[Congressional Bills 117th Congress]
[From the U.S. Government Publishing Office]
[H.R. 4890 Introduced in House (IH)]

<DOC>






117th CONGRESS
  1st Session
                                H. R. 4890

To amend title XVIII of the Social Security Act to establish a program 
    to allow qualified group practices to furnish certain items and 
    services at qualified skilled nursing facilities to individuals 
  entitled to benefits under part A and enrolled under part B of the 
Medicare program to reduce unnecessary hospitalizations, and for other 
                               purposes.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                             July 30, 2021

   Ms. Kuster (for herself and Mr. Smith of Nebraska) 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 establish a program 
    to allow qualified group practices to furnish certain items and 
    services at qualified skilled nursing facilities to individuals 
  entitled to benefits under part A and enrolled under part B of the 
Medicare program to reduce unnecessary hospitalizations, 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 ``Reducing Unnecessary Senior 
Hospitalizations Act of 2021'' or the ``RUSH Act of 2021''.

SEC. 2. SNF-BASED PROVISION OF PREVENTIVE ACUTE CARE AND 
              HOSPITALIZATION REDUCTION PROGRAM.

    Title XVIII of the Social Security Act is amended by adding at the 
end the following new section:

``SEC. 1899C. SNF-BASED PROVISION OF PREVENTIVE ACUTE CARE AND 
              HOSPITALIZATION REDUCTION PROGRAM.

    ``(a) Establishment.--There is established a program to be known as 
the `SNF-based Provision of Preventive Acute Care and Hospitalization 
Reduction Program' (in this section referred to as the `Program'), to 
be administered by the Secretary, for purposes of reducing unnecessary 
hospitalizations and emergency department visits by allowing qualified 
group practices (as defined in section 1877(h)(4)) on or after January 
1, 2022, to furnish items and services identified under subsection 
(b)(3) to individuals entitled to benefits under part A and enrolled 
under part B residing in qualified skilled nursing facilities.
    ``(b) Operation of Program.--Under the Program, the Secretary shall 
provide for the following:
            ``(1) Certification of skilled nursing facilities as 
        qualified skilled nursing facilities under subsection (c)(1).
            ``(2) Certification of group practices as qualified group 
        practices under subsection (c)(2).
            ``(3) Identification on an annual basis of minimum 
        required, clinically appropriate nonsurgical items and services 
        furnished at a hospital emergency department that may be safely 
        furnished by a qualified group practice at a qualified skilled 
        nursing facility under the Program and that such qualified 
        group practice shall offer to furnish under the Program. Such 
        items and services may include provider review of lab and 
        imaging reports for medical decision making, medication 
        management, blood glucose management, behavioral health 
        services, and other services offered to diagnose or treat low 
        acuity conditions.
            ``(4) Establishment of qualifications for nonphysician 
        employees who may furnish such items and services at a 
        qualified skilled nursing facility. Such qualifications shall 
        include the requirement that such an employee--
                    ``(A) be certified in basic life support by a 
                nationally recognized specialty board of certification 
                or equivalent certification board, in accordance with 
                requirements under section 483.24(a)(3) of title 42, 
                Code of Federal Regulations (or any successor 
                regulation); and
                    ``(B) have--
                            ``(i) clinical experience furnishing 
                        medical care--
                                    ``(I) in a skilled nursing 
                                facility;
                                    ``(II) in a hospital emergency 
                                department setting; or
                                    ``(III) as an employee of a 
                                provider or supplier of ambulance 
                                services; or
                            ``(ii) a certification in paramedicine.
            ``(5) Payment under this title for items and services 
        identified under paragraph (3) furnished by such qualified 
        group practices at such a facility in amounts determined under 
        subsection (d).
    ``(c) Certifications.--
            ``(1) Qualified skilled nursing facilities.--
                    ``(A) In general.--For purposes of this section, 
                the Secretary shall certify a skilled nursing facility 
                as a qualified skilled nursing facility if the facility 
                submits an application in a time and manner specified 
                by the Secretary and meets the following requirements:
                            ``(i) The facility has on-site diagnostic 
                        equipment necessary for a qualified group 
                        practice to furnish items and services under 
                        the Program and real-time audio and visual 
                        capabilities as provided by the agreement 
                        between the facility and the qualified group 
                        practice.
                            ``(ii) The facility has at least one 
                        individual who meets the qualifications 
                        described in subsection (b)(4) or a physician 
                        present 24 hours a day and 7 days a week to 
                        work with the qualified group practice, in 
                        accordance with section 483.35(a) of title 42, 
                        Code of Federal Regulations (or any successor 
                        regulation). Such individual may be a member of 
                        the staff of the qualified skilled nursing 
                        facility or of the qualified group practice.
                            ``(iii) The facility ensures that residents 
                        of such facility, upon entering such facility, 
                        are allowed to specify in an advanced care 
                        directive or otherwise documented in the 
                        individual's records whether the resident 
                        wishes to receive items and services furnished 
                        at the facility under the Program in a case 
                        where communication with the resident is not 
                        possible.
                            ``(iv) The facility ensures that 
                        individuals to be furnished such items and 
                        services under the Program at such facility 
                        have the opportunity, at their request, to 
                        instead be transported to a hospital emergency 
                        department.
                            ``(v) The facility is not part of the 
                        Special Focus Facility program of the Centers 
                        for Medicare & Medicaid Services (although the 
                        facility may, at the discretion of the 
                        Secretary, be a candidate for selection under 
                        such program).
                    ``(B) Required provision of services and 
                activities.--Nothing in this paragraph shall affect the 
                application of requirements under section 1819(b)(4), 
                relating to provision of services and activities, to a 
                facility.
            ``(2) Qualified group practices.--For purposes of this 
        section, the Secretary shall certify a group practice as a 
        qualified group practice for a period of 3 years if the group 
        practice submits an application in a time and manner specified 
        by the Secretary and meets the following requirements:
                    ``(A) The group practice offers to furnish all 
                minimum required items and services identified under 
                subsection (b)(3) under the Program.
                    ``(B) The group practice submits a notification to 
                the Secretary annually specifying which (if any) 
                additional items and services identified under 
                subsection (b)(3) for a year the group practice will 
                offer to furnish for such year under the Program.
                    ``(C) The group practice ensures that only 
                individuals who meet the qualifications established 
                under subsection (b)(4) or a physician who is part of 
                such group practice may furnish such minimum required 
                items and services and such additional items and 
                services.
                    ``(D) The group practice, as provided by the 
                agreement between the facility and the group practice 
                or under the supervision of the medical director of the 
                facility, ensures that, in the case where such minimum 
                required items and services or such additional items 
                and services are furnished by such an individual, such 
                individual furnishes such minimum required items and 
                services or additional items and services under the 
                supervision, either in-person or through the use of 
                telehealth (not including store-and-forward 
                technologies), of--
                            ``(i) a physician--
                                    ``(I) who is board certified or 
                                board eligible in emergency medicine, 
                                family medicine, geriatrics, or 
                                internal medicine; or
                                    ``(II) who has been certified by a 
                                nationally recognized specialty board 
                                of certification or equivalent 
                                certification board in basic life 
                                support;
                            ``(ii) a nurse practitioner who has been 
                        certified by a nationally recognized specialty 
                        board of certification or equivalent 
                        certification board in basic life support; or
                            ``(iii) a physician assistant who has been 
                        certified by a nationally recognized specialty 
                        board of certification or equivalent 
                        certification board in basic life support.
                    ``(E) With respect to any year in which the 
                qualified group practice would participate in the 
                Program, the Chief Actuary for the Centers for Medicare 
                & Medicaid Services determines that such participation 
                during such year will not result in total estimated 
                expenditures under this title for such year being 
                greater than total estimated expenditures under such 
                title for such year without such participation.
    ``(d) Payments and Treatment of Savings.--
            ``(1) Payments.--
                    ``(A) In general.--For 2022 and each subsequent 
                year, payments shall continue to be made to qualified 
                group practices and qualified skilled nursing 
                facilities participating in the Program under the 
                original Medicare fee-for-service program under parts A 
                and B in the same manner as they would otherwise be 
                made except that such group practices and skilled 
                nursing facilities are eligible to receive payment for 
                shared savings under paragraph (2) if they meet the 
                requirement under subparagraph (B)(i).
                    ``(B) Savings requirement and benchmark.--
                            ``(i) Determining savings.--In each year of 
                        the Program, a qualified group practice (and 
                        any qualified skilled nursing facility 
                        participating in the Program that has an 
                        agreement with the group practice for the 
                        furnishing of items and services identified 
                        under subsection (b)(3) to residents of the 
                        facility) shall be eligible to receive payment 
                        for shared savings under paragraph (2) only if 
                        the estimated average per capita Medicare 
                        expenditures for Medicare fee-for-service 
                        beneficiaries for parts A and B services 
                        furnished under the Program by the group 
                        practice (and any such facility), adjusted for 
                        beneficiary characteristics, is at least the 
                        percent specified by the Secretary below the 
                        applicable benchmark under clause (ii). The 
                        Secretary shall determine the appropriate 
                        percent described in the preceding sentence to 
                        account for normal variation in expenditures 
                        under this title, based upon the number of 
                        Medicare fee-for-service beneficiaries 
                        participating in the Program.
                            ``(ii) Establish and update benchmark.--For 
                        each qualified group practice (and any 
                        qualified skilled nursing facility 
                        participating in the Program that has an 
                        agreement with the group practice for the 
                        furnishing of items and services identified 
                        under subsection (b)(3) to residents of the 
                        facility) the Secretary shall estimate a single 
                        benchmark for each year that is applicable to 
                        both the group practice (and any such facility) 
                        using the most recent available 3 years of per-
                        beneficiary expenditures for parts A and B 
                        services for Medicare fee-for-service 
                        beneficiaries for items and services furnished 
                        by such group practice or skilled nursing 
                        facility under the Program. Such benchmark 
                        shall be adjusted for beneficiary 
                        characteristics and such other factors as the 
                        Secretary determines appropriate. Such 
                        benchmark shall be reset at the start of each 
                        year.
            ``(2) Payments for shared savings.--If a qualified group 
        practice (and any qualified skilled nursing facility 
        participating in the Program that has an agreement with the 
        group practice for the furnishing of items and services 
        identified under subsection (b)(3) to residents of the 
        facility) meets the requirements under paragraph (1), the 
        Secretary shall--
                    ``(A) pay to such qualified group practice an 
                amount equal to 37.5 percent of the difference between 
                such estimated average per capita Medicare expenditures 
                in a year, adjusted for beneficiary characteristics, 
                for items and services furnished under the Program by 
                the group practice (and any such facility) and such 
                benchmark for the qualified group practice (and any 
                such facility); and
                    ``(B) in the case of each such facility--
                            ``(i) if the qualified skilled nursing 
                        facility has at least a three-star rating under 
                        the Five Star Quality Rating System (or a 
                        successor system), pay to the facility an 
                        amount that bears the same ratio to 12.5 
                        percent of the estimated amount of such 
                        difference as the amount of expenditures under 
                        the Program for such items and services 
                        furnished with respect to individuals at such 
                        facility by such qualified group practice 
                        during such year bears to the total amount of 
                        expenditures under the Program for such items 
                        and services furnished with respect to all 
                        individuals by such qualified group practice 
                        during such year; and
                            ``(ii) in the case of a qualified skilled 
                        nursing facility that is not described in 
                        clause (i), retain in the Federal Hospital 
                        Insurance Trust Fund under section 1817 the 
                        amount that the facility would have been paid 
                        pursuant to clause (i) if the facility were 
                        described in such clause until such time as the 
                        facility has at least a three-star rating under 
                        the Five Star Quality Rating System (or a 
                        successor system), at which point the Secretary 
                        shall pay such amount to the facility.
            ``(3) Advanced alternative payment models.--Paragraph (2) 
        shall not apply to items and services furnished to an 
        individual entitled to benefits under part A and enrolled under 
        Part B for whom shared savings would otherwise be attributed 
        through an advanced alternative payment model as authorized 
        under section 1115A or section 1899.
    ``(e) Evaluation.--
            ``(1) In general.--With respect to a qualified group 
        practice and a qualified skilled nursing facility, not later 
        than 6 months after such group practice begins furnishing items 
        and services under the Program (or, in the case of a qualified 
        skilled nursing facility, not less than 6 months after a 
        qualified group practice first furnishes such items and 
        services at such facility), and not less than once every 2 
        years thereafter, the Secretary shall evaluate such qualified 
        group practice and such qualified facility using information 
        received under paragraph (2) on such criteria as determined 
        appropriate by the Secretary.
            ``(2) Reporting of performance and quality improvements.--
        In a time and manner specified by the Secretary, a qualified 
        group practice and a qualified skilled nursing facility shall 
        submit to the Secretary a report containing the following 
        information with respect to items and services furnished under 
        the Program during a reporting period (as specified by the 
        Secretary):
                    ``(A) The items and services most frequently 
                furnished under the Program in such period.
                    ``(B) The number of individuals with respect to 
                whom such group practice furnished such items and 
                services in such period (or, in the case of a qualified 
                skilled nursing facility, the number of individuals 
                with respect to whom such a group practice furnished 
                such items and services at such facility in such 
                period).
                    ``(C) The number of hospitalizations prevented 
                under the Program in such period.
                    ``(D) The number of such individuals who were 
                admitted to a hospital or treated in the emergency 
                department of a hospital within 24 hours of being 
                furnished such items and services.
                    ``(E) Other information determined appropriate by 
                the Secretary.
            ``(3) Loss of qualified certification.--
                    ``(A) In general.--Not later than 3 months after a 
                determination described in this sentence is made, the 
                Secretary may revoke the certification of a qualified 
                skilled nursing facility or a qualified group practice 
                made under subsection (c) if--
                            ``(i) the Chief Actuary of the Centers for 
                        Medicare & Medicaid Services determines that 
                        the participation of such skilled nursing 
                        facility or such group practice in the Program 
                        during a year resulted in total expenditures 
                        under this title for such period being greater 
                        than total expenditures under such title would 
                        have been during such period without such 
                        participation; or
                            ``(ii) a facility is selected for the 
                        Special Focus Facility program or, if the 
                        facility is a candidate for the Special Focus 
                        Facility program, the Secretary determines that 
                        the participation of such facility in the 
                        Program should be terminated.
                    ``(B) Exclusion from certification.--
                            ``(i) In general.--In the case that the 
                        Secretary revokes the certification of a 
                        qualified skilled nursing facility or a 
                        qualified group practice under subparagraph 
                        (A), such skilled nursing facility or such 
                        group practice shall be ineligible for 
                        certification as a qualified skilled nursing 
                        facility or a qualified group practice (as 
                        applicable) under subsection (c) for the 
                        applicable period (as defined under clause 
                        (ii)).
                            ``(ii) Applicable period defined.--In this 
                        subparagraph, the term `applicable period' 
                        means--
                                    ``(I) if the revocation of a 
                                facility or group practice under 
                                subparagraph (A) is due to the 
                                application of clause (i) of such 
                                subparagraph, a 1-year period beginning 
                                on the date of such revocation; and
                                    ``(II) in the revocation of a 
                                facility under subparagraph (A) is due 
                                to the application of clause (ii) of 
                                such subparagraph, the period beginning 
                                on the date of such revocation and 
                                ending on the date on which the 
                                facility graduates from the Special 
                                Focus Facility program (or, in the case 
                                of a facility that is a candidate for 
                                such program, the date on which the 
                                facility is no longer such a candidate, 
                                as determined by the Secretary).
    ``(f) Determination of Budget Neutrality; Termination of Program.--
            ``(1) Determination.--Not later than July 1, 2027, the 
        Chief Actuary of the Centers for Medicare & Medicaid Services 
        shall determine whether the Program has resulted in an increase 
        in total expenditures under this title with respect to the 
        period beginning on January 1, 2022, and ending on December 31, 
        2026, compared to what such expenditures would have been during 
        such period had the Program not been in operation.
            ``(2) Termination.--If the Chief Actuary makes a 
        determination under paragraph (1) that the Program has resulted 
        in an increase in total expenditures under this title, the 
        Secretary shall terminate the Program as of January 1 of the 
        first year beginning after such determination.''.
                                 <all>