[Congressional Bills 118th Congress]
[From the U.S. Government Publishing Office]
[H.R. 9125 Introduced in House (IH)]

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118th CONGRESS
  2d Session
                                H. R. 9125

To amend title XVIII of the Social Security Act to improve the accuracy 
  and predictability of Medicare payments to long-term care hospitals.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                             July 24, 2024

Mrs. Miller of West Virginia (for herself, Ms. Van Duyne, Mr. Smucker, 
 Mr. Smith of Nebraska, and Mr. Joyce of Pennsylvania) introduced the 
 following bill; which was referred to the Committee on Ways and Means

_______________________________________________________________________

                                 A BILL


 
To amend title XVIII of the Social Security Act to improve the accuracy 
  and predictability of Medicare payments to long-term care hospitals.

    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 ``Patient Access to LTCH Care Act''.

SEC. 2. ENSURING ADEQUACY OF PAYMENTS FOR HIGH-ACUITY LONG-TERM CARE 
              HOSPITAL PATIENTS.

    (a) In General.--Section 1886(m)(7) of the Social Security Act (42 
U.S.C. 1395ww(m)(7)) is amended--
            (1) in subparagraph (B)--
                    (A) by striking ``Notwithstanding subparagraph 
                (A)'' and inserting the following:
                            ``(i) In general.--Notwithstanding 
                        subparagraph (A)''; and
                    (B) by adding at the end the following new clause:
                            ``(ii) Limitation on increase of fixed loss 
                        amount.--Notwithstanding clause (i)--
                                    ``(I) in the case that application 
                                of such clause would result in a fixed 
                                loss amount established for fiscal year 
                                2025 or 2026 that is greater than 
                                $50,000, the Secretary shall set such 
                                fixed loss amount for such fiscal year 
                                at $50,000; and
                                    ``(II) in the case that application 
                                of such clause would result in a fixed 
                                loss amount established for fiscal year 
                                2027 or a subsequent fiscal year that 
                                is greater than 110 percent of the 
                                fixed loss amount established for the 
                                preceding fiscal year, the Secretary 
                                shall set such fixed loss amount for 
                                such fiscal year at 110 percent of the 
                                fixed loss amount established for the 
                                preceding fiscal year.''; and
            (2) in subparagraph (C), by striking ``reduction'' and 
        inserting ``change''.
    (b) Payment Adjustment for Complex Long-Term Care Hospital 
Patients.--Section 1886(m) of the Social Security Act (42 U.S.C. 
1395ww(m)) is amended by adding at the end the following new paragraph:
            ``(8) Payment adjustment for patients with complications or 
        comorbidities or major complications or comorbidities.--
                    ``(A) In general.--For discharges occurring on or 
                after October 1, 2025, or such earlier date as the 
                Secretary may specify, the Secretary shall increase 
                payment rates under the system described in paragraph 
                (1) in accordance with subparagraph (B) to fully 
                account for the higher costs associated with treating 
                the highest complexity individuals.
                    ``(B) Increase.--In calculating payment rates under 
                the system described in paragraph (1) for a discharge 
                of an individual occurring on or after October 1, 2025 
                (or such earlier date as the Secretary may specify), 
                the Secretary shall--
                            ``(i) in the case such individual had more 
                        than 5 major complications or comorbidities and 
                        fewer than 6 complications or comorbidities 
                        that were not major or had between 3 and 5 
                        major complications and comorbidities and 5 or 
                        more complications and comorbidities that were 
                        not major (as demonstrated by claims data on 
                        the claim form submitted by the long-term care 
                        hospital), increase the payment weight for the 
                        applicable diagnosis-related group by 5 
                        percent; and
                            ``(ii) in the case such individual had more 
                        than 5 major complications or comorbidities and 
                        more than 5 complications or comorbidities that 
                        were not major (as so demonstrated), increase 
                        the payment weight for the applicable 
                        diagnosis-related group by 10 percent.
                    ``(C) Assumptions and adjustments.--
                            ``(i) In general.--The Secretary shall 
                        annually determine the impact of ICD-10 coding 
                        changes on aggregate spending as a result of 
                        the application of the payment increases under 
                        subparagraph (A) with respect to fiscal years 
                        2026 through 2030.
                            ``(ii) Permanent adjustments.--The 
                        Secretary shall, at a time and in a manner 
                        determined appropriate by the Secretary, 
                        through notice and comment rulemaking, provide 
                        for one or more permanent increases or 
                        decreases to the standard prospective payment 
                        amount (or amounts) for fiscal years referenced 
                        in clause (i), on a prospective basis, to 
                        offset for increases or decreases in aggregate 
                        expenditures associated with coding changes 
                        attributable to the application of the payment 
                        increases under subparagraph (A).
                            ``(iii) Temporary adjustments for 
                        retrospective behavior.--The Secretary shall, 
                        at a time and in a manner determined 
                        appropriate by the Secretary, through notice 
                        and comment rulemaking, provide for one or more 
                        temporary increases or decreases to the 
                        standard prospective payment amount (or 
                        amounts) for fiscal years referenced in clause 
                        (i). Such a temporary increase or decrease 
                        shall apply only with respect to the fiscal 
                        year for which such temporary increase or 
                        decrease is made, and the Secretary shall not 
                        take into account such a temporary increase or 
                        decrease in computing such amount under this 
                        subsection for a subsequent fiscal year.
                    ``(D) Nonapplication of budget neutrality.--The 
                additional payments resulting from the application of 
                this paragraph shall not be implemented in a budget 
                neutral manner.''.

SEC. 3. SAFEGUARDING SERVICES FOR LONG-TERM CARE HOSPITAL PATIENTS WITH 
              CERTAIN COMPLEX CONDITIONS.

    Section 1886(m)(6) of the Social Security Act (42 U.S.C. 
1395ww(m)(6)) is amended--
            (1) in subparagraph (A)--
                    (A) in clause (i), by striking ``and (G)'' and 
                inserting ``(G), and (H)'';
                    (B) in clause (iii)(I), by inserting ``or, with 
                respect to discharges from a long-term care hospital 
                occurring on or after October 1, 2023, by a discharge 
                from a stay in a critical access hospital,'' after 
                ``from a subsection (d) hospital''; and
                    (C) in clause (iv)(I), by inserting ``for 
                discharges from a long-term care hospital occurring 
                before October 1, 2023,'' before ``the stay in the 
                long-term care hospital''.
            (2) by adding at the end the following new subparagraph:
                    ``(H) Additional exception for patients with 
                certain complex conditions.--
                            ``(i) In general.--For a discharge in a 
                        cost reporting period beginning on or after 
                        October 1, 2023, subparagraph (A)(i) shall not 
                        apply (and payment shall be made to a long-term 
                        care hospital without regard to this paragraph) 
                        if such discharge--
                                    ``(I) meets either of the criteria 
                                described in clause (ii); and
                                    ``(II) does not have a principal 
                                diagnosis relating to a psychiatric 
                                diagnosis or to rehabilitation.
                            ``(ii) Criteria described.--For purposes of 
                        clause (i), the criteria described in this 
                        clause are, with respect to a discharge of an 
                        individual from a long-term care hospital, the 
                        following:
                                    ``(I) The stay in the long-term 
                                care hospital ending with such 
                                discharge was immediately preceded by a 
                                discharge from a stay in a subsection 
                                (d) hospital or a critical access 
                                hospital and--
                                            ``(aa) such individual was 
                                        treated at the long-term care 
                                        hospital for a severe wound (as 
                                        defined in clause (iii));
                                            ``(bb) such discharge from 
                                        such long-term care hospital is 
                                        assigned to Medicare-Severity-
                                        Long-Term-Care-Diagnosis-
                                        Related-Group (MS-LTC-DRG) 189 
                                        relating to pulmonary edema and 
                                        respiratory failure (or any 
                                        successor MS-LTC-DRG);
                                            ``(cc) such discharge from 
                                        such long-term care hospital is 
                                        assigned to MS-LTC-DRG 871 
                                        relating to septicemia or 
                                        severe sepsis without 
                                        mechanical ventilation greater 
                                        than 96 hours with major 
                                        complications or comorbidities 
                                        (or any successor MS-LTC-DRG); 
                                        or
                                            ``(dd) such individual was 
                                        treated at the long-term care 
                                        hospital for COVID-19.
                                    ``(II) The discharge from such 
                                long-term care hospital is assigned to 
                                a MS-LTC-DRG with a relative weight 
                                that is equal to or greater than the 
                                specified amount (as defined in clause 
                                (iii)) for the fiscal year in which 
                                such discharge occurred.
                            ``(iii) Definitions.--In this subparagraph:
                                    ``(I) Severe wound.--The term 
                                `severe wound' means a stage 3 wound, 
                                stage 4 wound, unstageable wound, non-
                                healing surgical wound, infected wound, 
                                fistula, osteomyelitis, or a wound with 
                                morbid obesity, as identified by 
                                applicable codes on the claim from the 
                                long-term care hospital.
                                    ``(II) Specified amount.--The term 
                                `specified amount' means, with respect 
                                to fiscal year, an amount equal to the 
                                80th percentile of the relative weights 
                                for MS-LTC-DRGs that were assigned to 
                                primary diagnoses for all discharges 
                                occurring in the preceding fiscal year.
                                    ``(III) Wound.--The term `wound' 
                                means as an injury involving division 
                                of tissue or rupture or the integument 
                                or mucous membrane with exposure to the 
                                external environment.''.
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