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:

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.