I 

111TH CONGRESS 

1ST SESSION H. R. 3043 

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 

JUNE 25, 2009 

Ms. LINDA T. SA ́NCHEZ 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 

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 Adult Day 

5 Care Services Act of 2009’’. 

6 SEC. 2. FINDINGS. 

7 Congress makes the following findings: 


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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 care facilities 

9 provides seniors, people with disabilities, and their 

10 familial caregivers with more care hours and addi11 tional services that are critical to keeping patients 

12 healthier and in the home. 

13 (3) More than 50,000,000 people provide care 

14 for a chronically ill, disabled or aged family member 

15 or friend during any given year. In 2002, almost 

16 half of workers in the United States provided some 

17 form of caregiving. 

18 (4) Caregivers, the majority of whom are 

19 women, provide an estimated $306,000,000,000 in 

20 ‘‘free’’ services annually. The pool of potential family 

21 caregivers is dwindling, from 11 potential caregivers 

22 for each person needing care today to a projected 4 

23 to 1 ratio in 2050. 

24 (5) Caregiving families tend to have lower in25 comes than non-caregiving families, and the average 


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1 intensive caregiver loses $659,139 in wages, pension 

2 benefits, and Social Security benefits over a lifetime. 

3 At least 6 out of 10 employed caregivers reported 

4 that they had made some work-related adjustments 

5 as a result of their caregiving responsibilities, and 

6 an estimated 9 percent of caregivers left the work7 place altogether as a result of their caregiving re8 sponsibilities. 

9 (6) The total estimated cost to employers for 

10 full-time employees with intense caregiving respon11 sibilities is $17,100,000,000. The total estimated 

12 cost to employers for all full-time, employed care13 givers is $33,600,000,000 annually. 

14 (7) Adult day care centers, which are located in 

15 every State in the United States and the District of 

16 Columbia, serve as an effective source of relief to fa17 milial caregivers and provide quality health options 

18 to treat our Nation’s elderly population, which is 

19 about to dramatically increase with the aging of the 

20 baby boomer generation. 

21 SEC. 3. MEDICARE COVERAGE OF SUBSTITUTE ADULT DAY 

22 CARE SERVICES. 

23 (a) SUBSTITUTE ADULT DAY CARE SERVICES BEN24 EFIT.— 


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1 (1) IN GENERAL.—Section 1861(m) of the So2 cial Security Act (42 U.S.C. 1395x(m)) is amend3 ed— 

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

5 by inserting ‘‘or paragraph (8)’’ after ‘‘para6 graph (7)’’; 

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

8 the end; 

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

10 the end; and 

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

12 following new paragraph: 

13 ‘‘(8) substitute adult day care services (as de14 fined in subsection (hhh)(1)) furnished by a State li15 censed or certified or nationally accredited adult day 

16 dare facility (as defined in subsection (hhh)(2));’’. 

17 (2) SUBSTITUTE ADULT DAY CARE SERVICES

18 DEFINED.—Section 1861 of the Social Security Act 

19 (42 U.S.C. 1395x) is amended by adding at the end 

20 the following new subsection: 

21 ‘‘Substitute Adult Day Care Services; Adult Day Care 

22 Facility 

23 ‘‘(hhh)(1)(A) The term ‘substitute adult day care 

24 services’ means the items and services described in sub25 paragraph (B) that are furnished to an individual by a 


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1 State licensed or certified or nationally accredited adult 

2 day care facility as a part of a plan under subsection (m) 

3 that substitutes such services for a portion of the items 

4 and services described in subparagraph (B)(i) furnished 

5 by a home health agency under the plan, as determined 

6 by the physician 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 such adult day care facility in connection with 

13 any such item or service. 

14 ‘‘(iii) Meals. 

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

16 meets such criteria as the Secretary determines ap17 propriate) designed to promote physical and mental 

18 health that are furnished to the individual by such 

19 a facility in a group setting for a period of not fewer 

20 than 4 and not greater than 12 hours per day. 

21 ‘‘(v) A medication management program (as de22 fined in subparagraph (C)). 

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

24 ‘medication management program’ means a program of 


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1 education and services (that meets such criteria as the 

2 Secretary determines appropriate) to minimize— 

3 ‘‘(i) unnecessary or inappropriate use of pre4 scription drugs; and 

5 ‘‘(ii) adverse events due to unintended prescrip6 tion drug-to-drug interactions. 

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

8 term ‘State licensed or certified or nationally accredited 

9 adult day care facility’ means a public agency or private 

10 organization, or a subdivision of such an agency or organi11 zation, that— 

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

13 services and other therapeutic services directly or 

14 under arrangement with a home health agency; 

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

16 Secretary to assure quality of care and such other 

17 requirements as the Secretary finds necessary in the 

18 interest of the health and safety of individuals who 

19 are furnished services in the facility; 

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

21 in paragraph (1)(B); 

22 ‘‘(iv) subject to subparagraph (B), meets the 

23 requirements of paragraphs (2) through (8) of sub24 section (o); and 


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1 ‘‘(v) if the agency, organization, or subdivision 

2 is in a State not described in subsection (o)(4), is 

3 accredited through a nationally recognized accred4 iting agency. 

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

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

7 case of an agency or organization that provides a com8 parable surety bond under State law. 

9 ‘‘(C) For purposes of payment for home health serv10 ices consisting of substitute adult day care services fur11 nished under this title, any reference to a home health 

12 agency is deemed to be a reference to a State licensed or 

13 certified or nationally accredited adult day care facility. 

14 ‘‘(D) Nothing in this paragraph shall be construed 

15 as prohibiting a home health agency from— 

16 ‘‘(i) establishing a State licensed or certified or 

17 nationally accredited adult day care facility; or 

18 ‘‘(ii) providing services under arrangements 

19 with such a facility.’’. 

20 (3) CONFORMING AMENDMENTS.—Sections 

21 1814(a)(2)(C) and 1835(a)(2)(A)(i) of the Social 

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

23 1395n(a)(2)(A)(i)) are each amended by striking 

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

25 or (8) of section 1861(m)’’. 


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1 (b) PAYMENT FOR SUBSTITUTE ADULT DAY CARE

2 SERVICES UNDER THE HOME HEALTH PROSPECTIVE

3 PAYMENT SYSTEM.—Section 1895 of the Social Security 

4 Act (42 U.S.C. 1395fff) is amended by adding at the end 

5 the following new subsection: 

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

7 FOR SUBSTITUTE ADULT DAY CARE SERVICES.— 

8 ‘‘(1) PAYMENT RATE.— 

9 ‘‘(A) IN GENERAL.—The Secretary shall 

10 determine each component (as defined by the 

11 Secretary) of substitute adult day care services 

12 (under section 1861(hhh)(1)(B)(i)) furnished to 

13 an individual under the plan of care established 

14 under section 1861(m) with respect to such 

15 services. 

16 ‘‘(B) ESTIMATION OF PAYMENT

17 AMOUNT.—The Secretary shall estimate the 

18 amount that would otherwise be payable under 

19 this section for all home health services under 

20 that plan of care other than substitute adult 

21 day care services for a week or other period 

22 specified by the Secretary. 

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

24 amount payable for home health services con25 sisting of substitute adult day care services 


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1 under such plan of care is 98 percent of the 

2 amount estimated to be payable under subpara3 graph (B) furnished under the plan by a home 

4 health agency. 

5 ‘‘(2) LIMITATIONS.— 

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

7 health services consisting of substitute adult 

8 day care services, no payment may be made 

9 under this section for home health services con10 sisting of substitute adult day care services de11 scribed in clauses (ii) through (v) of section 

12 1861(hhh)(1)(B). 

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

14 A State licensed or certified or nationally ac15 credited adult day care facility shall accept as 

16 payment in full for substitute adult day care 

17 services (including those services described in 

18 clauses (ii) through (v) of section 

19 1861(hhh)(1)(B)) furnished by the facility to 

20 an individual entitled to benefits under this title 

21 the amount of payment provided under this sec22 tion for home health services consisting of sub23 stitute adult day care services.’’. 


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

2 the Social Security Act (42 U.S.C. 1395y(a)) is amend3 ed— 

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

5 (23); 

6 (2) by striking the period at the end of para7 graph (24) and inserting ‘‘; or’’; and 

8 (3) by inserting after paragraph (24) the fol9 lowing new paragraph: 

10 ‘‘(25) which are substitute adult day care serv11 ices for which payment may be made under section 

12 1895(f) and which are furnished to an individual by 

13 a State licensed or certified or nationally accredited 

14 adult day care facility pursuant to a plan of care es15 tablished under section 1861(m) with respect to 

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

17 unless the services are furnished under arrange18 ments (as defined in section 1861(w)(1)) with the 

19 entity made by such facility.’’. 

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

21 this section shall apply to items and services furnished on 

22 or after January 1, 2010. 

Æ 


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