[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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