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 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 certified adult day services under the 

Medicare program, and for other purposes. 

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 Services Act of 2019’’. 

6 SEC. 2. FINDINGS. 

7 Congress makes the following findings: 


pamtmann on DSKBFK8HB2PROD with BILLS
2 

•HR 4063 IH

1 (1) Adult day care can offer services, including 

2 medical care, rehabilitation therapies, dignified as3 sistance with activities of daily living, nutrition ther4 apy, health monitoring, social interaction, stimu5 lating activities, and transportation, to seniors and 

6 people with disabilities at no extra cost to the Medi7 care program. 

8 (2) The care given at adult day services centers 

9 under an interdisciplinary team provides seniors, 

10 people with disabilities, and their familial caregivers 

11 with more care hours and additional services that 

12 are critical to keeping patients healthier and in the 

13 homes of the patients instead of in a nursing home, 

14 and reduces the risk of hospital admission or read15 mission. 

16 SEC. 3. MEDICARE COVERAGE OF CERTIFIED ADULT DAY 

17 SERVICES. 

18 (a) MEDICARE CERTIFIED ADULT DAY SERVICES

19 BENEFIT.— 

20 (1) DEFINITION.—Section 1861 of the Social 

21 Security Act (42 U.S.C. 1395x) is amended by add22 ing at the end the following new subsection: 


pamtmann on DSKBFK8HB2PROD with BILLS
3 

•HR 4063 IH

1 ‘‘Certified Adult Day Services; Adult Day Services Pro2 vider; Certified Adult Day Services Center; Post-In3 stitutional Certified Adult Day Services; Certified 

4 Adult Day Services Spell of Illness 

5 ‘‘(kkk)(1)(A) The term ‘certified adult day services’ 

6 means, subject to paragraph (4), the items and services 

7 described in subparagraph (B) that are furnished to an 

8 individual who is under the care of a physician— 

9 ‘‘(i) by an adult day services provider (as de10 fined in paragraph (2)) or by another entity under 

11 an arrangement with such an adult day services pro12 vider to provide such services; 

13 ‘‘(ii) in accordance with a plan (for furnishing 

14 such items and services to such individual) approved 

15 and periodically reviewed by such physician; and 

16 ‘‘(iii) in a certified adult day services center (as 

17 defined in paragraph (3)). 

18 ‘‘(B) For purposes of subparagraph (A), the items 

19 and services described in this subparagraph are the fol20 lowing: 

21 ‘‘(i) Part-time or intermittent services (as de22 fined in subparagraph (C)(i)) provided by or under 

23 the supervision of a registered professional nurse. 


pamtmann on DSKBFK8HB2PROD with BILLS
4 

•HR 4063 IH

1 ‘‘(ii) Physical or occupational therapy or 

2 speech-language pathology services, or any combina3 tion of such services. 

4 ‘‘(iii) Medical social services under the direction 

5 of a physician. 

6 ‘‘(iv) Nutritional meals, including special diets, 

7 as ordered by a physician. 

8 ‘‘(v) A program of supervised activities (that 

9 meets such criteria as the Secretary determines ap10 propriate) designed to promote physical and mental 

11 health that are furnished in a group setting for a pe12 riod of not fewer than 4 and not greater than 8 

13 hours per day. 

14 ‘‘(vi) A medication management program (as 

15 defined in subparagraph (C)(ii)). 

16 ‘‘(vii) Medical supplies (including catheters, 

17 catheter supplies, ostomy bags, and supplies related 

18 to ostomy care, and a covered osteoporosis drug (as 

19 defined in subsection (kk)), but excluding other 

20 drugs and biologicals) and durable medical equip21 ment. 

22 ‘‘(viii) Transportation of the individual de23 scribed in subparagraph (A) to and from a certified 

24 adult day services center in connection with the proVerDate 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

1 vision of an item or service described in a previous 

2 provision of this subparagraph. 

3 ‘‘(C)(i) For purposes of subparagraph (B)(i), the 

4 term ‘part-time or intermittent services’ means certified 

5 adult day services furnished any number of days per week 

6 as long as such services are furnished fewer than 8 hours 

7 each day. For purposes of sections 1814(a)(2)(C) and 

8 1835(a)(2)(A), insofar as such respective section relates 

9 to certified adult day services, ‘intermittent’ means cer10 tified adult day services that are either provided or needed 

11 on fewer than 7 days each week, or less than 8 hours of 

12 each day for periods of 21 days or less (with extensions 

13 in exceptional circumstances when the need for additional 

14 care is finite and predictable). 

15 ‘‘(ii) For purposes of subparagraph (B)(vi), the term 

16 ‘medication management program’ means a program of 

17 education and services (that meets such criteria as the 

18 Secretary determines appropriate) to minimize— 

19 ‘‘(I) unnecessary or inappropriate use of pre20 scription drugs; and 

21 ‘‘(II) adverse events due to unintended prescrip22 tion drug-to-drug interactions. 

23 ‘‘(2) The term ‘adult day services provider’ means a 

24 provider of home and community-based services that is ap25 proved in the applicable State to provide long-term servVerDate 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

1 ices and supports, which may include nursing care, phys2 ical therapy, occupational therapy, social work services, 

3 transportation, and personal care services. 

4 ‘‘(3) The term ‘certified adult day services center’ 

5 means a facility— 

6 ‘‘(A) of a public agency or private organization, 

7 or a subdivision of such an agency or organization, 

8 that— 

9 ‘‘(i) is primarily engaged in providing an 

10 interdisciplinary approach that includes skilled 

11 nursing services and other therapeutic services 

12 directly; 

13 ‘‘(ii) has policies, established by a group of 

14 professional personnel (associated with the 

15 agency or organization), including one or more 

16 physicians and one or more registered profes17 sional nurses, to govern the services (referred to 

18 in subparagraph (A)) which it provides, and 

19 provides for supervision of such services; 

20 ‘‘(iii) maintains clinical records on all pa21 tients; 

22 ‘‘(iv) in the case of an agency or organiza23 tion in any State in which State or applicable 

24 local law provides for the licensing or certifi25 cation of agencies or organizations of this naVerDate 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

1 ture, (i) is licensed or certified pursuant to such 

2 law, or (ii) is approved, by the agency of such 

3 State or locality responsible for licensing or cer4 tifying agencies or organizations of this nature, 

5 as meeting the standards established for such 

6 licensing or certification; 

7 ‘‘(v) is licensed or certified by the State in8 volved or accredited as meeting requirements, 

9 including under section 1865, through a nation10 ally recognized accrediting agency that is recog11 nized by the Secretary; 

12 ‘‘(vi) has in effect an overall plan and 

13 budget that meets the requirements of sub14 section (z); 

15 ‘‘(vii) meets applicable conditions of par16 ticipation under section 1891(a) (or similar 

17 conditions specified by the Secretary as applica18 ble to such an agency or organization) and such 

19 other conditions of participation as the Sec20 retary may find necessary in the interest of the 

21 health and safety of individuals who are fur22 nished services by such agency or organization; 

23 and 

24 ‘‘(viii) meets such additional requirements 

25 (including conditions relating to bonding or esVerDate 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

1 tablishing of escrow accounts as the Secretary 

2 finds necessary for the financial security of the 

3 program) as the Secretary finds necessary for 

4 the effective and efficient operation of the pro5 gram; 

6 ‘‘(B) at which such agency or organization pro7 vides for items and services described in paragraph 

8 (1)(B); and 

9 ‘‘(C) that complies with all applicable State and 

10 local building codes, fire codes, zoning laws, and 

11 State licensing building standards that apply to a 

12 State licensed or certified or nationally accredited 

13 adult day center, and in States where there are no 

14 State licensing building standards for adult day cen15 ters, building standards based on the standards 

16 adopted by a nationally recognized accrediting agen17 cy that is recognized by the Secretary and applies to 

18 such a center standards that are comparable to the 

19 requirements applied to a skilled nursing facility 

20 pursuant to section 1819(d)(2)(B). 

21 ‘‘(4) For purposes of paragraph (1)(A), an item or 

22 service furnished to an individual, with respect to a period, 

23 shall not be considered an adult day service if— 

24 ‘‘(A) the individual is— 


pamtmann on DSKBFK8HB2PROD with BILLS
9 

•HR 4063 IH

1 ‘‘(i) concurrently receiving similar skilled 

2 services under a State plan under section 

3 1905(a) or under a home and community-based 

4 waiver authorized for a State under section 

5 1115, under subsection (c) or (d) of section 

6 1915, under a State plan amendment under 

7 subsection (i) of section 1915, or under section 

8 1902(a)(10)(D); and 

9 ‘‘(ii) receiving such item or service during 

10 such period under such State plan, waiver, 

11 amendment, or respective section; or 

12 ‘‘(B) the individual is receiving such item or 

13 service during such period pursuant to a plan of 

14 care from a home health agency under section 

15 1861(m). 

16 ‘‘(5) Nothing in this subsection shall be construed as 

17 prohibiting a home health agency from— 

18 ‘‘(A) establishing a State licensed or certified or 

19 nationally accredited certified adult day services cen20 ter and furnishing certified adult day services; or 

21 ‘‘(B) providing services under arrangements 

22 with such a center. 

23 ‘‘(6) The term ‘post-institutional certified adult day 

24 services’ means certified adult day services furnished to 

25 an individual— 


pamtmann on DSKBFK8HB2PROD with BILLS
10 

•HR 4063 IH

1 ‘‘(A) after discharge from a hospital or critical 

2 access hospital in which the individual was an inpa3 tient for not less than 3 consecutive days before 

4 such discharge if such certified adult day services 

5 were initiated within 14 days after the date of such 

6 discharge; or 

7 ‘‘(B) after discharge from a skilled nursing fa8 cility in which the individual was provided post-hos9 pital extended care services if such certified adult 

10 day services were initiated within 14 days after the 

11 date of such discharge. 

12 ‘‘(7) The term ‘certified adult day services spell of 

13 illness’ with respect to any individual means a period of 

14 consecutive days— 

15 ‘‘(A) beginning with the first day (not included 

16 in a previous certified adult day services spell of ill17 ness)— 

18 ‘‘(i) on which such individual is furnished 

19 post-institutional certified adult day services; 

20 and 

21 ‘‘(ii) which occurs in a month for which 

22 the individual is entitled to benefits under part 

23 A; and 

24 ‘‘(B) ending with the close of the first period of 

25 60 consecutive days thereafter on each of which the 


pamtmann on DSKBFK8HB2PROD with BILLS
11 

•HR 4063 IH

1 individual is neither an inpatient of a hospital or 

2 critical access hospital nor an inpatient of a facility 

3 described in section 1819(a)(1) or subsection (y)(1) 

4 nor provided home health services or certified adult 

5 day services.’’. 

6 (2) INCLUSION UNDER PART B BENEFIT.—Sec7 tion 1832(a)(2) of the Social Security Act (42 

8 U.S.C. 1395k(a)(2)) is amended— 

9 (A) in subparagraph (I), by striking at the 

10 end ‘‘and’’; 

11 (B) in subparagraph (J), by striking at the 

12 end the period and inserting ‘‘and’’; and 

13 (C) by adding at the end the following new 

14 subparagraph: 

15 ‘‘(K) certified adult day services (as de16 fined in section 1861(kkk)(1)(A)).’’. 

17 (3) INCLUSION UNDER PART A BENEFIT.—Sec18 tion 1812(a) of the Social Security Act (42 U.S.C. 

19 1395d(a)) is amended— 

20 (A) in paragraph (4), by striking at the 

21 end ‘‘and’’; 

22 (B) in paragraph (5), by striking the pe23 riod at the end and inserting ‘‘and’’; and 

24 (C) by adding at the end the following new 

25 paragraph: 


pamtmann on DSKBFK8HB2PROD with BILLS
12 

•HR 4063 IH

1 ‘‘(6) in the case of individuals not enrolled in 

2 part B, certified adult day services (as defined in 

3 paragraph (1)(A) of section 1861(kkk)), and in the 

4 case of individuals so enrolled, post-institutional cer5 tified adult day services (as defined in paragraph (6) 

6 of such section) furnished during a certified adult 

7 day services spell of illness (as defined in paragraph 

8 (7) of such section) for up to 100 visits during such 

9 spell of illness.’’. 

10 (b) PAYMENT OF CLAIMS REQUIREMENTS FOR HOME

11 HEALTH SERVICES APPLIED TO CERTIFIED ADULT DAY

12 SERVICES.— 

13 (1) PART A.—Section 1814(a)(2)(C) of the So14 cial Security Act (42 U.S.C. 1395f(a)(2)(C)) is 

15 amended by inserting ‘‘or certified adult day serv16 ices’’ after each occurrence of ‘‘home health serv17 ices’’. 

18 (2) PART B.—Section 1835(a)(2)(A) of the So19 cial Security Act (42 U.S.C. 1395n(a)(2)(A)) is 

20 amended— 

21 (A) in the matter preceding clause (i), by 

22 inserting ‘‘or certified adult day services (as de23 fined in section 1861(kkk)(1)(A))’’ after ‘‘home 

24 health services’’; and 


pamtmann on DSKBFK8HB2PROD with BILLS
13 

•HR 4063 IH

1 (B) in clause (i), by inserting ‘‘or certified 

2 adult day services’’ after ‘‘home health serv3 ices’’. 

4 (c) CONFORMING AMENDMENTS.— 

5 (1) INTERMITTENT SERVICES.—Section 

6 1861(m) of the Social Security Act (42 U.S.C. 

7 1395x(m)) is amended in the last sentence by insert8 ing ‘‘insofar as such respective section relates to 

9 home health services,’’ after ‘‘section 

10 1835(a)(2)(A),’’. 

11 (2) INTERACTION WITH COVERAGE OF HOME

12 HEALTH SERVICES.—Section 1861(m) of the Social 

13 Security Act (42 U.S.C. 1395x(m)), as amended by 

14 paragraph (1), is amended by adding at the end the 

15 following new sentence: ‘‘An individual described in 

16 this subsection, with respect to home health services 

17 furnished during a period, shall not include an indi18 vidual who is receiving comparable certified adult 

19 day services (as defined in section 1861(kkk)(1)) 

20 during such period.’’. 

21 (3) INSTITUTIONAL PLANNING REQUIRE22 MENT.—Section 1861(z) of the Social Security Act 

23 (42 U.S.C. 1395x(z)) is amended in the matter pre24 ceding paragraph (1), by striking ‘‘or home health 


pamtmann on DSKBFK8HB2PROD with BILLS
14 

•HR 4063 IH

1 agency’’ and inserting ‘‘home health agency, or cer2 tified adult day services center’’. 

3 (4) INCLUSION AS PROVIDER OF SERVICES.— 

4 Section 1861(u) of the Social Security Act (42 

5 U.S.C. 1395x(u)) is amended by inserting ‘‘certified 

6 adult day services center,’’ after ‘‘home health agen7 cy,’’. 

8 (d) PAYMENT FOR CERTIFIED ADULT DAY SERVICES

9 UNDER THE HOME HEALTH PROSPECTIVE PAYMENT

10 SYSTEM.—Section 1895 of the Social Security Act (42 

11 U.S.C. 1395fff) is amended by adding at the end the fol12 lowing new subsection: 

13 ‘‘(f) APPLICATION OF HOME HEALTH PROSPECTIVE

14 PAYMENT SYSTEM TO CERTIFIED ADULT DAY SERV15 ICES.— 

16 ‘‘(1) IN GENERAL.—The Secretary shall, in ac17 cordance with this subsection, develop a methodology 

18 under which the fee schedule and provisions under 

19 this section shall apply to certified adult day services 

20 (as defined in section 1861(kkk)(1)) in a similar 

21 manner to which such schedule and provisions apply 

22 to home health services. 

23 ‘‘(2) PAYMENT RATE DETERMINATION AND

24 LIMITATIONS.—Under such methodology, the fol25 lowing shall apply, with respect to certified adult day 


pamtmann on DSKBFK8HB2PROD with BILLS
15 

•HR 4063 IH

1 services furnished to an individual during a period 

2 specified by the Secretary under a plan of care es3 tablished under section 1861(kkk) for which pay4 ment may be made under this title: 

5 ‘‘(A) DETERMINATION OF COMPONENTS.— 

6 The Secretary shall determine each component 

7 (as defined by the Secretary) of such certified 

8 adult day services. 

9 ‘‘(B) ESTIMATION OF PAYMENT

10 AMOUNT.—The Secretary shall estimate the 

11 amount that would otherwise be payable under 

12 this section for the components of services de13 termined under subparagraph (A) if such serv14 ices were furnished by a home health agency 

15 (or, if such component or service would not oth16 erwise be so payable under this section if so 

17 furnished, the amount that would be payable 

18 under this section for a comparable home 

19 health service furnished by a home health agen20 cy) during such period. 

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

22 amount payable under this section for such cer23 tified adult day services furnished to such indi24 vidual during such period shall be 98 percent of 

25 the amount estimated to be payable for such 


pamtmann on DSKBFK8HB2PROD with BILLS
16 

•HR 4063 IH

1 services (or comparable services) under sub2 paragraph (B) for such period. 

3 ‘‘(D) LIMITATION.—No payment may be 

4 made under this section for certified adult day 

5 services described in clauses (iv) through (vi) 

6 and (ix) of section 1861(kkk)(1)(A). 

7 ‘‘(3) LIMITATION ON BALANCE BILLING.—A 

8 certified adult day services center shall accept as 

9 payment in full for certified adult day services de10 scribed in clauses (i) through (iii), (vii) through 

11 (viii), and (x) through (xii) of section 

12 1861(kkk)(1)(A) furnished by the center to an indi13 vidual entitled to benefits under this title the 

14 amount of payment provided under this section for 

15 home health services consisting of items and services 

16 described in such respective clauses.’’. 

17 (e) CONSOLIDATED BILLING.—Section 1862(a) of 

18 the Social Security Act (42 U.S.C. 1395y(a)) is amend19 ed— 

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

21 (24); 

22 (2) by striking the period at the end of para23 graph (25) and inserting, ‘‘or’’; and 

24 (3) by inserting after paragraph (25) the fol25 lowing new paragraph: 


pamtmann on DSKBFK8HB2PROD with BILLS
17 

•HR 4063 IH

1 ‘‘(26) which are certified adult day services for 

2 which payment may be made under section 1895(f) 

3 and which are furnished to an individual by a State 

4 licensed or certified or nationally accredited certified 

5 adult day services center pursuant to a plan of care 

6 established under section 1861(kkk) with respect to 

7 such services, by an entity other than such facility, 

8 unless the services are furnished under arrange9 ments (as defined in section 1861(w)(1)) with the 

10 entity made by such facility.’’. 

11 (f) TEMPORARY INCREASE FOR CERTIFIED ADULT

12 DAY SERVICES FURNISHED IN A RURAL AREA.— 

13 (1) IN GENERAL.—With respect to episodes and 

14 visits ending on or after January 1, 2018, and be15 fore January 1, 2020, in the case of certified adult 

16 day services (as defined in section 1861(kkk)(1)(A) 

17 of the Social Security Act, as added by subsection 

18 (a)), furnished in a rural area (as defined in section 

19 1886(d)(2)(D) of such Act (42 U.S.C. 

20 1395ww(d)(2)(D))), the Secretary of Health and 

21 Human Services shall increase the payment amount 

22 otherwise made under section 1895 of such Act (42 

23 U.S.C. 1395fff) for such services by 3 percent. 

24 (2) WAIVING BUDGET NEUTRALITY.—The Sec25 retary shall not reduce the standard prospective payVerDate Sep 11 2014 00:11 Aug 15, 2019 Jkt 089200 PO 00000 Frm 00017 Fmt 6652 Sfmt 6201 E:\BILLS\H4063.IH H4063

pamtmann on DSKBFK8HB2PROD with BILLS
18 

•HR 4063 IH

1 ment amount (or amounts) under section 1895 of 

2 the Social Security Act (42 U.S.C. 1395fff) applica3 ble to such certified adult day services furnished 

4 during a period to offset the increase in payments 

5 resulting from the application of paragraph (1). 

6 (3) NO EFFECT ON SUBSEQUENT PERIODS.— 

7 The payment increase provided under paragraph (1) 

8 for a period under such paragraph— 

9 (A) shall not apply to episodes and visits 

10 ending after such period; and 

11 (B) shall not be taken into account in cal12 culating the payment amounts applicable for 

13 episodes and visits occurring after such period. 

14 (g) ADULT DAY SERVICES PROVIDER TECHNICAL

15 ASSISTANCE.—In order to facilitate the development of 

16 certified adult day services under title XVIII of the Social 

17 Security Act, the Secretary of Health and Human Services 

18 shall, as deemed necessary by the Secretary, provide adult 

19 day services providers (as defined in section 1861(kkk)(2) 

20 of such Act) with technical assistance, consultation, tools, 

21 and other resources to assist them with the application 

22 process and implementation of certified adult day services 

23 (as defined in such section). 


pamtmann on DSKBFK8HB2PROD with BILLS
19 

•HR 4063 IH

1 (h) EFFECTIVE DATE.—The amendments made by 

2 this section shall apply to items and services furnished on 

3 or after January 1, 2020. 

Æ 


pamtmann on DSKBFK8HB2PROD with BILLS