Bundling and Coordinating Post-Acute Care Act of 2014 or the BACPAC Act of 2014 - Amends title XVIII (Medicare) of the Social Security Act to require a single bundled payment for post-acute care services under Medicare parts A (Hospital Insurance) and B (Supplementary Medical Insurance).
Defines "PAC physician" as the physician with primary responsibility for supervising delivery to an individual of a post-acute care (PAC) bundle of services between a qualifying discharge and the earlier of: (1) 90 days later, or (2) the date on which the individual is admitted to a hospital to receive services for a condition unrelated to the one for which he or she received the acute care inpatient hospital services.
Directs the Secretary of Health and Human Services (HHS) to: (1) establish a new Transitional Care Management (TCM) code, with respect to geographic adjustments to the physicians' fee schedule, to pay for care management by a PAC physician; or (2) revise and expand the use of existing TCM codes 99495 and 99494.
[Congressional Bills 113th Congress]
[From the U.S. Government Publishing Office]
[H.R. 4673 Introduced in House (IH)]
113th CONGRESS
2d Session
H. R. 4673
To amend title XVIII of the Social Security Act to provide bundled
payments for post-acute care services under parts A and B of Medicare,
and for other purposes.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
May 19, 2014
Mr. McKinley (for himself and Mr. Price of Georgia) introduced the
following bill; which was referred to the Committee on Ways and Means,
and in addition to the Committee on Energy and Commerce, for a period
to be subsequently determined by the Speaker, in each case for
consideration of such provisions as fall within the jurisdiction of the
committee concerned
_______________________________________________________________________
A BILL
To amend title XVIII of the Social Security Act to provide bundled
payments for post-acute care services under parts A and B of Medicare,
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 ``Bundling and Coordinating Post-Acute
Care Act of 2014'' and as the ``BACPAC Act of 2014''.
SEC. 2. PURPOSES.
The purposes of this Act are to--
(1) foster the delivery of high-quality post-acute care
services in the most cost-effective manner possible;
(2) preserve the ability of patients, with the guidance of
their physicians, to select their preferred providers of post-
acute care services;
(3) promote competition among post-acute care providers on
the basis of quality, cost, accountability, and customer
service;
(4) achieve long-term sustainability by ensuring
operational stability through regional breadth and the
engagement of experienced care PAC coordinators;
(5) advance innovation in fields including telehealth, care
coordination, medication management, and hospitalization
avoidance; and
(6) provide for the financial security of the Medicare
program by achieving substantial program savings through
maximized efficiencies, cost avoidance, and outcomes
improvement.
SEC. 3. PROVIDING BUNDLED PAYMENTS FOR POST-ACUTE CARE SERVICES UNDER
PARTS A AND B OF MEDICARE.
Title XVIII of the Social Security Act is amended by inserting
after section 1866E (42 U.S.C. 1395cc-5) the following new section:
``providing bundled payments for post-acute care services
``Sec. 1866F. (a) In General.--For a PAC bundle with respect to
qualifying discharges occurring on or after January 1, 2016, instead of
the payment otherwise provided under parts A and B, there shall be paid
a single payment amount (determined under subsection (d) and as limited
under paragraph (4) of such subsection) to be paid to a PAC coordinator
(as described in subsection (c)) selected by an individual under such
subsection.
``(b) PAC-Related Definitions.--In this section:
``(1) PAC bundle.--The term `PAC bundle' means PAC services
furnished to an individual during a PAC period in a PAC area.
``(2) PAC services.--
``(A) In general.--The term `PAC services'
includes--
``(i) post-hospital extended care services,
subject to subparagraph (C)(i);
``(ii) home health services, subject to
subparagraph (C)(ii);
``(iii) inpatient services provided in a
rehabilitation facility, subject to
subparagraph (C)(iii);
``(iv) inpatient hospital services provided
by a long-term care hospital, subject to
subparagraph (C)(iv);
``(v) durable medical equipment;
``(vi) outpatient prescription drugs and
biologicals; and
``(vii) skilled nursing facility services.
``(B) Exceptions.--Such term does not include--
``(i) physicians' services;
``(ii) hospice care;
``(iii) outpatient hospital services;
``(iv) ambulance services;
``(v) outpatient physical therapy services;
``(vi) outpatient occupational therapy
services;
``(vii) outpatient speech-language
pathology services; and
``(viii) the items and services described
in section 1861(s)(9).
``(C) Nonapplication of certain coverage
limitations.--
``(i) Waiver of skilled nursing facility
three-day stay requirement.--In applying
subparagraph (A)(i), the 3-day stay requirement
described in section 1861(i) (requiring that an
individual's inpatient stay in a discharging
hospital be for a duration of not less than 3
consecutive days) shall not apply.
``(ii) Waiver of homebound requirement for
home health services.--In applying subparagraph
(A)(ii), the requirements cited in sections
1814(a)(2)(C) and 1835(a)(2)(A) that home
health services are or were required because
the individual is or was confined to the home
of the individual shall not apply.
``(iii) Nonapplication of rehabilitation
facility percentage requirement.--In applying
subparagraph (A)(iii), any requirement that a
specified percentage of the inpatient
population served by the facility require
intensive rehabilitation services for treatment
of one or more of the conditions specified in
section 412.29(b)(2) of title 42, Code of
Federal Regulations, as of December 19, 2013,
shall not apply.
``(iv) Nonapplication of long-term care
hospital percentage requirement.--In applying
subparagraph (A)(iv), any requirement that a
specified percentage of the discharged Medicare
inpatient population of the long-term care
hospital or its satellite facility be admitted
to the hospital or its satellite facility from
its co-located hospital shall not apply.
``(3) PAC period.--The term `PAC period' means the period
beginning on the date of a qualifying discharge (as defined in
paragraph (10)) and ending on the date that is the earlier of
the following:
``(A) The date that is 90 days after the date of
such discharge.
``(B) The date on which the individual is admitted
to a hospital for purposes of receiving services for a
condition that is not related to the condition for
which the individual received the acute care inpatient
hospital services described in paragraph (10)(A).
``(4) PAC area.--The term `PAC area' means an area with
respect to which a PAC coordinator has a PAC agreement in
effect under subsection (c)(1)(B).
``(5) PAC physician.--The term `PAC physician' means, with
respect to an individual receiving a PAC bundle, the physician
who has primary responsibility with respect to supervising the
delivery of services during the course of a PAC period.
``(6) PAC provider.--The term `PAC provider' means, with
respect to PAC services, the provider of services or supplier
furnishing such services.
``(7) PAC network agreement.--The term `PAC network
agreement' means, in the case that an individual has selected a
PAC coordinator under subsection (c)(4)(A) for the furnishing
of PAC services, an agreement of a PAC coordinator with one or
more PAC providers to provide such services to such individual.
``(8) PAC readmission.--The term `PAC readmission' means,
with respect to an individual receiving a PAC bundle, the
individual's admission to a hospital within 90 days of the date
of the qualifying discharge of the individual, for purposes of
receiving services for a condition that is related to the
condition for which the individual received the acute care
inpatient hospital services described in paragraph (10)(A).
``(9) PAC assessment tool.--The term `PAC assessment tool'
means the Continuity Assessment Record and Evaluation (CARE)
tool (or such equivalent assessment tool as the Secretary may
specify).
``(10) Qualifying discharge.--Subject to subsection (e),
the term `qualifying discharge' means a discharge after
receiving acute care inpatient hospital services (as defined by
the Secretary) in a subsection (d) hospital (as defined in
section 1886(d)(1)(B)) for which the discharge plan includes
the furnishing of PAC services.
``(11) CRG.--The term `CRG' means a condition-related group
established under subsection (d)(1).
``(c) PAC Coordinators.--
``(1) In general.--In this section, the term `PAC
coordinator' means an entity (such as a hospital, health
insurance issuer, third-party benefit manager, or PAC provider)
that--
``(A) is certified, under a process established by
the Secretary, as meeting appropriate requirements
specified by the Secretary, including the requirements
specified in paragraph (2); and
``(B) has entered into and has in effect a PAC
agreement with the Secretary described in paragraph
(3).
``(2) Requirements.--The requirements specified in this
paragraph, with respect to an entity serving a PAC area, are
the following:
``(A) Financial solvency.--The entity has the
capacity, and provides sufficient assurances of
solvency, to bear financial risk as a PAC coordinator
under this section.
``(B) Capacity to manage care and funding.--The
entity has the capability to manage the care and
funding for PAC services in such area.
``(C) PAC network agreements.--
``(i) Network capacity to serve pac area.--
The entity has entered into PAC network
agreements with one or more PAC providers in a
PAC area in a manner sufficient to ensure the
availability of PAC services for individuals
residing in the area who select the entity for
the furnishing of PAC services.
``(ii) Limitation on balance billing.--Such
a PAC network agreement shall provide that the
PAC provider shall accept as payment in full
for PAC services furnished by such PAC provider
the applicable amount described in paragraph
(3)(C).
``(iii) Quality assurance.--Such a PAC
network agreement shall provide that the PAC
provider shall have in effect a written plan of
quality assurance and improvement, and
procedures implementing such plan, that meet
such quality standards as the Secretary may
specify.
``(D) Credit-worthiness.--The entity has
demonstrated credit-worthiness.
``(E) Medical director.--The entity employs or
contracts with a medical director who has an
appropriate medical background.
``(3) Terms of pac agreement.--The PAC agreement described
in this paragraph between an entity and the Secretary shall,
with respect to the PAC area specified under subparagraph (B),
have such terms and conditions as are specified by the
Secretary consistent with this section and shall include the
following:
``(A) Care coordination.--With respect to an
individual who selects the entity under paragraph
(4)(A)--
``(i) the entity shall select one or more
PAC providers in such area to furnish, directly
or indirectly, clinically appropriate PAC
services (as determined through the use of the
PAC assessment tool) to the individual; and
``(ii) the entity shall coordinate the
furnishing of all such services for the
individual.
``(B) PAC area covered.--The PAC agreement shall
specify the PAC area under the PAC agreement.
``(C) Payment amount for pac services.--For PAC
services furnished by a PAC provider and furnished with
respect to a qualifying discharge that occurs--
``(i) before January 1, 2019, the entity
shall pay the PAC provider under the PAC
network agreement between the entity and the
PAC provider--
``(I) with respect to such PAC
services that are services for which
the PAC provider would receive payment
under this title without regard to this
section, an amount that is not less
than the amount that would otherwise be
paid to such PAC provider under this
title for such services; and
``(II) with respect to such PAC
services that are services for which
the PAC provider would not receive
payment under this title without regard
to this section, an amount specified
under such PAC network agreement; and
``(ii) on or after January 1, 2019, the
entity shall pay the PAC provider under such
PAC network agreement an amount specified under
such agreement.
``(D) Distribution of savings.--Insofar as the
payment amount to a PAC coordinator under subsection
(d)(3) for a PAC bundle furnished to an individual is
greater than the aggregate amounts paid to PAC
providers under subparagraph (C) for such bundle for
such individual, the entity shall not retain an amount
greater than 70 percent of such savings and shall pay
an amount equivalent to--
``(i) not less than 10 percent of such
savings to such PAC providers;
``(ii) not less than 10 percent of such
savings to the PAC physician of the individual;
and
``(iii) in the case that there is no PAC
readmission of the individual, not less than 10
percent of such savings to the hospital
discharging the individual immediately prior to
the furnishing of such services.
Payments shall be made under each of clauses (i), (ii),
and (iii) to individuals and entities independent of
whether payment may be made to such an individual or
entity under another such clause.
``(E) Maintenance of advisory committee.--The
entity shall maintain an advisory committee of PAC
providers and of patient stakeholders to advise the
entity regarding its activities under this section.
``(4) Selection and change of selection of pac coordinators
by individual.--
``(A) In general.--The Secretary shall establish a
process for the selection and change of selection of a
PAC coordinator by an individual who is receiving
inpatient hospital services and whose discharge has
been or is likely to be classified as a qualifying
discharge.
``(B) Limitation on selection due to network
adequacy.--The process established under subparagraph
(A) may not allow an individual to select (or to change
a selection to) a PAC coordinator in a PAC area unless
the PAC coordinator has entered into PAC network
agreements with such PAC providers in such PAC area
such that the PAC coordinator has a sufficient number
and range of health care professionals and providers
willing to provide services under the terms of the PAC
agreement.
``(5) Construction relating to pac coordinators offering
non-pac services.--Nothing in this section shall be construed
as prohibiting PAC providers from offering, either directly or
indirectly, services that contribute to patient care, safety,
and readmission avoidance (such as medication management,
telehealth technologies, home environment services, and
transportation services) that are not PAC services.
``(6) Construction regarding flexibility in the delivery of
pac services.--Nothing in this section shall be construed to
prevent a PAC network agreement from permitting a PAC provider
to subcontract for the furnishing of PAC services that the PAC
provider is otherwise obligated to provide under the agreement
so long as the subcontractor meets the same terms and
conditions in furnishing such services as would apply if the
PAC provider were to provide such services.
``(d) Payment Amounts.--
``(1) Classification of conditions by crgs; methodology for
classification.--The Secretary shall establish a classification
of the conditions of individuals receiving a PAC bundle by CRG
and a methodology for classifying specific PAC bundles within
these groups. The methodology shall, to the extent feasible,
classify such bundles through the use of the PAC assessment
tool.
``(2) Computation of base rate.--
``(A) In general.--The Secretary shall compute an
average payment rate for PAC bundles classified in each
CRG and furnished during a PAC period ending in the
base year selected under subparagraph (B).
``(B) Base year selection.--The Secretary shall
select as a base year the most recent year ending
before the date of the enactment of this section for
which data are available to carry out this section.
``(C) Budget-neutral computation.--The average
payment rate for a PAC bundle classified in a CRG shall
be computed in a manner so that, if it had been applied
in the base year, the aggregate payments for PAC
bundles classified in such CRG and furnished during a
PAC period ending in such year would be equivalent to
the aggregate payments under this title for such
bundles.
``(3) Calculation of payment amount based on base rate.--
Subject to the succeeding provisions of this subsection, the
amount of the single payment described in this paragraph, with
respect to a PAC bundle classified within a CRG and furnished
to an individual during a PAC period ending--
``(A) in 2016, is the base average payment rate for
such bundle computed under paragraph (2), increased by
such percentage as the Secretary estimates is the
average rate of increase in payments under this title
for such bundle between the base year and 2016; and
``(B) in a subsequent year, is the amount of the
single payment for such bundle computed under this
paragraph for the previous year, increased by a
percentage specified by the Secretary consistent with
paragraph (4).
``(4) Calculation of annual percentage increase.--In
calculating the percentage increases applied under paragraph
(3)(B), the Secretary shall ensure that total expenditures for
all PAC bundles provided in accordance with this section do not
exceed 96 percent of the applicable baseline over the 8-fiscal-
year period beginning with fiscal year 2016.
``(5) Adjustment for readmissions during pac period.--The
amount paid to a PAC coordinator under this subsection for a
PAC bundle in a PAC period that includes a PAC readmission
shall be reduced by an amount equal to the aggregate amount of
payments made for such PAC readmission of such individual.
``(6) Adjustment for geographic and risk factors.--The
Secretary shall adjust the amount of payment described in
paragraph (3) with respect to services furnished to an
individual in a PAC area in a budget-neutral manner for a
year--
``(A) by an appropriate factor that reflects
variations in costs for the furnishing of PAC bundles
among different geographic areas;
``(B) by an appropriate factor that accounts for
variations in costs for the furnishing of such PAC
services to the individual based upon the health status
of the individual; and
``(C) by an amount that accounts for historical
local (hospital referral cluster) pricing.
``(7) Adjustment in case of change of selection by
individual.--In the case of a change of selection of PAC
coordinator by the individual under subsection (c)(4) during a
PAC period, the Secretary shall adjust the amount of payment
described in paragraph (3) in order to provide appropriate
partial payments to be paid to the PAC coordinator selected
initially by the individual and to the PAC coordinator selected
under the change of selection by the individual. The method of
calculating the respective amounts of such appropriate partial
payments shall be based on the method used for the Home Health
Partial Episode Payment adjustment.
``(8) Use of pac assessment tool for purposes of adjustment
for risk factors.--In determining an appropriate factor under
paragraph (6)(B) with respect to an individual, the Secretary
shall take into account an assessment of the individual
conducted using the PAC assessment tool.
``(e) Phase-In.--
``(1) Determination of pac expenditures by crg.--Based on
the most recent data available, the Secretary shall determine
the aggregate amount of expenditures under this title for PAC
services furnished during the PAC period for each CRG (as
defined in paragraph (b)(11)).
``(2) Ranking of crgs by volume of expenditure.--The
Secretary shall rank the CRGs in order based on the aggregate
amount of expenditures for PAC services described in clause (i)
for each CRG.
``(3) Grouping of crgs.--The Secretary shall group CRGs
into four groups as follows:
``(A) First group.--The first group consists of the
CRGs that have the highest rank under clause (ii) and
that collectively account for 25 percent of the
aggregate amount of expenditures for PAC services
described in clause (i).
``(B) Second group.--The second group consists of
the CRGs that have the next highest rank under clause
(ii) after the first group in subclause (I) and that
collectively account for 25 percent of the aggregate
amount of expenditures for PAC services described in
clause (i).
``(C) Third group.--The third group consists of the
CRGs that have the next highest rank under clause (ii)
after the second group in subclause (II) and that
collectively account for 25 percent of the aggregate
amount of expenditures for PAC services described in
clause (i).
``(D) Fourth group.--The fourth group consists of
the CRGs that are not included in the first, second, or
third group under this clause.
``(4) Phase-in by crg grouping.--In applying this section
for discharges in--
``(A) 2016, only discharges that are classified
within the first group under subclause (I) of clause
(iii) shall be included;
``(B) 2017, only discharges that are classified
within the first or second group under subclause (I) or
(II) of clause (iii) shall be included;
``(C) 2018, only discharges that are classified
within the first, second, or third group under
subclause (I), (II), or (III) of clause (iii) shall be
included; and
``(D) 2019 and subsequent years, discharges that
are classified within any group of CRGs shall be
included.''.
SEC. 4. TRANSITIONAL CARE MANAGEMENT PAYMENTS FOR PHYSICIANS.
For purposes of encouraging transitional care management by PAC
physicians (as defined in section 1866F(b)(5) of the Social Security
Act), in carrying out section 1848(e) of the Social Security Act (42
U.S.C. 1395w-4(e)), the Secretary of Health and Human Services shall
establish a new Transitional Care Management (TCM) code to pay for care
management by such a PAC physician or revise and expand the use of
existing TCM codes 99495 and 99494.
<all>
Introduced in House
Introduced in House
Referred to the Committee on Ways and Means, and in addition to the Committee on Energy and Commerce, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
Referred to the Committee on Ways and Means, and in addition to the Committee on Energy and Commerce, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
Referred to the Subcommittee on Health.
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