Sec. 1206. PAYMENT FOR INPATIENT SERVICES IN LONG-TERM CARE HOSPITALS (LTCHS)
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## SEC. 1206 PAYMENT FOR INPATIENT SERVICES IN LONG-TERM CARE HOSPITALS (LTCHS) ###
(a)Establishment of Criteria for Application of Site Neutral Payment ####
(1)In general Section 1886(m) of the Social Security Act (42 U.S.C. 1395ww(m)) is amended by adding at the end the following: > > #### “(6) Application of site neutral ipps payment rate in certain cases > > > ##### “(A) General application of site neutral ipps payment amount for discharges failing to meet applicable criteria > > > ###### “(i) In general > > 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)). > > > ###### “(ii) Exception for certain discharges meeting criteria > > 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— > > > ###### “(I) > > the discharge meets the ICU criterion under clause
(iii)or the ventilator criterion under clause (iv); and > > > ###### “(II) > > the discharge does not have a principal diagnosis relating to a psychiatric diagnosis or to rehabilitation. > > > ###### “(iii) Intensive care unit
(icu)criterion > > > ###### “(I) In general > > 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. > > > ###### “(II) Determining icu days > > 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). > > > ###### “(iv) Ventilator criterion > > 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— > > > ###### “(I) > > the stay in the long-term care hospital ending with such discharge was immediately preceded by a discharge from a stay in a subsection
(d)hospital; and > > > ###### “(II) > > 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. > > > ##### “(B) Applicable site neutral payment rate defined > > > ###### “(i) In general > > In this paragraph, the term ‘applicable site neutral payment rate’ means— > > > ###### “(I) > > for discharges in cost reporting periods beginning during fiscal year 2016 or fiscal year 2017, the blended payment rate specified in clause (iii); and > > > ###### “(II) > > 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)). > > > ###### “(ii) Site neutral payment rate defined > > In this paragraph, the term ‘site neutral payment rate’ means the lower of— > > > ###### “(I) > > 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 > > > ###### “(II) > > 100 percent of the estimated cost for the services involved. > > > ###### “(iii) Blended payment rate > > The blended payment rate specified in this clause, for a long-term care hospital for inpatient hospital services for a discharge, is comprised of— > > > ###### “(I) > > half of the site neutral payment rate (as defined in clause (ii)) for the discharge; and > > > ###### “(II) > > half of the payment rate that would otherwise be applicable to such discharge without regard to this paragraph, as determined by the Secretary. > > > ##### “(C) Limiting payment for all hospital discharges to site neutral payment rate for hospitals failing to meet applicable ltch discharge thresholds > > > ###### “(i) Notice of ltch discharge payment percentage > > 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. > > > ###### “(ii) Limitation > > 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— > > > ###### “(I) > > the Secretary shall inform the hospital of such fact; and > > > ###### “(II) > > 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. > > > ###### “(iii) Process for reinstatement > > 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. > > > ###### “(iv) LTCH discharge payment percentage > > 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— > > > ###### “(I) > > the number of discharges for such hospital and period for which payment is not made at the site neutral payment rate, to > > > ###### “(II) > > the total number of discharges for such hospital and period. > > > ##### “(D) Inclusion of subsection
(d)puerto rico hospitals > > 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.” > . ####
(2)Medpac study and report on impact of changes #####
(A)Study The Medicare Payment Advisory 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— ######
(i)the quality of patient care in long-term care hospitals; ######
(ii)the use of hospice care and post-acute care settings; ######
(iii)different types of long-term care hospitals; and ######
(iv)the growth in Medicare spending for services in such hospitals. #####
(B)Report 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. ####
(3)Calculation of length of stay excluding cases paid on a site neutral basis **[**[42 U.S.C. 1395ww note](/us/usc/t42/s1395ww)**]** For discharges occurring in cost reporting periods beginning on or after October 1, 2015, 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: #####
(A)Site neutral payment 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)). #####
(B)Medicare advantage Any patient for whom payment is made under a Medicare Advantage plan under part C of title XVIII of such Act. ###
(b)Extension of Certain LTCH Payment Rules and Moratorium on the Establishment of Certain Hospitals and Facilities ####
(1)Extension of certain payment rules #####
(A)Payment for hospitals-within-hospitals 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”. #####
(B)25 PERCENT PATIENT THRESHOLD PAYMENT ADJUSTMENT; MAKING THE GRANDFATHERED EXEMPTION FOR LONG-TERM CARE HOSPITALS PERMANENT 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— ######
(i)in the matter preceding subparagraph (A), by striking “for a 5-year period”; and ######
(ii)in subparagraph (A), by inserting “for a 9-year period,” before “section 412.536”. #####
(C)Report assessing continued suspension of 25 percent rule 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). ####
(2)Extension of moratorium on establishment of and increase in beds for ltchs 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— #####
(A)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 #####
(B)by adding at the end the following new paragraph: > > #### “(6) Limitation on application of exceptions > > Paragraphs
(2)and
(3)shall not apply during the period beginning January 1, 2015, and ending September 30, 2017.” > . ###
(c)Additional Quality Measure 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: > > ###### “(iv) Additional quality measures > > Not later than October 1, 2015, the Secretary shall establish a functional status quality measure for change in mobility among inpatients requiring ventilator support.” > . ###
(d)Review of Treatment of Certain LTCHs **[**[42 U.S.C. 1395ww note](/us/usc/t42/s1395ww)**]** ####
(1)Evaluation 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. ####
(2)Adjustment authority 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.
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- Pub. L. 111-148
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Sec. 1206
PAYMENT FOR INPATIENT SERVICES IN LONG-TERM CARE HOSPITALS (LTCHS)
Pub. L.Pub. L. 111-148
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