I 111th CONGRESS 2d Session H. R. 5803 IN THE HOUSE OF REPRESENTATIVES July 21, 2010 Mr. McGovern (for himself and Mr. Jones) introduced the following bill; which was referred to the Committee on Ways and Means, and in addition to the Committee on Energy and Commerce, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned A BILL To amend title XVIII of the Social Security Act to protect Medicare beneficiaries’ access to home health services under the Medicare Program.

1.

Short title

This Act may be cited as the Home Health Care Access Protection Act of 2010.

2.

Protecting access to Medicare home health services

Section 1895(b)(3)(B) of the Social Security Act (42 U.S.C. 1395fff(b)(3)(B)), as amended by section 3401(e) of the Patient Protection and Affordable Care Act, is amended— (1)in clause (iv), by striking Insofar as and inserting Subject to clause (vii), insofar as; and (2)by adding at the end the following new clause: (vii)

Special rules for case mix changes for 2011 and later

(I)

In general

The adjustment under clause (iv) shall only be made for years beginning with 2011 using standards developed by the Secretary consistent with the processes described in subclause (II) taking into account the criteria described in subclause (III). (II)

Processes and criteria for evaluating changes in case mix

For purposes of subclause (I), the processes described in this subclause are the following: (aa)In developing standards referred to in such subclause, the Secretary shall convene a Technical Advisory Group consisting of stakeholders, including individuals and organizations representing the interests of Medicare beneficiaries, the home health community, health care academia, and health care professionals, in equal numbers from each and limited to parties without an existing contractual relationship with the Secretary, to advise the Secretary concerning the establishment of such standards in order to distinguish between real changes in case mix and changes in coding or classification of different units of services that do not reflect real changes in case mix. The Technical Advisory Group shall be given the opportunity to review and comment on any proposed rulemaking or final determination by the Secretary on such standards prior to such rulemaking or determination. (bb)If the Secretary engages an outside contractor to participate in the evaluation of case mix changes described in item (aa), the Secretary shall only utilize a contractor that has not previously participated in the design and establishment of the case mix adjustment factors under this subparagraph. (cc)If the Secretary determines that any increase in case mix relates to changes in the volume or nature of services provided to home health services patients, the Secretary shall evaluate such increase through actual review of claims and services and shall not use any proxy or surrogate for determining whether the change in volume or nature of services is reasonable and necessary. (dd)The Secretary shall establish the standards referred to in item (aa) by regulation. (ee)With respect to establishment of such standards, the Secretary shall make public all data, reports, and supporting materials, including any comments by the Technical Advisory Group pursuant to item (aa), regarding the standards at the time of notice of such standards. (III)

Criteria

The criteria described in this subclause are the following: (aa)The impact of changes in the program under this title that may affect the characteristics of individuals receiving home health services. (bb)The impact of changes in the provision of health care services by providers of services other than home health agencies. (cc)Distinctions in the characteristics of individuals initiating home health services from the community and institutional care settings. (dd)Whether any changes in coding resulted in a change in expenditures overall annually and disregarding changes in coding that do not have an overall expenditure impact. (ee)Any other factors determined appropriate by the Secretary in consultation with the Technical Advisory Group under subclause (II)(aa)..