I 
117TH CONGRESS 
1ST SESSION H. R. 5514 
To amend title XVIII of the Social Security Act to improve extended care 
services by providing Medicare beneficiaries with an option for cost effec-
tive home-based extended care under the Medicare program, and for 
other purposes. 
IN THE HOUSE OF REPRESENTATIVES 
OCTOBER 8, 2021 
Mr. CUELLAR (for himself, Mr. COMER, Mr. SUOZZI, Mr. EVANS, Mr. HIG-
GINS of Louisiana, Mr. BISHOP of Georgia, Mr. HIGGINS of New York, 
Mr. VICENTE GONZALEZ of Texas, Mr. TONKO, Mr. CARTER of Georgia, 
Mr. O’HALLERAN, Mr. BRENDAN F. BOYLE of Pennsylvania, Ms. NOR-
TON, and Mr. JOHNSON of Louisiana) 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 provi-
sions as fall within the jurisdiction of the committee concerned 
A BILL 
To amend title XVIII of the Social Security Act to improve 
extended care services by providing Medicare bene-
ficiaries with an option for cost effective home-based 
extended care under the Medicare program, and for other 
purposes. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
VerDate Sep 11 2014 
01:09 Oct 13, 2021
Jkt 029200
PO 00000
Frm 00001
Fmt 6652
Sfmt 6201
E:\BILLS\H5514.IH
H5514
pbinns on DSKJLVW7X2PROD with BILLS
tended care services, after such services (or a com-
bination of such services and post-hospital extended 
care services) have been furnished to him for 20 
days during such spell).’’. 
(3) CERTIFICATION
REQUIREMENT.—Section 
1814(a)(2) of the Social Security Act (42 U.S.C. 
1395f(a)(2)) is amended— 
(A) in the matter preceding subparagraph 
(A), by inserting ‘‘or (E)’’ after ‘‘subparagraph 
(C)’’; 
(B) in subparagraph (C), by striking ‘‘or’’ 
at the end; 
(C) in subparagraph (D), by inserting ‘‘or’’ 
after the semicolon; and 
(D) by adding at the end the following new 
subparagraph: 
‘‘(E) in the case of post-hospital home- 
based extended care services, such services are 
or were required to be furnished because the in-
dividual otherwise needs or needed and qualifies 
for extended care services in a skilled nursing 
facility payable under this part under subpara-
graph (B), and such individual does not qualify 
for services in an inpatient rehabilitation facil-
VerDate Sep 11 2014 
01:09 Oct 13, 2021
Jkt 029200
PO 00000
Frm 00005
Fmt 6652
Sfmt 6201
E:\BILLS\H5514.IH
H5514
pbinns on DSKJLVW7X2PROD with BILLS
ity or long-term care hospital payable under 
this part;’’. 
(4) POST-HOSPITAL
EXTENDED
CARE
SERV-
ICES.—Section 1861(i) of the Social Security Act 
(42 U.S.C. 1395x(i)) is amended, in the second sen-
tence— 
(A) by striking ‘‘or (B)’’ and inserting 
‘‘(B)’’; and 
(B) by striking the period and inserting 
the following: ‘‘, or (C) in the case of an indi-
vidual receiving post-hospital home-based ex-
tended care services, within 30 days after dis-
charge from a hospital.’’. 
(5) DEFINITION
OF
HOME-BASED
EXTENDED 
CARE SERVICES.—Section 1861 of the Social Secu-
rity Act (42 U.S.C. 1395x) is amended by adding at 
the end the following new subsection: 
‘‘Home-Based Extended Care Services 
‘‘(lll)(1) The term ‘home-based extended care serv-
ices’ means the following items and services furnished to 
an individual in the individual’s home by a home health 
agency (as defined in subsection (o) including the addi-
tional requirements under paragraph (9) of such sub-
section), or by others under arrangements with such agen-
cy: 
VerDate Sep 11 2014 
01:09 Oct 13, 2021
Jkt 029200
PO 00000
Frm 00006
Fmt 6652
Sfmt 6201
E:\BILLS\H5514.IH
H5514
pbinns on DSKJLVW7X2PROD with BILLS
‘‘(A) Nursing care, other than as described in 
subsection (m), including when provided using tele-
communications technology as a supplement to daily 
in-person care. 
‘‘(B) Physical or occupational therapy or 
speech-language pathology services, other than as 
described in subsection (m), including when provided 
using telecommunications as a supplement to daily 
in-person care. 
‘‘(C) Meals and nutritional support. 
‘‘(D) Remote patient monitoring as a supple-
ment to in-person care other than as described in 
subsection (m). 
‘‘(E) Medical social services other than as de-
scribed in subsection (m). 
‘‘(F) Services of a home health aide other than 
as described in subsection (m) and personal care 
services. 
‘‘(G) Respite care, family caregiver and other 
unpaid caregiver supports, education, and training 
resources. 
‘‘(H) Assistance with adherence to drugs pre-
scribed for the individual. 
‘‘(I) Medical supplies, appliances, and equip-
ment, other than those described in subsection (m), 
VerDate Sep 11 2014 
01:09 Oct 13, 2021
Jkt 029200
PO 00000
Frm 00007
Fmt 6652
Sfmt 6201
E:\BILLS\H5514.IH
H5514
pbinns on DSKJLVW7X2PROD with BILLS
for use in the home, including related to bathing, 
dressing, toileting, walking, or feeding. 
‘‘(J) Nonemergency medical transportation 
other than ambulance services. 
‘‘(K) Care coordination and integration, includ-
ing providing discharge planning and care transi-
tions support to the individual and family and other 
unpaid caregivers, including referral for person-cen-
tered counseling or options counseling from their 
State’s Aging and Disability Resource Center/No 
Wrong Door System, upon completion of a 30-day 
episode or one or more subsequent 30-day episode or 
episodes, if applicable, under section 1812(a)(6)(C). 
To the greatest extent possible, care transitions sup-
port services provided as part of home-based ex-
tended care services should use evidence-based mod-
els and practices, particularly those that employ 
face-to-face visits. 
‘‘(L) Such other items and services as the home 
health agency determines are necessary for the care 
of the individual in the home. 
‘‘(2) Nothing in this subsection shall be construed as 
impacting an individual’s eligibility for transition of care 
services under any other provision of this title or otherwise 
for which the individual is eligible.’’. 
VerDate Sep 11 2014 
01:09 Oct 13, 2021
Jkt 029200
PO 00000
Frm 00008
Fmt 6652
Sfmt 6201
E:\BILLS\H5514.IH
H5514
pbinns on DSKJLVW7X2PROD with BILLS
(6) 
DISCHARGE
PLANNING.—Section 
1861(ee)(2) of the Social Security Act (42 U.S.C. 
1395x(ee)(2)) is amended— 
(A) in subparagraph (D)— 
(i) by striking ‘‘hospice care and post- 
hospital extended care services’’ and insert-
ing ‘‘hospice care, post-hospital extended 
care services, post-hospital home-based ex-
tended care services, and services furnished 
by inpatient rehabilitation facilities and 
units and long-term care hospitals’’; and 
(ii) by inserting ‘‘and home-based ex-
tended care services’’ after ‘‘home health 
services’’; and 
(B) by adding at the end the following new 
subparagraph: 
‘‘(I) The discharge planning evaluation and dis-
charge plan for an individual who meets applicable 
standards and criteria for extended care services 
under section 1812, and who does not need services 
provided by an inpatient rehabilitation facility or 
unit or a long-term care hospital, shall include, in 
addition to the items described in subparagraph 
(D)— 
VerDate Sep 11 2014 
01:09 Oct 13, 2021
Jkt 029200
PO 00000
Frm 00009
Fmt 6652
Sfmt 6201
E:\BILLS\H5514.IH
H5514
pbinns on DSKJLVW7X2PROD with BILLS
‘‘(i) an evaluation, in coordination with a 
qualified home health agency, of the appro-
priateness of home-based extended care serv-
ices, including consideration of patient charac-
teristics, including but not limited to functional, 
cognitive, and behavioral competencies and defi-
cits and primary and secondary diagnoses, the 
availability of able and willing caregivers, the 
scope of home-based extended care services 
needed and other services (if applicable), the 
length of time such services would be needed, 
the availability of the level of services needed, 
and the need for and availability of health care 
services following completion of home-based ex-
tended care services, the individual’s place of 
care preferences, and the integration of and 
consideration of social determinants, inclusive 
of race and ethnicity and the availability of and 
access to quality services, into measures used to 
determine eligibility of a beneficiary to receive 
home-based extended care services; 
‘‘(ii) a consultation with the individual as 
to the findings of such evaluation, including 
consideration of the individual’s place of care 
preferences, goals regarding care, family care-
VerDate Sep 11 2014 
01:09 Oct 13, 2021
Jkt 029200
PO 00000
Frm 00010
Fmt 6652
Sfmt 6201
E:\BILLS\H5514.IH
H5514
pbinns on DSKJLVW7X2PROD with BILLS
giver concerns, and the ability of the individual 
to safely and effectively receive care in the 
home; 
‘‘(iii) the provision of caregiver training re-
sources to family and other unpaid caregivers 
including guidance on medical, nursing, and 
personal care tasks; and 
‘‘(iv) obtaining verbal consent from the in-
dividual that is recorded in the individual’s in-
patient care record if the individual chooses to 
receive home-based extended care services. 
Clauses (i), (ii), and (iii) shall not preempt any ap-
plicable State law requirements. Clause (iv) shall 
preempt any State law requirements relating to con-
sent for home-based extended care services. The Sec-
retary shall establish, through notice and comment 
rulemaking, the right to an expedited appeal of any 
adverse determination regarding the determination 
to provide the individual with the option of home- 
based extended care services and the scope of home- 
based extended care services needed by the indi-
vidual.’’. 
(7) 
ADDITIONAL
REQUIREMENTS.—Section 
1861(o) of the Social Security Act (42 U.S.C. 
1395x(o)) is amended— 
VerDate Sep 11 2014 
01:09 Oct 13, 2021
Jkt 029200
PO 00000
Frm 00011
Fmt 6652
Sfmt 6201
E:\BILLS\H5514.IH
H5514
pbinns on DSKJLVW7X2PROD with BILLS
(A) in paragraph (7)(B), by striking ‘‘and’’ 
at the end; 
(B) in paragraph (8), by inserting ‘‘and’’ 
at the end; and 
(C) by inserting after paragraph (8) the 
following new paragraph: 
‘‘(9) for purposes of furnishing post-hospital 
home-based extended care services under section 
1812(a)(6), meets such additional requirements and 
conditions as the Secretary finds necessary, includ-
ing— 
‘‘(A) the provision of care on a 24-hour 
basis; 
‘‘(B) the ability to provide all items and 
services described in subsection (lll); 
‘‘(C) the provision of necessary and cov-
ered services; 
‘‘(D) education, training, and supervision 
requirements for those providing home-based 
extended care services; and 
‘‘(E) compliance with all requirements and 
conditions when such services are provided 
under arrangement as described in subsection 
(m) to ensure that others providing care under 
such arrangement with such agency are held to 
VerDate Sep 11 2014 
01:09 Oct 13, 2021
Jkt 029200
PO 00000
Frm 00012
Fmt 6652
Sfmt 6201
E:\BILLS\H5514.IH
H5514
pbinns on DSKJLVW7X2PROD with BILLS
the same standards (requirements and condi-
tions) as the agency;’’. 
(8) HOME-BASED
EXTENDED
CARE
SERVICES 
ADD-ON.—Section 1895 of the Social Security Act 
(42 U.S.C. 1395fff) is amended by adding at the 
end the following new subsection: 
‘‘(f) HOME-BASED EXTENDED CARE SERVICES ADD- 
ON.— 
‘‘(1) IN GENERAL.—An add-on payment in ad-
dition to the amount otherwise payable under this 
section for home health services shall be made to a 
home health agency that meets the additional re-
quirements of section 1861(o)(9) and provides home- 
based 
extended 
care 
services 
under 
section 
1812(a)(6). 
‘‘(2) PAYMENT
AMOUNT.—Subject to para-
graphs (3) and (4), the amount of such add-on pay-
ment for home-based extended care services provided 
to an individual shall be determined as follows: 
‘‘(A) 
DETERMINATION.—Such 
amount 
shall be determined based on the following: 
‘‘(i) The following four case-mix clas-
sifications, determined by the number of 
hours of personal care services provided to 
an individual, as follows: 
VerDate Sep 11 2014 
01:09 Oct 13, 2021
Jkt 029200
PO 00000
Frm 00013
Fmt 6652
Sfmt 6201
E:\BILLS\H5514.IH
H5514
pbinns on DSKJLVW7X2PROD with BILLS
‘‘(I) Up to 60 hours, including an 
initial assessment. 
‘‘(II) Sixty-one to 120 hours. 
‘‘(III) One hundred twenty-one to 
240 hours. 
‘‘(IV) Two hundred forty-one to 
360 hours of personal care services. 
‘‘(ii) In calculating the number of 
hours of personal care services under 
clause (i), part-time or intermittent serv-
ices provided by home health aides under 
sections 1812(a)(2) and 1835(a)(2)(A) 
shall not be included. 
‘‘(iii) Such other factors as the Sec-
retary determines appropriate. 
‘‘(B) FIXED
BASE
AMOUNT.—The Sec-
retary shall provide a fixed base amount for 
each of the 4 case-mix classifications described 
in subclauses (I) through (IV) of subparagraph 
(A)(i) as follows: 
‘‘(i) 2022.—For services furnished 
during 2022, a fixed base amount of— 
‘‘(I) in the case of the case-mix 
classification described in subclause 
(I) of subparagraph (A)(i), $2,010; 
VerDate Sep 11 2014 
01:09 Oct 13, 2021
Jkt 029200
PO 00000
Frm 00014
Fmt 6652
Sfmt 6201
E:\BILLS\H5514.IH
H5514
pbinns on DSKJLVW7X2PROD with BILLS
‘‘(II) in the case of the case-mix 
classification described in subclause 
(II) of such subparagraph, $4,020; 
‘‘(III) in the case of the case-mix 
classification described in subclause 
(III) of such subparagraph, $7,360; 
and 
‘‘(IV) in the case of the case-mix 
classification described in subclause 
(IV) of such subparagraph, $10,720, 
respectively. 
‘‘(ii) 
2023 
AND
SUBSEQUENT 
YEARS.—For services furnished during 
2023, or a subsequent year, a fixed base 
amount equal to the amount determined 
under this subparagraph for the preceding 
year for the applicable case-mix classifica-
tion, updated by the home health applica-
ble increase percentage under subsection 
(b)(3)(B) applicable to the year involved. 
‘‘(C) AREA WAGE INDEX ADJUSTMENT.— 
The fixed base amount determined under sub-
paragraph (B) shall be subject to the applicable 
area wage index under subsection (b)(4)(C). 
VerDate Sep 11 2014 
01:09 Oct 13, 2021
Jkt 029200
PO 00000
Frm 00015
Fmt 6652
Sfmt 6201
E:\BILLS\H5514.IH
H5514
pbinns on DSKJLVW7X2PROD with BILLS
‘‘(3) 
ALTERNATIVE
ADD-ON
PAYMENT 
MODEL.—For services furnished in 2023, or in a 
subsequent year, the Secretary may apply an alter-
native model of payment that shall be based on rel-
evant and reliable data on patient characteristics 
that reflect the variations in resource use and inten-
sity within a patient case mix. 
‘‘(4) LIMITATION.—Notwithstanding any other 
provision in this section, the amount of the addi-
tional payment under this subsection to a home 
health agency for home-based extended care services, 
in combination with the amount of payment for 
home health services under this section for a unit of 
services furnished to an individual, shall not result 
in a total amount of payment under this section for 
such services that exceeds an amount equal to 80 
percent of the national median 30-day payment 
amount for extended care services furnished in a 
skilled nursing facility under section 1812 for the 
most recent fiscal year prior to the payment year for 
which data is available, updated based on the skilled 
nursing facility market basket percentage change 
under section 1888(e)(5)(B). The Secretary may ad-
just the amount of the additional payment for home- 
based extended care services under this subsection in 
VerDate Sep 11 2014 
01:09 Oct 13, 2021
Jkt 029200
PO 00000
Frm 00016
Fmt 6652
Sfmt 6201
E:\BILLS\H5514.IH
H5514
pbinns on DSKJLVW7X2PROD with BILLS