I 
112TH CONGRESS 
2D SESSION 
H. R. 6476 
To amend title XVIII of the Social Security Act to provide for coverage 
of certified adult day services under the Medicare program. 
IN THE HOUSE OF REPRESENTATIVES 
SEPTEMBER 20, 2012 
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 de-
termined 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. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE. 
This Act may be cited as the ‘‘Medicare Adult Day 
Services Act of 2012’’. 
SEC. 2. FINDINGS. 
Congress makes the following findings: 
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(1) Adult day care can offer services, including 
medical care, rehabilitation therapies, dignified as-
sistance with activities of daily living, nutrition ther-
apy, health monitoring, social interaction, stimu-
lating activities, and transportation, to seniors and 
people with disabilities at no extra cost to the Medi-
care program. 
(2) The care given at adult day services centers 
under an interdisciplinary team provides seniors, 
people with disabilities, and their familial caregivers 
with more care hours and additional services that 
are critical to keeping patients healthier and in the 
homes of the patients instead of in a nursing home, 
and reduces the risk of hospital admission or read-
mission. 
SEC. 3. MEDICARE COVERAGE OF CERTIFIED ADULT DAY 
SERVICES. 
(a) MEDICARE CERTIFIED ADULT DAY SERVICES 
BENEFIT.— 
(1) DEFINITION.—Section 1861 of the Social 
Security Act (42 U.S.C. 1395x) is amended by add-
ing at the end the following new subsection: 
‘‘(iii) CERTIFIED ADULT DAY SERVICES; ADULT DAY 
SERVICES PROVIDER; CERTIFIED ADULT DAY SERVICES 
CENTER; POST-INSTITUTIONAL CERTIFIED ADULT DAY 
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‘‘(iii) Medical social services under the direction 
of a physician. 
‘‘(iv) Nutritional meals, including special diets, 
as ordered by a physician. 
‘‘(v) A program of supervised activities (that 
meets such criteria as the Secretary determines ap-
propriate) designed to promote physical and mental 
health that are furnished in a group setting for a pe-
riod of not fewer than 4 and not greater than 8 
hours per day. 
‘‘(vi) A medication management program (as 
defined in subparagraph (C)(ii)). 
‘‘(vii) Medical supplies (including catheters, 
catheter supplies, ostomy bags, and supplies related 
to ostomy care, and a covered osteoporosis drug (as 
defined in subsection (kk)), but excluding other 
drugs and biologicals) and durable medical equip-
ment. 
‘‘(viii) Transportation of the individual de-
scribed in subparagraph (A) to and from a certified 
adult day services center in connection with the pro-
vision of an item or service described in a previous 
provision of this subparagraph. 
‘‘(C)(i) For purposes of subparagraph (B)(i), the 
term ‘part-time or intermittent services’ means certified 
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adult day services furnished any number of days per week 
as long as such services are furnished fewer than 8 hours 
each day. For purposes of sections 1814(a)(2)(C) and 
1835(a)(2)(A), insofar as such respective section relates 
to certified adult day services, ‘intermittent’ means cer-
tified adult day services that are either provided or needed 
on fewer than 7 days each week, or less than 8 hours of 
each day for periods of 21 days or less (with extensions 
in exceptional circumstances when the need for additional 
care is finite and predictable). 
‘‘(ii) For purposes of subparagraph (B)(vi), the term 
‘medication management program’ means a program of 
education and services (that meets such criteria as the 
Secretary determines appropriate) to minimize— 
‘‘(I) unnecessary or inappropriate use of pre-
scription drugs; and 
‘‘(II) adverse events due to unintended prescrip-
tion drug-to-drug interactions. 
‘‘(2) The term ‘adult day services provider’ means a 
provider of home and community based services that is 
approved in the applicable State to provide long-term serv-
ices and supports, which may include nursing care, phys-
ical therapy, occupational therapy, social work services, 
transportation, and personal care services. 
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‘‘(3) The term ‘certified adult day services center’ 
means a facility— 
‘‘(A) of a public agency or private organization, 
or a subdivision of such an agency or organization, 
that— 
‘‘(i) is primarily engaged in providing an 
interdisciplinary approach that includes skilled 
nursing services and other therapeutic services 
directly; 
‘‘(ii) has policies, established by a group of 
professional personnel (associated with the 
agency or organization), including one or more 
physicians and one or more registered profes-
sional nurses, to govern the services (referred to 
in subparagraph (A)) which it provides, and 
provides for supervision of such services; 
‘‘(iii) maintains clinical records on all pa-
tients; 
‘‘(iv) in the case of an agency or organiza-
tion in any State in which State or applicable 
local law provides for the licensing or certifi-
cation of agencies or organizations of this na-
ture, (i) is licensed or certified pursuant to such 
law, or (ii) is approved, by the agency of such 
State or locality responsible for licensing or cer-
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tifying agencies or organizations of this nature, 
as meeting the standards established for such 
licensing or certification; 
‘‘(v) is licensed or certified by the State in-
volved or accredited as meeting requirements, 
including under section 1865, through a nation-
ally recognized accrediting agency that is recog-
nized by the Secretary; 
‘‘(vi) has in effect an overall plan and 
budget that meets the requirements of sub-
section (z); 
‘‘(vii) meets applicable conditions of par-
ticipation under section 1891(a) (or similar 
conditions specified by the Secretary as applica-
ble to such an agency or organization) and such 
other conditions of participation as the Sec-
retary may find necessary in the interest of the 
health and safety of individuals who are fur-
nished services by such agency or organization; 
and 
‘‘(viii) meets such additional requirements 
(including conditions relating to bonding or es-
tablishing of escrow accounts as the Secretary 
finds necessary for the financial security of the 
program) as the Secretary finds necessary for 
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the effective and efficient operation of the pro-
gram; 
‘‘(B) at which such agency or organization pro-
vides for items and services described in paragraph 
(1)(B); and 
‘‘(C) that complies with all applicable State and 
local building codes, fire codes, zoning laws, and 
State licensing building standards that apply to a 
State licensed or certified or nationally accredited 
adult day center, and in States where there are no 
State licensing building standards for adult day cen-
ters, building standards based on the standards 
adopted by a nationally recognized accrediting agen-
cy that is recognized by the Secretary and applies to 
such a center standards that are comparable to the 
requirements applied to a skilled nursing facility 
pursuant to section 1819(d)(2)(B). 
‘‘(4) For purposes of paragraph (1)(A), an item or 
service furnished to an individual, with respect to a period, 
shall not be considered an adult day service if— 
‘‘(A) the individual is— 
‘‘(i) concurrently receiving similar skilled 
services under a State plan under section 
1905(a) or under a home and community-based 
waiver authorized for a State under section 
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1115, under subsection (c) or (d) of section 
1915, under a State plan amendment under 
subsection (i) of section 1915, or under section 
1902(a)(10)(D); and 
‘‘(ii) receiving such item or service during 
such period under such State plan, waiver, 
amendment, or respective section; or 
‘‘(B) the individual is receiving such item or 
service during such period pursuant to a plan of 
care from a home health agency under section 
1861(m). 
‘‘(5) Nothing in this subsection shall be construed as 
prohibiting a home health agency from— 
‘‘(A) establishing a State licensed or certified or 
nationally accredited certified adult day services cen-
ter and furnishing certified adult day services; or 
‘‘(B) providing services under arrangements 
with such a center. 
‘‘(6) The term ‘post-institutional certified adult day 
services’ means certified adult day services furnished to 
an individual— 
‘‘(A) after discharge from a hospital or critical 
access hospital in which the individual was an inpa-
tient for not less than 3 consecutive days before 
such discharge if such certified adult day services 
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case of individuals so enrolled, post-institutional cer-
tified adult day services (as defined in paragraph (6) 
of such section) furnished during a certified adult 
day services spell of illness (as defined in paragraph 
(7) of such section) for up to 100 visits during such 
spell of illness.’’. 
(b) PAYMENT OF CLAIMS REQUIREMENTS FOR HOME 
HEALTH SERVICES APPLIED TO CERTIFIED ADULT DAY 
SERVICES.— 
(1) PART A.—Section 1814(a)(2)(C) of the So-
cial Security Act (42 U.S.C. 1395f(a)(2)(C)) is 
amended by inserting ‘‘or certified adult day serv-
ices’’ after each occurrence of ‘‘home health serv-
ices’’. 
(2) PART B.—Section 1835(a)(2)(A) of the So-
cial Security Act (42 U.S.C. 1395n(a)(2)(A)) is 
amended— 
(A) in the matter preceding clause (i), by 
inserting ‘‘or certified adult day services (as de-
fined in section 1861(iii)(1)(A))’’ after ‘‘home 
health services’’; and 
(B) in clause (i), by inserting ‘‘or certified 
adult day services’’ after ‘‘home health serv-
ices’’. 
(c) CONFORMING AMENDMENTS.— 
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(1) INTERACTION WITH COVERAGE OF HOME 
HEALTH SERVICES.—Section 1861(m) of the Social 
Security Act (42 U.S.C. 1395x(m)) is amended by 
adding at the end the following new sentence: ‘‘An 
individual described in this subsection, with respect 
to home health services furnished during a period, 
shall not include an individual who is receiving com-
parable certified adult day services (as defined in 
section 1861(iii)(1)) during such period.’’. 
(2) 
INTERMITTENT
SERVICES.—Section 
1861(m) of the Social Security Act (42 U.S.C. 
1395x(m)) is amended in the last sentence by insert-
ing ‘‘insofar as such respective section relates to 
home 
health 
services,’’ 
after 
‘‘section 
1835(a)(2)(A),’’. 
(3) 
INSTITUTIONAL
PLANNING
REQUIRE-
MENT.—Section 1861(z) of the Social Security Act 
(42 U.S.C. 1395x(z)) is amended in the matter pre-
ceding paragraph (1), by striking ‘‘or home health 
agency’’ and inserting ‘‘home health agency, or cer-
tified adult day services center’’. 
(4) INCLUSION AS PROVIDER OF SERVICES.— 
Section 1861(u) of the Social Security Act (42 
U.S.C. 1395x(u)) is amended by inserting ‘‘certified 
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adult day services center,’’ after ‘‘home health agen-
cy,’’. 
(d) PAYMENT FOR CERTIFIED ADULT DAY SERVICES 
UNDER
THE HOME HEALTH PROSPECTIVE PAYMENT 
SYSTEM.—Section 1895 of the Social Security Act (42 
U.S.C. 1395fff) is amended by adding at the end the fol-
lowing new subsection: 
‘‘(f) APPLICATION OF HOME HEALTH PROSPECTIVE 
PAYMENT SYSTEM
TO CERTIFIED ADULT DAY SERV-
ICES.— 
‘‘(1) IN GENERAL.—The Secretary shall, in ac-
cordance with this subsection, develop a methodology 
under which the fee schedule and provisions under 
this section shall apply to certified adult day services 
(as defined in section 1861(iii)(1)) in a similar man-
ner to which such schedule and provisions apply to 
home health services. 
‘‘(2) PAYMENT
RATE
DETERMINATION
AND 
LIMITATIONS.—Under such methodology, the fol-
lowing shall apply, with respect to certified adult day 
services furnished to an individual during a period 
specified by the Secretary under a plan of care es-
tablished under section 1861(iii) for which payment 
may be made under this title: 
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‘‘(A) DETERMINATION OF COMPONENTS.— 
The Secretary shall determine each component 
(as defined by the Secretary) of such certified 
adult day services. 
‘‘(B) 
ESTIMATION
OF
PAYMENT 
AMOUNT.—The Secretary shall estimate the 
amount that would otherwise be payable under 
this section for the components of services de-
termined under subparagraph (A) if such serv-
ices were furnished by a home health agency 
(or, if such component or service would not oth-
erwise be so payable under this section if so 
furnished, the amount that would be payable 
under this section for a comparable home 
health service furnished by a home health agen-
cy) during such period. 
‘‘(C) AMOUNT
OF
PAYMENT.—The total 
amount payable under this section for such cer-
tified adult day services furnished to such indi-
vidual during such period shall be 98 percent of 
the amount estimated to be payable for such 
services (or comparable services) under sub-
paragraph (B) for such period. 
‘‘(D) LIMITATION.—No payment may be 
made under this section for certified adult day 
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services described in clauses (iv) through (vi) 
and (ix) of section 1861(iii)(1)(A). 
‘‘(3) LIMITATION
ON
BALANCE
BILLING.—A 
certified adult day services center shall accept as 
payment in full for certified adult day services de-
scribed in clauses (i) through (iii), (vii) through 
(viii), and (x) through (xii) of section 1861(iii)(1)(A) 
furnished by the center to an individual entitled to 
benefits under this title the amount of payment pro-
vided under this section for home health services 
consisting of items and services described in such re-
spective clauses.’’. 
(e) CONSOLIDATED BILLING.—Section 1862(a) of 
the Social Security Act (42 U.S.C. 1395y(a)) is amend-
ed— 
(1) by striking ‘‘or’’ at the end of paragraph 
(23); 
(2) by striking the period at the end of para-
graph (24) and inserting, ‘‘or’’; and 
(3) by inserting after paragraph (24) the fol-
lowing new paragraph: 
‘‘(25) which are certified adult day services for 
which payment may be made under section 1895(f) 
and which are furnished to an individual by a State 
licensed or certified or nationally accredited certified 
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adult day services center pursuant to a plan of care 
established under section 1861(iii) with respect to 
such services, by an entity other than such facility, 
unless the services are furnished under arrange-
ments (as defined in section 1861(w)(1)) with the 
entity made by such facility.’’. 
(f) TEMPORARY INCREASE FOR CERTIFIED ADULT 
DAY SERVICES FURNISHED IN A RURAL AREA.— 
(1) IN GENERAL.—With respect to episodes and 
visits ending on or after January 1, 2011, and be-
fore January 1, 2016, in the case of certified adult 
day services (as defined in section 1861(iii)(1)(A) of 
the Social Security Act, as added by subsection (a)), 
furnished in a rural area (as defined in section 
1886(d)(2)(D) 
of 
such 
Act 
(42 
U.S.C. 
1395ww(d)(2)(D))), the Secretary of Health and 
Human Services shall increase the payment amount 
otherwise made under section 1895 of such Act (42 
U.S.C. 1395fff) for such services by 3 percent. 
(2) WAIVING BUDGET NEUTRALITY.—The Sec-
retary shall not reduce the standard prospective pay-
ment amount (or amounts) under section 1895 of 
the Social Security Act (42 U.S.C. 1395fff) applica-
ble to such certified adult day services furnished 
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