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[Congressional Bills 118th Congress]
[From the U.S. Government Publishing Office]
[S. 4860 Introduced in Senate (IS)]

<DOC>

118th CONGRESS
  2d Session
                                S. 4860

 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 SENATE OF THE UNITED STATES

                             July 30, 2024

   Mr. Casey introduced the following bill; which was read twice and 
                  referred to the Committee on Finance

_______________________________________________________________________

                                 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 paragraph (4), by striking ``and'' at the end;
            (2) in paragraph (5), by striking the period at the end and 
        inserting a semicolon; and
            (3) 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 that--
                    ``(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) manages 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 that--
                    ``(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) manages 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 that--
                    ``(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 a semicolon; 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), 1861(ooo)(1), and 1861(ppp)(1) (in this 
        subsection collectively referred to as `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 section 1861(ppp)(3), 
        respectively (in this subsection collectively referred to as 
        `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, 
                2025, 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.--
                        Payment 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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