1.Payment for long-term care
hospital services
(a)Long-Term care
hospital payment adjustments
(1)Section 1886(m) of the Social Security Act (42 U.S.C.
1395ww(m)) is amended by adding at the end the following new paragraph:
(6)High episode
efficient case and episode outlier case payment adjustments
(A)Establishment of
episode efficient case payment adjustmentsIn making payment
under the system described in paragraph (1) to a long-term care hospital
described in subsection (d)(1)(B)(iv)(I), for discharges occurring in rate
years beginning on and after October 1, 2011, the Secretary shall make payment
adjustments—
(i)under clause (ii)
of subparagraph (C) for cases identified as meeting or exceeding the fixed high
episode efficient case threshold under clause (i) of such subparagraph;
and
(ii)under clause (ii)
of subparagraph (D) for cases identified as meeting or below the episode
outlier case threshold under clause (i) of such subparagraph.
(B)Determination of
episode efficient casesFor the rate year beginning on and after
October 1, 2011, the Secretary shall adopt rules which identify the predicted
probability of those Medicare beneficiaries admitted as inpatients to long-term
care hospitals from a subsection (d) hospital for whom the payment for services
received during an episode of hospital care (as defined in subparagraph (G)) is
predicted to be less than if they had remained in the subsection (d) hospital
(in this paragraph referred to as episode efficient cases
). The
rules for determining episode efficient cases shall identify the
characteristics of individuals while they were an inpatient in a subsection (d)
hospital, including their length of stay, number of diagnoses, number of
medical procedures, and the number of days of care provided in an intensive
care or cardiac care unit. Such characteristics shall be determined by the
Secretary to be characteristics for which information is usually available to
long-term care hospitals before the admission of an individual to a long-term
care hospital.
(C)High episode
efficient cases
(i)Subject
to subparagraph (F), the Secretary shall establish from year to year fixed high
episode efficient case thresholds which identify Medicare beneficiaries
discharged from long-term care hospitals with the highest 10 percent
probability of being episode efficient cases.
(ii)High episode
efficient case payment adjustmentThe Secretary shall annually
establish, consistent with subparagraph (E), the payment adjustment under this
clause for cases which meet or exceed the applicable fixed high episode
efficient case threshold established under clause (i). Such payment adjustment
shall be a per discharge incentive payment, expressed as a percentage of the
amount payable under the system under paragraph (1), which shall be made in
addition to the amount payable for the long-term care hospital under such
system.
(D)
(i)Subject
to subparagraph (F), the Secretary shall establish from year to year episode
outlier case thresholds at the percentage of predictive probability which
identify Medicare beneficiary discharges the Secretary determines to have the
lowest 10 percent probability of being episode efficient cases. In every year
(after the first year in which this paragraph applies), the Secretary shall
maintain such episode outlier case threshold, except that in any year the
Secretary shall, if necessary, reduce the episode outlier case threshold so
that no more than 10 percent of Medicare beneficiaries discharged from
long-term care hospitals are subject to the episode outlier case payment
adjustment under clause (ii).
(ii)Episode outlier
case payment adjustmentThe payment adjustment under this clause
for cases which are classified at or below the applicable episode outlier case
threshold under clause (i) shall be the lesser of the amount payable under the
system under paragraph (1) or 80 percent of the long-term care hospital’s
reasonable cost for each such Medicare patient discharge determined under
section 1861(v)(1)(A). A long-term care hospital shall not be subject to the
episode outlier case payment adjustment under this clause for more than 15
percent of Medicare beneficiaries who were discharged from the hospital in a
rate year.
(E)The Secretary shall prospectively adjust the aggregate
prospective payment adjustments for high episode efficient cases under
subparagraph (C)(ii) for a year so that it is equal to the projected aggregate
prospective payment adjustments for episode outlier cases under subparagraph
(D)(ii) for that year.
(F)Establishment of
separate thresholds for certain geographic areasThe
Secretary—
(i)shall establish
separate high episode efficient case and episode outlier case thresholds under
subparagraphs (C)(i) and (D)(i) for long-term care hospitals located in a rural
area;
(ii)shall establish
separate high episode efficient case and episode outlier case thresholds under
such subparagraphs for long-term care hospitals located in urban areas for
beneficiaries discharged from a subsection (d) hospital which accounts for more
than 25 percent of the Medicare beneficiaries discharged from subsection (d)
hospitals in a Metropolitan Statistical Area;
(iii)the episode
outlier thresholds set under subparagraphs (C)(i) and (D)(i) shall be
established at a level no higher than the lowest 5 percent probability of being
episode efficient cases; and
(iv)may consider such
other geographic factors as the Secretary determines to be appropriate in
establishing such thresholds.
(G)Episode of
hospital care definedIn this paragraph, the term episode
of hospital care means the combined inpatient stay of a Medicare
beneficiary discharged from a subsection (d) hospital and subsequently admitted
to a long-term care hospital within a time period specified by the
Secretary.
(H)The Secretary shall provide long-term care hospitals with an
opportunity to review data used to determine the classification of Medicare
beneficiaries within the fixed high episode efficient case threshold and the
episode outlier case threshold under this paragraph.
(I)Medicare
beneficiary definedIn this paragraph, the term Medicare
beneficiary means an individual entitled to benefits under part
A.
.
(b)No application
of 25 percent patient threshold payment adjustment to any long-Term care
hospitalThe Secretary of Health and Human Services shall not
apply sections 412.534 or 412.536 of title 42, Code of Federal Regulations or
any similar provision, with respect to discharges in rate years beginning on or
after July 1, 2012.
(c)No application
of one-Time payment adjustment to any long-Term care hospitalThe
Secretary of Health and Human Services shall not make the one-time prospective
payment adjustment to long-term care hospital prospective payment rates
provided for in section 412.523(d)(3) of title 42, Code of Federal Regulations,
or any similar provision.
(d)No application
of very short-Stay outlier policyThe Secretary of Health and
Human Services shall not apply the amendments to the short-stay outlier payment
provision for long-term care hospitals contained in section 412.529(c)(3)(i) of
title 42, Code of Federal Regulations as finalized on May 11, 2007 (72 Federal
Register 26904, 26992), or any similar provision.
(e)Two-Year
moratorium on the establishment of long-Term care hospitals, long-Term care
satellite facilities and on the increase of long-Term care hospital beds in
existing long-Term care hospitals or satellite facilities
(1)In the case of a
long-term care hospital described in subsection (d)(1)(B)(iv)(I) of section
1886(m) of the Social Security Act (42 U.S.C. 1395ww(m)), there shall be a
2-year moratorium (beginning on December 29, 2012) on the establishment of new
long-term care hospitals or satellite facilities and, subject to paragraph (2),
on the increase in beds in existing long-term care hospitals or satellite
facilities. For the purposes of this subsection, the term existing
means, a hospital or satellite facility that received payment under the
provisions of subpart O of part 412 of title 42, Code of Federal Regulations,
as of the date of the enactment of this Act.
(2)A
long-term care hospital which submitted plans to a State on or before January
1, 2009, to rebuild a hospital to comply with the seismic code requirements of
a State, may expand its bed complement by no more than 10 beds upon approval by
the State.