home health agency under the plan, as determined by the physician 
establishing the plan.
    ``(B) The items and services described in this subparagraph are the 
following items and services:
            ``(i) Items and services described in paragraphs (1) 
        through (7) of subsection (m).
            ``(ii) Meals.
            ``(iii) A program of supervised activities designed to 
        promote physical and mental health and furnished to the 
        individual by the adult day services facility in a group 
setting for a period of not fewer than 4 and not greater than 12 hours 
per day.
            ``(iv) A medication management program (as defined in 
        subparagraph (C)).
    ``(C) For purposes of subparagraph (B)(iv), the term `medication 
management program' means a program of services, including medicine 
screening and patient and health care provider education programs, that 
provides services to minimize--
            ``(i) unnecessary or inappropriate use of prescription 
        drugs; and
            ``(ii) adverse events due to unintended prescription drug-
        to-drug interactions.
    ``(2)(A) Except as provided in subparagraphs (B) and (C), the term 
`adult day services facility' means a public agency or private 
organization, or a subdivision of such an agency or organization, 
that--
            ``(i) is engaged in providing skilled nursing services and 
        other therapeutic services directly or under arrangement with a 
        home health agency;
            ``(ii) provides the items and services described in 
        paragraph (1)(B); and
            ``(iii) meets the requirements of paragraphs (2) through 
        (8) of subsection (o).
    ``(B) Notwithstanding subparagraph (A), the term `adult day 
services facility' shall include a home health agency in which the 
items and services described in clauses (ii) through (iv) of paragraph 
(1)(B) are provided--
            ``(i) by an adult day services program that is licensed or 
        certified by a State, or accredited, to furnish such items and 
        services in the State; and
            ``(ii) under arrangements with that program made by such 
        agency.
    ``(C) The Secretary may waive the requirement of a surety bond 
under paragraph (7) of subsection (o) in the case of an agency or 
organization that provides a comparable surety bond under State law.''.
    (b) Payment for Substitute Adult Day Services.--Section 1895 of the 
Social Security Act (42 U.S.C. 1395fff) is amended by adding at the end 
the following new subsection:
    ``(f) Payment Rate for Substitute Adult Day Services.--
            ``(1) Payment rate.--For purposes of making payments to an 
        adult day services facility for substitute adult day services 
        (as defined in section 1861(ww)), the following rules shall 
        apply:
                    ``(A) Estimation of payment amount.--The Secretary 
                shall estimate the amount that would otherwise be 
                payable to a home health agency under this section for 
                all home health services described in paragraph 
                (1)(B)(i) of such section under the plan of care.
                    ``(B) Amount of payment.--Subject to paragraph 
                (3)(B), the total amount payable for substitute adult 
                day services under the plan of care is equal to 95 
                percent of the amount estimated to be payable under 
                subparagraph (A).
            ``(2) Limitation on balance billing.--An adult day services 
        facility shall accept as payment in full for substitute adult 
        day services (including those services described in clauses 
        (ii) through (iv) of section 1861(ww)(1)(B)) furnished by the 
        facility to an individual entitled to benefits under this title 
        the amount of payment provided under this subsection for home 
        health services consisting of substitute adult day services.
            ``(3) Adjustment in case of overutilization of substitute 
        adult day services.--
                    ``(A) Monitoring expenditures.--Beginning with 
                fiscal year 2005, the Secretary shall monitor the 
                expenditures made under this title for home health 
                services, including such services consisting of 
                substitute adult day services, for the fiscal year and 
                shall compare such expenditures to expenditures that 
                the Secretary estimates would have been made under this 
                title for home health services for the fiscal year if 
                the Medicare Adult Day Services Alternative Act of 2003 
                had not been enacted.
                    ``(B) Required reduction in payment rate.--If the 
                Secretary determines, after making the comparison under 
                subparagraph (A) and making such adjustments for 
                changes in demographics and age of the medicare 
                beneficiary population as the Secretary determines 
                appropriate, that expenditures for home health services 
                under the this title, including such services 
                consisting of substitute adult day services, for the 
                fiscal year exceed expenditures that would have been 
                made under this title for home health services for the 
                fiscal year if the Medicare Adult Day Services 
                Alternative Act of 2003 not been enacted, then the 
                Secretary shall adjust the rate of payment to adult day 
                services facilities under paragraph (1)(B) for home 
                health services consisting of substitute adult day 
                services furnished in the fiscal year in order to 
                eliminate such excess.''.
    (c) Effective Date.--The amendments made by this section shall 
apply to items and services furnished on or after January 1, 2004.
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