Sponsors (7)
The bill extends Medicare inpatient‑equivalent coverage and predictable payments to residential SUD treatment—broadening access and raising quality standards—but increases federal costs and imposes compliance and administrative requirements that could limit provider participation and leave some services uncovered.
Medicare beneficiaries with substance use disorders (SUDs) gain inpatient‑equivalent Medicare Part A coverage for three levels of residential SUD treatment, expanding access to covered treatment services.
Residential SUD facilities receive a dedicated prospective per‑diem Medicare payment system (PPS) beginning Oct 1, 2026, giving providers more predictable and stable reimbursement.
Coverage is tied to evidence‑based, SUD‑specific admission/continued‑stay criteria and periodic clinical reviews, which should improve appropriateness, quality, and continuity of care for patients with chronic conditions.
Expanding Medicare benefits and setting the initial PPS at 100% of estimated costs will raise federal spending and could increase pressure on the Medicare trust fund unless offsets are provided.
Implementing accreditation, staffing, documentation, and other compliance requirements will raise costs for providers and may drive smaller or rural residential SUD providers out of the Medicare market.
Frequent mandatory clinical reviews (as often as every 10 days for some levels) increase administrative burden and may lead to shorter stays or disputes over continued coverage, disrupting care for beneficiaries.
Based on analysis of 2 sections of legislative text.
Adds Medicare Part A inpatient‑equivalent coverage and statutory definitions for specified residential SUD service levels and facilities, with initial and periodic evidence‑based medical‑necessity reviews.
Official title: To amend title XVIII of the Social Security Act to establish coverage for certain residential substance use disorder services under the Medicare program.
Introduced June 30, 2026 by Lauren Underwood · Last progress June 30, 2026
Expands Medicare Part A to cover specified residential substance use disorder (SUD) treatment levels as inpatient‑equivalent services when furnished in defined residential SUD facilities. It requires periodic initial and ongoing medical-necessity reviews using evidence-based, SUD-specific criteria approved by the Secretary and developed by a nonprofit medical association with addiction expertise. Adds statutory definitions for clinically managed low‑intensity and high‑intensity residential SUD services, programs, and facilities and for medically managed residential SUD services, and gives the Secretary authority to set review frequency (no less often than specified minimums) and to approve the edition of the evidence‑based criteria used for coverage determinations.