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HR 9538

Residential Recovery for Seniors Act

119th Congress Introduced by Mike Bost and 5 co-sponsors

Medicare would cover clinically managed residential SUD services across three levels (low, high, medically managed) with a per diem payment system starting Oct 1, 2026.

Introduced in House
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WeVote Research Nonpartisan
Bill Summary · HR 9538

Overview

  • Bill: HR 9538
  • Session: 119th Congress
  • Title: Residential Recovery for Seniors Act
  • Sponsor(s): Reps. Underwood, Tonko, Miller (WV), LaHood, Valadao, Bost; with multiple co-sponsors
  • Purpose: Amend the Social Security Act to establish Medicare coverage for specific residential substance use disorder (SUD) services, including various levels of residential treatment, and to create a new prospective payment system for these services under Part A of Medicare.

Main purpose and intent

  • Establish Medicare coverage under Part A for certain residential SUD services provided to beneficiaries, specifically within clinically managed residential facilities.
  • Create a structured framework for defining, certifying, and paying for three tiers of residential SUD services and facilities (low-intensity, high-intensity, medically managed) in residential settings.
  • Implement a per diem prospective payment system (PPS) for these residential SUD services, with initial coverage effective for cost reporting periods beginning October 1, 2026, and future-rate updates tied to a market basket-based increase factor.

Key provisions and changes

A. Coverage under Medicare Part A

  • Adds coverage for:
    • Clinically managed low-intensity residential SUD services
    • Clinically managed high-intensity residential SUD services
    • Medically managed residential SUD services
  • Coverage applies when furnished to residents of appropriately defined clinically managed residential SUD facilities.

B. Definitions and program standards

  • Defines three main service/facility types:
    • Clinically managed low-intensity residential SUD services and program/facility
    • Clinically managed high-intensity residential SUD services and program/facility
    • Medically managed residential SUD services and facility
  • Each category includes:
    • Required services (clinical, diagnostic, and support components)
    • Staffing and supervision expectations
    • Medical management, medication administration, and laboratory capabilities
    • Records and documentation standards
    • Coordination of transitions to higher or lower levels of care
  • Establishes criteria for facilities to qualify as clinically managed or medically managed residential SUD facilities, including:
    • Enrollment under Medicare 1866(j)
    • Accreditation by Secretary-approved bodies
    • State-licensing compliance
    • Additional health and safety requirements as determined by the Secretary
  • Certifying bodies and accreditation are recognized as meeting program standards.

C. Inclusion in Medicare provider framework

  • Adds clinically managed residential SUD facilities to Medicare providers, with coverage limited to the specified service types.
  • Clarifies alignment with existing Medicare provider categories and standards.

D. Prospective payment system (PPS)

  • Develops a per diem PPS for:
    • Low-intensity clinically managed residential SUD services
    • High-intensity clinically managed residential SUD services
    • Medically managed residential SUD services
  • PPS to reflect resource intensity differences among the three service levels.
  • Requires cost reporting and data submission from facilities to support system development.
  • Implementation details:
    • For cost reporting periods beginning on/after October 1, 2026
    • Initial payments set to 100% of estimated reasonable costs
    • In subsequent years, payment rates continue from the prior year, adjusted by a market-basket-based increase factor

Who is affected

  • Medicare beneficiaries with substance use disorders who require residential treatment services
  • Clinically managed low-, high-, and medically managed residential SUD facilities
  • Providers and administrators of residential SUD programs seeking Medicare enrollment and certification
  • Entities involved in accreditation, quality standards development, and data/reporting for Medicare-funded SUD services

Procedural and timeline aspects

  • Introduction date: June 30, 2026
  • Referral: House Committee on Ways and Means
  • Effective rollout:
    • Cost reporting period alignment begins October 1, 2026
    • Initial PPS implementation to cover approved residential SUD services and facilities
  • Ongoing oversight: Secretary of Health and Human Services to define criteria, standards, and adjustments, including evidence-based criteria from a recognized non-profit medical association for SUD treatment.

Potential impact

  • Expanded Medicare coverage for residential SUD treatment, potentially increasing access for older adults and individuals on Medicare who need structured, residential care.
  • Standardized definitions and standards may improve quality and consistency of residential SUD care across facilities.
  • The PPS design aims to align payments with resource use, providing a predictable funding mechanism while allowing adjustments for cost changes.
  • Could influence where and how residential SUD care is delivered, favoring facilities that meet the new certification and accreditation requirements.

Note: The summary reflects the bill’s text as introduced and may be refined by committee amendments or subsequent legislative action.

Compiled from official sources — confirm details with the bill’s official record.

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