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106TH CONGRESS

1ST SESSION H. R. 745

To amend title XVIII of the Social Security Act to provide for coverage

of substitute adult day care services under the Medicare Program.

IN THE HOUSE OF REPRESENTATIVES

FEBRUARY 11, 1999

Mr. STARK (for himself, Mr. CARDIN, Mr. RANGEL, Mr. LEWIS of Georgia,

Mr. WAXMAN, Mrs. MINK of Hawaii, Mr. BRADY of Texas, Mr. HINCHEY, Mr. BENTSEN, Mr. BALDACCI, Mr. WISE, Mr. FROST, Mr.

GEORGE MILLER of California, Mr. ROMERO-BARCELO ́, Mr. STUPAK, Mr.

SHOWS, Mr. HILLIARD, Mrs. CLAYTON, Mr. SANDERS, Ms. DELAURO,

and Mr. KLECZKA) introduced the following bill; which was referred to

the Committee on Ways and Means, and in addition to the Committee

on 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 substitute adult day care services under

the Medicare Program.

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled,

3 SECTION 1. SHORT TITLE.

4 This Act may be cited as the ‘‘Medicare Substitute

5 Adult Day Care Services Act of 1999’’.
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1 SEC. 2. COVERAGE OF SUBSTITUTE ADULT DAY CARE SERV2 ICES UNDER MEDICARE.

3 (a) SUBSTITUTE ADULT DAY CARE SERVICES BENE4 FIT.—

5 (1) IN GENERAL.—Section 1861(m) of the So6 cial Security Act (42 U.S.C. 1395x(m)) is

7 amended—

8 (A) in the matter preceding paragraph (1),

9 by inserting ‘‘or paragraph (8)’’ after ‘‘para10 graph (7)’’;

11 (B) in paragraph (6), by striking ‘‘and’’ at

12 the end;

13 (C) in paragraph (7), by adding ‘‘and’’ at

14 the end; and

15 (D) by inserting after paragraph (7), the

16 following new paragraph:

17 ‘‘(8) substitute adult day care services (as de18 fined in subsection (uu));’’.

19 (2) SUBSTITUTE ADULT DAY CARE SERVICES

20 DEFINED.—Section 1861 of such Act (42 U.S.C.

21 1395x) is amended by adding at the end the follow22 ing new subsection:

23 ‘‘Substitute Adult Day Care Services; Adult Day Care

24 Facility

25 ‘‘(uu)(1)(A) The term ‘substitute adult day care serv26 ices’ means the items and services described in subpara-
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1 graph (B) furnished to an individual by an adult day care

2 facility as a part of a plan under subsection (m) substitut3 ing such services for a portion of the items and services

4 described in subparagraph (B)(i) furnished by a home

5 health agency under the plan, as determined by the physi6 cian establishing the plan.

7 ‘‘(B) The items and services described in this sub8 paragraph are the following items and services:

9 ‘‘(i) Items and services described in paragraphs

10 (1) through (7) of subsection (m).

11 ‘‘(ii) Transportation of the individual to and

12 from the adult day care facility in connection with

13 any such item or service.

14 ‘‘(iii) Meals.

15 ‘‘(iv) A program of supervised activities de16 signed to promote physical and mental health and

17 furnished to the individual by the adult day care fa18 cility in a group setting for a period of not fewer

19 than four and not greater than twelve hours per day.

20 ‘‘(2)(A) Except as provided in subparagraph (B), the

21 term ‘adult day care facility’ means a public agency or

22 private organization, or a subdivision of such an agency

23 or organization, that—

24 ‘‘(i) is engaged in providing skilled nursing

25 services and other therapeutic services;
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1 ‘‘(ii) meets such standards established by the

2 Secretary to assure quality of care and such other

3 requirements as the Secretary finds necessary in the

4 interest of the health and safety of individuals who

5 are furnished services in the facility; and

6 ‘‘(iii) meets the requirements of paragraphs (2)

7 through (8) of subsection (o).

8 ‘‘(B) The Secretary may waive the requirement of a

9 surety bond under paragraph (7) of subsection (o) in the

10 case of an agency or organization that provides a com11 parable surety bond under State law.

12 ‘‘(C) For purposes of payment for home health serv13 ices consisting of substitute adult day care services fur14 nished under this title, any reference to a home health

15 agency is deemed to be a reference to an adult day care

16 facility.’’.

17 (3) CONFORMING AMENDMENTS.—Sections

18 1814(a)(2)(C) and 1835(a)(2)(A)(i) of such Act (42

19 U.S.C. 1395f(a)(2)(C) and 42 U.S.C.

20 1395f(a)(2)(C)) are each amended by striking ‘‘sec21 tion 1861(m)(7)’’ and inserting ‘‘paragraph (7) or

22 (8) of section 1861(m)’’.

23 (b) PAYMENT FOR SUBSTITUTE ADULT DAY CARE

24 SERVICES.—
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1 (1) REASONABLE COST.—Section 1861(v)(1)(L)

2 of such Act (42 U.S.C. 1395x(v)(1)(L)) is amended

3 by adding at the end the following new clause:

4 ‘‘(x) In the case home health services consisting of

5 substitute adult day care services, the following rules

6 apply:

7 ‘‘(I) The Secretary shall determine each compo8 nent (as defined by the Secretary) of substitute

9 adult day care services (under subsection

10 (uu)(1)(B)(i)) furnished to an individual under the

11 plan of care established under subsection (m) with

12 respect to such services.

13 ‘‘(II) The Secretary shall estimate the amount

14 that would otherwise be payable under this subpara15 graph for all home health services under that plan

16 of care other than substitute adult day care services

17 for a week or other period specified by the Sec18 retary.

19 ‘‘(III) The total amount payable for home

20 health services consisting of substitute adult day

21 care services may not exceed 95 percent of the

22 amount estimated to be payable under subclause (II)

23 furnished under the plan by a home health agency.

24 ‘‘(IV) No payment may be made under this title

25 for home health services consisting of substitute
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1 adult day care services described in clauses (ii), (iii),

2 and (iv) of subsection (uu)(1)(B).’’.

3 (2) PROSPECTIVE PAYMENT SYSTEM.—Section

4 1895 of such Act (42 U.S.C. 1395fff) is amended by

5 adding at the end the following new subsection:

6 ‘‘(e) PAYMENT RATE FOR SUBSTITUTE ADULT DAY

7 CARE SERVICES.—In the case home health services con8 sisting of substitute adult day care services, the following

9 rules apply:

10 ‘‘(1) The Secretary shall determine each compo11 nent (as defined by the Secretary) of substitute

12 adult day care services (under section

13 1861(uu)(1)(B)(i)) furnished to an individual under

14 the plan of care established under section 1861(m)

15 with respect to such services.

16 ‘‘(2) The Secretary shall estimate the amount

17 that would otherwise be payable under this section

18 for all home health services under that plan of care

19 other than substitute adult day care services for a

20 week or other period specified by the Secretary.

21 ‘‘(3) The total amount payable for home health

22 services consisting of substitute adult day care serv23 ices may not exceed 95 percent of the amount esti24 mated to be payable under paragraph (2) furnished

25 under the plan by a home health agency.
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1 ‘‘(4) No payment may be made under this title

2 for home health services consisting of substitute

3 adult day care services described in clauses (ii), (iii),

4 and (iv) of section 1861(uu)(1)(B).’’.

5 (c) ADJUSTMENT IN CASE OF OVERUTILIZATION OF

6 SUBSTITUTE ADULT DAY CARE SERVICES.—

7 (1) MONITORING EXPENDITURES.—The Sec8 retary of Health and Human Services shall monitor

9 the expenditures made under the Medicare Program

10 under title XVIII of the Social Security Act for

11 home health services furnished under section

12 1861(m) of such Act for a fiscal year beginning with

13 fiscal year 2002, including substitute adult day care

14 services under paragraph (8) of such section (as

15 added by subsection (a)), and compare such expendi16 tures to expenditures that the Secretary estimates

17 would have been made for home health services for

18 that fiscal year if subsection (a) had not been en19 acted.

20 (2) REQUIRED REDUCTION IN PAYMENT

21 RATE.—If the Secretary determines, after making

22 the comparison under paragraph (1) and making

23 such adjustments for changes in demographics and

24 age of the Medicare beneficiary population as the

25 Secretary determines appropriate, that expenditures
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1 for home health services including such substitute

2 adult day care services exceed expenditures that

3 would have been made for home health services fur4 nished under section 1861(m) of such Act for a year

5 if subsection (a) had not been enacted, then the Sec6 retary shall adjust the rate of payment to adult day

7 care facilities so that total expenditures for home

8 health services furnished under such section in a fis9 cal year does not exceed the Secretary’s estimate of

10 such expenditures if subsection (a) had not been en11 acted.

12 (d) EFFECTIVE DATE.—The amendments made by

13 this section shall apply to items and services furnished on

14 or after the date that is the earlier of—

15 (1) January 1, 2001, or

16 (2) the date on which the prospective payment

17 system, for home health services furnished under the

18 medicare program, under section 1895 of the Social

19 Security Act (42 U.S.C. 1395fff) is established and

20 implemented.

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