I 
119TH CONGRESS 
1ST SESSION H. R. 6592 
To amend title XIX of the Social Security Act to develop national quality 
standards for continuous skilled nursing services provided through Med-
icaid, and for other purposes. 
IN THE HOUSE OF REPRESENTATIVES 
DECEMBER 10, 2025 
Mr. RULLI (for himself, Mr. STANTON, and Mr. PAPPAS) introduced the 
following bill; which was referred to the Committee on Energy and Commerce 
A BILL 
To amend title XIX of the Social Security Act to develop 
national quality standards for continuous skilled nursing 
services provided through Medicaid, and for other pur-
poses. 
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 ‘‘Continuous Skilled 
Nursing Quality Improvement Act of 2025’’. 
SEC. 2. DEFINITIONS. 
In this Act: 
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(1) FULL-BENEFIT
DUAL
ELIGIBLE
INDI-
VIDUAL.—The term ‘‘full-benefit dual eligible indi-
vidual’’ means an individual who is entitled to, or 
enrolled for, benefits under part A of title XVIII of 
the Social Security Act (42 U.S.C. 1395 et seq.), or 
enrolled for benefits under part B of title XVIII of 
such Act, and is eligible for medical assistance under 
the Medicaid program for full benefits under section 
1902(a)(10)(A) 
of 
such 
Act 
(42 
U.S.C. 
1396a(a)(10)(A)) or 1902(a)(10)(C) of such Act (42 
U.S.C. 1396a(a)(10)(C)), by reason of section 
1902(f) of such Act (42 U.S.C. 1396a(f)), or under 
any other category of eligibility for medical assist-
ance for full benefits, as determined by the Sec-
retary. 
(2) MEDICAID BENEFICIARY.—The term ‘‘Med-
icaid beneficiary’’ means an individual who is eligible 
for, and enrolled in, a State Medicaid program. 
(3) MEDICAID PROGRAM.—The term ‘‘Medicaid 
program’’ means, with respect to a State, the State 
program under title XIX of the Social Security Act 
(42 U.S.C. 1396 et seq.) (including any waiver or 
demonstration under such title or under section 
1115 of such Act (42 U.S.C. 1315) relating to such 
title). 
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(4) PRIVATE DUTY NURSING SERVICES.—The 
term ‘‘private duty nursing services’’ has the mean-
ing given that term for purposes of section 
1905(a)(8) of the Social Security Act (42 U.S.C. 
1396d(a)(8)) (as in effect on the date of enactment 
of this Act). 
(5) SECRETARY.—The term ‘‘Secretary’’ means 
the Secretary of Health and Human Services. 
(6) STATE.—The term ‘‘State’’ has the mean-
ing given such term in section 1101(a) of the Social 
Security Act (42 U.S.C. 1301(a)) for purposes of 
title XIX of such Act (42 U.S.C. 1396 et seq.). 
SEC. 3. REDEFINING PRIVATE DUTY NURSING SERVICES 
PROVIDED THROUGH MEDICAID. 
(a) DEFINITION OF MEDICAL ASSISTANCE.— 
(1) IN GENERAL.—Section 1905(a)(8) of the 
Social Security Act (42 U.S. 1396d(a)(8)) is amend-
ed by striking ‘‘private duty nursing services;’’ and 
inserting ‘‘continuous skilled nursing services;’’. 
(2) EFFECTIVE DATE.—The amendment made 
by paragraph (1) takes effect on the date that is 18 
months after the date of enactment of this Act. 
(b) DEFINITION OF CONTINUOUS SKILLED NURSING 
SERVICES.—Not later than 18 months after the date of 
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enactment of this Act, the Secretary, through notice and 
comment rulemaking, shall— 
(1) revise the definition of ‘‘private duty nurs-
ing services’’ in section 440.80 of title 42, Code of 
Federal Regulations, to be ‘‘continuous skilled nurs-
ing services’’; and 
(2) require that such services under the Med-
icaid program provided to complex-care patients who 
require multiple hours of continuous nursing services 
per day, as determined by the State, are provided by 
a licensed nurse, including a registered nurse or a 
licensed practical nurse. 
SEC. 4. DEVELOPMENT OF NATIONAL QUALITY STANDARDS 
FOR CONTINUOUS SKILLED NURSING SERV-
ICES PROVIDED THROUGH MEDICAID. 
(a) IN GENERAL.—Not later than 180 days after the 
date of enactment of this Act, the Secretary shall convene 
a working group that includes representatives of inde-
pendent and national providers of private duty nursing 
services under the Medicaid program, other private duty 
nursing agencies, associations representing providers of 
continuous skilled nursing services, full-benefit dual eligi-
ble individuals, Medicaid beneficiaries, patient advocacy 
groups, officials of State Medicaid programs, private duty 
nursing accrediting bodies, and other relevant stake-
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holders, to develop and establish national quality stand-
ards for the purposes of improving the standard of care 
for private duty nursing services provided by States under 
the Medicaid program. 
(b) ENSURING CLINICALLY APPROPRIATE STAND-
ARDS.—The Secretary shall issue a letter to State Med-
icaid Directors stating that providers of private duty nurs-
ing services under the Medicaid program are not required 
to adhere to conditions of participation for home health 
agencies under title XVIII of the Social Security Act (42 
U.S.C. 1395 et seq.). 
(c) PUBLICATION OF NATIONAL STANDARDS.—Not 
later than 1 year after the date on which the working 
group described in subsection (a) is first convened, the 
Secretary, after providing a period of public notice and 
opportunity for comment, shall publish the national qual-
ity standards developed by the working group for use by 
State Medicaid programs, managed care entities that 
enter into contracts with such programs, and providers of 
items and services under such programs. 
SEC. 5. MAINTAINING UP-TO-DATE CONTINUOUS SKILLED 
NURSING STANDARDS. 
(a) UPDATING
HOME
AND
COMMUNITY-BASED 
WAIVER SERVICES.—Not later than 18 months after the 
date of enactment of this Act, the Secretary, through no-
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tice and comment rulemaking, shall revise the list of serv-
ices that are included as ‘‘home and community-based 
waiver services’’ under section 440.180(b) of title 42, Code 
of Federal Regulations, to include continuous skilled nurs-
ing care services, as defined for purposes of section 
1905(a)(8) of the Social Security Act (as amended by sec-
tion 3(a)) under section 440.80 of title 42, Code of Fed-
eral Regulations (as revised after the application of section 
3(b)). 
(b) UPDATING THE HOME AND COMMUNITY-BASED 
SERVICES QUALITY MEASURE SET.— 
(1) IN GENERAL.—Not later than 1 year after 
the date of enactment of this Act, the Secretary 
shall update and publish the HCBS Quality Measure 
Set, described in the State Medicaid Director Letter 
#22–003 issued on July 21, 2022, to include core 
and supplemental quality measures for continuous 
skilled nursing services for use by State Medicaid 
programs, managed care entities that enter into con-
tracts with such programs, and providers of items 
and services under such programs. 
(2) REGULAR
REVIEWS
AND
UPDATES.—The 
Secretary shall review and update the core set and 
supplemental set of continuous skilled nursing serv-
ices quality measures published under paragraph (1) 
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not less frequently than every 8 years. Any such up-
date shall include a period of public notice and op-
portunity for comment. 
Æ 
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