[Congressional Bills 119th Congress]
[From the U.S. Government Publishing Office]
[H.R. 9538 Introduced in House (IH)]
<DOC>
119th CONGRESS
2d Session
H. R. 9538
To amend title XVIII of the Social Security Act to establish coverage
for certain residential substance use disorder services under the
Medicare program.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
June 30, 2026
Ms. Underwood (for herself, Mr. Valadao, Mr. Tonko, Mrs. Miller of West
Virginia, Mr. LaHood, and Mr. Bost) introduced the following bill;
which was referred to the Committee on Ways and Means
_______________________________________________________________________
A BILL
To amend title XVIII of the Social Security Act to establish coverage
for certain residential substance use disorder 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 ``Residential Recovery for Seniors
Act''.
SEC. 2. ESTABLISHING COVERAGE FOR CERTAIN RESIDENTIAL SUBSTANCE USE
DISORDER SERVICES UNDER THE MEDICARE PROGRAM.
(a) Coverage Under Part A.--Section 1812(a) of the Social Security
Act (42 U.S.C. 1395d(a)) is amended--
(1) in the header, by striking ``and'' and inserting ``,
and Residential Substance Use Disorder Services'' after
``Hospice Care'';
(2) in paragraph (4), by striking ``and'' at the end;
(3) in paragraph (5), by striking the period at the end and
inserting ``;''; and
(4) by adding at the end the following new paragraphs:
``(6) clinically managed low-intensity residential
substance use disorder services (as defined in section
1861(nnn)(1)) furnished to an individual who is a resident of a
clinically managed residential substance use disorder facility
(as defined in section 1861(nnn)(3)) if the individual's
initial need for such level of services is performed, and
continued need for such level of services is reviewed and
reaffirmed periodically (on a frequency specified by the
Secretary that is not less often than every 30 days), in
accordance with the most current edition approved by the
Secretary of evidence-based, substance use disorder-specific
criteria developed by a nonprofit medical association generally
recognized for its expertise in addiction treatment;
``(7) clinically managed high-intensity residential
substance use disorder services (as defined in section
1861(ooo)(1)) furnished to an individual who is a resident of a
clinically managed residential substance use disorder facility
(as defined in section 1861(nnn)(3)) if the individual's
initial need for such level of services is performed, and
continued need for such level of services is reviewed and
reaffirmed periodically (on a frequency specified by the
Secretary that is not less often than every 30 days), in
accordance with the most current edition approved by the
Secretary of evidence-based, substance use disorder-specific
criteria developed by a nonprofit medical association generally
recognized for its expertise in addiction treatment; and
``(8) medically managed residential substance use disorder
services (as defined in section 1861(ppp)(1)) furnished to an
individual who is a resident of a medically managed residential
substance use disorder facility (as defined in section
1861(ppp)(3)) if the individual's initial need for such level
of services is performed, and continued need for such level of
services is reviewed and reaffirmed periodically (on a
frequency specified by the Secretary that is not less often
than every 10 days), in accordance with the most current
edition approved by the Secretary of evidence-based, substance
use disorder-specific criteria developed by a nonprofit medical
association generally recognized for its expertise in addiction
treatment.''.
(b) Residential Substance Use Disorder Services, Programs, and
Facilities Defined.--Section 1861 of the Social Security Act (42 U.S.C.
1395x) is amended by adding at the end the following new subsections:
``(nnn) Clinically Managed Low-Intensity Residential Substance Use
Disorder Services, Program, and Facility.--
``(1) Clinically managed low-intensity residential
substance use disorder services.--The term `clinically managed
low-intensity residential substance use disorder services'
means the following items and services furnished to an
individual in a clinically managed low-intensity residential
substance use disorder program (as defined in paragraph (2))
and (except as provided in subparagraph (C)) by such program
for the treatment of substance use disorders and co-occurring
conditions, including--
``(A) bed and board;
``(B) such clinical services and other related
services (including substance use disorder and co-
occurring condition assessments and treatment
planning), such use of clinically managed residential
substance use disorder facilities, and such medical
social services (including recovery support services),
as are ordinarily furnished by the clinically managed
low-intensity residential substance use disorder
program for the care and treatment of individuals in
such program, and such drugs, supplies, appliances, and
equipment, for use in the clinically managed low-
intensity residential substance use disorder program,
as are ordinarily furnished by such program for the
care and treatment of individuals in such program; and
``(C) such other diagnostic or therapeutic items or
services, furnished by the clinically managed low-
intensity residential substance use disorder program or
by others under arrangements with them made by the
clinically managed low-intensity residential substance
use disorder program, as are ordinarily furnished to
individuals either by such clinically managed low-
intensity residential substance use disorder program or
by others under such arrangements, excluding--
``(i) medical or surgical services provided
by a physician, services described by
subsection (s)(2)(K), and qualified
psychologist services; and
``(ii) the services of a private-duty nurse
or other private-duty attendant.
``(2) Clinically managed low-intensity residential
substance use disorder program.--The term `clinically managed
low-intensity residential substance use disorder program' means
a residential program which--
``(A) is primarily engaged in providing 24-hour
structure and support and integrated clinical services
for the diagnosis, treatment, and care of individuals
with substance use disorders who need structure and
support to build and practice their recovery and coping
skills;
``(B) directly provides a substance use disorder-
specific multidimensional level of care assessment at
admission to determine the recommended level of care,
using protocols developed by a physician or advanced
practice provider with experience in specialty
addiction treatment to confirm the appropriateness of
treatment in such program for individuals who are
intoxicated, experiencing withdrawal, or presenting
with biomedical comorbidities;
``(C) directly provides, or has a direct
affiliation with, a provider or providers who can
provide physical examinations, prescribe all addiction
and psychiatric medications, and provide medication
management and laboratory testing as needed (except
that access to methadone is not required if no
providers of methadone for opioid use disorder are
available, as determined by the Secretary);
``(D) directly provides weekly clinical services,
in hourly increments to be determined by the Secretary,
in an amount, frequency, and intensity appropriate to
an individual's needs as determined by a substance use
disorder-specific multidimensional assessment, with
structured services available seven days per week;
``(E) maintains clinical records on all patients
and maintains such records as the Secretary finds to be
necessary to determine the degree and intensity of the
treatment provided to individuals entitled to
clinically managed low-intensity residential substance
use disorder program insurance benefits under part A,
provided that the Secretary shall not require a program
to maintain such records in a manner that is more
extensive, detailed, or stringent than what is required
of an institution that is considered a `hospital' under
subsection (e);
``(F) coordinates patient referrals and transitions
to other levels of care when needed, including
transition planning in partnership with other providers
participating in the Medicare program; and
``(G) meets such additional staffing requirements
and other conditions as the Secretary shall specify to
ensure the effective and efficient furnishing of such
program's services and the compliance of such program
with clinically managed low-intensity residential
substance use disorder program standards described in
the most current edition approved by the Secretary of
evidence-based, substance use disorder-specific
criteria developed by a nonprofit medical association
generally recognized for its expertise in addiction
treatment.
Obtaining and maintaining certification from a certifying body
that has the necessary competencies to assess compliance with
such program standards and is approved by the Secretary shall
be deemed to demonstrate compliance with the standards
described in subparagraph (G).
``(3) Clinically managed residential substance use disorder
facility.--The term `clinically managed residential substance
use disorder treatment facility' means a facility which--
``(A) is enrolled under section 1866(j);
``(B) is accredited by an accrediting body approved
by the Secretary;
``(C) is legally authorized to provide a clinically
managed low- or high-intensity residential substance
use disorder program under the law of the State (or
under a State regulatory mechanism provided by State
law) in which the facility is located; and
``(D) meets such additional conditions as the
Secretary finds necessary in the interest of the health
and safety of individuals who are residents of such
facilities and are furnished clinically managed low-
intensity residential substance use disorder services
(or clinically managed high-intensity residential
substance use disorder services, as the case may be).
``(ooo) Clinically Managed High-Intensity Residential Substance Use
Disorder Services and Program.--
``(1) Clinically managed high-intensity residential
substance use disorder services.--The term `clinically managed
high-intensity residential substance use disorder services'
means the following items and services furnished to an
individual in a clinically managed high-intensity residential
substance use disorder program (as defined in paragraph (2))
and (except as provided in subparagraph (C)) by such program
for the treatment of substance use disorders and co-occurring
conditions, including--
``(A) bed and board;
``(B) such clinical services and other related
services (including substance use disorder and co-
occurring condition assessments and treatment
planning), such use of clinically managed residential
substance use disorder facilities, and such medical
social services (including recovery support services),
as are ordinarily furnished by the clinically managed
high-intensity residential substance use disorder
program for the care and treatment of individuals in
such program, and such drugs, supplies, appliances, and
equipment, for use in the clinically managed high-
intensity residential substance use disorder program,
as are ordinarily furnished by such program for the
care and treatment of individuals in such program; and
``(C) such other diagnostic or therapeutic items or
services, furnished by the clinically managed high-
intensity residential substance use disorder program or
by others under arrangements with them made by the
clinically managed high-intensity residential substance
use disorder program, as are ordinarily furnished to
individuals either by such clinically managed high-
intensity residential substance use disorder program or
by others under such arrangements, excluding--
``(i) medical or surgical services provided
by a physician, services described by
subsection (s)(2)(K), and qualified
psychologist services; and
``(ii) the services of a private-duty nurse
or other private-duty attendant.
``(2) Clinically managed high-intensity residential
substance use disorder program.--The term `clinically managed
high-intensity residential substance use disorder program'
means a residential program which--
``(A) is primarily engaged in providing 24-hour
supervision for the diagnosis, treatment, and care of
individuals with substance use disorders who need a
safe and stable living environment to develop
sufficient recovery skills so that they do not
immediately relapse or continue to use in an imminently
dangerous manner upon transition to a less intensive
level of care;
``(B) directly provides a substance use disorder-
specific multidimensional level of care assessment at
admission to determine the recommended level of care,
using protocols developed by a physician or advanced
practice provider experienced in specialty addiction
treatment to confirm the appropriateness of treatment
in such facility for individuals who are intoxicated,
experiencing withdrawal, or presenting with biomedical
comorbidities;
``(C) directly provides, or has a direct
affiliation with, a provider or providers who can
provide physical examinations, prescribe all addiction
and psychiatric medications, and provide medication
management and laboratory testing as needed (except
that access to methadone is not required if no
providers of methadone for opioid use disorder are
available, as determined by the Secretary);
``(D) directly provides 20 hours or more of
clinical services per week in an amount, frequency, and
intensity appropriate to individual patient needs as
determined by a substance use disorder-specific
multidimensional assessment, with structured services
available seven days per week;
``(E) directly provides clinically managed
residential withdrawal management, including 24-hour
supervision, observation, and support for individuals
who are intoxicated or experiencing withdrawal, who do
not need medically monitored or managed care (as
determined through a medical evaluation);
``(F) maintains clinical records on all patients
and maintains such records as the Secretary finds to be
necessary to determine the degree and intensity of the
treatment provided to individuals entitled to
clinically managed high-intensity residential substance
use disorder program insurance benefits under part A,
provided that the Secretary shall not require a program
to maintain such records in a manner that is more
extensive, detailed, or stringent than what is required
of an institution that is considered a `hospital' under
subsection (e);
``(G) management of patient referrals and
transitions to other levels of care when needed; and
``(H) meets such additional staffing requirements
and other conditions as the Secretary shall specify to
ensure the effective and efficient furnishing of such
program's services and the compliance of such program
with clinically managed high-intensity residential
substance use disorder program standards described in
the most current edition approved by the Secretary of
evidence-based, substance use disorder-specific
criteria developed by a nonprofit medical association
generally recognized for its expertise in addiction
treatment.
Obtaining and maintaining certification from a certifying body
that has the necessary competencies to assess compliance with
such program standards and is approved by the Secretary shall
be deemed to demonstrate compliance with the standards
described in subparagraph (H).
``(ppp) Medically Managed Residential Substance Use Disorder
Services, Program, and Facility.--
``(1) Medically managed residential substance use disorder
services.--The term `medically managed residential substance
use disorder services' means the following items and services
furnished to an individual in a medically managed residential
substance use disorder program (as defined in paragraph (2))
and (except as provided in subparagraph (C)) by such program
for the treatment of substance use disorders and co-occurring
conditions, including--
``(A) bed and board;
``(B) 24-hour nursing services;
``(C) such clinical services and other related
services (including substance use disorder and co-
occurring condition assessments and treatment
planning), such use of medically managed residential
substance use disorder facilities, and such medical
social services (including recovery support services),
as are ordinarily furnished by the medically managed
residential substance use disorder program for the care
and treatment of residents of such program, and such
drugs, supplies, appliances, and equipment, for use in
the medically managed residential substance use
disorder program, as are ordinarily furnished by such
program for the care and treatment of residents of such
program; and
``(D) such other diagnostic or therapeutic items or
services, furnished by the medically managed
residential substance use disorder program or by others
under arrangements with them made by the medically
managed residential substance use disorder program, as
are ordinarily furnished to residents either by the
medically managed residential substance use disorder
program or by others under such arrangements,
excluding--
``(i) medical or surgical services provided
by a physician, services described by
subsection (s)(2)(K), and qualified
psychologist services; and
``(ii) the services of a private-duty nurse
or other private-duty attendant.
``(2) Medically managed residential substance use disorder
program.--The term `medically managed residential substance use
disorder program' means a residential program which--
``(A) is primarily engaged in providing management
of substance withdrawal and biomedical comorbidities,
including diagnosis, treatment, and care, for
individuals with substance use disorders who need 24-
hour observation, monitoring, and treatment, but do not
require the full resources of a hospital;
``(B) directly provides a comprehensive nursing
assessment at the time of admission, with a substance
use disorder-focused history obtained as part of the
initial assessment which is reviewed by a physician or
advanced practice provider within 24 hours of
admission;
``(C) directly provides a comprehensive physical
examination by a physician or advanced practice
provider within 24 hours of admission;
``(D) directly provides sufficient biopsychosocial
screening and assessments of the patient's substance
use disorders and co-occurring disorders to determine
the appropriate recommended level of care and treatment
planning;
``(E) directly provides daily medical
interventions, including nursing and medical monitoring
for stabilization of acute withdrawal, biomedical and
psychiatric conditions, and psychosocial services to
encourage engagement in ongoing treatment, all in an
amount, frequency, and intensity appropriate to
individual patient needs as determined by a substance
use disorder-specific multidimensional assessment;
``(F) directly provides essential medications on
site with policies and procedures that define essential
medicines based on current standards of clinical
practice and that ensure these medications are stocked
and access to all Food and Drug Administration-approved
medications for the treatment of substance use
disorders (except that access to methadone is not
required if no providers of methadone for opioid use
disorder are available, as determined by the
Secretary);
``(G) directly provides residential intoxication
and withdrawal management services and residential
management of biomedical conditions;
``(H) maintains clinical records on all patients
and maintains such records as the Secretary finds to be
necessary to determine the degree and intensity of the
treatment provided to individuals entitled to
clinically managed high-intensity residential substance
use disorder program insurance benefits under part A,
provided that the Secretary shall not require a program
to maintain such records in a manner that is more
extensive, detailed, or stringent than what is required
of an institution that is considered a `hospital' under
subsection (e);
``(I) management of patient transitions to other
levels of care when needed; and
``(J) meets such additional staffing requirements
and other conditions as the Secretary shall specify to
ensure the effective and efficient furnishing of such
program's services and the compliance of such program
with clinically managed high-intensity residential
substance use disorder program standards described in
the most current edition approved by the Secretary of
evidence-based, substance use disorder-specific
criteria developed by a nonprofit medical association
generally recognized for its expertise in addiction
treatment.
Obtaining and maintaining certification from a certifying body
that has the necessary competencies to assess compliance with
such program standards and is approved by the Secretary shall
be deemed to demonstrate compliance with the standards
described in subparagraph (J).
``(3) Medically managed residential substance use disorder
facility.--The term `medically managed residential substance
use disorder treatment facility' means a facility which--
``(A) is enrolled under section 1866(j);
``(B) is accredited by an accrediting body approved
by the Secretary;
``(C) is legally authorized to provide a medically
managed residential substance use disorder program
under the law of the State (or under a State regulatory
mechanism provided by State law) in which the facility
is located; and
``(D) meets such additional conditions as the
Secretary finds necessary in the interest of the health
and safety of individuals who are residents of such
facilities and are furnished medically managed
residential substance use disorder services.''.
(c) Including Residential Substance Use Disorder Facilities as
Medicare Providers.--Section 1866(e) of the Social Security Act (42
U.S.C. 1395cc(e)) is amended--
(1) in paragraph (2), by striking at the end ``and'';
(2) in paragraph (3), by striking the period at the end and
inserting ``;''; and
(3) by adding at the end the following new paragraphs:
``(4) clinically managed residential substance use disorder
facilities (as defined in paragraph (3) of section 1861(nnn)),
but only with respect to the furnishing of clinically managed
low-intensity residential substance use disorder services (as
defined in paragraph (1) of such section) and clinically
managed high-intensity residential substance use disorder
services (as defined in paragraph (1) of section 1861(ooo)), as
applicable; and
``(5) medically managed residential substance use disorder
facilities (as defined in paragraph (3) of section 1861(ppp)),
but only with respect to the furnishing of clinically managed
low-intensity residential substance use disorder services (as
defined in paragraph (1) of section 1861(nnn)), clinically
managed high-intensity residential substance use disorder
services (as defined in paragraph (1) of section 1861(ooo)),
and medically managed residential substance use disorder
services (as defined in paragraph (1) of section 1861(ppp)), as
applicable.''.
(d) Prospective Payment System for Residential Substance Use
Disorder Services.--Section 1886 of the Social Security Act (42 U.S.C.
1395ww) is amended by adding at the end the following new subsection:
``(u) Prospective Payment for Residential Substance Use Disorder
Facilities.--
``(1) Development of system.--The Secretary shall develop a
per diem prospective payment system for low-intensity
clinically managed, high-intensity clinically managed, and
medically managed residential substance use disorder services,
as those terms are defined, respectively, in sections
1861(nnn)(1), (ooo)(1), and 1861(ppp)(1) (collectively,
`residential substance use disorder services'). Such system
shall include appropriate adjustments to reflect the differing
resource-intensity of low-intensity clinically managed, high-
intensity clinically managed, and medically managed residential
substance use disorder services, and may include an adequate
patient classification system that reflects differences in
patient resource use and cost. In developing such system, the
Secretary may require clinically managed and medically managed
residential substance use disorder facilities, as those terms
are defined in sections 1861(nnn)(3) and (ppp)(3), respectively
(collectively, `residential substance use disorder
facilities'), to submit such information to the Secretary,
including cost reports, as the Secretary may require to develop
such system.
``(2) Implementation.--
``(A) In general.--The Secretary shall provide, for
cost reporting periods beginning on or after October 1,
2026, for payments for residential substance use
disorder services furnished by residential substance
use disorder facilities in accordance with the
prospective payment system established by the Secretary
under this subsection.
``(B) Payments.--
``(i) Initial payments.--The Secretary
shall implement such prospective payment system
in the initial fiscal year so that the
estimated aggregate amount of prospective
payment rates is equal to 100 percent of the
estimated amount of reasonable costs incurred
by residential substance use disorder
facilities in furnishing such services.
``(ii) Payments in subsequent years.--
Payments rates in years after the year of
implementation of such system shall be the
payment rates in the previous year, adjusted by
an increase factor. Such factor shall be based
on an appropriate percentage increase in a
market basket of goods and services comprising
the services for which payment is made under
this subsection.''.
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