Sec. 1206. Payment for inpatient services in long-term care hospitals (LTCHs)
1,500 words·~7 min read·
/bill/113/hjres/59/enr/section-1206·A research copy — for the controlling text, always check the official state or federal source. Not legal advice.
Section 1886(m) of the Social Security Act ( 42 U.S.C. 1395ww(m) ) is amended by adding at the end the following: For a discharge in cost reporting periods beginning on or after October 1, 2015, except as provided in clause
(ii)and subparagraph (C), payment under this title to a long-term care hospital for inpatient hospital services shall be made at the applicable site neutral payment rate (as defined in subparagraph (B)). Clause
(i)shall not apply (and payment shall be made to a long-term care hospital without regard to this paragraph) for a discharge if— the discharge meets the ICU criterion under clause
(iii)or the ventilator criterion under clause (iv); and the discharge does not have a principal diagnosis relating to a psychiatric diagnosis or to rehabilitation. The criterion specified in this clause (in this paragraph referred to as the ICU criterion ), for a discharge from a long-term care hospital, is that the stay in the long-term care hospital ending with such discharge was immediately preceded by a discharge from a stay in a subsection
(d)hospital that included at least 3 days in an intensive care unit (ICU), as determined by the Secretary. In determining intensive care unit days under subclause (I), the Secretary shall use data from revenue center codes 020x or 021x (or such successor codes as the Secretary may establish). The criterion specified in this clause (in this paragraph referred to as the ventilator criterion ), for a discharge from a long-term care hospital, is that— the stay in the long-term care hospital ending with such discharge was immediately preceded by a discharge from a stay in a subsection
(d)hospital; and the individual discharged was assigned to a Medicare-Severity-Long-Term-Care-Diagnosis-Related-Group (MS–LTC–DRG) based on the receipt of ventilator services of at least 96 hours. In this paragraph, the term applicable site neutral payment rate means— for discharges in cost reporting periods beginning during fiscal year 2016 or fiscal year 2017, the blended payment rate specified in clause (iii); and for discharges in cost reporting periods beginning during fiscal year 2018 or a subsequent fiscal year, the site neutral payment rate (as defined in clause (ii)). In this paragraph, the term site neutral payment rate means the lower of— the IPPS comparable per diem amount determined under paragraph (d)(4) of section 412.529 of title 42, Code of Federal Regulations, including any applicable outlier payments under section 412.525 of such title; or 100 percent of the estimated cost for the services involved. The blended payment rate specified in this clause, for a long-term care hospital for inpatient hospital services for a discharge, is comprised of— half of the site neutral payment rate (as defined in clause (ii)) for the discharge; and half of the payment rate that would otherwise be applicable to such discharge without regard to this paragraph, as determined by the Secretary. For cost reporting periods beginning during or after fiscal year 2016, the Secretary shall inform each long-term care hospital of its LTCH discharge payment percentage (as defined in clause (iv)) for such period. For cost reporting periods beginning during or after fiscal year 2020, if the Secretary determines for a long-term care hospital that its LTCH discharge payment percentage for the period is not at least 50 percent— the Secretary shall inform the hospital of such fact; and subject to clause (iii), for all discharges in the hospital in each succeeding cost reporting period, the payment amount under this subsection shall be the payment amount that would apply under subsection
(d)for the discharge if the hospital were a subsection
(d)hospital. The Secretary shall establish a process whereby a long-term care hospital may seek to and have the provisions of subclause
(II)of clause
(ii)discontinued with respect to that hospital. In this subparagraph, the term LTCH discharge payment percentage means, with respect to a long-term care hospital for a cost reporting period beginning during or after fiscal year 2020, the ratio (expressed as a percentage) of— the number of discharges for such hospital and period for which payment is not made at the site neutral payment rate, to the total number of discharges for such hospital and period. In this paragraph, any reference in this paragraph to a subsection
(d)hospital shall be deemed to include a reference to a subsection
(d)Puerto Rico hospital. . The Medicare Payment Assessment Commission shall examine the effect of applying section 1886(m)(6) of the Social Security Act, as added by the amendment made by paragraph (1), on— the quality of patient care in long-term care hospitals; the use of hospice care and post-acute care settings; different types of long-term care hospitals; and the growth in Medicare spending for services in such hospitals. Not later than June 30, 2019, the Commission shall submit to Congress a report on such study. The Commission shall include in such report such recommendations for changes in the application of such section as the Commission deems appropriate as well as the impact of the application of such section on the need to continue applying the 25 percent rule described under sections 412.534 and 412.536 of title 42, Code of Federal Regulations. For discharges occurring in cost reporting periods beginning on or after October 1, 2015, subject to subparagraph (B), in calculating the length of stay requirement applicable to a long-term care hospital or satellite facility under section 1886(d)(1)(B)(iv)(I) of the Social Security Act ( 42 U.S.C. 1395ww(d)(1)(B)(iv)(I) ) and section 1861(ccc)(2) of such Act ( 42 U.S.C. 1395x(ccc)(2) ), the Secretary of Health and Human Services shall exclude the following: Any patient for whom payment is made at the site neutral payment rate (as defined in section 1886(m)(6)(B)(ii)) of such Act, as added by paragraph (1)). Any patient for whom payment is made under a Medicare Advantage plan under part C of title XVIII of such Act. Subparagraph
(A)shall not apply to a hospital that is classified as of December 10, 2013, as a subsection
(d)hospital (as defined in section 1886(d)(1)(B) of the Social Security Act, 42 U.S.C. 1395ww(d)(1)(B) ) for purposes of determining whether the requirements of section 1886(d)(1)(B)(iv)(I) or 1861(ccc)(2) of such Act ( 42 U.S.C. 1395ww(d)(1)(B)(iv)(I) , 1395x(ccc)(2)) are met. Paragraph (2)(C) of section 114(c) of the Medicare, Medicaid, and SCHIP Extension Act of 2007 ( 42 U.S.C. 1395ww note), as amended by sections 3106(a) and 10312(a) of Public Law 111–148 , is amended by striking 5-year period and inserting 9-year period . Section 114(c)(1) of the Medicare, Medicaid, and SCHIP Extension Act of 2007 ( 42 U.S.C. 1395ww note), as amended by sections 3106(a) and 10312(a) of Public Law 111–148 , is amended— in the matter preceding subparagraph (A), by striking for a 5-year period ; and in subparagraph (A), by inserting for a 9-year period, before section 412.536 . Not later than 1 year before the end of the 9-year period referred to in section 114(c)(1) of the Medicare, Medicaid, and SCHIP Extension Act of 2007 ( 42 U.S.C. 1395ww note), as amended by subparagraph (B), the Secretary of Health and Human Services shall submit to Congress a report on the need for any further extensions (or modifications of the extensions) of the 25 percent rule described in sections 412.534 and 412.536 of title 42, Code of Federal Regulations, particularly taking into account the application of section 1886(m)(6) of the Social Security Act, as added by subsection (a)(1). Section 114(d) of the Medicare, Medicaid, and SCHIP Extension Act of 2007 ( 42 U.S.C. 1395ww note), as amended by sections 3106(b) and 10312(b) of Public Law 111–148 , is amended— in paragraph (1), in the matter preceding subparagraph (A), by inserting after 5-year period the following: (and for the period beginning January 1, 2015, and ending September 30, 2017) ; and by adding at the end the following new paragraph: Paragraphs
(2)and
(3)shall not apply during the period beginning January 1, 2015, and ending September 30, 2017. . Section 1886(m)(5)(D) of the Social Security Act ( 42 U.S.C. 1395ww(m)(5)(D) ) is amended by adding at the end the following new clause: Not later than October 1, 2015, the Secretary shall establish a functional status quality measure for change in mobility among inpatients requiring ventilator support. . As part of the annual rulemaking for fiscal year 2015 or fiscal year 2016 to carry out the payment rates under subsection
(d)of section 1886 of the Social Security Act ( 42 U.S.C. 1395ww ), the Secretary shall evaluate both the payment rates and regulations governing hospitals which are classified under subclause
(II)of subsection (d)(1)(B)(iv) of such section. Based upon such evaluation, the Secretary may adjust payment rates under subsection (b)(3) of section 1886 of the Social Security Act ( 42 U.S.C. 1395ww ) for a hospital so classified (such as payment based upon the TEFRA-payment model) and may adjust the regulations governing such hospitals, including applying the regulations governing hospitals which are classified under clause
(I)of subsection (d)(1)(B) of such section.
Connectionstraces to 2
Traces to 2 documents
1 reference not yet in our index
- Pub. L. 111-148
Citation graph
cites case law
Sec. 1206
Payment for inpatient services in long-term care hospitals (LTCHs)
Pub. L.Pub. L. 111-148
Cites 3Cited by 0 across 0 sources