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Medicare Adult Day Services Alternative Act of 2003 (Introduced in Senate)
S 1227 IS
108th CONGRESS
1st Session
S. 1227
To amend title XVIII of the Social Security Act to provide for coverage of substitute adult day services under the medicare program.
IN THE SENATE OF THE UNITED STATES
June 10, 2003
Mr. SANTORUM (for himself and Mrs. LINCOLN) introduced the following bill; which was read twice and referred to the Committee on Finance
A BILL
To amend title XVIII of the Social Security Act to provide for coverage of substitute adult day services under the medicare program.
Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the `Medicare Adult Day Services Alternative Act of 2003'.
SEC. 2. FINDINGS.
(1) adult day services offers services, including medical care, rehabilitation therapies, dignified assistance with activities of daily living, social interaction, and stimulating activities, to seniors who are frail, physically challenged, or cognitively impaired;
(2) access to adult day services provides seniors and their familial caregivers support that is critical to keeping the senior in the family home;
(3) more than 22,000,000 families in the United States serve as caregivers for aging or ailing seniors, nearly 1 in 4 American families, providing close to 80 percent of the care to individuals requiring long-term care;
(4) nearly 75 percent of those actively providing such care are women who also maintain other responsibilities, such as working outside of the home and raising young children;
(5) the average loss of income to these caregivers has been shown to be $659,130 in wages, pension, and Social Security benefits;
(6) the loss in productivity in United States businesses ranges from $11,000,000,000 to $29,000,000,000 annually;
(7) the services offered in adult day services facilities provide continuity of care and an important sense of community for both the senior and the caregiver;
(8) there are adult day services facilities in every State in the United States and the District of Columbia;
(9) these centers generally offer transportation, meals, personal care, and counseling in addition to the medical services and socialization benefits offered; and
(10) with the need for quality options in how to best care for our senior population about to dramatically increase with the aging of the baby boomer generation, the time to address these issues is now.
SEC. 3. MEDICARE COVERAGE OF SUBSTITUTE ADULT DAY SERVICES.
(a) SUBSTITUTE ADULT DAY SERVICES BENEFIT-
(1) IN GENERAL- Section 1861(m) of the Social Security Act (42 U.S.C. 1395x(m)) is amended--
(A) in the matter preceding paragraph (1), by inserting `or (8)' after `paragraph (7)';
(B) in paragraph (6), by striking `and' at the end;
(C) in paragraph (7), by adding `and' at the end; and
(D) by inserting after paragraph (7), the following new paragraph:
`(8) substitute adult day services (as defined in subsection (ww));'.
(2) SUBSTITUTE ADULT DAY SERVICES DEFINED- Section 1861 of the Social Security Act (42 U.S.C. 1395x) is amended by adding at the end the following new subsection:
`Substitute Adult Day Services; Adult Day Services Facility
`(ww)(1)(A) The term `substitute adult day services' means the items and services described in subparagraph (B) that are furnished to an individual by an adult day services facility as a part of a plan under subsection (m) that substitutes such services for some or all of the items and services described in subparagraph (B)(i) furnished by a home health agency under the plan, as determined by the physician establishing the plan.
`(B) The items and services described in this subparagraph are the following items and services:
`(i) Items and services described in paragraphs (1) through (7) of subsection (m).
`(iii) A program of supervised activities designed to promote physical and mental health and furnished to the individual by the adult day services
facility in a group setting for a period of not fewer than 4 and not greater than 12 hours per day.
`(iv) A medication management program (as defined in subparagraph (C)).
`(C) For purposes of subparagraph (B)(iv), the term `medication management program' means a program of services, including medicine screening and patient and health care provider education programs, that provides services to minimize--
`(i) unnecessary or inappropriate use of prescription drugs; and
`(ii) adverse events due to unintended prescription drug-to-drug interactions.
`(2)(A) Except as provided in subparagraphs (B) and (C), the term `adult day services facility' means a public agency or private organization, or a subdivision of such an agency or organization, that--
`(i) is engaged in providing skilled nursing services and other therapeutic services directly or under arrangement with a home health agency;
`(ii) provides the items and services described in paragraph (1)(B); and
`(iii) meets the requirements of paragraphs (2) through (8) of subsection (o).
`(B) Notwithstanding subparagraph (A), the term `adult day services facility' shall include a home health agency in which the items and services described in clauses (ii) through (iv) of paragraph (1)(B) are provided--
`(i) by an adult day services program that is licensed or certified by a State, or accredited, to furnish such items and services in the State; and
`(ii) under arrangements with that program made by such agency.
`(C) The Secretary may waive the requirement of a surety bond under paragraph (7) of subsection (o) in the case of an agency or organization that provides a comparable surety bond under State law.'.
(b) PAYMENT FOR SUBSTITUTE ADULT DAY SERVICES- Section 1895 of the Social Security Act (42 U.S.C. 1395fff) is amended by adding at the end the following new subsection:
`(f) PAYMENT RATE FOR SUBSTITUTE ADULT DAY SERVICES-
`(1) PAYMENT RATE- For purposes of making payments to an adult day services facility for substitute adult day services (as defined in section 1861(ww)), the following rules shall apply:
`(A) ESTIMATION OF PAYMENT AMOUNT- The Secretary shall estimate the amount that would otherwise be payable to a home health agency under this section for all home health services described in paragraph (1)(B)(i) of such section under the plan of care.
`(B) AMOUNT OF PAYMENT- Subject to paragraph (3)(B), the total amount payable for substitute adult day services under the plan of care is equal to 95 percent of the amount estimated to be payable under subparagraph (A).
`(2) LIMITATION ON BALANCE BILLING- An adult day services facility shall accept as payment in full for substitute adult day services (including those services described in clauses (ii) through (iv) of section 1861(ww)(1)(B)) furnished by the facility to an individual entitled to benefits under this title the amount of payment provided under this subsection for home health services consisting of substitute adult day services.
`(3) ADJUSTMENT IN CASE OF OVERUTILIZATION OF SUBSTITUTE ADULT DAY SERVICES-
`(A) MONITORING EXPENDITURES- Beginning with fiscal year 2005, the Secretary shall monitor the expenditures made under this title for home health services, including such services consisting of substitute adult day services, for the fiscal year and shall compare such expenditures to expenditures that the Secretary estimates would have been made under this title for home health services for the fiscal year if the Medicare Adult Day Services Alternative Act of 2003 had not been enacted.
`(B) REQUIRED REDUCTION IN PAYMENT RATE- If the Secretary determines, after making the comparison under subparagraph (A) and making such adjustments for changes in demographics and age of the medicare beneficiary population as the Secretary determines appropriate, that expenditures for home health services under the this title, including such services consisting of substitute adult day services, for the fiscal year exceed expenditures that would have been made under this title for home health services for the fiscal year if the Medicare Adult Day Services Alternative Act of 2003 not been enacted, then the Secretary shall adjust the rate of payment to adult day services facilities under paragraph (1)(B) for home health services consisting of substitute adult day services furnished in the fiscal year in order to eliminate such excess.'.
(c) EFFECTIVE DATE- The amendments made by this section shall apply to items and services furnished on or after January 1, 2004.
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