S. 1920 — Continuous Skilled Nursing Quality Improvement Act of 2025

This section defines six terms for purposes of the Act: (1) full-benefit dual eligible individual (i.e., an individual entitled to or enrolled for Medicare benefits under parts A or B of title XVIII of the Social Security Act and eligible for full Medicaid benefits under specified categories of title XIX); (2) Medicaid beneficiary (i.e., an individual eligible for and enrolled in a state Medicaid program); (3) Medicaid program (i.e., a state program under title XIX of the Social Security Act, including waivers or demonstrations under that title or section 1115); (4) private duty nursing services (i.e., as defined in section 1905(a)(8) of the Social Security Act as in effect on the date of enactment); (5) Secretary (i.e., the Secretary of Health and Human Services); and (6) State (i.e., as defined in section 1101(a) of the Social Security Act for title XIX purposes).

This section revises the definition of medical assistance under Medicaid in Section 1905(a)(8) of the Social Security Act by replacing "private duty nursing services" with "continuous skilled nursing services," effective 18 months after enactment. (As background, private duty nursing services provide skilled nursing care, typically to medically fragile children, in home or community settings as an optional Medicaid benefit.) The section further directs the HHS Secretary, through notice-and-comment rulemaking completed not later than 18 months after enactment, to (1) revise the regulatory definition of private duty nursing services in 42 CFR 440.80 to "continuous skilled nursing services"; and (2) require that such services for complex-care patients needing multiple hours of continuous nursing services per day (as determined by the state) be provided by a licensed nurse, including a registered nurse or licensed practical nurse.

This section directs the Secretary of Health and Human Services, not later than 180 days after enactment, to convene a working group—including representatives of private duty nursing providers and agencies, associations for continuous skilled nursing services, full-benefit dual eligible individuals, Medicaid beneficiaries, patient advocacy groups, state Medicaid officials, private duty nursing accrediting bodies, and other stakeholders—to develop national quality standards for private duty nursing services under Medicaid (i.e., continuous skilled nursing care provided in the home, typically for medically complex individuals such as children requiring ventilators or other ongoing support). The section further requires the Secretary to issue a letter to state Medicaid directors clarifying that such providers are not required to adhere to Medicare conditions of participation for home health agencies. Not later than one year after convening the working group, the Secretary must publish the standards, after public notice and comment, for use by state Medicaid programs, managed care entities, and providers.

This section directs the Secretary of Health and Human Services (1) not later than 18 months after enactment to revise regulations at 42 CFR 440.180(b) to include continuous skilled nursing care services—defined under SSA section 1905(a)(8) and 42 CFR 440.80, as amended by section 3—as home and community-based services available under Medicaid Section 1915(c) waivers (i.e., state-operated programs providing long-term care services in community settings as an alternative to institutional care) and (2) not later than one year after enactment to update the HCBS Quality Measure Set, as described in CMS State Medicaid Director Letter #22-003 (July 21, 2022), to incorporate core and supplemental quality measures for such services for state Medicaid programs, managed care plans, and providers, with reviews and updates (including public comment periods) at least every eight years.