Establishment of a home-based extended care services benefit as part of Medicare

(a)

Improved support for health care at home

(1)

In general

Section 1812 of the Social Security Act (42 U.S.C. 1395d) is amended—(A)in subsection (a)—(i)in paragraph (2)(A), by inserting (reduced by the number of days of home-based extended care services furnished under paragraph (6) during such spell of illness) after spell of illness;(ii)in paragraph (4), by striking and at the end;(iii)in paragraph (5), by striking the period at the end and inserting ; and; and(iv)by adding at the end the following new paragraph:

(6)(A)home-based extended care services for a 30-day episode for individuals who otherwise qualify for post-hospital extended care services under paragraph (2)(A); (B)to the extent provided in subsection (f), home-based extended care services that are not post-hospital home-based extended care services; and(C)in such circumstances as the Secretary may specify, home-based extended care services for one or more subsequent 30-day episode or episodes up to a maximum of 100 days of home-based extended care services in a spell of illness.

;

(B)in subsection (b)—(i)in paragraph (2), by striking or at the end;(ii)in paragraph (3), by striking the period at the end and inserting ; or; and(iii)by inserting after paragraph (3) the following new paragraph:

(4)home-based extended care services furnished to an individual after such services have been furnished to the individual for a 30-day episode during such spell, except as provided by the Secretary pursuant to subparagraph (B) or (C) of subsection (a)(6).

; and

(C)in subsection (f)—(i)in paragraph (1)—(I)by inserting and, under subsection (a)(6)(B), of home-based extended care services, as applicable, after extended care services the first place it appears;(II)by inserting or post-hospital home-based extended care services after post-hospital extended care services; and(III)by inserting or subsection (a)(6), as applicable before the period; and(ii)in paragraph (2)—(I)in subparagraph (A), by inserting or subsection (a)(6)(B), as applicable after subsection (a)(2)(B); and(II)in subparagraph (B), by striking subsection and inserting subsections.(2)

Coinsurance and deductible

Section 1813(a)(3) of the Social Security Act (42 U.S.C. 1395e(a)(3)) is amended by inserting the following before the period: (or, in the case where an individual is furnished post-hospital home-based extended care services, after such services (or a combination of such services and post-hospital extended care services) have been furnished to him for 20 days during such spell).(3)

Certification requirement

Section 1814(a)(2) of the Social Security Act (42 U.S.C. 1395f(a)(2)) is amended—(A)in the matter preceding subparagraph (A), by inserting or (E) after subparagraph (C);(B)in subparagraph (C), by striking or at the end;(C)in subparagraph (D), by inserting or after the semicolon; and(D)by adding at the end the following new subparagraph:

(E)in the case of post-hospital home-based extended care services, such services are or were required to be furnished because the individual otherwise needs or needed and qualifies for extended care services in a skilled nursing facility payable under this part under subparagraph (B), and such individual does not qualify for services in an inpatient rehabilitation facility or long-term care hospital payable under this part;

(4)

Post-hospital extended care services

Section 1861(i) of the Social Security Act (42 U.S.C. 1395x(i)) is amended, in the second sentence—(A)by striking or (B) and inserting (B); and(B)by inserting the following before the period , or (C) in the case of an individual receiving post-hospital home-based extended care services, within 30 days after discharge from a hospital.(5)

Definition of home-based extended care services

Section 1861 of the Social Security Act (42 U.S.C. 1395x) is amended by adding at the end the following new subsection:

(lll)

Home-Based Extended Care Services

(1)The term home-based extended care services means the following items and services furnished to an individual in the individual’s home by a home health agency (as defined in subsection (o) including the additional requirements under paragraph (9) of such subsection), or by others under arrangements with such agency:(A)Nursing care, other than as described in subsection (m), including when provided using telecommunications technology as a supplement to daily in-person care.(B)Physical or occupational therapy or speech-language pathology services, other than as described in subsection (m), including when provided using telecommunications as a supplement to daily in-person care.(C)Meals and nutritional support.(D)Remote patient monitoring as a supplement to in-person care other than as described in subsection (m).(E)Medical social services other than as described in subsection (m).(F)Services of a home health aide other than as described in subsection (m) and personal care services.(G)Respite care, family caregiver and other unpaid caregiver supports, education, and training resources.(H)Assistance with adherence to drugs prescribed for the individual.(I)Medical supplies, appliances, and equipment, other than those described in subsection (m), for use in the home, including related to bathing, dressing, toileting, walking, or feeding.(J)Nonemergency medical transportation other than ambulance services.(K)Care coordination and integration, including providing discharge planning and care transitions support to the individual and family and other unpaid caregivers, including referral for person-centered counseling or options counseling from their State’s Aging and Disability Resource Center/No Wrong Door System, upon completion of a 30-day episode or one or more subsequent 30-day episode or episodes, if applicable, under section 1812(a)(6)(C). To the greatest extent possible, care transitions support services provided as part of home-based extended care services should use evidence-based models and practices, particularly those that employ face-to-face visits. (L)Such other items and services as the home health agency determines are necessary for the care of the individual in the home.(2)Nothing in this subsection shall be construed as impacting an individual’s eligibility for transition of care services under any other provision of this title or otherwise for which the individual is eligible.

(6)

Discharge planning

Section 1861(ee)(2) of the Social Security Act (42 U.S.C. 1395x(ee)(2)) is amended—(A)in subparagraph (D)—(i)by striking hospice care and post-hospital extended care services and inserting hospice care, post-hospital extended care services, post-hospital home-based extended care services, and services furnished by inpatient rehabilitation facilities and units and long-term care hospitals; and(ii)by inserting and home-based extended care services after home health services; and(B)by adding at the end the following new subparagraph:

(I)The discharge planning evaluation and discharge plan for an individual who meets applicable standards and criteria for extended care services under section 1812, and who does not need services provided by an inpatient rehabilitation facility or unit or a long-term care hospital, shall include, in addition to the items described in subparagraph (D)— (i)an evaluation, in coordination with a qualified home health agency, of the appropriateness of home-based extended care services, including consideration of patient characteristics, including but not limited to functional, cognitive, and behavioral competencies and deficits and primary and secondary diagnoses, the availability of able and willing caregivers, the scope of home-based extended care services needed and other services (if applicable), the length of time such services would be needed, the availability of the level of services needed, and the need for and availability of health care services following completion of home-based extended care services, the individual’s place of care preferences, and the integration of and consideration of social determinants, inclusive of race and ethnicity and the availability of and access to quality services, into measures used to determine eligibility of a beneficiary to receive home-based extended care services;(ii)a consultation with the individual as to the findings of such evaluation, including consideration of the individual’s place of care preferences, goals regarding care, family caregiver concerns, and the ability of the individual to safely and effectively receive care in the home; (iii)the provision of caregiver training resources to family and other unpaid caregivers including guidance on medical, nursing, and personal care tasks; and (iv)obtaining verbal consent from the individual that is recorded in the individual’s inpatient care record if the individual chooses to receive home-based extended care services.

Clauses (i), (ii), and (iii) shall not preempt any applicable State law requirements. Clause (iv) shall preempt any State law requirements relating to consent for home-based extended care services. The Secretary shall establish, through notice and comment rulemaking, the right to an expedited appeal of any adverse determination regarding the determination to provide the individual with the option of home-based extended care services and the scope of home-based extended care services needed by the individual.

(7)

Additional requirements

Section 1861(o) of the Social Security Act (42 U.S.C. 1395x(o)) is amended—(A)in paragraph (7)(B), by striking and at the end;(B)in paragraph (8), by inserting and at the end; and(C)by inserting after paragraph (8) the following new paragraph:

(9)for purposes of furnishing post-hospital home-based extended care services under section 1812(a)(6), meets such additional requirements and conditions as the Secretary finds necessary, including—(A)the provision of care on a 24-hour basis;(B)the ability to provide all items and services described in subsection (lll);(C)the provision of necessary and covered services;(D)education, training, and supervision requirements for those providing home-based extended care services; and(E)compliance with all requirements and conditions when such services are provided under arrangement as described in subsection (m) to ensure that others providing care under such arrangement with such agency are held to the same standards (requirements and conditions) as the agency;

(8)

Home-based extended care services add-on

Section 1895 of the Social Security Act (42 U.S.C. 1395fff) is amended by adding at the end the following new subsection:

(f)

Home-Based extended care services add-On

(1)

In general

An add-on payment in addition to the amount otherwise payable under this section for home health services shall be made to a home health agency that meets the additional requirements of section 1861(o)(9) and provides home-based extended care services under section 1812(a)(6).(2)

Payment amount

Subject to paragraphs (3) and (4), the amount of such add-on payment for home-based extended care services provided to an individual shall be determined as follows:(A)

Determination

Such amount shall be determined based on the following:(i)The following four case-mix classifications, determined by the number of hours of personal care services provided to an individual, as follows:(I)Up to 60 hours, including an initial assessment.(II)61 to 120 hours.(III)121 to 240 hours.(IV)241 to 360 hours of personal care services.(ii)In calculating the number of hours of personal care services under clause (i), part-time or intermittent services provided by home health aides under sections 1812(a)(2) and 1835(a)(2)(A) shall not be included. (iii)Such other factors as the Secretary determines appropriate.(B)

Fixed base amount

The Secretary shall provide a fixed base amount for each of the 4 case-mix classifications described in subclauses (I) through (IV) of subparagraph (A)(i) as follows:(i)

2022

For services furnished during 2022, a fixed base amount of—(I)in the case of the case-mix classification described in subclause (I) of subparagraph (A)(i), $2,010;(II)in the case of the case-mix classification described in subclause (II) of such subparagraph, $4,020;(III)in the case of the case-mix classification described in subclause (III) of such subparagraph, $7,360; and(IV)in the case of the case-mix classification described in subclause (IV) of such subparagraph, $10,720, respectively.(ii)

2023 and subsequent years

For services furnished during 2023, or a subsequent year, a fixed base amount equal to the amount determined under this subparagraph for the preceding year for the applicable case-mix classification, updated by the home health applicable increase percentage under subsection (b)(3)(B) applicable to the year involved.(C)

Area wage index adjustment

The fixed base amount determined under subparagraph (B) shall be subject to the applicable area wage index under subsection (b)(4)(C).(3)

Alternative add-on payment model

For services furnished in 2023, or in a subsequent year, the Secretary may apply an alternative model of payment that shall be based on relevant and reliable data on patient characteristics that reflect the variations in resource use and intensity within a patient case mix. (4)

Limitation

Notwithstanding any other provision in this section, the amount of the additional payment under this subsection to a home health agency for home-based extended care services, in combination with the amount of payment for home health services under this section for a unit of services furnished to an individual, shall not result in a total amount of payment under this section for such services that exceeds an amount equal to 80 percent of the national median 30-day payment amount for extended care services furnished in a skilled nursing facility under section 1812 for the most recent fiscal year prior to the payment year for which data is available, updated based on the skilled nursing facility market basket percentage change under section 1888(e)(5)(B). The Secretary may adjust the amount of the additional payment for home-based extended care services under this subsection in order to comply with the limitation under the preceding sentence.

(b)

Transparency in notice and comment rulemaking

In establishing standards and procedures under the provisions of, and amendments made by, this Act, the Secretary of Health and Human Services (in this section referred to as the Secretary) shall include full transparency through notice and comment rulemaking of the methodology, assumptions, evidence, and all data used in support of proposed payment rates, standards for eligibility and payment for services, provider conditions for participation, and any other matter related to the implementation of such provisions and amendments.(c)

Stakeholder input

In establishing any proposed standards and procedures under the provisions of, and amendments made by, this Act, the Secretary shall solicit written input on such proposed standards and procedures from providers, representatives of providers, Medicare beneficiaries, families, and related stakeholder groups and consider such input in the development of such standards and procedures.(d)

Annual report to Congress

For calendar year 2022, and each calendar year thereafter, the Secretary shall submit a report to Congress on the coverage of home-based extended care services under the Medicare program (42 U.S.C. 1395 et seq.) pursuant to the provisions of, and amendments made by, this Act. Each report submitted under this subsection shall include the following:(1)The total number of individuals receiving such services pursuant to such provisions and amendments, including which services such individuals received, how long such individuals received such services, and what the average hours were per individual, and the total amount of expenditures for such services under the Medicare program, including an itemization of expenditures associated with home health care and in-home support services.(2)An analysis of the efficiency and effectiveness of the processes for discharge planning evaluation and discharge planning under section 1861(ee)(2)(I) of the Social Security Act, as added by subsection (a)(6), an itemization of the diagnoses, treatment protocols, and outcomes of individuals receiving benefits (including family or other unpaid caregivers, as applicable), an evaluation comparing clinical outcomes and patient experience for similar patients receiving home-based extended care services and services in skilled nursing facilities, an evaluation (which shall include audits) of whether home-based extended care services are being appropriately targeted to individuals who need and would benefit from the scope, level, and duration of such home-based extended care services and whether individuals receiving such services are receiving the appropriate scope, level and duration of care, and the cost effectiveness of furnishing home-based extended care services in relation to alternative skilled nursing facility costs.(3)Data by race and ethnicity as it applies to eligibility, decision on participation of the beneficiary, utilization rates, and availability of quality home health services in defined locales, as well as any protocol or changes in practice that were instituted to address existing inequities. (4)Recommendations for such administrative or legislative action as the Secretary determines necessary to improve the furnishing of such services. (e)

Program integrity

The Secretary shall take such actions and establish safeguards as are reasonable and necessary under existing law to ensure the program integrity of the provision of home-based extended care services pursuant to the provisions of, and amendments made by, this Act.(f)

Implementation

(1)

Establishment of standards and procedures

Not later than July 1, 2021, or as soon as practical after enactment of this Act during a public health emergency period described in section 1135(g) of the Social Security Act (42 U.S.C. 1320b–5(g)), the Secretary shall establish standards and procedures related to furnishing home-based extended care services pursuant to the provisions of, and amendments made by, this Act.(2)

Provision of information regarding the home-based extended care services benefit

The Secretary shall provide comprehensive information to Medicare beneficiaries and other stakeholders regarding the establishment and availability of the home-based extended care services benefit under the Medicare program under title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.) pursuant to the provisions of, and amendments made by, this Act. Such information shall be in addition to any publication of standards and procedures with respect to such services in the Federal Register and Code of Federal Regulations. (3)

Authorization of payments during public health emergency period

Notwithstanding any other provision of law, the Secretary is authorized to make payments for home-based extended care services as described in section 1895(f) of the Social Security Act, as added by subsection (a)(8), for such services furnished prior to 2022 during any period in which there exists such a public health emergency period.