[Congressional Bills 113th Congress]
[From the U.S. Government Publishing Office]
[H.R. 4994 Enrolled Bill (ENR)]
H.R.4994
One Hundred Thirteenth Congress
of the
United States of America
AT THE SECOND SESSION
Begun and held at the City of Washington on Friday,
the third day of January, two thousand and fourteen
An Act
To amend title XVIII of the Social Security Act to provide for
standardized post-acute care assessment data for quality, payment, and
discharge planning, and for other purposes.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Improving Medicare Post-Acute Care
Transformation Act of 2014'' or the ``IMPACT Act of 2014''.
SEC. 2. STANDARDIZATION OF POST-ACUTE CARE DATA.
(a) In General.--Title XVIII of the Social Security Act is amended
by adding at the end the following new section:
``SEC. 1899B. STANDARDIZED POST-ACUTE CARE (PAC) ASSESSMENT DATA FOR
QUALITY, PAYMENT, AND DISCHARGE PLANNING.
``(a) Requirement for Standardized Assessment Data.--
``(1) In general.--The Secretary shall--
``(A) require under the applicable reporting provisions
post-acute care providers (as defined in paragraph (2)(A)) to
report--
``(i) standardized patient assessment data in
accordance with subsection (b);
``(ii) data on quality measures under subsection
(c)(1); and
``(iii) data on resource use and other measures under
subsection (d)(1);
``(B) require data described in subparagraph (A) to be
standardized and interoperable so as to allow for the exchange
of such data among such post-acute care providers and other
providers and the use by such providers of such data that has
been so exchanged, including by using common standards and
definitions, in order to provide access to longitudinal
information for such providers to facilitate coordinated care
and improved Medicare beneficiary outcomes; and
``(C) in accordance with subsections (b)(1) and (c)(2),
modify PAC assessment instruments (as defined in paragraph
(2)(B)) applicable to post-acute care providers to--
``(i) provide for the submission of standardized
patient assessment data under this title with respect to
such providers; and
``(ii) enable comparison of such assessment data across
all such providers to whom such data are applicable.
``(2) Definitions.--For purposes of this section:
``(A) Post-acute care (pac) provider.--The terms `post-
acute care provider' and `PAC provider' mean--
``(i) a home health agency;
``(ii) a skilled nursing facility;
``(iii) an inpatient rehabilitation facility; and
``(iv) a long-term care hospital (other than a hospital
classified under section 1886(d)(1)(B)(iv)(II)).
``(B) PAC assessment instrument.--The term `PAC assessment
instrument' means--
``(i) in the case of home health agencies, the
instrument used for purposes of reporting and assessment
with respect to the Outcome and Assessment Information Set
(OASIS), as described in sections 484.55 and 484.250 of
title 42, the Code of Federal Regulations, or any successor
regulation, or any other instrument used with respect to
home health agencies for such purposes;
``(ii) in the case of skilled nursing facilities, the
resident's assessment under section 1819(b)(3);
``(iii) in the case of inpatient rehabilitation
facilities, any Medicare beneficiary assessment instrument
established by the Secretary for purposes of section
1886(j); and
``(iv) in the case of long-term care hospitals, the
Medicare beneficiary assessment instrument used with
respect to such hospitals for the collection of data
elements necessary to calculate quality measures as
described in the August 18, 2011, Federal Register (76 Fed.
Reg. 51754-51755), including for purposes of section
1886(m)(5)(C), or any other instrument used with respect to
such hospitals for assessment purposes.
``(C) Applicable reporting provision.--The term `applicable
reporting provision' means--
``(i) for home health agencies, section
1895(b)(3)(B)(v);
``(ii) for skilled nursing facilities, section
1888(e)(6);
``(iii) for inpatient rehabilitation facilities,
section 1886(j)(7); and
``(iv) for long-term care hospitals, section
1886(m)(5).
``(D) PAC payment system.--The term `PAC payment system'
means--
``(i) with respect to a home health agency, the
prospective payment system under section 1895;
``(ii) with respect to a skilled nursing facility, the
prospective payment system under section 1888(e);
``(iii) with respect to an inpatient rehabilitation
facility, the prospective payment system under section
1886(j); and
``(iv) with respect to a long-term care hospital, the
prospective payment system under section 1886(m).
``(E) Specified application date.--The term `specified
application date' means the following:
``(i) Quality measures.--In the case of quality
measures under subsection (c)(1)--
``(I) with respect to the domain described in
subsection (c)(1)(A) (relating to functional status,
cognitive function, and changes in function and
cognitive function)--
``(aa) for PAC providers described in clauses
(ii) and (iii) of paragraph (2)(A), October 1,
2016;
``(bb) for PAC providers described in clause
(iv) of such paragraph, October 1, 2018; and
``(cc) for PAC providers described in clause
(i) of such paragraph, January 1, 2019;
``(II) with respect to the domain described in
subsection (c)(1)(B) (relating to skin integrity and
changes in skin integrity)--
``(aa) for PAC providers described in clauses
(ii), (iii), and (iv) of paragraph (2)(A), October
1, 2016; and
``(bb) for PAC providers described in clause
(i) of such paragraph, January 1, 2017;
``(III) with respect to the domain described in
subsection (c)(1)(C) (relating to medication
reconciliation)--
``(aa) for PAC providers described in clause
(i) of such paragraph, January 1, 2017; and
``(bb) for PAC providers described in clauses
(ii), (iii), and (iv) of such paragraph, October 1,
2018;
``(IV) with respect to the domain described in
subsection (c)(1)(D) (relating to incidence of major
falls)--
``(aa) for PAC providers described in clauses
(ii), (iii), and (iv) of paragraph (2)(A), October
1, 2016; and
``(bb) for PAC providers described in clause
(i) of such paragraph, January 1, 2019; and
``(V) with respect to the domain described in
subsection (c)(1)(E) (relating to accurately
communicating the existence of and providing for the
transfer of health information and care preferences)--
``(aa) for PAC providers described in clauses
(ii), (iii), and (iv) of paragraph (2)(A), October
1, 2018; and
``(bb) for PAC providers described in clause
(i) of such paragraph, January 1, 2019.
``(ii) Resource use and other measures.--In the case of
resource use and other measures under subsection (d)(1)--
``(I) for PAC providers described in clauses (ii),
(iii), and (iv) of paragraph (2)(A), October 1, 2016;
and
``(II) for PAC providers described in clause (i) of
such paragraph, January 1, 2017.
``(F) Medicare beneficiary.--The term `Medicare
beneficiary' means an individual entitled to benefits under
part A or, as appropriate, enrolled for benefits under part B.
``(b) Standardized Patient Assessment Data.--
``(1) Requirement for reporting assessment data.--
``(A) In general.--Beginning not later than October 1,
2018, for PAC providers described in clauses (ii), (iii), and
(iv) of subsection (a)(2)(A) and January 1, 2019, for PAC
providers described in clause (i) of such subsection, the
Secretary shall require PAC providers to submit to the
Secretary, under the applicable reporting provisions and
through the use of PAC assessment instruments, the standardized
patient assessment data described in subparagraph (B). The
Secretary shall require such data be submitted with respect to
admission and discharge of an individual (and may be submitted
more frequently as the Secretary deems appropriate).
``(B) Standardized patient assessment data described.--For
purposes of subparagraph (A), the standardized patient
assessment data described in this subparagraph is data required
for at least the quality measures described in subsection
(c)(1) and that is with respect to the following categories:
``(i) Functional status, such as mobility and self care
at admission to a PAC provider and before discharge from a
PAC provider.
``(ii) Cognitive function, such as ability to express
ideas and to understand, and mental status, such as
depression and dementia.
``(iii) Special services, treatments, and
interventions, such as need for ventilator use, dialysis,
chemotherapy, central line placement, and total parenteral
nutrition.
``(iv) Medical conditions and co-morbidities, such as
diabetes, congestive heart failure, and pressure ulcers.
``(v) Impairments, such as incontinence and an impaired
ability to hear, see, or swallow.
``(vi) Other categories deemed necessary and
appropriate by the Secretary.
``(2) Alignment of claims data with standardized patient
assessment data.--To the extent practicable, not later than October
1, 2018, for PAC providers described in clauses (ii), (iii), and
(iv) of subsection (a)(2)(A), and January 1, 2019, for PAC
providers described in clause (i) of such subsection, the Secretary
shall match claims data with assessment data pursuant to this
section for purposes of assessing prior service use and concurrent
service use, such as antecedent hospital or PAC provider use, and
may use such matched data for such other uses as the Secretary
determines appropriate.
``(3) Replacement of certain existing data.--In the case of
patient assessment data being used with respect to a PAC assessment
instrument that duplicates or overlaps with standardized patient
assessment data within a category described in paragraph (1), the
Secretary shall, as soon as practicable, revise or replace such
existing data with the standardized data.
``(4) Clarification.--Standardized patient assessment data
submitted pursuant to this subsection shall not be used to require
individuals to be provided post-acute care by a specific type of
PAC provider in order for such care to be eligible for payment
under this title.
``(c) Quality Measures.--
``(1) Requirement for reporting quality measures.--Not later
than the specified application date, as applicable to measures and
PAC providers, the Secretary shall specify quality measures on
which PAC providers are required under the applicable reporting
provisions to submit standardized patient assessment data described
in subsection (b)(1) and other necessary data specified by the
Secretary. Such measures shall be with respect to at least the
following domains:
``(A) Functional status, cognitive function, and changes in
function and cognitive function.
``(B) Skin integrity and changes in skin integrity.
``(C) Medication reconciliation.
``(D) Incidence of major falls.
``(E) Accurately communicating the existence of and
providing for the transfer of health information and care
preferences of an individual to the individual, family
caregiver of the individual, and providers of services
furnishing items and services to the individual, when the
individual transitions--
``(i) from a hospital or critical access hospital to
another applicable setting, including a PAC provider or the
home of the individual; or
``(ii) from a PAC provider to another applicable
setting, including a different PAC provider, a hospital, a
critical access hospital, or the home of the individual.
``(2) Reporting through pac assessment instruments.--
``(A) In general.--To the extent possible, the Secretary
shall require such reporting by a PAC provider of quality
measures under paragraph (1) through the use of a PAC
assessment instrument and shall modify such PAC assessment
instrument as necessary to enable the use of such instrument
with respect to such quality measures.
``(B) Limitation.--The Secretary may not make significant
modifications to a PAC assessment instrument more than once per
calendar year or fiscal year, as applicable, unless the
Secretary publishes in the Federal Register a justification for
such significant modification.
``(3) Adjustments.--
``(A) In general.--The Secretary shall consider applying
adjustments to the quality measures under this subsection
taking into consideration the studies under section 2(d) of the
IMPACT Act of 2014.
``(B) Risk adjustment.--Such quality measures shall be risk
adjusted, as determined appropriate by the Secretary.
``(d) Resource Use and Other Measures.--
``(1) Requirement for resource use and other measures.--Not
later than the specified application date, as applicable to
measures and PAC providers, the Secretary shall specify resource
use and other measures on which PAC providers are required under
the applicable reporting provisions to submit any necessary data
specified by the Secretary, which may include standardized
assessment data in addition to claims data. Such measures shall be
with respect to at least the following domains:
``(A) Resource use measures, including total estimated
Medicare spending per beneficiary.
``(B) Discharge to community.
``(C) Measures to reflect all-condition risk-adjusted
potentially preventable hospital readmission rates.
``(2) Aligning methodology adjustments for resource use
measures.--
``(A) Period of time.--With respect to the period of time
used for calculating measures under paragraph (1)(A), the
Secretary shall, to the extent the Secretary determines
appropriate, align resource use with the methodology used for
purposes of section 1886(o)(2)(B)(ii).
``(B) Geographic and other adjustments.--The Secretary
shall standardize measures with respect to the domain described
in paragraph (1)(A) for geographic payment rate differences and
payment differentials (and other adjustments, as applicable)
consistent with the methodology published in the Federal
Register on August 18, 2011 (76 Fed. Reg. 51624 through 51626),
or any subsequent modifications made to the methodology.
``(C) Medicare spending per beneficiary.--The Secretary
shall adjust, as appropriate, measures with respect to the
domain described in paragraph (1)(A) for the factors applied
under section 1886(o)(2)(B)(ii).
``(3) Adjustments.--
``(A) In general.--The Secretary shall consider applying
adjustments to the resource use and other measures specified
under this subsection with respect to the domain described in
paragraph (1)(A), taking into consideration the studies under
section 2(d) of the IMPACT Act of 2014.
``(B) Risk adjustment.--Such resource use and other
measures shall be risk adjusted, as determined appropriate by
the Secretary.
``(e) Measurement Implementation Phases; Selection of Quality
Measures and Resource Use and Other Measures.--
``(1) Measurement implementation phases.--In the case of
quality measures specified under subsection (c)(1) and resource use
and other measures specified under subsection (d)(1), the
provisions of this section shall be implemented in accordance with
the following phases:
``(A) Initial implementation phase.--The initial
implementation phase, with respect to such a measure, shall, in
accordance with subsections (c) and (d), as applicable, consist
of--
``(i) measure specification, including informing the
public of the measure's numerator, denominator, exclusions,
and any other aspects the Secretary determines necessary;
``(ii) data collection, including, in the case of
quality measures, requiring PAC providers to report data
elements needed to calculate such a measure; and
``(iii) data analysis, including, in the case of
resource use and other measures, the use of claims data to
calculate such a measure.
``(B) Second implementation phase.--The second
implementation phase, with respect to such a measure, shall
consist of the provision of feedback reports to PAC providers,
in accordance with subsection (f).
``(C) Third implementation phase.--The third implementation
phase, with respect to such a measure, shall consist of public
reporting of PAC providers' performance on such measure in
accordance with subsection (g).
``(2) Consensus-based entity.--
``(A) In general.--Subject to subparagraph (B), each
measure specified by the Secretary under this section shall be
endorsed by the entity with a contract under section 1890(a).
``(B) Exception.--In the case of a specified area or
medical topic determined appropriate by the Secretary for which
a feasible and practical measure has not been endorsed by the
entity with a contract under section 1890(a), the Secretary may
specify a measure that is not so endorsed as long as due
consideration is given to measures that have been endorsed or
adopted by a consensus organization identified by the
Secretary.
``(3) Treatment of application of pre-rulemaking process
(measure applications partnership process).--
``(A) In general.--Subject to subparagraph (B), the
provisions of section 1890A shall apply in the case of a
quality measure specified under subsection (c) or a resource
use or other measure specified under subsection (d).
``(B) Exceptions.--
``(i) Expedited procedures.--For purposes of satisfying
subparagraph (A), the Secretary may use expedited
procedures, such as ad-hoc reviews, as necessary, in the
case of a quality measure specified under subsection (c) or
a resource use or other measure specified in subsection (d)
required with respect to data submissions under the
applicable reporting provisions during the 1-year period
before the specified application date applicable to such a
measure and provider involved.
``(ii) Option to waive provisions.--The Secretary may
waive the application of the provisions of section 1890A in
the case of a quality measure or resource use or other
measure described in clause (i), if the application of such
provisions (including through the use of an expedited
procedure described in such clause) would result in the
inability of the Secretary to satisfy any deadline
specified in this section with respect to such measure.
``(f) Feedback Reports to PAC Providers.--
``(1) In general.--Beginning one year after the specified
application date, as applicable to PAC providers and quality
measures and resource use and other measures under this section,
the Secretary shall provide confidential feedback reports to such
PAC providers on the performance of such providers with respect to
such measures required under the applicable provisions.
``(2) Frequency.--To the extent feasible, the Secretary shall
provide feedback reports described in paragraph (1) not less
frequently than on a quarterly basis. Notwithstanding the previous
sentence, with respect to measures described in such paragraph that
are reported on an annual basis, the Secretary may provide such
feedback reports on an annual basis.
``(g) Public Reporting of PAC Provider Performance.--
``(1) In general.--Subject to the succeeding paragraphs of this
subsection, the Secretary shall provide for public reporting of PAC
provider performance on quality measures under subsection (c)(1)
and the resource use and other measures under subsection (d)(1),
including by establishing procedures for making available to the
public information regarding the performance of individual PAC
providers with respect to such measures.
``(2) Opportunity to review.--The procedures under paragraph
(1) shall ensure, including through a process consistent with the
process applied under section 1886(b)(3)(B)(viii)(VII) for similar
purposes, that a PAC provider has the opportunity to review and
submit corrections to the data and information that is to be made
public with respect to the provider prior to such data being made
public.
``(3) Timing.--Such procedures shall provide that the data and
information described in paragraph (1), with respect to a measure
and PAC provider, is made publicly available beginning not later
than two years after the specified application date applicable to
such a measure and provider.
``(4) Coordination with existing programs.--Such procedures
shall provide that data and information described in paragraph (1)
with respect to quality measures and resource use and other
measures under subsections (c)(1) and (d)(1) shall be made publicly
available consistent with the following provisions:
``(A) In the case of home health agencies, section
1895(b)(3)(B)(v)(III).
``(B) In the case of skilled nursing facilities, sections
1819(i) and 1919(i).
``(C) In the case of inpatient rehabilitation facilities,
section 1886(j)(7)(E).
``(D) In the case of long-term care hospitals, section
1886(m)(5)(E).
``(h) Removing, Suspending, or Adding Measures.--
``(1) In general.--The Secretary may remove, suspend, or add a
quality measure or resource use or other measure described in
subsection (c)(1) or (d)(1), so long as, subject to paragraph (2),
the Secretary publishes in the Federal Register (with a notice and
comment period) a justification for such removal, suspension, or
addition.
``(2) Exception.--In the case of such a quality measure or
resource use or other measure for which there is a reason to
believe that the continued collection of such measure raises
potential safety concerns or would cause other unintended
consequences, the Secretary may promptly suspend or remove such
measure and satisfy paragraph (1) by publishing in the Federal
Register a justification for such suspension or removal in the next
rulemaking cycle following such suspension or removal.
``(i) Use of Standardized Assessment Data, Quality Measures, and
Resource Use and Other Measures To Inform Discharge Planning and
Incorporate Patient Preference.--
``(1) In general.--Not later than January 1, 2016, and
periodically thereafter (but not less frequently than once every 5
years), the Secretary shall promulgate regulations to modify
conditions of participation and subsequent interpretive guidance
applicable to PAC providers, hospitals, and critical access
hospitals. Such regulations and interpretive guidance shall require
such providers to take into account quality, resource use, and
other measures under the applicable reporting provisions (which, as
available, shall include measures specified under subsections (c)
and (d), and other relevant measures) in the discharge planning
process. Specifically, such regulations and interpretive guidance
shall address the settings to which a patient may be discharged in
order to assist subsection (d) hospitals, critical access
hospitals, hospitals described in section 1886(d)(1)(B)(v), PAC
providers, patients, and families of such patients with discharge
planning from inpatient settings, including such hospitals, and
from PAC provider settings. In addition, such regulations and
interpretive guidance shall include procedures to address--
``(A) treatment preferences of patients; and
``(B) goals of care of patients.
``(2) Discharge planning.--All requirements applied pursuant to
paragraph (1) shall be used to help inform and mandate the
discharge planning process.
``(3) Clarification.--Such regulations shall not require an
individual to be provided post-acute care by a specific type of PAC
provider in order for such care to be eligible for payment under
this title.
``(j) Stakeholder Input.--Before the initial rulemaking process to
implement this section, the Secretary shall allow for stakeholder
input, such as through town halls, open door forums, and mail-box
submissions.
``(k) Funding.--For purposes of carrying out this section, the
Secretary shall provide for the transfer to the Centers for Medicare &
Medicaid Services Program Management Account, from the Federal Hospital
Insurance Trust Fund under section 1817 and the Federal Supplementary
Medical Insurance Trust Fund under section 1841, in such proportion as
the Secretary determines appropriate, of $130,000,000. Fifty percent of
such amount shall be available on the date of the enactment of this
section and fifty percent of such amount shall be equally proportioned
for each of fiscal years 2015 through 2019. Such sums shall remain
available until expended.
``(l) Limitation.--There shall be no administrative or judicial
review under sections 1869 and 1878 or otherwise of the specification
of standardized patient assessment data required, the determination of
measures, and the systems to report such standardized data under this
section.
``(m) Non-Application of Paperwork Reduction Act.--Chapter 35 of
title 44, United States Code (commonly referred to as the `Paperwork
Reduction Act of 1995') shall not apply to this section and the
sections referenced in subsection (a)(2)(B) that require modification
in order to achieve the standardization of patient assessment data.''.
(b) Studies of Alternative PAC Payment Models.--
(1) MedPAC.--Using data from the Post-Acute Payment Reform
Demonstration authorized under section 5008 of the Deficit
Reduction Act of 2005 (Public Law 109-171) or other data, as
available, not later than June 30, 2016, the Medicare Payment
Advisory Commission shall submit to Congress a report that
evaluates and recommends features of PAC payment systems (as
defined in section 1899B(a)(2)(D) of the Social Security Act, as
added by subsection (a)) that establish, or a unified post-acute
care payment system under title XVIII of the Social Security Act
that establishes, payment rates according to characteristics of
individuals (such as cognitive ability, functional status, and
impairments) instead of according to the post-acute care setting
where the Medicare beneficiary involved is treated. To the extent
feasible, such report shall consider the impacts of moving from PAC
payment systems (as defined in subsection (a)(2)(D) of such section
1899B) in existence as of the date of the enactment of this Act to
new post-acute care payment systems under title XVIII of the Social
Security Act.
(2) Recommendations for pac prospective payment.--
(A) Report by secretary.--Not later than 2 years after the
date by which the Secretary of Health and Human Services has
collected 2 years of data on quality measures under subsection
(c) of section 1899B, as added by subsection (a), the Secretary
shall, in consultation with the Medicare Payment Advisory
Commission and appropriate stakeholders, submit to Congress a
report, including--
(i) recommendations and a technical prototype, on a
post-acute care prospective payment system under title
XVIII of the Social Security Act that would--
(I) in lieu of the rates that would otherwise apply
under PAC payment systems (as defined in subsection
(a)(2)(D) of such section 1899B), base payments under
such title, with respect to items and services
furnished to an individual by a PAC provider (as
defined in subsection (a)(2)(A) of such section),
according to individual characteristics (such as
cognitive ability, functional status, and impairments)
of such individual instead of the post-acute care
setting in which the individual is furnished such items
and services;
(II) account for the clinical appropriateness of
items and services so furnished and Medicare
beneficiary outcomes;
(III) be designed to incorporate (or otherwise
account for) standardized patient assessment data under
section 1899B; and
(IV) further clinical integration, such as by
motivating greater coordination around a single
condition or procedure to integrate hospital systems
with PAC providers (as so defined).
(ii) recommendations on which Medicare fee-for-service
regulations for post-acute care payment systems under title
XVIII of the Social Security Act should be altered (such as
the skilled nursing facility 3-day stay and inpatient
rehabilitation facility 60 percent rule);
(iii) an analysis of the impact of the recommended
payment system described in clause (i) on Medicare
beneficiary cost-sharing, access to care, and choice of
setting;
(iv) a projection of any potential reduction in
expenditures under title XVIII of the Social Security Act
that may be attributable to the application of the
recommended payment system described in clause (i); and
(v) a review of the value of subsection (d) hospitals
(as defined in section 1886(d)(1)(B) of the Social Security
Act (42 U.S.C. 1395ww(d)(1)(B)), hospitals described in
section 1886(d)(1)(B)(v) of such Act (42 U.S.C.
1395ww(d)(1)(B)(v)), and critical access hospitals
described in section 1820(c)(2)(B) of such Act (42 U.S.C.
1395i-4(c)(2)(B)) collecting and reporting to the Secretary
standardized patient assessment data with respect to
inpatient hospital services furnished by such a hospital or
critical access hospital to individuals who are entitled to
benefits under part A of title XVIII of such Act or, as
appropriate, enrolled for benefits under part B of such
title.
(B) Report by medpac.--Not later than the first June 30th
following the date on which the report is required under
subparagraph (A), the Medicare Payment Advisory Commission
shall submit to Congress a report, including recommendations
and a technical prototype, on a post-acute care prospective
payment system under title XVIII of the Social Security Act
that would satisfy the criteria described in subparagraph (A).
(3) Medicare beneficiary defined.--For purposes of this
subsection, the term ``Medicare beneficiary'' has the meaning given
such term in section 1899B(a)(2) of the Social Security Act, as
added by subsection (a).
(c) Payment Consequences Under the Applicable Reporting
Provisions.--
(1) Home health agencies.--Section 1895(b)(3)(B)(v) of the
Social Security Act (42 U.S.C. 1395fff(b)(3)(B)(v)) is amended--
(A) in subclause (I), by striking ``subclause (II)'' and
inserting ``subclauses (II) and (IV)'';
(B) in subclause (II), by striking ``For 2007'' and
inserting ``Subject to subclause (V), for 2007'';
(C) in subclause (III), by inserting ``and subclause
(IV)(aa)'' after ``subclause (II)''; and
(D) by adding at the end the following new subclauses:
``(IV) Submission of additional data.--
``(aa) In general.--For the year beginning on
the specified application date (as defined in
subsection (a)(2)(E) of section 1899B), as
applicable with respect to home health agencies and
quality measures under subsection (c)(1) of such
section and measures under subsection (d)(1) of
such section, and each subsequent year, in addition
to the data described in subclause (II), each home
health agency shall submit to the Secretary data on
such quality measures and any necessary data
specified by the Secretary under such subsection
(d)(1).
``(bb) Standardized patient assessment data.--
For 2019 and each subsequent year, in addition to
such data described in item (aa), each home health
agency shall submit to the Secretary standardized
patient assessment data required under subsection
(b)(1) of section 1899B.
``(cc) Submission.--Data shall be submitted
under items (aa) and (bb) in the form and manner,
and at the time, specified by the Secretary for
purposes of this clause.
``(V) Non-duplication.--To the extent data
submitted under subclause (IV) duplicates other data
required to be submitted under subclause (II), the
submission of such data under subclause (IV) shall be
in lieu of the submission of such data under subclause
(II). The previous sentence shall not apply insofar as
the Secretary determines it is necessary to avoid a
delay in the implementation of section 1899B, taking
into account the different specified application dates
under subsection (a)(2)(E) of such section.''.
(2) Inpatient rehabilitation facilities.--Section 1886(j)(7) of
the Social Security Act (42 U.S.C. 1395ww(j)(7)) is amended--
(A) in subparagraph (A)(i), by striking ``subparagraph
(C)'' and inserting ``subparagraphs (C) and (F)'';
(B) in subparagraph (C), by striking ``For fiscal year 2014
and each subsequent rate year'' and inserting ``Subject to
subparagraph (G), for fiscal year 2014 and each subsequent
fiscal year'';
(C) in subparagraph (E), by inserting ``and subparagraph
(F)(i)'' after ``subparagraph (C)''; and
(D) by adding at the end the following new subparagraphs:
``(F) Submission of additional data.--
``(i) In general.--For the fiscal year beginning on the
specified application date (as defined in subsection
(a)(2)(E) of section 1899B), as applicable with respect to
inpatient rehabilitation facilities and quality measures
under subsection (c)(1) of such section and measures under
subsection (d)(1) of such section, and each subsequent
fiscal year, in addition to such data on the quality
measures described in subparagraph (C), each rehabilitation
facility shall submit to the Secretary data on the quality
measures under such subsection (c)(1) and any necessary
data specified by the Secretary under such subsection
(d)(1).
``(ii) Standardized patient assessment data.--For
fiscal year 2019 and each subsequent fiscal year, in
addition to such data described in clause (i), each
rehabilitation facility shall submit to the Secretary
standardized patient assessment data required under
subsection (b)(1) of section 1899B.
``(iii) Submission.--Such data shall be submitted in
the form and manner, and at the time, specified by the
Secretary for purposes of this subparagraph.
``(G) Non-duplication.--To the extent data submitted under
subparagraph (F) duplicates other data required to be submitted
under subparagraph (C), the submission of such data under
subparagraph (F) shall be in lieu of the submission of such
data under subparagraph (C). The previous sentence shall not
apply insofar as the Secretary determines it is necessary to
avoid a delay in the implementation of section 1899B, taking
into account the different specified application dates under
subsection (a)(2)(E) of such section.''.
(3) Long-term care hospitals.--Section 1886(m)(5) of the Social
Security Act (42 U.S.C. 1395ww(m)(5)) is amended--
(A) in subparagraph (A)(i), by striking ``subparagraph
(C)'' and inserting ``subparagraphs (C) and (F)'';
(B) in subparagraph (C), by striking ``For rate year'' and
inserting ``Subject to subparagraph (G), for rate year'';
(C) in subparagraph (E), by inserting ``and subparagraph
(F)(i)'' after ``subparagraph (C)''; and
(D) by adding at the end the following new subparagraphs:
``(F) Submission of additional data.--
``(i) In general.--For the rate year beginning on the
specified application date (as defined in subsection
(a)(2)(E) of section 1899B), as applicable with respect to
long-term care hospitals and quality measures under
subsection (c)(1) of such section and measures under
subsection (d)(1) of such section, and each subsequent rate
year, in addition to the data on the quality measures
described in subparagraph (C), each long-term care hospital
(other than a hospital classified under subsection
(d)(1)(B)(iv)(II)) shall submit to the Secretary data on
the quality measures under such subsection (c)(1) and any
necessary data specified by the Secretary under such
subsection (d)(1).
``(ii) Standardized patient assessment data.--For rate
year 2019 and each subsequent rate year, in addition to
such data described in clause (i), each long-term care
hospital (other than a hospital classified under subsection
(d)(1)(B)(iv)(II)) shall submit to the Secretary
standardized patient assessment data required under
subsection (b)(1) of section 1899B.
``(iii) Submission.--Such data shall be submitted in
the form and manner, and at the time, specified by the
Secretary for purposes of this subparagraph.
``(G) Non-duplication.--To the extent data submitted under
subparagraph (F) duplicates other data required to be submitted
under subparagraph (C), the submission of such data under
subparagraph (F) shall be in lieu of the submission of such
data under subparagraph (C). The previous sentence shall not
apply insofar as the Secretary determines it is necessary to
avoid a delay in the implementation of section 1899B, taking
into account the different specified application dates under
subsection (a)(2)(E) of such section.''.
(4) Skilled nursing facilities.--
(A) In general.--Paragraph (6) of section 1888(e) of the
Social Security Act (42 U.S.C. 1395yy(e)) is amended to read as
follows:
``(6) Reporting of assessment and quality data.--
``(A) Reduction in update for failure to report.--
``(i) In general.--For fiscal years beginning with
fiscal year 2018, in the case of a skilled nursing facility
that does not submit data, as applicable, in accordance
with subclauses (II) and (III) of subparagraph (B)(i) with
respect to such a fiscal year, after determining the
percentage described in paragraph (5)(B)(i), and after
application of paragraph (5)(B)(ii), the Secretary shall
reduce such percentage for payment rates during such fiscal
year by 2 percentage points.
``(ii) Special rule.--The application of this
subparagraph may result in the percentage described in
paragraph (5)(B)(i), after application of paragraph
(5)(B)(ii), being less than 0.0 for a fiscal year, and may
result in payment rates under this subsection for a fiscal
year being less than such payment rates for the preceding
fiscal year.
``(iii) Noncumulative application.--Any reduction under
clause (i) shall apply only with respect to the fiscal year
involved and the Secretary shall not take into account such
reduction in computing the payment amount under this
subsection for a subsequent fiscal year.
``(B) Assessment and measure data.--
``(i) In general.--A skilled nursing facility, or a
facility (other than a critical access hospital) described
in paragraph (7)(B), shall submit to the Secretary, in a
manner and within the timeframes prescribed by the
Secretary--
``(I) subject to clause (iii), the resident
assessment data necessary to develop and implement the
rates under this subsection;
``(II) for fiscal years beginning on or after the
specified application date (as defined in subsection
(a)(2)(E) of section 1899B), as applicable with respect
to skilled nursing facilities and quality measures
under subsection (c)(1) of such section and measures
under subsection (d)(1) of such section, data on such
quality measures under such subsection (c)(1) and any
necessary data specified by the Secretary under such
subsection (d)(1); and
``(III) for fiscal years beginning on or after
October 1, 2018, standardized patient assessment data
required under subsection (b)(1) of section 1899B.
``(ii) Use of standard instrument.--For purposes of
meeting the requirement under clause (i), a skilled nursing
facility, or a facility (other than a critical access
hospital) described in paragraph (7)(B), may submit the
resident assessment data required under section 1819(b)(3),
using the standard instrument designated by the State under
section 1819(e)(5).
``(iii) Non-duplication.--To the extent data submitted
under subclause (II) or (III) of clause (i) duplicates
other data required to be submitted under clause (i)(I),
the submission of such data under such a subclause shall be
in lieu of the submission of such data under clause (i)(I).
The previous sentence shall not apply insofar as the
Secretary determines it is necessary to avoid a delay in
the implementation of section 1899B, taking into account
the different specified application dates under subsection
(a)(2)(E) of such section.''.
(B) Funding for nursing home compare website.--Section
1819(i) of the Social Security Act (42 U.S.C. 1395i-3(i)) is
amended by adding at the end the following new paragraph:
``(3) Funding.--The Secretary shall transfer to the Centers for
Medicare & Medicaid Services Program Management Account, from the
Federal Hospital Insurance Trust Fund under section 1817 a one-time
allocation of $11,000,000. The amount shall be available on the
date of the enactment of this paragraph. Such sums shall remain
available until expended. Such sums shall be used to implement
section 1128I(g).''.
(d) Improving Payment Accuracy Under the PAC Payment Systems and
Other Medicare Payment Systems.--
(1) Studies and reports of effect of certain information on
quality and resource use.--
(A) Study using existing medicare data.--
(i) Study.--The Secretary of Health and Human Services
(in this subsection referred to as the ``Secretary'') shall
conduct a study that examines the effect of individuals'
socioeconomic status on quality measures and resource use
and other measures for individuals under the Medicare
program under title XVIII of the Social Security Act (42
U.S.C. 1395 et seq.) (such as to recognize that less
healthy individuals may require more intensive
interventions). The study shall use information collected
on such individuals in carrying out such program, such as
urban and rural location, eligibility for Medicaid under
title XIX of such Act (42 U.S.C. 1396 et seq.) (recognizing
and accounting for varying Medicaid eligibility across
States), and eligibility for benefits under the
supplemental security income (SSI) program. The Secretary
shall carry out this paragraph acting through the Assistant
Secretary for Planning and Evaluation.
(ii) Report.--Not later than 2 years after the date of
the enactment of this Act, the Secretary shall submit to
Congress a report on the study conducted under clause (i).
(B) Study using other data.--
(i) Study.--The Secretary shall conduct a study that
examines the impact of risk factors, such as those
described in section 1848(p)(3) of the Social Security Act
(42 U.S.C. 1395w-4(p)(3)), race, health literacy, limited
English proficiency (LEP), and Medicare beneficiary
activation, on quality measures and resource use and other
measures under the Medicare program (such as to recognize
that less healthy individuals may require more intensive
interventions). In conducting such study the Secretary may
use existing Federal data and collect such additional data
as may be necessary to complete the study.
(ii) Report.--Not later than 5 years after the date of
the enactment of this Act, the Secretary shall submit to
Congress a report on the study conducted under clause (i).
(C) Examination of data in conducting studies.--In
conducting the studies under subparagraphs (A) and (B), the
Secretary shall examine what non-Medicare data sets, such as
data from the American Community Survey (ACS), can be useful in
conducting the types of studies under such paragraphs and how
such data sets that are identified as useful can be coordinated
with Medicare administrative data in order to improve the
overall data set available to do such studies and for the
administration of the Medicare program.
(D) Recommendations to account for information in payment
adjustment mechanisms.--If the studies conducted under
subparagraphs (A) and (B) find a relationship between the
factors examined in the studies and quality measures and
resource use and other measures, then the Secretary shall also
provide recommendations for how the Centers for Medicare &
Medicaid Services should--
(i) obtain access to the necessary data (if such data
is not already being collected) on such factors, including
recommendations on how to address barriers to the Centers
in accessing such data; and
(ii) account for such factors--
(I) in quality measures, resource use measures, and
other measures under title XVIII of the Social Security
Act (including such measures specified under
subsections (c) and (d) of section 1899B of such Act,
as added by subsection (a)); and
(II) in determining payment adjustments based on
such measures in other applicable provisions of such
title.
(E) Funding.--There are hereby appropriated to the
Secretary from the Federal Hospital Insurance Trust Fund under
section 1817 of the Social Security Act (42 U.S.C. 1395i) and
the Federal Supplementary Medical Insurance Trust Fund under
section 1841 of such Act (42 U.S.C. 1395t) (in proportions
determined appropriate by the Secretary) to carry out this
paragraph $6,000,000, to remain available until expended.
(2) CMS activities.--
(A) In general.--Taking into account the relevant studies
conducted and recommendations made in reports under paragraph
(1) and, as appropriate, other information, including
information collected before completion of such studies and
recommendations, the Secretary, on an ongoing basis, shall, as
the Secretary determines appropriate and based on an
individual's health status and other factors--
(i) assess appropriate adjustments to quality measures,
resource use measures, and other measures under title XVIII
of the Social Security Act (42 U.S.C. 1395 et seq.)
(including measures specified in subsections (c) and (d) of
section 1899B of such Act, as added by subsection (a)); and
(ii) assess and implement appropriate adjustments to
payments under such title based on measures described in
clause (i).
(B) Accessing data.--The Secretary shall collect or
otherwise obtain access to the data necessary to carry out this
paragraph through existing and new data sources.
(C) Periodic analyses.--The Secretary shall carry out
periodic analyses, at least every 3 years, based on the factors
referred to in subparagraph (A) so as to monitor changes in
possible relationships.
(D) Funding.--There are hereby appropriated to the
Secretary from the Federal Hospital Insurance Trust Fund under
section 1817 of the Social Security Act (42 U.S.C. 1395i) and
the Federal Supplementary Medical Insurance Trust Fund under
section 1841 of such Act (42 U.S.C. 1395t) (in proportions
determined appropriate by the Secretary) to carry out this
paragraph $10,000,000, to remain available until expended.
(3) Strategic plan for accessing race and ethnicity data.--Not
later than 18 months after the date of the enactment of this Act,
the Secretary shall develop and report to Congress on a strategic
plan for collecting or otherwise accessing data on race and
ethnicity for purposes of specifying quality measures and resource
use and other measures under subsections (c) and (d) of section
1899B of the Social Security Act, as added by subsection (a), and,
as the Secretary determines appropriate, other similar provisions
of, including payment adjustments under, title XVIII of such Act
(42 U.S.C. 1395 et seq.).
SEC. 3. HOSPICE CARE.
(a) Hospice Survey Requirement.--
(1) In general.--Section 1861(dd)(4) of the Social Security Act
(42 U.S.C. 1395x(dd)(4)) is amended by adding at the end the
following new subparagraph:
``(C) Any entity that is certified as a hospice program shall be
subject to a standard survey by an appropriate State or local survey
agency, or an approved accreditation agency, as determined by the
Secretary, not less frequently than once every 36 months beginning 6
months after the date of the enactment of this subparagraph and ending
September 30, 2025.''.
(2) Funding.--For purposes of carrying out subparagraph (C) of
section 1861(dd)(4) of the Social Security Act (42 U.S.C.
1395x(dd)(4)), as added by paragraph (1), there shall be
transferred from the Federal Hospital Insurance Trust Fund under
section 1817 of such Act (42 U.S.C. 1395i) to the Centers for
Medicare & Medicaid Services Program Management Account--
(A) $25,000,000 for fiscal years 2015 through 2017, to be
made available for such purposes in equal parts for each such
fiscal year; and
(B) $45,000,000 for fiscal years 2018 through 2025, to be
made available for such purposes in equal parts for each such
fiscal year.
(b) Hospice Program Eligibility Recertification Technical
Correction to Apply Limitation on Liability of Beneficiary Rules.--
Section 1879 of the Social Security Act (42 U.S.C. 1395pp) is amended
by adding at the end the following new subsection:
``(i) The provisions of this section shall apply with respect to a
denial of a payment under this title by reason of section 1814(a)(7)(E)
in the same manner as such provisions apply with respect to a denial of
a payment under this title by reason of section 1862(a)(1).''.
(c) Revision to Requirement for Medical Review of Certain Hospice
Care.--Section 1814(a)(7) of the Social Security Act (42 U.S.C.
1395f(a)(7)) is amended--
(1) in subparagraph (C), by striking ``and'' at the end;
(2) in subparagraph (D), in the matter preceding clause (i), by
inserting ``(and, in the case of clause (ii), before the date of
enactment of subparagraph (E))'' after ``2011''; and
(3) by adding at the end the following new subparagraph:
``(E) on and after the date of enactment of this
subparagraph, in the case of hospice care provided an
individual for more than 180 days by a hospice program for
which the number of such cases for such program comprises more
than a percent (specified by the Secretary) of the total number
of all cases of individuals provided hospice care by the
program under this title, the hospice care provided to such
individual is medically reviewed (in accordance with procedures
established by the Secretary); and''.
(d) Update of Hospice Aggregate Payment Cap.--Section 1814(i)(2)(B)
of the Social Security Act (42 U.S.C. 1395f(i)(2)(B)) is amended--
(1) by striking ``(B) For purposes'' and inserting ``(B)(i)
Except as provided in clause (ii), for purposes''; and
(2) by adding at the end the following:
``(ii) For purposes of subparagraph (A) for accounting years that
end after September 30, 2016, and before October 1, 2025, the `cap
amount' is the cap amount under this subparagraph for the preceding
accounting year updated by the percentage update to payment rates for
hospice care under paragraph (1)(C) for services furnished during the
fiscal year beginning on the October 1 preceding the beginning of the
accounting year (including the application of any productivity or other
adjustment under clause (iv) of that paragraph).
``(iii) For accounting years that end after September 30, 2025, the
cap amount shall be computed under clause (i) as if clause (ii) had
never applied.''.
(e) Medicare Improvement Fund.--Section 1898 of the Social Security
Act (42 U.S.C. 1395iii) is amended--
(1) by amending the heading to read as follows: ``medicare
improvement fund'';
(2) by amending subsection (a) to read as follows:
``(a) Establishment.--The Secretary shall establish under this
title a Medicare Improvement Fund (in this section referred to as the
`Fund') which shall be available to the Secretary to make improvements
under the original Medicare fee-for-service program under parts A and B
for individuals entitled to, or enrolled for, benefits under part or
enrolled under part B including adjustments to payments for items and
services furnished by providers of services and suppliers under such
original Medicare fee-for-service program.'';
(3) in subsection (b)(1), by striking ``during'' and all that
follows and inserting ``during and after fiscal year 2020,
$195,000,000.''; and
(4) in subsection (b)(2), by striking ``from the Federal'' and
all that follows and inserting ``from the Federal Hospital
Insurance Trust Fund and the Federal Supplementary Medical
Insurance Trust Fund in such proportion as the Secretary determines
appropriate.''.
Speaker of the House of Representatives.
Vice President of the United States and
President of the Senate.