1.This Act may be cited as the
Medicare Adult Day Services Act of
2012
.
2.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.
3.Medicare coverage
of certified adult day services
(a)Medicare
certified adult day services benefit
(1)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 benefitSection 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 benefitSection 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)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)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)
(1)Interaction with
coverage of home health servicesSection 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)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 requirementSection 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 servicesSection
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
systemSection 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)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 limitationsUnder 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
componentsThe Secretary shall determine each component (as
defined by the Secretary) of such certified adult day services.
(B)Estimation of
payment amountThe 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)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)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 billingA 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)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)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
neutralityThe 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 periodsThe 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 assistanceIn 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)The amendments made by this section shall apply to items and
services furnished on or after January 1, 2013.