HR 3043

HR 3043 IH

To amend title XVIII of the Social Security Act to provide for coverage of substitute adult day care services under the Medicare Program.

June 25, 2009

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

To amend title XVIII of the Social Security Act to provide for coverage of substitute adult day care 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 Care Services Act of 2009’.

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 care facilities 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 home.

(3) More than 50,000,000 people provide care for a chronically ill, disabled or aged family member or friend during any given year. In 2002, almost half of workers in the United States provided some form of caregiving.

(4) Caregivers, the majority of whom are women, provide an estimated $306,000,000,000 in ‘free’ services annually. The pool of potential family caregivers is dwindling, from 11 potential caregivers for each person needing care today to a projected 4 to 1 ratio in 2050.

(5) Caregiving families tend to have lower incomes than non-caregiving families, and the average intensive caregiver loses $659,139 in wages, pension benefits, and Social Security benefits over a lifetime. At least 6 out of 10 employed caregivers reported that they had made some work-related adjustments as a result of their caregiving responsibilities, and an estimated 9 percent of caregivers left the workplace altogether as a result of their caregiving responsibilities.

(6) The total estimated cost to employers for full-time employees with intense caregiving responsibilities is $17,100,000,000. The total estimated cost to employers for all full-time, employed caregivers is $33,600,000,000 annually.

(7) Adult day care centers, which are located in every State in the United States and the District of Columbia, serve as an effective source of relief to familial caregivers and provide quality health options to treat our Nation’s elderly population, which is about to dramatically increase with the aging of the baby boomer generation.

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

(a) Substitute Adult Day Care 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 paragraph (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 care services (as defined in subsection (hhh)(1)) furnished by a State licensed or certified or nationally accredited adult day dare facility (as defined in subsection (hhh)(2));’.

(2) SUBSTITUTE ADULT DAY CARE 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 Care Services; Adult Day Care Facility

‘(hhh)(1)(A) The term ‘substitute adult day care services’ means the items and services described in subparagraph (B) that are furnished to an individual by a State licensed or certified or nationally accredited adult day care facility as a part of a plan under subsection (m) that substitutes such services for a portion 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) Transportation of the individual to and from such adult day care facility in connection with any such item or service.

‘(iii) Meals.

‘(iv) A program of supervised activities (that meets such criteria as the Secretary determines appropriate) designed to promote physical and mental health that are furnished to the individual by such a facility in a group setting for a period of not fewer than 4 and not greater than 12 hours per day.

‘(v) A medication management program (as defined in subparagraph (C)).

‘(C) For purposes of subparagraph (B)(v), 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)(A) Except as provided in subparagraph (B), the term ‘State licensed or certified or nationally accredited adult day care 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) meets such standards established by the Secretary to assure quality of care and such other requirements as the Secretary finds necessary in the interest of the health and safety of individuals who are furnished services in the facility;

‘(iii) provides the items and services described in paragraph (1)(B);

‘(iv) subject to subparagraph (B), meets the requirements of paragraphs (2) through (8) of subsection (o); and

‘(v) if the agency, organization, or subdivision is in a State not described in subsection (o)(4), is accredited through a nationally recognized accrediting agency.

‘(B) 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.

‘(C) For purposes of payment for home health services consisting of substitute adult day care services furnished under this title, any reference to a home health agency is deemed to be a reference to a State licensed or certified or nationally accredited adult day care facility.

‘(D) Nothing in this paragraph shall be construed as prohibiting a home health agency from--

‘(i) establishing a State licensed or certified or nationally accredited adult day care facility; or

‘(ii) providing services under arrangements with such a facility.’.

(3) CONFORMING AMENDMENTS- Sections 1814(a)(2)(C) and 1835(a)(2)(A)(i) of the Social Security Act (42 U.S.C. 1395f(a)(2)(C) and 1395n(a)(2)(A)(i)) are each amended by striking ‘section 1861(m)(7)’ and inserting ‘paragraph (7) or (8) of section 1861(m)’.

(b) Payment for Substitute Adult Day Care 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) Payment Rate and Limitation on Payment for Substitute Adult Day Care Services-

‘(1) PAYMENT RATE-

‘(A) IN GENERAL- The Secretary shall determine each component (as defined by the Secretary) of substitute adult day care services (under section 1861(hhh)(1)(B)(i)) furnished to an individual under the plan of care established under section 1861(m) with respect to such services.

‘(B) ESTIMATION OF PAYMENT AMOUNT- The Secretary shall estimate the amount that would otherwise be payable under this section for all home health services under that plan of care other than substitute adult day care services for a week or other period specified by the Secretary.

‘(C) AMOUNT OF PAYMENT- The total amount payable for home health services consisting of substitute adult day care services under such plan of care is 98 percent of the amount estimated to be payable under subparagraph (B) furnished under the plan by a home health agency.

‘(2) LIMITATIONS-

‘(A) IN GENERAL- With respect to home health services consisting of substitute adult day care services, no payment may be made under this section for home health services consisting of substitute adult day care services described in clauses (ii) through (v) of section 1861(hhh)(1)(B).

‘(B) LIMITATION ON BALANCE BILLING- A State licensed or certified or nationally accredited adult day care facility shall accept as payment in full for substitute adult day care services (including those services described in clauses (ii) through (v) of section 1861(hhh)(1)(B)) furnished by the facility to an individual entitled to benefits under this title the amount of payment provided under this section for home health services consisting of substitute adult day care services.’.

(c) 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 substitute adult day care 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 adult day care facility pursuant to a plan of care established under section 1861(m) 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.’.

(d) Effective Date- The amendments made by this section shall apply to items and services furnished on or after January 1, 2010.