    [United States Statutes at Large, Volume 128, 113th Congress, 2nd Session]
    [From the U.S. Government Publishing Office, www.gpo.gov]

    Public Law 113-185
    113th Congress

    An Act

    To amend title XVIII of the Social Security Act to provide for
    standardized post-acute care assessment data for quality, payment, and
    discharge planning, and for other purposes. <>

    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 ``Improving Medicare Post-Acute Care
    Transformation Act of 2014'' or the ``IMPACT Act of 2014''.
    SEC. 2. STANDARDIZATION OF POST-ACUTE CARE DATA.

    (a) In General.--Title XVIII of the Social Security Act is amended
    by adding at the end the following new section:
    ``SEC. 1899B. <>  STANDARDIZED POST-ACUTE
    CARE (PAC) ASSESSMENT DATA FOR
    QUALITY, PAYMENT, AND DISCHARGE
    PLANNING.

    ``(a) Requirement for Standardized Assessment Data.--
    ``(1) In general.--The Secretary shall--
    ``(A) require under the applicable reporting
    provisions post-acute care providers (as defined in
    paragraph (2)(A)) to report--
    ``(i) standardized patient assessment data in
    accordance with subsection (b);
    ``(ii) data on quality measures under
    subsection (c)(1); and
    ``(iii) data on resource use and other
    measures under subsection (d)(1);
    ``(B) require data described in subparagraph (A) to
    be standardized and interoperable so as to allow for the
    exchange of such data among such post-acute care
    providers and other providers and the use by such
    providers of such data that has been so exchanged,
    including by using common standards and definitions, in
    order to provide access to longitudinal information for
    such providers to facilitate coordinated care and
    improved Medicare beneficiary outcomes; and
    ``(C) in accordance with subsections (b)(1) and
    (c)(2), modify PAC assessment instruments (as defined in
    paragraph (2)(B)) applicable to post-acute care
    providers to--
    ``(i) provide for the submission of
    standardized patient assessment data under this
    title with respect to such providers; and

    [[Page 1953]]

    ``(ii) enable comparison of such assessment
    data across all such providers to whom such data
    are applicable.
    ``(2) Definitions.--For purposes of this section:
    ``(A) Post-acute care (pac) provider.--The terms
    `post-acute care provider' and `PAC provider' mean--
    ``(i) a home health agency;
    ``(ii) a skilled nursing facility;
    ``(iii) an inpatient rehabilitation facility;
    and
    ``(iv) a long-term care hospital (other than a
    hospital classified under section
    1886(d)(1)(B)(iv)(II)).
    ``(B) PAC assessment instrument.--The term `PAC
    assessment instrument' means--
    ``(i) in the case of home health agencies, the
    instrument used for purposes of reporting and
    assessment with respect to the Outcome and
    Assessment Information Set (OASIS), as described
    in sections 484.55 and 484.250 of title 42, the
    Code of Federal Regulations, or any successor
    regulation, or any other instrument used with
    respect to home health agencies for such purposes;
    ``(ii) in the case of skilled nursing
    facilities, the resident's assessment under
    section 1819(b)(3);
    ``(iii) in the case of inpatient
    rehabilitation facilities, any Medicare
    beneficiary assessment instrument established by
    the Secretary for purposes of section 1886(j); and
    ``(iv) in the case of long-term care
    hospitals, the Medicare beneficiary assessment
    instrument used with respect to such hospitals for
    the collection of data elements necessary to
    calculate quality measures as described in the
    August 18, 2011, Federal Register (76 Fed. Reg.
    51754-51755), including for purposes of section
    1886(m)(5)(C), or any other instrument used with
    respect to such hospitals for assessment purposes.
    ``(C) Applicable reporting provision.--The term
    `applicable reporting provision' means--
    ``(i) for home health agencies, section
    1895(b)(3)(B)(v);
    ``(ii) for skilled nursing facilities, section
    1888(e)(6);
    ``(iii) for inpatient rehabilitation
    facilities, section 1886(j)(7); and
    ``(iv) for long-term care hospitals, section
    1886(m)(5).
    ``(D) PAC payment system.--The term `PAC payment
    system' means--
    ``(i) with respect to a home health agency,
    the prospective payment system under section 1895;
    ``(ii) with respect to a skilled nursing
    facility, the prospective payment system under
    section 1888(e);
    ``(iii) with respect to an inpatient
    rehabilitation facility, the prospective payment
    system under section 1886(j); and
    ``(iv) with respect to a long-term care
    hospital, the prospective payment system under
    section 1886(m).
    ``(E) Specified application date.--The term
    `specified application date' means the following:

    [[Page 1954]]

    ``(i) Quality measures.--In the case of
    quality measures under subsection (c)(1)--
    ``(I) with respect to the domain
    described in subsection (c)(1)(A)
    (relating to functional status,
    cognitive function, and changes in
    function and cognitive function)--
    ``(aa) for PAC providers
    described in clauses (ii) and
    (iii) of paragraph (2)(A),
    October 1, 2016;
    ``(bb) for PAC providers
    described in clause (iv) of such
    paragraph, October 1, 2018; and
    ``(cc) for PAC providers
    described in clause (i) of such
    paragraph, January 1, 2019;
    ``(II) with respect to the domain
    described in subsection (c)(1)(B)
    (relating to skin integrity and changes
    in skin integrity)--
    ``(aa) for PAC providers
    described in clauses (ii),
    (iii), and (iv) of paragraph
    (2)(A), October 1, 2016; and
    ``(bb) for PAC providers
    described in clause (i) of such
    paragraph, January 1, 2017;
    ``(III) with respect to the domain
    described in subsection (c)(1)(C)
    (relating to medication
    reconciliation)--
    ``(aa) for PAC providers
    described in clause (i) of such
    paragraph, January 1, 2017; and
    ``(bb) for PAC providers
    described in clauses (ii),
    (iii), and (iv) of such
    paragraph, October 1, 2018;
    ``(IV) with respect to the domain
    described in subsection (c)(1)(D)
    (relating to incidence of major falls)--
    ``(aa) for PAC providers
    described in clauses (ii),
    (iii), and (iv) of paragraph
    (2)(A), October 1, 2016; and
    ``(bb) for PAC providers
    described in clause (i) of such
    paragraph, January 1, 2019; and
    ``(V) with respect to the domain
    described in subsection (c)(1)(E)
    (relating to accurately communicating
    the existence of and providing for the
    transfer of health information and care
    preferences)--
    ``(aa) for PAC providers
    described in clauses (ii),
    (iii), and (iv) of paragraph
    (2)(A), October 1, 2018; and
    ``(bb) for PAC providers
    described in clause (i) of such
    paragraph, January 1, 2019.
    ``(ii) Resource use and other measures.--In
    the case of resource use and other measures under
    subsection (d)(1)--
    ``(I) for PAC providers described in
    clauses (ii), (iii), and (iv) of
    paragraph (2)(A), October 1, 2016; and
    ``(II) for PAC providers described
    in clause (i) of such paragraph, January
    1, 2017.
    ``(F) Medicare beneficiary.--The term `Medicare
    beneficiary' means an individual entitled to benefits
    under

    [[Page 1955]]

    part A or, as appropriate, enrolled for benefits under
    part B.

    ``(b) Standardized Patient Assessment Data.--
    ``(1) Requirement for reporting assessment data.--
    ``(A) <>  In general.--Beginning
    not later than October 1, 2018, for PAC providers
    described in clauses (ii), (iii), and (iv) of subsection
    (a)(2)(A) and January 1, 2019, for PAC providers
    described in clause (i) of such subsection, the
    Secretary shall require PAC providers to submit to the
    Secretary, under the applicable reporting provisions and
    through the use of PAC assessment instruments, the
    standardized patient assessment data described in
    subparagraph (B). The Secretary shall require such data
    be submitted with respect to admission and discharge of
    an individual (and may be submitted more frequently as
    the Secretary deems appropriate).
    ``(B) Standardized patient assessment data
    described.--For purposes of subparagraph (A), the
    standardized patient assessment data described in this
    subparagraph is data required for at least the quality
    measures described in subsection (c)(1) and that is with
    respect to the following categories:
    ``(i) Functional status, such as mobility and
    self care at admission to a PAC provider and
    before discharge from a PAC provider.
    ``(ii) Cognitive function, such as ability to
    express ideas and to understand, and mental
    status, such as depression and dementia.
    ``(iii) Special services, treatments, and
    interventions, such as need for ventilator use,
    dialysis, chemotherapy, central line placement,
    and total parenteral nutrition.
    ``(iv) Medical conditions and co-morbidities,
    such as diabetes, congestive heart failure, and
    pressure ulcers.
    ``(v) Impairments, such as incontinence and an
    impaired ability to hear, see, or swallow.
    ``(vi) Other categories deemed necessary and
    appropriate by the Secretary.
    ``(2) Alignment of claims data with standardized patient
    assessment data. <> --To the extent
    practicable, not later than October 1, 2018, for PAC providers
    described in clauses (ii), (iii), and (iv) of subsection
    (a)(2)(A), and January 1, 2019, for PAC providers described in
    clause (i) of such subsection, the Secretary shall match claims
    data with assessment data pursuant to this section for purposes
    of assessing prior service use and concurrent service use, such
    as antecedent hospital or PAC provider use, and may use such
    matched data for such other uses as the Secretary determines
    appropriate.
    ``(3) Replacement of certain existing data.--In the case of
    patient assessment data being used with respect to a PAC
    assessment instrument that duplicates or overlaps with
    standardized patient assessment data within a category described
    in paragraph (1), the Secretary shall, as soon as practicable,
    revise or replace such existing data with the standardized data.

    [[Page 1956]]

    ``(4) Clarification.--Standardized patient assessment data
    submitted pursuant to this subsection shall not be used to
    require individuals to be provided post-acute care by a specific
    type of PAC provider in order for such care to be eligible for
    payment under this title.

    ``(c) Quality Measures.--
    ``(1) <>  Requirement for
    reporting quality measures.--Not later than the specified
    application date, as applicable to measures and PAC providers,
    the Secretary shall specify quality measures on which PAC
    providers are required under the applicable reporting provisions
    to submit standardized patient assessment data described in
    subsection (b)(1) and other necessary data specified by the
    Secretary. Such measures shall be with respect to at least the
    following domains:
    ``(A) Functional status, cognitive function, and
    changes in function and cognitive function.
    ``(B) Skin integrity and changes in skin integrity.
    ``(C) Medication reconciliation.
    ``(D) Incidence of major falls.
    ``(E) Accurately communicating the existence of and
    providing for the transfer of health information and
    care preferences of an individual to the individual,
    family caregiver of the individual, and providers of
    services furnishing items and services to the
    individual, when the individual transitions--
    ``(i) from a hospital or critical access
    hospital to another applicable setting, including
    a PAC provider or the home of the individual; or
    ``(ii) from a PAC provider to another
    applicable setting, including a different PAC
    provider, a hospital, a critical access hospital,
    or the home of the individual.
    ``(2) Reporting through pac assessment instruments.--
    ``(A) In general. <> --To the
    extent possible, the Secretary shall require such
    reporting by a PAC provider of quality measures under
    paragraph (1) through the use of a PAC assessment
    instrument and shall modify such PAC assessment
    instrument as necessary to enable the use of such
    instrument with respect to such quality measures.
    ``(B) <>
    Limitation.--The Secretary may not make significant
    modifications to a PAC assessment instrument more than
    once per calendar year or fiscal year, as applicable,
    unless the Secretary publishes in the Federal Register a
    justification for such significant modification.
    ``(3) Adjustments.--
    ``(A) In general.--The Secretary shall consider
    applying adjustments to the quality measures under this
    subsection taking into consideration the studies under
    section 2(d) of the IMPACT Act of 2014.
    ``(B) Risk adjustment.--Such quality measures shall
    be risk adjusted, as determined appropriate by the
    Secretary.

    ``(d) Resource Use and Other Measures.--
    ``(1) Requirement for resource use and other
    measures. <> --Not later than
    the specified application date, as applicable to measures and
    PAC providers, the Secretary shall specify resource use and
    other measures on which PAC providers are required under the
    applicable reporting provisions

    [[Page 1957]]

    to submit any necessary data specified by the Secretary, which
    may include standardized assessment data in addition to claims
    data. Such measures shall be with respect to at least the
    following domains:
    ``(A) Resource use measures, including total
    estimated Medicare spending per beneficiary.
    ``(B) Discharge to community.
    ``(C) Measures to reflect all-condition risk-
    adjusted potentially preventable hospital readmission
    rates.
    ``(2) Aligning methodology adjustments for resource use
    measures.--
    ``(A) Period of time.--With respect to the period of
    time used for calculating measures under paragraph
    (1)(A), the Secretary shall, to the extent the Secretary
    determines appropriate, align resource use with the
    methodology used for purposes of section
    1886(o)(2)(B)(ii).
    ``(B) Geographic and other adjustments.--The
    Secretary shall standardize measures with respect to the
    domain described in paragraph (1)(A) for geographic
    payment rate differences and payment differentials (and
    other adjustments, as applicable) consistent with the
    methodology published in the Federal Register on August
    18, 2011 (76 Fed. Reg. 51624 through 51626), or any
    subsequent modifications made to the methodology.
    ``(C) Medicare spending per beneficiary.--The
    Secretary shall adjust, as appropriate, measures with
    respect to the domain described in paragraph (1)(A) for
    the factors applied under section 1886(o)(2)(B)(ii).
    ``(3) Adjustments.--
    ``(A) In general.--The Secretary shall consider
    applying adjustments to the resource use and other
    measures specified under this subsection with respect to
    the domain described in paragraph (1)(A), taking into
    consideration the studies under section 2(d) of the
    IMPACT Act of 2014.
    ``(B) Risk adjustment.--Such resource use and other
    measures shall be risk adjusted, as determined
    appropriate by the Secretary.

    ``(e) Measurement Implementation Phases; Selection of Quality
    Measures and Resource Use and Other Measures.--
    ``(1) Measurement implementation phases.--In the case of
    quality measures specified under subsection (c)(1) and resource
    use and other measures specified under subsection (d)(1), the
    provisions of this section shall be implemented in accordance
    with the following phases:
    ``(A) Initial implementation phase.--The initial
    implementation phase, with respect to such a measure,
    shall, in accordance with subsections (c) and (d), as
    applicable, consist of--
    ``(i) <>  measure
    specification, including informing the public of
    the measure's numerator, denominator, exclusions,
    and any other aspects the Secretary determines
    necessary;
    ``(ii) <>  data collection,
    including, in the case of quality measures,
    requiring PAC providers to report data elements
    needed to calculate such a measure; and

    [[Page 1958]]

    ``(iii) data analysis, including, in the case
    of resource use and other measures, the use of
    claims data to calculate such a measure.
    ``(B) <>  Second implementation
    phase.--The second implementation phase, with respect to
    such a measure, shall consist of the provision of
    feedback reports to PAC providers, in accordance with
    subsection (f).
    ``(C) <>  Third
    implementation phase.--The third implementation phase,
    with respect to such a measure, shall consist of public
    reporting of PAC providers' performance on such measure
    in accordance with subsection (g).
    ``(2) Consensus-based entity.--
    ``(A) <>  In general.--Subject to
    subparagraph (B), each measure specified by the
    Secretary under this section shall be endorsed by the
    entity with a contract under section 1890(a).
    ``(B) Exception.--In the case of a specified area or
    medical topic determined appropriate by the Secretary
    for which a feasible and practical measure has not been
    endorsed by the entity with a contract under section
    1890(a), the Secretary may specify a measure that is not
    so endorsed as long as due consideration is given to
    measures that have been endorsed or adopted by a
    consensus organization identified by the Secretary.
    ``(3) Treatment of application of pre-rulemaking process
    (measure applications partnership process).--
    ``(A) In general.--Subject to subparagraph (B), the
    provisions of section 1890A shall apply in the case of a
    quality measure specified under subsection (c) or a
    resource use or other measure specified under subsection
    (d).
    ``(B) Exceptions.--
    ``(i) Expedited procedures.--For purposes of
    satisfying subparagraph (A), the Secretary may use
    expedited procedures, such as ad-hoc reviews, as
    necessary, in the case of a quality measure
    specified under subsection (c) or a resource use
    or other measure specified in subsection (d)
    required with respect to data submissions under
    the applicable reporting provisions during the 1-
    year period before the specified application date
    applicable to such a measure and provider
    involved.
    ``(ii) Option to waive provisions.--The
    Secretary may waive the application of the
    provisions of section 1890A in the case of a
    quality measure or resource use or other measure
    described in clause (i), if the application of
    such provisions (including through the use of an
    expedited procedure described in such clause)
    would result in the inability of the Secretary to
    satisfy any deadline specified in this section
    with respect to such measure.

    ``(f) Feedback Reports to PAC Providers.--
    ``(1) <>  In general.--Beginning one
    year after the specified application date, as applicable to PAC
    providers and quality measures and resource use and other
    measures under this section, the Secretary shall provide
    confidential feedback reports to such PAC providers on the
    performance of such

    [[Page 1959]]

    providers with respect to such measures required under the
    applicable provisions.
    ``(2) Frequency.--To the extent feasible, the Secretary
    shall provide feedback reports described in paragraph (1) not
    less frequently than on a quarterly basis. Notwithstanding the
    previous sentence, with respect to measures described in such
    paragraph that are reported on an annual basis, the Secretary
    may provide such feedback reports on an annual basis.

    ``(g) Public Reporting of PAC Provider Performance.--
    ``(1) <>  In general.--Subject to the
    succeeding paragraphs of this subsection, the Secretary shall
    provide for public reporting of PAC provider performance on
    quality measures under subsection (c)(1) and the resource use
    and other measures under subsection (d)(1), including by
    establishing procedures for making available to the public
    information regarding the performance of individual PAC
    providers with respect to such measures.
    ``(2) Opportunity to review.--The procedures under paragraph
    (1) shall ensure, including through a process consistent with
    the process applied under section 1886(b)(3)(B)(viii)(VII) for
    similar purposes, that a PAC provider has the opportunity to
    review and submit corrections to the data and information that
    is to be made public with respect to the provider prior to such
    data being made public.
    ``(3) Timing.--Such procedures shall provide that the data
    and information described in paragraph (1), with respect to a
    measure and PAC provider, is made publicly available beginning
    not later than two years after the specified application date
    applicable to such a measure and provider.
    ``(4) Coordination with existing programs.--Such procedures
    shall provide that data and information described in paragraph
    (1) with respect to quality measures and resource use and other
    measures under subsections (c)(1) and (d)(1) shall be made
    publicly available consistent with the following provisions:
    ``(A) In the case of home health agencies, section
    1895(b)(3)(B)(v)(III).
    ``(B) In the case of skilled nursing facilities,
    sections 1819(i) and 1919(i).
    ``(C) In the case of inpatient rehabilitation
    facilities, section 1886(j)(7)(E).
    ``(D) In the case of long-term care hospitals,
    section 1886(m)(5)(E).

    ``(h) <>  Removing,
    Suspending, or Adding Measures.--
    ``(1) In general.--The Secretary may remove, suspend, or add
    a quality measure or resource use or other measure described in
    subsection (c)(1) or (d)(1), so long as, subject to paragraph
    (2), the Secretary publishes in the Federal Register (with a
    notice and comment period) a justification for such removal,
    suspension, or addition.
    ``(2) Exception.--In the case of such a quality measure or
    resource use or other measure for which there is a reason to
    believe that the continued collection of such measure raises
    potential safety concerns or would cause other unintended
    consequences, the Secretary may promptly suspend or remove such
    measure and satisfy paragraph (1) by publishing in the

    [[Page 1960]]

    Federal Register a justification for such suspension or removal
    in the next rulemaking cycle following such suspension or
    removal.

    ``(i) Use of Standardized Assessment Data, Quality Measures, and
    Resource Use and Other Measures To Inform Discharge Planning and
    Incorporate Patient Preference.--
    ``(1) <>  In general.--Not
    later than January 1, 2016, and periodically thereafter (but not
    less frequently than once every 5 years), the Secretary shall
    promulgate regulations to modify conditions of participation and
    subsequent interpretive guidance applicable to PAC providers,
    hospitals, and critical access hospitals. Such regulations and
    interpretive guidance shall require such providers to take into
    account quality, resource use, and other measures under the
    applicable reporting provisions (which, as available, shall
    include measures specified under subsections (c) and (d), and
    other relevant measures) in the discharge planning process.
    Specifically, such regulations and interpretive guidance shall
    address the settings to which a patient may be discharged in
    order to assist subsection (d) hospitals, critical access
    hospitals, hospitals described in section 1886(d)(1)(B)(v), PAC
    providers, patients, and families of such patients with
    discharge planning from inpatient settings, including such
    hospitals, and from PAC provider
    settings. <>  In addition, such regulations
    and interpretive guidance shall include procedures to address--
    ``(A) treatment preferences of patients; and
    ``(B) goals of care of patients.
    ``(2) Discharge planning.--All requirements applied pursuant
    to paragraph (1) shall be used to help inform and mandate the
    discharge planning process.
    ``(3) Clarification.--Such regulations shall not require an
    individual to be provided post-acute care by a specific type of
    PAC provider in order for such care to be eligible for payment
    under this title.

    ``(j) Stakeholder Input.--Before the initial rulemaking process to
    implement this section, the Secretary shall allow for stakeholder input,
    such as through town halls, open door forums, and mail-box submissions.
    ``(k) Funding.--For purposes of carrying out this section, the
    Secretary shall provide for the transfer to the Centers for Medicare &
    Medicaid Services Program Management Account, from the Federal Hospital
    Insurance Trust Fund under section 1817 and the Federal Supplementary
    Medical Insurance Trust Fund under section 1841, in such proportion as
    the Secretary determines appropriate, of $130,000,000. Fifty percent of
    such amount shall be available on the date of the enactment of this
    section and fifty percent of such amount shall be equally proportioned
    for each of fiscal years 2015 through 2019. Such sums shall remain
    available until expended.
    ``(l) Limitation.--There shall be no administrative or judicial
    review under sections 1869 and 1878 or otherwise of the specification of
    standardized patient assessment data required, the determination of
    measures, and the systems to report such standardized data under this
    section.
    ``(m) Non-Application of Paperwork Reduction Act.--Chapter 35 of
    title 44, United States Code (commonly referred to as the `Paperwork
    Reduction Act of 1995') shall not apply to

    [[Page 1961]]

    this section and the sections referenced in subsection (a)(2)(B) that
    require modification in order to achieve the standardization of patient
    assessment data.''.
    (b) Studies of Alternative PAC Payment Models.--
    (1) <>  MedPAC.--Using data from
    the Post-Acute Payment Reform Demonstration authorized under
    section 5008 of the Deficit Reduction Act of 2005 (Public Law
    109-171) or other data, as available, not later than June 30,
    2016, the Medicare Payment Advisory Commission shall submit to
    Congress a report that evaluates and recommends features of PAC
    payment systems (as defined in section 1899B(a)(2)(D) of the
    Social Security Act, as added by subsection (a)) that establish,
    or a unified post-acute care payment system under title XVIII of
    the Social Security Act that establishes, payment rates
    according to characteristics of individuals (such as cognitive
    ability, functional status, and impairments) instead of
    according to the post-acute care setting where the Medicare
    beneficiary involved is treated. To the extent feasible, such
    report shall consider the impacts of moving from PAC payment
    systems (as defined in subsection (a)(2)(D) of such section
    1899B) in existence as of the date of the enactment of this Act
    to new post-acute care payment systems under title XVIII of the
    Social Security Act.
    (2) Recommendations for pac prospective payment.--
    (A) <>  Report by secretary.--
    Not later than 2 years after the date by which the
    Secretary of Health and Human Services has collected 2
    years of data on quality measures under subsection (c)
    of section 1899B, as added by subsection (a), the
    Secretary shall, in consultation with the Medicare
    Payment Advisory Commission and appropriate
    stakeholders, submit to Congress a report, including--
    (i) recommendations and a technical prototype,
    on a post-acute care prospective payment system
    under title XVIII of the Social Security Act that
    would--
    (I) in lieu of the rates that would
    otherwise apply under PAC payment
    systems (as defined in subsection
    (a)(2)(D) of such section 1899B), base
    payments under such title, with respect
    to items and services furnished to an
    individual by a PAC provider (as defined
    in subsection (a)(2)(A) of such
    section), according to individual
    characteristics (such as cognitive
    ability, functional status, and
    impairments) of such individual instead
    of the post-acute care setting in which
    the individual is furnished such items
    and services;
    (II) account for the clinical
    appropriateness of items and services so
    furnished and Medicare beneficiary
    outcomes;
    (III) be designed to incorporate (or
    otherwise account for) standardized
    patient assessment data under section
    1899B; and
    (IV) further clinical integration,
    such as by motivating greater
    coordination around a single condition
    or procedure to integrate hospital
    systems with PAC providers (as so
    defined).

    [[Page 1962]]

    (ii) recommendations on which Medicare fee-
    for-service regulations for post-acute care
    payment systems under title XVIII of the Social
    Security Act should be altered (such as the
    skilled nursing facility 3-day stay and inpatient
    rehabilitation facility 60 percent rule);
    (iii) an analysis of the impact of the
    recommended payment system described in clause (i)
    on Medicare beneficiary cost-sharing, access to
    care, and choice of setting;
    (iv) a projection of any potential reduction
    in expenditures under title XVIII of the Social
    Security Act that may be attributable to the
    application of the recommended payment system
    described in clause (i); and
    (v) a review of the value of subsection (d)
    hospitals (as defined in section 1886(d)(1)(B) of
    the Social Security Act (42 U.S.C.
    1395ww(d)(1)(B)), hospitals described in section
    1886(d)(1)(B)(v) of such Act (42 U.S.C.
    1395ww(d)(1)(B)(v)), and critical access hospitals
    described in section 1820(c)(2)(B) of such Act (42
    U.S.C. 1395i-4(c)(2)(B)) collecting and reporting
    to the Secretary standardized patient assessment
    data with respect to inpatient hospital services
    furnished by such a hospital or critical access
    hospital to individuals who are entitled to
    benefits under part A of title XVIII of such Act
    or, as appropriate, enrolled for benefits under
    part B of such title.
    (B) <>  Report by
    medpac.--Not later than the first June 30th following
    the date on which the report is required under
    subparagraph (A), the Medicare Payment Advisory
    Commission shall submit to Congress a report, including
    recommendations and a technical prototype, on a post-
    acute care prospective payment system under title XVIII
    of the Social Security Act that would satisfy the
    criteria described in subparagraph (A).
    (3) Medicare beneficiary defined.--For purposes of this
    subsection, the term ``Medicare beneficiary'' has the meaning
    given such term in section 1899B(a)(2) of the Social Security
    Act, as added by subsection (a).

    (c) Payment Consequences Under the Applicable Reporting
    Provisions.--
    (1) Home health agencies.--Section 1895(b)(3)(B)(v) of the
    Social Security Act (42 U.S.C. 1395fff(b)(3)(B)(v)) is amended--
    (A) in subclause (I), by striking ``subclause (II)''
    and inserting ``subclauses (II) and (IV)'';
    (B) in subclause (II), by striking ``For 2007'' and
    inserting ``Subject to subclause (V), for 2007'';
    (C) in subclause (III), by inserting ``and subclause
    (IV)(aa)'' after ``subclause (II)''; and
    (D) by adding at the end the following new
    subclauses:
    ``(IV) Submission of additional
    data.--
    ``(aa) In general.--For the
    year beginning on the specified
    application date (as defined in
    subsection (a)(2)(E) of section
    1899B), as

    [[Page 1963]]

    applicable with respect to home
    health agencies and quality
    measures under subsection (c)(1)
    of such section and measures
    under subsection (d)(1) of such
    section, and each subsequent
    year, in addition to the data
    described in subclause (II),
    each home health agency shall
    submit to the Secretary data on
    such quality measures and any
    necessary data specified by the
    Secretary under such subsection
    (d)(1).
    ``(bb) Standardized patient
    assessment data.--For 2019 and
    each subsequent year, in
    addition to such data described
    in item (aa), each home health
    agency shall submit to the
    Secretary standardized patient
    assessment data required under
    subsection (b)(1) of section
    1899B.
    ``(cc) Submission.--Data
    shall be submitted under items
    (aa) and (bb) in the form and
    manner, and at the time,
    specified by the Secretary for
    purposes of this clause.
    ``(V) Non-duplication.--To the
    extent data submitted under subclause
    (IV) duplicates other data required to
    be submitted under subclause (II), the
    submission of such data under subclause
    (IV) shall be in lieu of the submission
    of such data under subclause (II). The
    previous sentence shall not apply
    insofar as the Secretary determines it
    is necessary to avoid a delay in the
    implementation of section 1899B, taking
    into account the different specified
    application dates under subsection
    (a)(2)(E) of such section.''.
    (2) Inpatient rehabilitation facilities.--Section 1886(j)(7)
    of the Social Security Act (42 U.S.C. 1395ww(j)(7)) is amended--
    (A) in subparagraph (A)(i), by striking
    ``subparagraph (C)'' and inserting ``subparagraphs (C)
    and (F)'';
    (B) in subparagraph (C), by striking ``For fiscal
    year 2014 and each subsequent rate year'' and inserting
    ``Subject to subparagraph (G), for fiscal year 2014 and
    each subsequent fiscal year'';
    (C) in subparagraph (E), by inserting ``and
    subparagraph (F)(i)'' after ``subparagraph (C)''; and
    (D) by adding at the end the following new
    subparagraphs:
    ``(F) Submission of additional data.--
    ``(i) <>  In general.--
    For the fiscal year beginning on the specified
    application date (as defined in subsection
    (a)(2)(E) of section 1899B), as applicable with
    respect to inpatient rehabilitation facilities and
    quality measures under subsection (c)(1) of such
    section and measures under subsection (d)(1) of
    such section, and each subsequent fiscal year, in
    addition to such data on the quality measures
    described in subparagraph (C), each rehabilitation
    facility shall submit to the Secretary data on the
    quality measures under such

    [[Page 1964]]

    subsection (c)(1) and any necessary data specified
    by the Secretary under such subsection (d)(1).
    ``(ii) Standardized patient assessment data.--
    For fiscal year 2019 and each subsequent fiscal
    year, in addition to such data described in clause
    (i), each rehabilitation facility shall submit to
    the Secretary standardized patient assessment data
    required under subsection (b)(1) of section 1899B.
    ``(iii) Submission.--Such data shall be
    submitted in the form and manner, and at the time,
    specified by the Secretary for purposes of this
    subparagraph.
    ``(G) Non-duplication.--To the extent data submitted
    under subparagraph (F) duplicates other data required to
    be submitted under subparagraph (C), the submission of
    such data under subparagraph (F) shall be in lieu of the
    submission of such data under subparagraph (C). The
    previous sentence shall not apply insofar as the
    Secretary determines it is necessary to avoid a delay in
    the implementation of section 1899B, taking into account
    the different specified application dates under
    subsection (a)(2)(E) of such section.''.
    (3) Long-term care hospitals.--Section 1886(m)(5) of the
    Social Security Act (42 U.S.C. 1395ww(m)(5)) is amended--
    (A) in subparagraph (A)(i), by striking
    ``subparagraph (C)'' and inserting ``subparagraphs (C)
    and (F)'';
    (B) in subparagraph (C), by striking ``For rate
    year'' and inserting ``Subject to subparagraph (G), for
    rate year'';
    (C) in subparagraph (E), by inserting ``and
    subparagraph (F)(i)'' after ``subparagraph (C)''; and
    (D) by adding at the end the following new
    subparagraphs:
    ``(F) Submission of additional data.--
    ``(i) <>  In general.--
    For the rate year beginning on the specified
    application date (as defined in subsection
    (a)(2)(E) of section 1899B), as applicable with
    respect to long-term care hospitals and quality
    measures under subsection (c)(1) of such section
    and measures under subsection (d)(1) of such
    section, and each subsequent rate year, in
    addition to the data on the quality measures
    described in subparagraph (C), each long-term care
    hospital (other than a hospital classified under
    subsection (d)(1)(B)(iv)(II)) shall submit to the
    Secretary data on the quality measures under such
    subsection (c)(1) and any necessary data specified
    by the Secretary under such subsection (d)(1).
    ``(ii) Standardized patient assessment data.--
    For rate year 2019 and each subsequent rate year,
    in addition to such data described in clause (i),
    each long-term care hospital (other than a
    hospital classified under subsection
    (d)(1)(B)(iv)(II)) shall submit to the Secretary
    standardized patient assessment data required
    under subsection (b)(1) of section 1899B.
    ``(iii) Submission.--Such data shall be
    submitted in the form and manner, and at the time,
    specified by the Secretary for purposes of this
    subparagraph.
    ``(G) Non-duplication.--To the extent data submitted
    under subparagraph (F) duplicates other data required to

    [[Page 1965]]

    be submitted under subparagraph (C), the submission of
    such data under subparagraph (F) shall be in lieu of the
    submission of such data under subparagraph (C). The
    previous sentence shall not apply insofar as the
    Secretary determines it is necessary to avoid a delay in
    the implementation of section 1899B, taking into account
    the different specified application dates under
    subsection (a)(2)(E) of such section.''.
    (4) Skilled nursing facilities.--
    (A) In general.--Paragraph (6) of section 1888(e) of
    the Social Security Act (42 U.S.C. 1395yy(e)) is amended
    to read as follows:
    ``(6) Reporting of assessment and quality data.--
    ``(A) Reduction in update for failure to report.--
    ``(i) <>  In general.--
    For fiscal years beginning with fiscal year 2018,
    in the case of a skilled nursing facility that
    does not submit data, as applicable, in accordance
    with subclauses (II) and (III) of subparagraph
    (B)(i) with respect to such a fiscal year, after
    determining the percentage described in paragraph
    (5)(B)(i), and after application of paragraph
    (5)(B)(ii), the Secretary shall reduce such
    percentage for payment rates during such fiscal
    year by 2 percentage points.
    ``(ii) Special rule.--The application of this
    subparagraph may result in the percentage
    described in paragraph (5)(B)(i), after
    application of paragraph (5)(B)(ii), being less
    than 0.0 for a fiscal year, and may result in
    payment rates under this subsection for a fiscal
    year being less than such payment rates for the
    preceding fiscal year.
    ``(iii) Noncumulative application.--Any
    reduction under clause (i) shall apply only with
    respect to the fiscal year involved and the
    Secretary shall not take into account such
    reduction in computing the payment amount under
    this subsection for a subsequent fiscal year.
    ``(B) Assessment and measure data.--
    ``(i) In general.--A skilled nursing facility,
    or a facility (other than a critical access
    hospital) described in paragraph (7)(B), shall
    submit to the Secretary, in a manner and within
    the timeframes prescribed by the Secretary--
    ``(I) subject to clause (iii), the
    resident assessment data necessary to
    develop and implement the rates under
    this subsection;
    ``(II) for fiscal years beginning on
    or after the specified application date
    (as defined in subsection (a)(2)(E) of
    section 1899B), as applicable with
    respect to skilled nursing facilities
    and quality measures under subsection
    (c)(1) of such section and measures
    under subsection (d)(1) of such section,
    data on such quality measures under such
    subsection (c)(1) and any necessary data
    specified by the Secretary under such
    subsection (d)(1); and
    ``(III) <>
    for fiscal years beginning on or after
    October 1, 2018, standardized patient
    assessment

    [[Page 1966]]

    data required under subsection (b)(1) of
    section 1899B.
    ``(ii) Use of standard instrument.--For
    purposes of meeting the requirement under clause
    (i), a skilled nursing facility, or a facility
    (other than a critical access hospital) described
    in paragraph (7)(B), may submit the resident
    assessment data required under section 1819(b)(3),
    using the standard instrument designated by the
    State under section 1819(e)(5).
    ``(iii) Non-duplication.--To the extent data
    submitted under subclause (II) or (III) of clause
    (i) duplicates other data required to be submitted
    under clause (i)(I), the submission of such data
    under such a subclause shall be in lieu of the
    submission of such data under clause (i)(I). The
    previous sentence shall not apply insofar as the
    Secretary determines it is necessary to avoid a
    delay in the implementation of section 1899B,
    taking into account the different specified
    application dates under subsection (a)(2)(E) of
    such section.''.
    (B) Funding for nursing home compare website.--
    Section 1819(i) of the Social Security Act (42 U.S.C.
    1395i-3(i)) is amended by adding at the end the
    following new paragraph:
    ``(3) Funding.--The Secretary shall transfer to the Centers
    for Medicare & Medicaid Services Program Management Account,
    from the Federal Hospital Insurance Trust Fund under section
    1817 a one-time allocation of $11,000,000. <>  The amount shall be available on the date of the
    enactment of this paragraph. Such sums shall remain available
    until expended. Such sums shall be used to implement section
    1128I(g).''.

    (d) <>  Improving Payment Accuracy Under
    the PAC Payment Systems and Other Medicare Payment Systems.--
    (1) Studies and reports of effect of certain information on
    quality and resource use.--
    (A) Study using existing medicare data.--
    (i) Study.--The Secretary of Health and Human
    Services (in this subsection referred to as the
    ``Secretary'') shall conduct a study that examines
    the effect of individuals' socioeconomic status on
    quality measures and resource use and other
    measures for individuals under the Medicare
    program under title XVIII of the Social Security
    Act (42 U.S.C. 1395 et seq.) (such as to recognize
    that less healthy individuals may require more
    intensive interventions). The study shall use
    information collected on such individuals in
    carrying out such program, such as urban and rural
    location, eligibility for Medicaid under title XIX
    of such Act (42 U.S.C. 1396 et seq.) (recognizing
    and accounting for varying Medicaid eligibility
    across States), and eligibility for benefits under
    the supplemental security income (SSI) program.
    The Secretary shall carry out this paragraph
    acting through the Assistant Secretary for
    Planning and Evaluation.
    (ii) Report.--Not later than 2 years after the
    date of the enactment of this Act, the Secretary
    shall submit

    [[Page 1967]]

    to Congress a report on the study conducted under
    clause (i).
    (B) Study using other data.--
    (i) Study.--The Secretary shall conduct a
    study that examines the impact of risk factors,
    such as those described in section 1848(p)(3) of
    the Social Security Act (42 U.S.C. 1395w-4(p)(3)),
    race, health literacy, limited English proficiency
    (LEP), and Medicare beneficiary activation, on
    quality measures and resource use and other
    measures under the Medicare program (such as to
    recognize that less healthy individuals may
    require more intensive interventions). In
    conducting such study the Secretary may use
    existing Federal data and collect such additional
    data as may be necessary to complete the study.
    (ii) Report.--Not later than 5 years after the
    date of the enactment of this Act, the Secretary
    shall submit to Congress a report on the study
    conducted under clause (i).
    (C) Examination of data in conducting studies.--In
    conducting the studies under subparagraphs (A) and (B),
    the Secretary shall examine what non-Medicare data sets,
    such as data from the American Community Survey (ACS),
    can be useful in conducting the types of studies under
    such paragraphs and how such data sets that are
    identified as useful can be coordinated with Medicare
    administrative data in order to improve the overall data
    set available to do such studies and for the
    administration of the Medicare program.
    (D) Recommendations to account for information in
    payment adjustment mechanisms.--If the studies conducted
    under subparagraphs (A) and (B) find a relationship
    between the factors examined in the studies and quality
    measures and resource use and other measures, then the
    Secretary shall also provide recommendations for how the
    Centers for Medicare & Medicaid Services should--
    (i) obtain access to the necessary data (if
    such data is not already being collected) on such
    factors, including recommendations on how to
    address barriers to the Centers in accessing such
    data; and
    (ii) account for such factors--
    (I) in quality measures, resource
    use measures, and other measures under
    title XVIII of the Social Security Act
    (including such measures specified under
    subsections (c) and (d) of section 1899B
    of such Act, as added by subsection
    (a)); and
    (II) in determining payment
    adjustments based on such measures in
    other applicable provisions of such
    title.
    (E) Funding.--There are hereby appropriated to the
    Secretary from the Federal Hospital Insurance Trust Fund
    under section 1817 of the Social Security Act (42 U.S.C.
    1395i) and the Federal Supplementary Medical Insurance
    Trust Fund under section 1841 of such Act (42 U.S.C.
    1395t) (in proportions determined appropriate by the
    Secretary) to carry out this paragraph $6,000,000, to
    remain available until expended.

    [[Page 1968]]

    (2) CMS activities.--
    (A) In general.--Taking into account the relevant
    studies conducted and recommendations made in reports
    under paragraph (1) and, as appropriate, other
    information, including information collected before
    completion of such studies and recommendations, the
    Secretary, on an ongoing basis, shall, as the Secretary
    determines appropriate and based on an individual's
    health status and other factors--
    (i) assess appropriate adjustments to quality
    measures, resource use measures, and other
    measures under title XVIII of the Social Security
    Act (42 U.S.C. 1395 et seq.) (including measures
    specified in subsections (c) and (d) of section
    1899B of such Act, as added by subsection (a));
    and
    (ii) assess and implement appropriate
    adjustments to payments under such title based on
    measures described in clause (i).
    (B) Accessing data.--The Secretary shall collect or
    otherwise obtain access to the data necessary to carry
    out this paragraph through existing and new data
    sources.
    (C) Periodic analyses.--The Secretary shall carry
    out periodic analyses, at least every 3 years, based on
    the factors referred to in subparagraph (A) so as to
    monitor changes in possible relationships.
    (D) Funding.--There are hereby appropriated to the
    Secretary from the Federal Hospital Insurance Trust Fund
    under section 1817 of the Social Security Act (42 U.S.C.
    1395i) and the Federal Supplementary Medical Insurance
    Trust Fund under section 1841 of such Act (42 U.S.C.
    1395t) (in proportions determined appropriate by the
    Secretary) to carry out this paragraph $10,000,000, to
    remain available until expended.
    (3) Strategic plan for accessing race and ethnicity
    data. <> --Not later than 18 months after the
    date of the enactment of this Act, the Secretary shall develop
    and report to Congress on a strategic plan for collecting or
    otherwise accessing data on race and ethnicity for purposes of
    specifying quality measures and resource use and other measures
    under subsections (c) and (d) of section 1899B of the Social
    Security Act, as added by subsection (a), and, as the Secretary
    determines appropriate, other similar provisions of, including
    payment adjustments under, title XVIII of such Act (42 U.S.C.
    1395 et seq.).
    SEC. 3. HOSPICE CARE.

    (a) Hospice Survey Requirement.--
    (1) In general.--Section 1861(dd)(4) of the Social Security
    Act (42 U.S.C. 1395x(dd)(4)) is amended by adding at the end the
    following new subparagraph:

    ``(C) <>  Any entity that is
    certified as a hospice program shall be subject to a standard survey by
    an appropriate State or local survey agency, or an approved
    accreditation agency, as determined by the Secretary, not less
    frequently than once every 36 months beginning 6 months after the date
    of the enactment of this subparagraph and ending September 30, 2025.''.
    (2) Funding.--For purposes of carrying out subparagraph (C)
    of section 1861(dd)(4) of the Social Security Act (42 U.S.C.

    [[Page 1969]]

    1395x(dd)(4)), as added by paragraph (1), there shall be
    transferred from the Federal Hospital Insurance Trust Fund under
    section 1817 of such Act (42 U.S.C. 1395i) to the Centers for
    Medicare & Medicaid Services Program Management Account--
    (A) $25,000,000 for fiscal years 2015 through 2017,
    to be made available for such purposes in equal parts
    for each such fiscal year; and
    (B) $45,000,000 for fiscal years 2018 through 2025,
    to be made available for such purposes in equal parts
    for each such fiscal year.

    (b) Hospice Program Eligibility Recertification Technical Correction
    to Apply Limitation on Liability of Beneficiary Rules.--Section 1879 of
    the Social Security Act (42 U.S.C. 1395pp) is amended by adding at the
    end the following new subsection:
    ``(i) The provisions of this section shall apply with respect to a
    denial of a payment under this title by reason of section 1814(a)(7)(E)
    in the same manner as such provisions apply with respect to a denial of
    a payment under this title by reason of section 1862(a)(1).''.
    (c) Revision to Requirement for Medical Review of Certain Hospice
    Care.--Section 1814(a)(7) of the Social Security Act (42 U.S.C.
    1395f(a)(7)) is amended--
    (1) in subparagraph (C), by striking ``and'' at the end;
    (2) in subparagraph (D), in the matter preceding clause (i),
    by inserting ``(and, in the case of clause (ii), before the date
    of enactment of subparagraph (E))'' after ``2011''; and
    (3) by adding at the end the following new subparagraph:
    ``(E) on and after the date of enactment of this
    subparagraph, in the case of hospice care provided an
    individual for more than 180 days by a hospice program
    for which the number of such cases for such program
    comprises more than a percent (specified by the
    Secretary) of the total number of all cases of
    individuals provided hospice care by the program under
    this title, the hospice care provided to such individual
    is medically reviewed (in accordance with procedures
    established by the Secretary); and''.

    (d) Update of Hospice Aggregate Payment Cap.--Section 1814(i)(2)(B)
    of the Social Security Act (42 U.S.C. 1395f(i)(2)(B)) is amended--
    (1) by striking ``(B) For purposes'' and inserting ``(B)(i)
    Except as provided in clause (ii), for purposes''; and
    (2) by adding at the end the following:

    ``(ii) <>  For purposes of subparagraph (A) for
    accounting years that end after September 30, 2016, and before October
    1, 2025, the `cap amount' is the cap amount under this subparagraph for
    the preceding accounting year updated by the percentage update to
    payment rates for hospice care under paragraph (1)(C) for services
    furnished during the fiscal year beginning on the October 1 preceding
    the beginning of the accounting year (including the application of any
    productivity or other adjustment under clause (iv) of that paragraph).

    ``(iii) For accounting years that end after September 30, 2025, the
    cap amount shall be computed under clause (i) as if clause (ii) had
    never applied.''.
    (e) Medicare Improvement Fund.--Section 1898 of the Social Security
    Act (42 U.S.C. 1395iii) is amended--

    [[Page 1970]]

    (1) by amending the heading to read as follows: ``medicare
    improvement fund'';
    (2) by amending subsection (a) to read as follows:

    ``(a) Establishment.--The Secretary shall establish under this title
    a Medicare Improvement Fund (in this section referred to as the `Fund')
    which shall be available to the Secretary to make improvements under the
    original Medicare fee-for-service program under parts A and B for
    individuals entitled to, or enrolled for, benefits under part or
    enrolled under part B including adjustments to payments for items and
    services furnished by providers of services and suppliers under such
    original Medicare fee-for-service program.'';
    (3) in subsection (b)(1), by striking ``during'' and all
    that follows and inserting ``during and after fiscal year 2020,
    $195,000,000.''; and
    (4) in subsection (b)(2), by striking ``from the Federal''
    and all that follows and inserting ``from the Federal Hospital
    Insurance Trust Fund and the Federal Supplementary Medical
    Insurance Trust Fund in such proportion as the Secretary
    determines appropriate.''.

    Approved October 6, 2014.

    LEGISLATIVE HISTORY--H.R. 4994:
    ---------------------------------------------------------------------------

    CONGRESSIONAL RECORD, Vol. 160 (2014):
    Sept. 16, considered and passed House.
    Sept. 18, considered and passed Senate.