HR-8875-119
Ordered to be Reported in the Nature of a Substitute by the Yeas and Nays: 28 - 13.
Sponsored by Carol Miller (R-WV)
What it does
This bill would amend the Medicare program (Title XVIII of the Social Security Act) to add two new covered services under the self-care home dialysis support benefit, effective January 1, 2028. First, it would cover "staff-assisted home dialysis respite care" — temporary in-home dialysis assistance by a qualified nurse or technician for patients who cannot independently perform dialysis, limited to the first 30 days of home dialysis (or at any time for patients with a physical limitation), capped at 20 sessions per calendar year. Second, it would cover "renal mental health services" for new home dialysis patients during the first 60 days, capped at 4 sessions. Both services would receive add-on payment adjustments under the Medicare bundled payment system, with higher rates for rural areas, and neither adjustment would be made in a budget-neutral manner.
Who benefits
Medicare-enrolled patients with end-stage renal disease (ESRD) who dialyze at home — estimated at roughly 70,000–80,000 patients currently, a number that has been growing. New home dialysis patients in particular would benefit during the critical early transition period. Patients with physical limitations would benefit most from the respite care provision, as they face no time cap. Family caregivers and unpaid household members who currently assist with home dialysis would gain relief through the respite care provision. Rural ESRD patients would receive higher payment rates, potentially improving provider availability in underserved areas. Registered nurses, licensed practical nurses, and certified patient care technicians who provide these services would gain a new reimbursable service line. Mental health professionals meeting CMS qualifications would gain a new covered service category.
Who is hurt
The Medicare Trust Fund would bear additional costs, as both payment adjustments are explicitly non-budget-neutral — meaning no offsetting cuts elsewhere in the program. Medicare beneficiaries broadly, and taxpayers, may face indirect cost pressure if the added spending contributes to program financing challenges. Dialysis facilities that provide in-center dialysis could face increased competition if the bill accelerates the shift to home dialysis. Patients who do not qualify — such as those in skilled nursing facilities or nursing homes — are explicitly excluded and would not benefit. Patients who exhaust the session caps (20 respite, 4 mental health) before their needs are met would receive no further coverage under these provisions.
Supporters argue
Supporters argue that home dialysis is clinically preferable for many ESRD patients — associated with better outcomes and lower overall Medicare costs — but that the transition from in-center to home dialysis fails disproportionately due to lack of support in the critical early weeks. They contend that covering respite care and mental health services directly addresses the two most common barriers to successful home dialysis initiation: caregiver burden and psychological distress. They further argue that the non-budget-neutral payment structure is appropriate because the services generate downstream savings by preventing costly hospitalizations and treatment failures that result when patients abandon home dialysis.
Opponents argue
Opponents argue that adding non-budget-neutral payment adjustments increases Medicare spending without a clear offset, contributing to the program's long-term fiscal strain at a time when the Medicare Hospital Insurance Trust Fund faces projected shortfalls. They contend that the session caps — 20 respite visits and 4 mental health sessions — are arbitrary and may be too low to meaningfully support patients with complex needs, making the benefit more symbolic than substantive. They further argue that delegating qualification standards for "qualified personnel" and successor regulations to the Secretary of HHS creates regulatory uncertainty for providers and, post-Loper Bright, may invite legal challenges if the Secretary's implementing rules are contested in court.
Constitutional context
Congress has broad authority to structure Medicare benefits under the Taxing and Spending Clause (Art. I, §8, cl. 1), which the Supreme Court affirmed in NFIB v. Sebelius (2012). This bill modifies an existing Medicare program rather than creating new mandates, so it does not raise the Commerce Clause activity/inactivity concerns from NFIB. However, the bill delegates qualification standards and successor regulation authority to the HHS Secretary; under Loper Bright v. Raimondo (2024), courts would independently review any implementing regulations rather than deferring to the agency's interpretation.
Checks and balances
Congress expands the Medicare benefit and sets payment parameters; the HHS Secretary gains authority to define qualified personnel standards and successor regulations; courts retain independent review of agency rulemaking under Loper Bright (2024).
Historical precedent
The Medicare ESRD bundled payment system, established under the ACA (2010) and modified by the ESRD Treatment Choices Model, has previously added support services to the home dialysis benefit, providing a direct structural precedent for this type of incremental expansion.