[Congressional Record Volume 167, Number 134 (Friday, July 30, 2021)]
[Senate]
[Pages S5218-S5220]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. THUNE (for himself and Mr. Cardin):
  S. 2576. 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; to the Committee on Finance.

                                S. 2576

       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

[[Page S5219]]

     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

[[Page S5220]]

     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.''.

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