[Congressional Record Volume 161, Number 44 (Monday, March 16, 2015)]
[House]
[Pages H1644-H1646]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]
NOTICE OF OBSERVATION TREATMENT AND IMPLICATION FOR CARE ELIGIBILITY
ACT
Mr. RYAN of Wisconsin. Mr. Speaker, I move to suspend the rules and
pass the bill (H.R. 876) to amend title XVIII of the Social Security
Act to require hospitals to provide certain notifications to
individuals classified by such hospitals under observation status
rather than admitted as inpatients of such hospitals, as amended.
The Clerk read the title of the bill.
The text of the bill is as follows:
H.R. 876
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 ``Notice of Observation
Treatment and Implication for Care Eligibility Act'' or the
``NOTICE Act''.
SEC. 2. MEDICARE REQUIREMENT FOR HOSPITAL NOTIFICATIONS OF
OBSERVATION STATUS.
Section 1866(a)(1) of the Social Security Act (42 U.S.C.
1395cc(a)(1)) is amended--
(1) in subparagraph (V), by striking at the end ``and'';
(2) in the first subparagraph (W), by striking at the end
the period and inserting a comma;
(3) in the second subparagraph (W)--
(A) by redesignating such subparagraph as subparagraph (X);
and
(B) by striking at the end the period and inserting ``,
and''; and
(4) by inserting after such subparagraph (X) the following
new subparagraph:
``(Y) beginning 12 months after the date of the enactment
of this subparagraph, in the case of a hospital or critical
access hospital, with respect to each individual who receives
observation services as an outpatient at such hospital or
critical access hospital for more than 24 hours, to provide
to such individual not later than 36 hours after the time
such individual begins receiving such services (or, if
sooner, upon release)--
``(i) such oral explanation of the written notification
described in clause (ii), and such documentation of the
provision of such explanation, as the Secretary determines to
be appropriate;
``(ii) a written notification (as specified by the
Secretary pursuant to rulemaking and containing such language
as the Secretary prescribes consistent with this paragraph)
which--
``(I) explains the status of the individual as an
outpatient receiving observation services and not as an
inpatient of the hospital or critical access hospital and the
reasons for such status of such individual;
``(II) explains the implications of such status on services
furnished by the hospital or critical access hospital
(including services furnished on an inpatient basis), such as
implications for cost-sharing requirements under this title
and for subsequent eligibility for coverage under this title
for services furnished by a skilled nursing facility;
``(III) includes such additional information as the
Secretary determines appropriate;
``(IV) either--
``(aa) is signed by such individual or a person acting on
such individual's behalf to acknowledge receipt of such
notification; or
``(bb) if such individual or person refuses to provide the
signature described in item (aa), is signed by the staff
member of the hospital or critical access hospital who
presented the written notification and includes the name and
title of such staff member, a certification that the
notification was presented, and the date and time the
notification was presented; and
``(V) is written and formatted using plain language and is
made available in appropriate languages as determined by the
Secretary.''.
The SPEAKER pro tempore. Pursuant to the rule, the gentleman from
Wisconsin (Mr. Ryan) and the gentleman from Texas (Mr. Doggett) each
will control 20 minutes.
The Chair recognizes the gentleman from Wisconsin.
General Leave
Mr. RYAN of Wisconsin. Mr. Speaker, I ask unanimous consent that all
Members may have 5 legislative days within which to revise and extend
their remarks and include extraneous material on H.R. 876, currently
under consideration.
The SPEAKER pro tempore. Is there objection to the request of the
gentleman from Wisconsin?
There was no objection.
Mr. RYAN of Wisconsin. Mr. Speaker, this is commonsense legislation
dealing with the Medicare program that is bipartisan that the Committee
on Ways and Means marked up a couple of weeks ago.
I want to just commend my colleagues Congressman Young from Indiana
and Congressman Doggett from Texas for their work on this.
This is common sense. This tells patients what the rules are so that
they know what is going to happen when they are in the hospital, so
they know what kind of billing they are going to have.
I yield whatever time he may consume to the gentleman from Indiana
(Mr. Young), the coauthor of this legislation, for the purpose of
describing this legislation.
Mr. YOUNG of Indiana. Mr. Speaker, I thank the chairman for taking up
this important piece of legislation today. I also want to thank the
gentleman from Texas (Mr. Doggett) for his leadership on this issue.
When seniors require a hospital stay, they are rightfully more
concerned with their recovery than with understanding how the hospital
classifies their status as a patient; but when that classification can
impact future coverage of health care services related to their
recovery, they deserve to be made aware of the potential ramifications.
This act, the NOTICE Act, would require hospitals to provide
meaningful written and oral notification to patients who are in the
hospital under observation for more than 24 hours. This notice would
alert the beneficiary or person acting on their behalf of the Medicare
patient's admission status and the financial implications of that
classification so he or she can advocate on their own behalf while in
the hospital.
No one should be caught off guard by a large medical bill just
because they weren't aware of the status codes or the billing
procedures. In a time of sickness and stress, families should focus on
the recovery of their loved ones instead of dealing with the hidden
costs due to lack of notice.
Mr. DOGGETT. Mr. Speaker, I rise in support of the bill and yield
myself such time as I might consume.
The NOTICE Act, as the name suggests, is about giving notice. In this
case, it gives notice to patients when they are about to be billed
personally, perhaps for many thousands of dollars, because they were
characterized as under observation rather than regular inpatient status
without them even knowing.
I am pleased to have worked on this legislation since last summer
with Mr. Young when we originally filed the bill, and I am appreciative
of Chairman Ryan's prompt consideration of it in our committee.
This is a consumer protection bill designed to provide at least
limited protection to health care consumers. Currently, a hospital may
either admit a patient as an inpatient or keep them under observation.
This categorization might apply to heart murmur, irregular heartbeat,
indigestion, or other symptoms that would cause a senior or an
individual with a disability who is covered by Medicare to go into the
hospital.
It probably makes little or no difference in the way the hospital
treats the physical condition, but it can make a very big difference in
terms of how the patient's pocketbook is cared for. Indeed, the effect
of being under observation is that the patient gets stuck with the bill
for any skilled nursing home care that is required for rehabilitative
services after the stay at the hospital.
Medicare will pay for that needed care if a Medicare recipient
patient is hospitalized for more than 3 days as an inpatient, but
Medicare will not pay for skilled nursing home care if someone is
simply under observation. Since Medicare has paid nothing, there is
also no gap to be covered by Medigap; and instead of being in a gap,
folks like this are really left in just a giant black hole. A Medicare
patient that is sucked into this hole will be billed for the entire
cost of rehabilitation at the nursing home, which can run into tens of
thousands of dollars.
This practice is happening more and more across America, though it is
largely unknown to most people until they get caught up in it. In 2012,
Medicare patients had more than 600,000 observation stays that lasted 3
days or more. According to one study, over a 6-year span, the number of
stays under observation has increased by 88 percent. Many Medicare
patients are being put under observation for a length of time that
exceeds the guidelines that have been set by Medicare.
Last year on the NBC Nightly News, Kate Snow profiled Ms. Kelley-
Nelum, who discovered that this costly classification had a big impact
on her hospitalized husband. After repeated questioning and demanding
to know why
[[Page H1645]]
her husband was under observation, she got the hospital to reclassify
him. She later learned that had that not occurred, had she not been
persistent in standing up for her ill husband, that they would have
faced about $22,000 in out-of-pocket rehabilitation bills.
Last year, with so many patients facing insurmountable out-of-pocket
costs for skilled nursing care after unknowingly being placed under
observation, The New York Times actually ran a piece that was designed
to provide guidance to health care consumers about how to get out of
this observation category. The first step is knowing you are in it, and
this bill provides for that meaningful disclosure.
This legislation is endorsed by AARP, by the Alliance for Retired
Americans, the Center for Medicare Advocacy, the National Association
of Professional Geriatric Care Managers, LeadingAge, American Health
Care Association, and the National Committee to Preserve Social
Security and Medicare.
I include in the Record letters from two of those groups in support
of the legislation.
AARP,
February 24, 2015.
Hon. Lloyd Doggett,
Rayburn Office Building,
House of Representatives, Washington, DC.
Hon. Todd Young,
Longworth Office Building,
House of Representatives, Washington, DC.
Dear Representative Doggett and Representative Young: On
behalf of the nearly 38 million AARP members and the millions
more Americans with Medicare, we are pleased to endorse the
Notice of Observation Treatment and Implication for Care
Eligibility (NOTICE) Act of 2015 (H.R. 876). Thank you for
working together to address the growing problem of Medicare
beneficiaries paying high out-of-pocket costs due to hospital
stays in which they were classified as an outpatient, rather
than being formally admitted as an inpatient.
As you know, the use of ``observation status'' has become
more prevalent in recent years, and the duration of
observation stays has grown longer. While there may be
several reasons for these trends, it is clear that Medicare
beneficiaries are spending more and more time in the hospital
without being formally admitted. Admission as an inpatient
activates Medicare Part A cost-sharing and a three-day stay
requirement for skilled nursing facility (SNF) coverage; in
contrast, observation status is billed under Part B, and can
expose beneficiaries to unexpectedly high out-of-pocket costs
amounting to thousands of dollars.
Beneficiaries must be informed and made aware of how any
changes to their status will affect them. This legislation
would require hospitals to provide meaningful written and
oral notification to patients who are in the hospital ``under
observation'' for more than 24 hours. While this does not
solve all the problems regarding cost-sharing and access to
SNF coverage, it is an important step to ensuring Medicare
beneficiaries have access to information about their care.
Clearly understanding their admission status will help
patients, and their caregivers, better plan treatment options
with their health care providers.
Again, thank you for your continued work to protect
Medicare beneficiaries. If you have any questions, please
contact me, or have your staff contact Ariel Gonzalez,
Director of Federal Health and Family.
Sincerely,
Joyce A. Rogers,
Senior Vice President,
Government Affairs.
____
American Health Care Association,
Washington, DC, February 11, 2015.
Hon. Lloyd Doggett,
Rayburn House Office Building,
Washington, DC.
Congressman Doggett: I serve as the president and chief
executive officer of AHCA/NCAL, the nation's largest
association of long term and post-acute care providers. The
association advocates for quality care and services for the
frail, elderly, and individuals with disabilities. Our
members provide essential care to millions of individuals in
more than 12,000 not for profit and for profit member
facilities.
AHCA/NCAL, its affiliates, and member providers advocate
for the continuing vitality of the long term care provider
community. We are committed to developing and advocating for
public policies that support quality care and quality of life
for our nation's most vulnerable. Therefore, we are in
support of the legislation, Notice of Observation Treatment
and Implication for Care Eligibility (NOTICE) Act, that you
and Congressman Todd Young (R-IN-9) have introduced again
this Congress.
The NOTICE Act requires hospitals to give formal notice to
patients within a period of time after classifying them as an
inpatient or as an outpatient under observation. More
specifically, the legislation works to ensure that hospitals
notify patients entitled to Medicare part A coverage of their
outpatient status within 36 hours after the time of their
classification or, if sooner, upon discharge.
Often times, patients have no idea what their status is in
a hospital or the importance of it. This can lead to
thousands of dollars in out-of-pocket medical expenses should
they need skilled nursing center care following their
hospital stay. The observation stays issue is a financial
burden on seniors and their families. It can cause
unnecessary spend-down, accelerating the time frame in which
seniors will have to turn to programs such as Medicaid to pay
for their care.
This legislation is a positive step forward, and raises
attention to a complex and critical issue hurting the
nation's seniors. AHCA/NCAL applauds Congressmen Doggett and
Young for serving as champions for seniors and those
individuals who need our services the most.
Sincerely,
Mark Parkinson,
AHCA/NCAL President & CEO.
Mr. DOGGETT. Mr. Speaker, I also appreciate the help we have received
from the Center for Medicare Advocacy. They have had reports, again,
from people all over the country being placed in this situation.
The hospitals may act in the best interests of a patient's health but
not always in the best interest of the patient's pocketbook. The NOTICE
Act will equip patients and their loved ones with the knowledge that
they need to be effective advocates and avoid crippling financial
repercussions.
Mr. Speaker, I reserve the balance of my time.
Mr. RYAN of Wisconsin. Mr. Speaker, may I inquire of the gentleman
from Texas if they have any other speakers? We are prepared to close.
Mr. DOGGETT. I have one speaker on the way. If you are prepared to
close and he is not arriving, then we will close.
Do you have any other speakers?
Mr. RYAN of Wisconsin. I will just say a few things. I yield myself
such time as I may consume, Mr. Speaker.
This is basically common sense. What is happening is people on
Medicare are going to the hospital. They don't know what their status
is, whether they are considered inpatient or outpatient. As far as they
are concerned, it is the same thing. The problem is they are being
declared one or the other, unbeknownst to them, and that has a huge
difference in the billing that they receive.
So what this bill simply says is you will know your status so that
you can make an informed decision as a patient in a hospital, because
there are huge financial implications to that status. This is very
simple. It is good government.
I reserve the balance of my time.
Mr. DOGGETT. Mr. Speaker, I yield myself 15 seconds and will welcome
my colleague, Joe Courtney, who has long sought to respond
legislatively to protect health care consumers from the financial pain
of this observation status.
While the passage of the NOTICE Act is an important step,
Representative Courtney has an Improving Access to Medicare Coverage
Act that would treat observation stays the same as inpatient stays. I
support his legislation as he has supported, from the beginning, this
initiative, and I appreciate his leadership.
Mr. Speaker, I yield 3 minutes to the gentleman from Connecticut (Mr.
Courtney).
Mr. COURTNEY. Mr. Speaker, I want to, first of all, salute
Congressman Doggett for his effort in terms of bringing this
legislation forward. As the chairman of the committee said, this is
really about giving patients a fighting chance to challenge this
coding, a change that happens while people are in the hospital and have
absolutely no idea that they are not being treated as full part A
inpatient patients at hospital facilities.
The impact of being coded as observation versus inpatient may sound
extremely arcane, but what that means is that at time of discharge, if
a patient is medically prescribed to go to a nursing home for rehab
care for a broken bone or for home health services for a heart
condition, they are not covered by Medicare if they are in the
observation bucket as opposed to the inpatient bucket.
The inspector general's office for Medicare issued a report in 2012
that 600,000 patients across the country with long-stay hospital visits
over 3 days fell into this black hole, this no man's land where, again,
their doctors are telling them that they need to have rehab services so
that people can walk again and deal with activities of daily living;
but the price for doing that, because you are in observation status,
[[Page H1646]]
can be tens of thousands of dollars, which is where long-term care
facilities, nursing home coverage for private-pay patients, out-of-
pocket patients, exist today.
This bill at least gives patients the opportunity to challenge that
decision. But the fact of the matter is, what we need to do is to
restore the 3-day rule, which is in statute. It has been there since
1965. Observation status is something new within the last 10 years, and
what we need to do as a Congress is to restore that 3-day rule, which
says to a patient: If you are coded observation or if you are coded
inpatient, it should not interfere with your medically prescribed
course of treatment at the time that you are discharged from the
hospital.
That, unfortunately, is not going to be fixed as a result of this
legislation. We should build on this legislation and again restore
Medicare's promise, which, again, from day one, has said that medically
prescribed care will be covered by the system at time of discharge from
a hospital for longer than 3 days.
The horror stories of people who in some instances were in hospital
for 9 days with broken bones, broken hips, who, again, are staring at a
10 to $15,000 fee to be admitted to a nursing home--again, 600,000
cases in 2012.
So again, we need to build on this legislation, but fundamentally, we
need to restore the 3-day rule which has been in statute since 1965. We
will be introducing that legislation later this week. It will be a
bipartisan bill. We think we can withstand the test of any pay-fors to
make sure that it allows the Medicare system's finances to stay in a
stable condition. In the meantime, we should pass this legislation
today.
Again, I want to salute the Member from Texas for his leadership on
this issue.
{time} 1645
Mr. DOGGETT. Mr. Speaker, I concur with the gentleman from
Connecticut.
I yield back the balance of my time.
Mr. RYAN of Wisconsin. I agree, Mr. Speaker.
I yield back the balance of my time.
The SPEAKER pro tempore. The question is on the motion offered by the
gentleman from Wisconsin (Mr. Ryan) that the House suspend the rules
and pass the bill, H.R. 876, as amended.
The question was taken.
The SPEAKER pro tempore. In the opinion of the Chair, two-thirds
being in the affirmative, the ayes have it.
Mr. RYAN of Wisconsin. Mr. Speaker, on that I demand the yeas and
nays.
The yeas and nays were ordered.
The SPEAKER pro tempore. Pursuant to clause 8 of rule XX, further
proceedings on this motion will be postponed.
____________________