I 

109TH CONGRESS 

1ST SESSION H. R. 1981

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

under the Medicare Program of substitute adult day care services. 

IN THE HOUSE OF REPRESENTATIVES 

APRIL 28, 2005

Mr. DOGGETT (for himself, Mr. ANDREWS, Mr. BACA, Mr. BECERRA, Mr. 

BROWN of Ohio, Mr. CARDIN, Mr. CARDOZA, Mr. CONYERS, Mr. 

CUELLAR, Mr. DELAHUNT, Ms. DELAURO, Mr. EVANS, Mr. FILNER, Mr. 

FRANK of Massachusetts, Mr. GONZALEZ, Mr. AL GREEN of Texas, Mr. 

GENE GREEN of Texas, Mr. GRIJALVA, Mr. GUTIERREZ, Mr. HINCHEY, 

Mr. HINOJOSA, Mr. HONDA, Mr. INSLEE, Ms. JACKSON-LEE of Texas, 

Mr. JEFFERSON, Ms. EDDIE BERNICE JOHNSON of Texas, Ms. KILPATRICK of Michigan, Mr. LEWIS of Georgia, Mr. LYNCH, Mr. 

MCDERMOTT, Mr. MCGOVERN, Mr. GEORGE MILLER of California, Ms. 

MOORE of Wisconsin, Mr. MORAN of Virginia, Mrs. NAPOLITANO, Mr. 

OLVER, Mr. ORTIZ, Mr. PASTOR, Mr. RANGEL, Mr. REYES, Ms. ROYBALALLARD, Mr. RUSH, Ms. LINDA T. SA ́NCHEZ of California, Ms. LORETTA

SANCHEZ of California, Mr. SANDERS, Ms. SOLIS, Mr. STARK, Mr. 

THOMPSON of Mississippi, Mr. TIERNEY, Mrs. JONES of Ohio, Ms. WATSON, and Mr. WAXMAN) 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 

A BILL

To amend title XVIII of the Social Security Act to provide 

for coverage under the Medicare Program of substitute 

adult day care services.
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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 Adult Day 

5 Care Services Act of 2005’’. 

6 SEC. 2. FINDINGS. 

7 Congress makes the following findings: 

8 (1) Adult day care offers services, including 

9 medical care, rehabilitation therapies, dignified as10 sistance with activities of daily living, nutrition ther11 apy, health monitoring, social interaction, stimu12 lating activities, and transportation, to seniors who 

13 are frail, physically challenged, or cognitively im14 paired at no extra cost to the medicare program. 

15 (2) The care given at adult day care centers 

16 provides seniors and their familial caregivers support 

17 that is critical to keeping the senior in the family 

18 home. 

19 (3) One quarter of all workers provide some 

20 form of elder care for those age 65 and older, and 

21 by 2007, the number of households involved in 

22 caregiving to persons age 50 or older could reach 39 

23 million. 

24 (4) The pool of potential family caregivers, who 

25 are primarily women and who provide an estimated 
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1 $257,000,000,000 in ‘‘free’’ services annually, is 

2 dwindling, from 11 potential caregivers for each per3 son needing care today to a projected 4 to 1 ratio 

4 in 2050. 

5 (5) Caregiving families tend to have lower in6 comes than non-caregiving families, and the average 

7 caregiver loses $659,139 in wages, pension benefits, 

8 and Social Security benefits over a lifetime. 

9 (6) The loss in productivity in United States 

10 businesses attributable to caregivers for aging or ail11 ing seniors ranges from $11,000,000,000 to 

12 $29,000,000,000 annually. 

13 (7) Adult day care centers, located in every 

14 State in the United States and the District of Co15 lumbia, serve as quality health options to treat our 

16 Nation’s elderly population, which is about to dra17 matically increase with the aging of the baby boomer 

18 generation. 

19 SEC. 3. MEDICARE COVERAGE OF SUBSTITUTE ADULT DAY 

20 CARE SERVICES. 

21 (a) SUBSTITUTE ADULT DAY CARE SERVICES BEN22 EFIT.—

23 (1) IN GENERAL.—Section 1861(m) of the So24 cial Security Act (42 U.S.C. 1395x(m)) is amend25 ed—
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1 (A) in the matter preceding paragraph (1), 

2 by inserting ‘‘or paragraph (8)’’ after ‘‘para3 graph (7)’’; 

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

5 the end; 

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

7 the end; and 

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

9 following new paragraph: 

10 ‘‘(8) substitute adult day care services (as de11 fined in subsection (bbb));’’. 

12 (2) SUBSTITUTE ADULT DAY CARE SERVICES

13 DEFINED.—Section 1861 of the Social Security Act 

14 (42 U.S.C. 1395x) is amended by adding at the end 

15 the following new subsection: 

16 ‘‘Substitute Adult Day Care Services; Adult Day Care 

17 Facility 

18 ‘‘(bbb)(1)(A) The term ‘substitute adult day care 

19 services’ means the items and services described in sub20 paragraph (B) that are furnished to an individual by an 

21 adult day care facility as a part of a plan under subsection 

22 (m) that substitutes such services for a portion of the 

23 items and services described in subparagraph (B)(i) fur24 nished by a home health agency under the plan, as deter25 mined by the physician establishing the plan. 
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1 ‘‘(B) The items and services described in this sub2 paragraph are the following items and services: 

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

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

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

6 from the adult day care facility in connection with 

7 any such item or service. 

8 ‘‘(iii) Meals. 

9 ‘‘(iv) A program of supervised activities (that 

10 meets such criteria as the Secretary determines ap11 propriate) designed to promote physical and mental 

12 health that are furnished to the individual by the 

13 adult day care facility in a group setting for a period 

14 of not fewer than 4 and not greater than 12 hours 

15 per day. 

16 ‘‘(v) A medication management program (as de17 fined in subparagraph (C)). 

18 ‘‘(C) For purposes of subparagraph (B)(v), the term 

19 ‘medication management program’ means a program of 

20 education and services (that meets such criteria as the 

21 Secretary determines appropriate) to minimize—

22 ‘‘(i) unnecessary or inappropriate use of pre23 scription drugs; and 

24 ‘‘(ii) adverse events due to unintended prescrip25 tion drug-to-drug interactions. 
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1 ‘‘(2)(A) Except as provided in subparagraph (B), the 

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

3 private organization, or a subdivision of such an agency 

4 or organization, that—

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

6 services and other therapeutic services directly or 

7 under arrangement with a home health agency; 

8 ‘‘(ii) meets such standards established by the 

9 Secretary to assure quality of care and such other 

10 requirements as the Secretary finds necessary in the 

11 interest of the health and safety of individuals who 

12 are furnished services in the facility; 

13 ‘‘(iii) provides the items and services described 

14 in paragraph (1)(B); and 

15 ‘‘(iv) meets the requirements of paragraphs (2) 

16 through (8) of subsection (o). 

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

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

19 case of an agency or organization that provides a com20 parable surety bond under State law. 

21 ‘‘(C) For purposes of payment for home health serv22 ices consisting of substitute adult day care services fur23 nished under this title, any reference to a home health 

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

25 facility. 
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1 ‘‘(D) Nothing in this paragraph shall be construed 

2 as prohibiting a home health agency from—

3 ‘‘(i) establishing a substitute adult day care fa4 cility; or 

5 ‘‘(ii) providing services under arrangements 

6 with a substitute adult day care facility.’’. 

7 (3) CONFORMING AMENDMENTS.—Sections 

8 1814(a)(2)(C) and 1835(a)(2)(A)(i) of the Social 

9 Security Act (42 U.S.C. 1395f(a)(2)(C) and 

10 1395n(a)(2)(A)(i)) are each amended by striking 

11 ‘‘section 1861(m)(7)’’ and inserting ‘‘paragraph (7) 

12 or (8) of section 1861(m)’’. 

13 (b) PAYMENT FOR SUBSTITUTE ADULT DAY CARE

14 SERVICES UNDER THE HOME HEALTH PROSPECTIVE

15 PAYMENT SYSTEM.—Section 1895 of the Social Security 

16 Act (42 U.S.C. 1395fff) is amended—

17 (1) in the first sentence of paragraph (b)(1), by 

18 inserting after ‘‘home health services’’ the following: 

19 ‘‘or home health services consisting of substitute 

20 adult day care services.’’; and 

21 (2) by adding at the end the following new sub22 section: 

23 ‘‘(f) PAYMENT RATE AND LIMITATION ON PAYMENT

24 FOR SUBSTITUTE ADULT DAY CARE SERVICES.—

25 ‘‘(1) PAYMENT RATE.—
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1 ‘‘(A) IN GENERAL.—The Secretary shall 

2 determine each component (as defined by the 

3 Secretary) of substitute adult day care services 

4 (under section 1861(bbb)(1)(B)(i)) furnished to 

5 an individual under the plan of care established 

6 under section 1861(m) with respect to such 

7 services. 

8 ‘‘(B) ESTIMATION OF PAYMENT

9 AMOUNT.—The Secretary shall estimate the 

10 amount that would otherwise be payable under 

11 this section for all home health services under 

12 that plan of care other than substitute adult 

13 day care services for a week or other period 

14 specified by the Secretary. 

15 ‘‘(C) AMOUNT OF PAYMENT.—The total 

16 amount payable for home health services con17 sisting of substitute adult day care services 

18 under such plan of care is equal to the amount 

19 estimated to be payable under subparagraph 

20 (B) furnished under the plan by a home health 

21 agency. 

22 ‘‘(2) LIMITATIONS.—

23 ‘‘(A) IN GENERAL.—With respect to home 

24 health services consisting of substitute adult 

25 day care services, no payment may be made 
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1 under this section for home health services con2 sisting of substitute adult day care services de3 scribed in clauses (ii) through (v) of section 

4 1861(bbb)(1)(B). 

5 ‘‘(B) LIMITATION ON BALANCE BILLING.—

6 An adult day care facility shall accept as pay7 ment in full for substitute adult day care serv8 ices (including those services described in 

9 clauses (ii) through (v) of section 

10 1861(bbb)(1)(B)) furnished by the facility to an 

11 individual entitled to benefits under this title 

12 the amount of payment provided under this sec13 tion for home health services consisting of sub14 stitute adult day care services.’’. 

15 (c) CONSOLIDATED BILLING.—Section 1862(a) of 

16 the Social Security Act (42 U.S.C. 1395y(a)), is amend17 ed—

18 (1) by striking ‘‘or’’ at the end of paragraph 

19 (21); 

20 (2) by striking the period at the end of para21 graph (22) and inserting ‘‘; or’’; and 

22 (3) by inserting after paragraph (22) the fol23 lowing new paragraph: 

24 ‘‘(23) which are substitute adult day care serv25 ices for which payment may be made under section 
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1 1895(f) and which are furnished to an individual by 

2 a substitute adult day care facility pursuant to a 

3 plan of care established under section 1861(m) with 

4 respect to such services, by an entity other than the 

5 substitute adult day care facility, unless the services 

6 are furnished under arrangements (as defined in sec7 tion 1861(w)(1)) with the entity made by the sub8 stitute adult day care facility.’’. 

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

10 this section shall apply to items and services furnished on 

11 or after January 1, 2006. 

12 (e) RELATIONSHIP TO DEMONSTRATION PROJECT.—

13 (1) Notwithstanding subsection (d) of section 703 of the 

14 Medicare Prescription Drug, Improvement, and Mod15 ernization Act of 2003 (Public Law 108–173; 117 Stat. 

16 2336), the Secretary may terminate the demonstration 

17 project for medical adult day care services established 

18 under such section 703, but in no case earlier than the 

19 date on which the Secretary has fully implemented the 

20 preceding provisions of this section. The Secretary shall 

21 ensure that individuals receiving medical adult day care 

22 services under such demonstration program do not experi23 ence any interruption in the receipt of such services by 

24 reason of the termination of the demonstration program. 
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1 (2) Section 703 of the Medicare Prescription Drug, 

2 Improvement, and Modernization Act of 2003 (Public Law 

3 108–173; 117 Stat. 2336) is amended by striking sub4 section (h).

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