Residential Recovery for Seniors Act
- Sponsor
- Rep. Underwood, Lauren [D-IL-14]
- Committees
- Ways and Means Committee (primary)
- Last action
- Jun 30, 2026
Bottom line
This bill expands Medicare coverage to include residential substance use disorder treatment, aiming to provide seniors with access to a broader and more intensive continuum of care for addiction.
What it actually does
This bill amends Title XVIII of the Social Security Act to expand Medicare Part A coverage to include three distinct levels of residential substance use disorder (SUD) services: clinically managed low-intensity, clinically managed high-intensity, and medically managed. It establishes detailed definitions for these services, the programs that provide them, and the facilities where they are offered, and mandates the Secretary of Health and Human Services to develop a per diem prospective payment system for these newly covered services.
Proponents argue
Proponents argue this bill addresses a critical gap in Medicare coverage, allowing older adults struggling with substance use disorders to access necessary residential treatment, which is often more effective for complex cases than outpatient care alone. They would emphasize that it aligns Medicare with modern addiction treatment standards and provides a crucial pathway to recovery for a vulnerable population, improving health outcomes and quality of life.
Opponents contend
Potential opponents might raise concerns about the increased cost to the Medicare program and taxpayers, especially given the establishment of a new prospective payment system with initial payments set at 100% of estimated reasonable costs. They might also question the oversight mechanisms for these new facilities and the potential for fraud or abuse, or argue that existing programs, if expanded, could sufficiently address the need.
The bill is moderately detailed, requiring careful reading to understand the new definitions and payment system, but is manageable for a dedicated reader.
Section 2(a) of the bill, amending Section 1812(a) of the Social Security Act
Establishes Medicare Part A Coverage for Residential SUD Services
This provision expands Medicare Part A benefits to include three new categories of residential substance use disorder services: clinically managed low-intensity, clinically managed high-intensity, and medically managed. Coverage is contingent on an initial assessment and periodic review (every 30 days for low/high-intensity, every 10 days for medically managed) of the individual's need for such services, using evidence-based criteria from recognized addiction treatment associations.
Supporters argue
Supporters argue this is a vital expansion, ensuring that older adults, who are increasingly affected by SUDs, can receive comprehensive, evidence-based residential care, which is often a critical step in sustained recovery.
Critics contend
Critics might argue that expanding Part A coverage for these services could significantly increase Medicare expenditures without sufficient evidence of long-term cost-effectiveness compared to other treatment modalities.
Tradeoffs
Balances the need to provide comprehensive SUD treatment for seniors against potential increases in Medicare spending and the administrative burden of defining and overseeing new service categories.
Section 2(b) of the bill, adding new subsection (nnn) to Section 1861 of the Social Security Act
Defines Clinically Managed Low-Intensity Residential SUD Services and Facilities
This section provides detailed definitions for 'clinically managed low-intensity residential substance use disorder services,' the 'program' that provides them, and the 'facility' where they are furnished. These services include bed and board, clinical services, assessments, treatment planning, and recovery support. The program must provide 24-hour structure, multidimensional assessments, access to medical professionals for medication management, weekly clinical services, and maintain clinical records. Facilities must be enrolled, accredited, and legally authorized by the state.
Section 2(b) of the bill, adding new subsection (ooo) to Section 1861 of the Social Security Act
Defines Clinically Managed High-Intensity Residential SUD Services and Facilities
This section defines 'clinically managed high-intensity residential substance use disorder services,' the 'program' providing them, and the 'facility.' These services involve 24-hour supervision, multidimensional assessments, access to medical professionals, 20+ hours of weekly clinical services, and clinically managed residential withdrawal management. Facilities must meet similar enrollment, accreditation, and state authorization requirements as low-intensity facilities.
Section 2(b) of the bill, adding new subsection (ppp) to Section 1861 of the Social Security Act
Defines Medically Managed Residential SUD Services and Facilities
This section defines 'medically managed residential substance use disorder services,' the 'program' providing them, and the 'facility.' These services are for individuals needing 24-hour observation, monitoring, and treatment for withdrawal and biomedical comorbidities, but not full hospital resources. They include 24-hour nursing, daily medical interventions, comprehensive assessments, and access to essential and FDA-approved medications. Facilities must meet enrollment, accreditation, and state authorization requirements.
Section 2(c) of the bill, amending Section 1866(e) of the Social Security Act
Designates Residential SUD Facilities as Medicare Providers
This provision formally includes clinically managed residential substance use disorder facilities and medically managed residential substance use disorder facilities as recognized Medicare providers. This means these facilities can enter into agreements with the Secretary of HHS to provide covered services to Medicare beneficiaries and receive reimbursement.
Section 2(d) of the bill, adding new subsection (u) to Section 1886 of the Social Security Act
Establishes a Prospective Payment System (PPS) for Residential SUD Services
This provision mandates the Secretary of HHS to develop and implement a per diem prospective payment system for all three levels of residential SUD services. The system must include adjustments for differing resource intensity. For cost reporting periods beginning on or after October 1, 2026, payments will be made under this PPS. Initial payments will equal 100% of estimated reasonable costs, with subsequent years adjusted by an increase factor based on a market basket.
For all three levels of residential SUD services, continued need for services must be reviewed and reaffirmed periodically (not less often than every 30 days for low/high-intensity, and not less often than every 10 days for medically managed services) in accordance with evidence-based criteria.
Section 2(a), paragraphs (6), (7), and (8)
Why it matters:Standard legislative practice to include conditions directly within the coverage language to ensure clinical appropriateness and prevent overutilization.
Case for: Ensures that beneficiaries receive the appropriate level of care for the necessary duration, preventing overutilization or underutilization of intensive services. It promotes clinical appropriateness and cost-effectiveness.
Case against: Some might argue that frequent reviews, especially the 10-day requirement for medically managed services, could create an administrative burden for providers and potentially disrupt continuity of care if not managed efficiently.
Estimated impact: Ensures clinical oversight for potentially high-cost services, impacting both provider workflow and beneficiary length of stay.
Obtaining and maintaining certification from a Secretary-approved certifying body with necessary competencies to assess compliance with program standards shall be deemed to demonstrate compliance with the specified program standards.
Section 2(b), subsections (nnn)(2)(G), (ooo)(2)(H), and (ppp)(2)(J) (final sentences)
Why it matters:This is a technical detail regarding compliance pathways, often placed at the end of regulatory requirements to streamline implementation.
Case for: Streamlines the compliance process for providers by allowing them to use existing or new accreditation bodies rather than requiring direct federal oversight for every standard, potentially speeding up program implementation and reducing administrative burden for both providers and the Secretary.
Case against: Could be seen as delegating federal oversight to third parties, which might raise concerns about the rigor and consistency of enforcement if the certifying bodies are not sufficiently robust or independent.
Estimated impact: Significantly impacts the administrative pathway for facilities to become Medicare-eligible, potentially accelerating provider enrollment and reducing direct CMS oversight burden.
Excludes medical or surgical services provided by a physician, services described by subsection (s)(2)(K) (e.g., outpatient physical therapy), qualified psychologist services, and private-duty nursing from the definition of residential SUD services.
Section 2(b), subsections (nnn)(1)(C)(i)-(ii), (ooo)(1)(C)(i)-(ii), and (ppp)(1)(D)(i)-(ii)
Why it matters:These are carve-outs to prevent double-billing or to ensure certain services are billed under other existing Medicare parts (e.g., Part B for physician services).
Case for: Prevents duplication of benefits and ensures that services that are typically covered under other parts of Medicare (like physician services) continue to be billed appropriately, maintaining the integrity of the payment system.
Case against: Some might argue that excluding certain services from the bundled residential rate could lead to fragmented care or additional out-of-pocket costs for beneficiaries if not clearly communicated and coordinated.
Estimated impact: Clarifies the scope of the new residential SUD benefit and its interaction with existing Medicare benefits, impacting billing practices and beneficiary cost-sharing.