I 116TH CONGRESS 1ST SESSION H. R. 4063 To amend title XVIII of the Social Security Act to provide for coverage of certified adult day services under the Medicare program, and for other purposes. IN THE HOUSE OF REPRESENTATIVES JULY 25, 2019 Ms. SA´NCHEZ (for herself, Mr. COHEN, Ms. MENG, and Ms. ROYBAL-ALLARD) introduced the following bill; which was referred to the Committee on Ways and Means, and in addition to the Committee on Energy and Com- merce, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdic- tion 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, and for other purposes. Be it enacted by the Senate and House of Representa- 1 tives of the United States of America in Congress assembled, 2 SECTION 1. SHORT TITLE. 3 This Act may be cited as the ‘‘Medicare Adult Day 4 Services Act of 2019’’. 5 SEC. 2. FINDINGS. 6 Congress makes the following findings: 7 VerDate Sep 11 2014 00:11 Aug 15, 2019 Jkt 089200 PO 00000 Frm 00001 Fmt 6652 Sfmt 6201 E:\BILLS\H4063.IH H4063 pamtmann on DSKBFK8HB2PROD with BILLS 2 •HR 4063 IH (1) Adult day care can offer services, including 1 medical care, rehabilitation therapies, dignified as- 2 sistance with activities of daily living, nutrition ther- 3 apy, health monitoring, social interaction, stimu- 4 lating activities, and transportation, to seniors and 5 people with disabilities at no extra cost to the Medi- 6 care program. 7 (2) The care given at adult day services centers 8 under an interdisciplinary team provides seniors, 9 people with disabilities, and their familial caregivers 10 with more care hours and additional services that 11 are critical to keeping patients healthier and in the 12 homes of the patients instead of in a nursing home, 13 and reduces the risk of hospital admission or read- 14 mission. 15 SEC. 3. MEDICARE COVERAGE OF CERTIFIED ADULT DAY 16 SERVICES. 17 (a) MEDICARE CERTIFIED ADULT DAY SERVICES 18 BENEFIT.— 19 (1) DEFINITION.—Section 1861 of the Social 20 Security Act (42 U.S.C. 1395x) is amended by add- 21 ing at the end the following new subsection: 22 VerDate Sep 11 2014 00:11 Aug 15, 2019 Jkt 089200 PO 00000 Frm 00002 Fmt 6652 Sfmt 6201 E:\BILLS\H4063.IH H4063 pamtmann on DSKBFK8HB2PROD with BILLS 3 •HR 4063 IH ‘‘Certified Adult Day Services; Adult Day Services Pro- 1 vider; Certified Adult Day Services Center; Post-In- 2 stitutional Certified Adult Day Services; Certified 3 Adult Day Services Spell of Illness 4 ‘‘(kkk)(1)(A) The term ‘certified adult day services’ 5 means, subject to paragraph (4), the items and services 6 described in subparagraph (B) that are furnished to an 7 individual who is under the care of a physician— 8 ‘‘(i) by an adult day services provider (as de- 9 fined in paragraph (2)) or by another entity under 10 an arrangement with such an adult day services pro- 11 vider to provide such services; 12 ‘‘(ii) in accordance with a plan (for furnishing 13 such items and services to such individual) approved 14 and periodically reviewed by such physician; and 15 ‘‘(iii) in a certified adult day services center (as 16 defined in paragraph (3)). 17 ‘‘(B) For purposes of subparagraph (A), the items 18 and services described in this subparagraph are the fol- 19 lowing: 20 ‘‘(i) Part-time or intermittent services (as de- 21 fined in subparagraph (C)(i)) provided by or under 22 the supervision of a registered professional nurse. 23 VerDate Sep 11 2014 00:11 Aug 15, 2019 Jkt 089200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 E:\BILLS\H4063.IH H4063 pamtmann on DSKBFK8HB2PROD with BILLS 4 •HR 4063 IH ‘‘(ii) Physical or occupational therapy or 1 speech-language pathology services, or any combina- 2 tion of such services. 3 ‘‘(iii) Medical social services under the direction 4 of a physician. 5 ‘‘(iv) Nutritional meals, including special diets, 6 as ordered by a physician. 7 ‘‘(v) A program of supervised activities (that 8 meets such criteria as the Secretary determines ap- 9 propriate) designed to promote physical and mental 10 health that are furnished in a group setting for a pe- 11 riod of not fewer than 4 and not greater than 8 12 hours per day. 13 ‘‘(vi) A medication management program (as 14 defined in subparagraph (C)(ii)). 15 ‘‘(vii) Medical supplies (including catheters, 16 catheter supplies, ostomy bags, and supplies related 17 to ostomy care, and a covered osteoporosis drug (as 18 defined in subsection (kk)), but excluding other 19 drugs and biologicals) and durable medical equip- 20 ment. 21 ‘‘(viii) Transportation of the individual de- 22 scribed in subparagraph (A) to and from a certified 23 adult day services center in connection with the pro- 24 VerDate Sep 11 2014 00:11 Aug 15, 2019 Jkt 089200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\H4063.IH H4063 pamtmann on DSKBFK8HB2PROD with BILLS 5 •HR 4063 IH vision of an item or service described in a previous 1 provision of this subparagraph. 2 ‘‘(C)(i) For purposes of subparagraph (B)(i), the 3 term ‘part-time or intermittent services’ means certified 4 adult day services furnished any number of days per week 5 as long as such services are furnished fewer than 8 hours 6 each day. For purposes of sections 1814(a)(2)(C) and 7 1835(a)(2)(A), insofar as such respective section relates 8 to certified adult day services, ‘intermittent’ means cer- 9 tified adult day services that are either provided or needed 10 on fewer than 7 days each week, or less than 8 hours of 11 each day for periods of 21 days or less (with extensions 12 in exceptional circumstances when the need for additional 13 care is finite and predictable). 14 ‘‘(ii) For purposes of subparagraph (B)(vi), the term 15 ‘medication management program’ means a program of 16 education and services (that meets such criteria as the 17 Secretary determines appropriate) to minimize— 18 ‘‘(I) unnecessary or inappropriate use of pre- 19 scription drugs; and 20 ‘‘(II) adverse events due to unintended prescrip- 21 tion drug-to-drug interactions. 22 ‘‘(2) The term ‘adult day services provider’ means a 23 provider of home and community-based services that is ap- 24 proved in the applicable State to provide long-term serv- 25 VerDate Sep 11 2014 00:11 Aug 15, 2019 Jkt 089200 PO 00000 Frm 00005 Fmt 6652 Sfmt 6201 E:\BILLS\H4063.IH H4063 pamtmann on DSKBFK8HB2PROD with BILLS 6 •HR 4063 IH ices and supports, which may include nursing care, phys- 1 ical therapy, occupational therapy, social work services, 2 transportation, and personal care services. 3 ‘‘(3) The term ‘certified adult day services center’ 4 means a facility— 5 ‘‘(A) of a public agency or private organization, 6 or a subdivision of such an agency or organization, 7 that— 8 ‘‘(i) is primarily engaged in providing an 9 interdisciplinary approach that includes skilled 10 nursing services and other therapeutic services 11 directly; 12 ‘‘(ii) has policies, established by a group of 13 professional personnel (associated with the 14 agency or organization), including one or more 15 physicians and one or more registered profes- 16 sional nurses, to govern the services (referred to 17 in subparagraph (A)) which it provides, and 18 provides for supervision of such services; 19 ‘‘(iii) maintains clinical records on all pa- 20 tients; 21 ‘‘(iv) in the case of an agency or organiza- 22 tion in any State in which State or applicable 23 local law provides for the licensing or certifi- 24 cation of agencies or organizations of this na- 25 VerDate Sep 11 2014 00:11 Aug 15, 2019 Jkt 089200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\H4063.IH H4063 pamtmann on DSKBFK8HB2PROD with BILLS 7 •HR 4063 IH ture, (i) is licensed or certified pursuant to such 1 law, or (ii) is approved, by the agency of such 2 State or locality responsible for licensing or cer- 3 tifying agencies or organizations of this nature, 4 as meeting the standards established for such 5 licensing or certification; 6 ‘‘(v) is licensed or certified by the State in- 7 volved or accredited as meeting requirements, 8 including under section 1865, through a nation- 9 ally recognized accrediting agency that is recog- 10 nized by the Secretary; 11 ‘‘(vi) has in effect an overall plan and 12 budget that meets the requirements of sub- 13 section (z); 14 ‘‘(vii) meets applicable conditions of par- 15 ticipation under section 1891(a) (or similar 16 conditions specified by the Secretary as applica- 17 ble to such an agency or organization) and such 18 other conditions of participation as the Sec- 19 retary may find necessary in the interest of the 20 health and safety of individuals who are fur- 21 nished services by such agency or organization; 22 and 23 ‘‘(viii) meets such additional requirements 24 (including conditions relating to bonding or es- 25 VerDate Sep 11 2014 00:11 Aug 15, 2019 Jkt 089200 PO 00000 Frm 00007 Fmt 6652 Sfmt 6201 E:\BILLS\H4063.IH H4063 pamtmann on DSKBFK8HB2PROD with BILLS 8 •HR 4063 IH tablishing of escrow accounts as the Secretary 1 finds necessary for the financial security of the 2 program) as the Secretary finds necessary for 3 the effective and efficient operation of the pro- 4 gram; 5 ‘‘(B) at which such agency or organization pro- 6 vides for items and services described in paragraph 7 (1)(B); and 8 ‘‘(C) that complies with all applicable State and 9 local building codes, fire codes, zoning laws, and 10 State licensing building standards that apply to a 11 State licensed or certified or nationally accredited 12 adult day center, and in States where there are no 13 State licensing building standards for adult day cen- 14 ters, building standards based on the standards 15 adopted by a nationally recognized accrediting agen- 16 cy that is recognized by the Secretary and applies to 17 such a center standards that are comparable to the 18 requirements applied to a skilled nursing facility 19 pursuant to section 1819(d)(2)(B). 20 ‘‘(4) For purposes of paragraph (1)(A), an item or 21 service furnished to an individual, with respect to a period, 22 shall not be considered an adult day service if— 23 ‘‘(A) the individual is— 24 VerDate Sep 11 2014 00:11 Aug 15, 2019 Jkt 089200 PO 00000 Frm 00008 Fmt 6652 Sfmt 6201 E:\BILLS\H4063.IH H4063 pamtmann on DSKBFK8HB2PROD with BILLS 9 •HR 4063 IH ‘‘(i) concurrently receiving similar skilled 1 services under a State plan under section 2 1905(a) or under a home and community-based 3 waiver authorized for a State under section 4 1115, under subsection (c) or (d) of section 5 1915, under a State plan amendment under 6 subsection (i) of section 1915, or under section 7 1902(a)(10)(D); and 8 ‘‘(ii) receiving such item or service during 9 such period under such State plan, waiver, 10 amendment, or respective section; or 11 ‘‘(B) the individual is receiving such item or 12 service during such period pursuant to a plan of 13 care from a home health agency under section 14 1861(m). 15 ‘‘(5) Nothing in this subsection shall be construed as 16 prohibiting a home health agency from— 17 ‘‘(A) establishing a State licensed or certified or 18 nationally accredited certified adult day services cen- 19 ter and furnishing certified adult day services; or 20 ‘‘(B) providing services under arrangements 21 with such a center. 22 ‘‘(6) The term ‘post-institutional certified adult day 23 services’ means certified adult day services furnished to 24 an individual— 25 VerDate Sep 11 2014 00:11 Aug 15, 2019 Jkt 089200 PO 00000 Frm 00009 Fmt 6652 Sfmt 6201 E:\BILLS\H4063.IH H4063 pamtmann on DSKBFK8HB2PROD with BILLS 10 •HR 4063 IH ‘‘(A) after discharge from a hospital or critical 1 access hospital in which the individual was an inpa- 2 tient for not less than 3 consecutive days before 3 such discharge if such certified adult day services 4 were initiated within 14 days after the date of such 5 discharge; or 6 ‘‘(B) after discharge from a skilled nursing fa- 7 cility in which the individual was provided post-hos- 8 pital extended care services if such certified adult 9 day services were initiated within 14 days after the 10 date of such discharge. 11 ‘‘(7) The term ‘certified adult day services spell of 12 illness’ with respect to any individual means a period of 13 consecutive days— 14 ‘‘(A) beginning with the first day (not included 15 in a previous certified adult day services spell of ill- 16 ness)— 17 ‘‘(i) on which such individual is furnished 18 post-institutional certified adult day services; 19 and 20 ‘‘(ii) which occurs in a month for which 21 the individual is entitled to benefits under part 22 A; and 23 ‘‘(B) ending with the close of the first period of 24 60 consecutive days thereafter on each of which the 25 VerDate Sep 11 2014 00:11 Aug 15, 2019 Jkt 089200 PO 00000 Frm 00010 Fmt 6652 Sfmt 6201 E:\BILLS\H4063.IH H4063 pamtmann on DSKBFK8HB2PROD with BILLS 11 •HR 4063 IH individual is neither an inpatient of a hospital or 1 critical access hospital nor an inpatient of a facility 2 described in section 1819(a)(1) or subsection (y)(1) 3 nor provided home health services or certified adult 4 day services.’’. 5 (2) INCLUSION UNDER PART B BENEFIT.—Sec- 6 tion 1832(a)(2) of the Social Security Act (42 7 U.S.C. 1395k(a)(2)) is amended— 8 (A) in subparagraph (I), by striking at the 9 end ‘‘and’’; 10 (B) in subparagraph (J), by striking at the 11 end the period and inserting ‘‘and’’; and 12 (C) by adding at the end the following new 13 subparagraph: 14 ‘‘(K) certified adult day services (as de- 15 fined in section 1861(kkk)(1)(A)).’’. 16 (3) INCLUSION UNDER PART A BENEFIT.—Sec- 17 tion 1812(a) of the Social Security Act (42 U.S.C. 18 1395d(a)) is amended— 19 (A) in paragraph (4), by striking at the 20 end ‘‘and’’; 21 (B) in paragraph (5), by striking the pe- 22 riod at the end and inserting ‘‘and’’; and 23 (C) by adding at the end the following new 24 paragraph: 25 VerDate Sep 11 2014 00:11 Aug 15, 2019 Jkt 089200 PO 00000 Frm 00011 Fmt 6652 Sfmt 6201 E:\BILLS\H4063.IH H4063 pamtmann on DSKBFK8HB2PROD with BILLS 12 •HR 4063 IH ‘‘(6) in the case of individuals not enrolled in 1 part B, certified adult day services (as defined in 2 paragraph (1)(A) of section 1861(kkk)), and in the 3 case of individuals so enrolled, post-institutional cer- 4 tified adult day services (as defined in paragraph (6) 5 of such section) furnished during a certified adult 6 day services spell of illness (as defined in paragraph 7 (7) of such section) for up to 100 visits during such 8 spell of illness.’’. 9 (b) PAYMENT OF CLAIMS REQUIREMENTS FOR HOME 10 HEALTH SERVICES APPLIED TO CERTIFIED ADULT DAY 11 SERVICES.— 12 (1) PART A.—Section 1814(a)(2)(C) of the So- 13 cial Security Act (42 U. 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