Reducing Unnecessary Senior Hospitalizations Act of 2021 or the RUSH Act of 2021
This bill establishes a program through which qualified group practices may provide certain items and services that are normally provided at hospital emergency departments to individuals who (1) are entitled to Medicare hospital services, (2) are enrolled for Medicare medical services, and (3) reside in qualified skilled nursing facilities.
[Congressional Bills 117th Congress]
[From the U.S. Government Publishing Office]
[H.R. 4890 Introduced in House (IH)]
<DOC>
117th CONGRESS
1st Session
H. R. 4890
To amend title XVIII of the Social Security Act to establish a program
to allow qualified group practices to furnish certain items and
services at qualified skilled nursing facilities to individuals
entitled to benefits under part A and enrolled under part B of the
Medicare program to reduce unnecessary hospitalizations, and for other
purposes.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
July 30, 2021
Ms. Kuster (for herself and Mr. Smith of Nebraska) 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 establish a program
to allow qualified group practices to furnish certain items and
services at qualified skilled nursing facilities to individuals
entitled to benefits under part A and enrolled under part B of the
Medicare program to reduce unnecessary hospitalizations, and for other
purposes.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Reducing Unnecessary Senior
Hospitalizations Act of 2021'' or the ``RUSH Act of 2021''.
SEC. 2. SNF-BASED PROVISION OF PREVENTIVE ACUTE CARE AND
HOSPITALIZATION REDUCTION PROGRAM.
Title XVIII of the Social Security Act is amended by adding at the
end the following new section:
``SEC. 1899C. SNF-BASED PROVISION OF PREVENTIVE ACUTE CARE AND
HOSPITALIZATION REDUCTION PROGRAM.
``(a) Establishment.--There is established a program to be known as
the `SNF-based Provision of Preventive Acute Care and Hospitalization
Reduction Program' (in this section referred to as the `Program'), to
be administered by the Secretary, for purposes of reducing unnecessary
hospitalizations and emergency department visits by allowing qualified
group practices (as defined in section 1877(h)(4)) on or after January
1, 2022, to furnish items and services identified under subsection
(b)(3) to individuals entitled to benefits under part A and enrolled
under part B residing in qualified skilled nursing facilities.
``(b) Operation of Program.--Under the Program, the Secretary shall
provide for the following:
``(1) Certification of skilled nursing facilities as
qualified skilled nursing facilities under subsection (c)(1).
``(2) Certification of group practices as qualified group
practices under subsection (c)(2).
``(3) Identification on an annual basis of minimum
required, clinically appropriate nonsurgical items and services
furnished at a hospital emergency department that may be safely
furnished by a qualified group practice at a qualified skilled
nursing facility under the Program and that such qualified
group practice shall offer to furnish under the Program. Such
items and services may include provider review of lab and
imaging reports for medical decision making, medication
management, blood glucose management, behavioral health
services, and other services offered to diagnose or treat low
acuity conditions.
``(4) Establishment of qualifications for nonphysician
employees who may furnish such items and services at a
qualified skilled nursing facility. Such qualifications shall
include the requirement that such an employee--
``(A) be certified in basic life support by a
nationally recognized specialty board of certification
or equivalent certification board, in accordance with
requirements under section 483.24(a)(3) of title 42,
Code of Federal Regulations (or any successor
regulation); and
``(B) have--
``(i) clinical experience furnishing
medical care--
``(I) in a skilled nursing
facility;
``(II) in a hospital emergency
department setting; or
``(III) as an employee of a
provider or supplier of ambulance
services; or
``(ii) a certification in paramedicine.
``(5) Payment under this title for items and services
identified under paragraph (3) furnished by such qualified
group practices at such a facility in amounts determined under
subsection (d).
``(c) Certifications.--
``(1) Qualified skilled nursing facilities.--
``(A) In general.--For purposes of this section,
the Secretary shall certify a skilled nursing facility
as a qualified skilled nursing facility if the facility
submits an application in a time and manner specified
by the Secretary and meets the following requirements:
``(i) The facility has on-site diagnostic
equipment necessary for a qualified group
practice to furnish items and services under
the Program and real-time audio and visual
capabilities as provided by the agreement
between the facility and the qualified group
practice.
``(ii) The facility has at least one
individual who meets the qualifications
described in subsection (b)(4) or a physician
present 24 hours a day and 7 days a week to
work with the qualified group practice, in
accordance with section 483.35(a) of title 42,
Code of Federal Regulations (or any successor
regulation). Such individual may be a member of
the staff of the qualified skilled nursing
facility or of the qualified group practice.
``(iii) The facility ensures that residents
of such facility, upon entering such facility,
are allowed to specify in an advanced care
directive or otherwise documented in the
individual's records whether the resident
wishes to receive items and services furnished
at the facility under the Program in a case
where communication with the resident is not
possible.
``(iv) The facility ensures that
individuals to be furnished such items and
services under the Program at such facility
have the opportunity, at their request, to
instead be transported to a hospital emergency
department.
``(v) The facility is not part of the
Special Focus Facility program of the Centers
for Medicare & Medicaid Services (although the
facility may, at the discretion of the
Secretary, be a candidate for selection under
such program).
``(B) Required provision of services and
activities.--Nothing in this paragraph shall affect the
application of requirements under section 1819(b)(4),
relating to provision of services and activities, to a
facility.
``(2) Qualified group practices.--For purposes of this
section, the Secretary shall certify a group practice as a
qualified group practice for a period of 3 years if the group
practice submits an application in a time and manner specified
by the Secretary and meets the following requirements:
``(A) The group practice offers to furnish all
minimum required items and services identified under
subsection (b)(3) under the Program.
``(B) The group practice submits a notification to
the Secretary annually specifying which (if any)
additional items and services identified under
subsection (b)(3) for a year the group practice will
offer to furnish for such year under the Program.
``(C) The group practice ensures that only
individuals who meet the qualifications established
under subsection (b)(4) or a physician who is part of
such group practice may furnish such minimum required
items and services and such additional items and
services.
``(D) The group practice, as provided by the
agreement between the facility and the group practice
or under the supervision of the medical director of the
facility, ensures that, in the case where such minimum
required items and services or such additional items
and services are furnished by such an individual, such
individual furnishes such minimum required items and
services or additional items and services under the
supervision, either in-person or through the use of
telehealth (not including store-and-forward
technologies), of--
``(i) a physician--
``(I) who is board certified or
board eligible in emergency medicine,
family medicine, geriatrics, or
internal medicine; or
``(II) who has been certified by a
nationally recognized specialty board
of certification or equivalent
certification board in basic life
support;
``(ii) a nurse practitioner who has been
certified by a nationally recognized specialty
board of certification or equivalent
certification board in basic life support; or
``(iii) a physician assistant who has been
certified by a nationally recognized specialty
board of certification or equivalent
certification board in basic life support.
``(E) With respect to any year in which the
qualified group practice would participate in the
Program, the Chief Actuary for the Centers for Medicare
& Medicaid Services determines that such participation
during such year will not result in total estimated
expenditures under this title for such year being
greater than total estimated expenditures under such
title for such year without such participation.
``(d) Payments and Treatment of Savings.--
``(1) Payments.--
``(A) In general.--For 2022 and each subsequent
year, payments shall continue to be made to qualified
group practices and qualified skilled nursing
facilities participating in the Program under the
original Medicare fee-for-service program under parts A
and B in the same manner as they would otherwise be
made except that such group practices and skilled
nursing facilities are eligible to receive payment for
shared savings under paragraph (2) if they meet the
requirement under subparagraph (B)(i).
``(B) Savings requirement and benchmark.--
``(i) Determining savings.--In each year of
the Program, a qualified group practice (and
any qualified skilled nursing facility
participating in the Program that has an
agreement with the group practice for the
furnishing of items and services identified
under subsection (b)(3) to residents of the
facility) shall be eligible to receive payment
for shared savings under paragraph (2) only if
the estimated average per capita Medicare
expenditures for Medicare fee-for-service
beneficiaries for parts A and B services
furnished under the Program by the group
practice (and any such facility), adjusted for
beneficiary characteristics, is at least the
percent specified by the Secretary below the
applicable benchmark under clause (ii). The
Secretary shall determine the appropriate
percent described in the preceding sentence to
account for normal variation in expenditures
under this title, based upon the number of
Medicare fee-for-service beneficiaries
participating in the Program.
``(ii) Establish and update benchmark.--For
each qualified group practice (and any
qualified skilled nursing facility
participating in the Program that has an
agreement with the group practice for the
furnishing of items and services identified
under subsection (b)(3) to residents of the
facility) the Secretary shall estimate a single
benchmark for each year that is applicable to
both the group practice (and any such facility)
using the most recent available 3 years of per-
beneficiary expenditures for parts A and B
services for Medicare fee-for-service
beneficiaries for items and services furnished
by such group practice or skilled nursing
facility under the Program. Such benchmark
shall be adjusted for beneficiary
characteristics and such other factors as the
Secretary determines appropriate. Such
benchmark shall be reset at the start of each
year.
``(2) Payments for shared savings.--If a qualified group
practice (and any qualified skilled nursing facility
participating in the Program that has an agreement with the
group practice for the furnishing of items and services
identified under subsection (b)(3) to residents of the
facility) meets the requirements under paragraph (1), the
Secretary shall--
``(A) pay to such qualified group practice an
amount equal to 37.5 percent of the difference between
such estimated average per capita Medicare expenditures
in a year, adjusted for beneficiary characteristics,
for items and services furnished under the Program by
the group practice (and any such facility) and such
benchmark for the qualified group practice (and any
such facility); and
``(B) in the case of each such facility--
``(i) if the qualified skilled nursing
facility has at least a three-star rating under
the Five Star Quality Rating System (or a
successor system), pay to the facility an
amount that bears the same ratio to 12.5
percent of the estimated amount of such
difference as the amount of expenditures under
the Program for such items and services
furnished with respect to individuals at such
facility by such qualified group practice
during such year bears to the total amount of
expenditures under the Program for such items
and services furnished with respect to all
individuals by such qualified group practice
during such year; and
``(ii) in the case of a qualified skilled
nursing facility that is not described in
clause (i), retain in the Federal Hospital
Insurance Trust Fund under section 1817 the
amount that the facility would have been paid
pursuant to clause (i) if the facility were
described in such clause until such time as the
facility has at least a three-star rating under
the Five Star Quality Rating System (or a
successor system), at which point the Secretary
shall pay such amount to the facility.
``(3) Advanced alternative payment models.--Paragraph (2)
shall not apply to items and services furnished to an
individual entitled to benefits under part A and enrolled under
Part B for whom shared savings would otherwise be attributed
through an advanced alternative payment model as authorized
under section 1115A or section 1899.
``(e) Evaluation.--
``(1) In general.--With respect to a qualified group
practice and a qualified skilled nursing facility, not later
than 6 months after such group practice begins furnishing items
and services under the Program (or, in the case of a qualified
skilled nursing facility, not less than 6 months after a
qualified group practice first furnishes such items and
services at such facility), and not less than once every 2
years thereafter, the Secretary shall evaluate such qualified
group practice and such qualified facility using information
received under paragraph (2) on such criteria as determined
appropriate by the Secretary.
``(2) Reporting of performance and quality improvements.--
In a time and manner specified by the Secretary, a qualified
group practice and a qualified skilled nursing facility shall
submit to the Secretary a report containing the following
information with respect to items and services furnished under
the Program during a reporting period (as specified by the
Secretary):
``(A) The items and services most frequently
furnished under the Program in such period.
``(B) The number of individuals with respect to
whom such group practice furnished such items and
services in such period (or, in the case of a qualified
skilled nursing facility, the number of individuals
with respect to whom such a group practice furnished
such items and services at such facility in such
period).
``(C) The number of hospitalizations prevented
under the Program in such period.
``(D) The number of such individuals who were
admitted to a hospital or treated in the emergency
department of a hospital within 24 hours of being
furnished such items and services.
``(E) Other information determined appropriate by
the Secretary.
``(3) Loss of qualified certification.--
``(A) In general.--Not later than 3 months after a
determination described in this sentence is made, the
Secretary may revoke the certification of a qualified
skilled nursing facility or a qualified group practice
made under subsection (c) if--
``(i) the Chief Actuary of the Centers for
Medicare & Medicaid Services determines that
the participation of such skilled nursing
facility or such group practice in the Program
during a year resulted in total expenditures
under this title for such period being greater
than total expenditures under such title would
have been during such period without such
participation; or
``(ii) a facility is selected for the
Special Focus Facility program or, if the
facility is a candidate for the Special Focus
Facility program, the Secretary determines that
the participation of such facility in the
Program should be terminated.
``(B) Exclusion from certification.--
``(i) In general.--In the case that the
Secretary revokes the certification of a
qualified skilled nursing facility or a
qualified group practice under subparagraph
(A), such skilled nursing facility or such
group practice shall be ineligible for
certification as a qualified skilled nursing
facility or a qualified group practice (as
applicable) under subsection (c) for the
applicable period (as defined under clause
(ii)).
``(ii) Applicable period defined.--In this
subparagraph, the term `applicable period'
means--
``(I) if the revocation of a
facility or group practice under
subparagraph (A) is due to the
application of clause (i) of such
subparagraph, a 1-year period beginning
on the date of such revocation; and
``(II) in the revocation of a
facility under subparagraph (A) is due
to the application of clause (ii) of
such subparagraph, the period beginning
on the date of such revocation and
ending on the date on which the
facility graduates from the Special
Focus Facility program (or, in the case
of a facility that is a candidate for
such program, the date on which the
facility is no longer such a candidate,
as determined by the Secretary).
``(f) Determination of Budget Neutrality; Termination of Program.--
``(1) Determination.--Not later than July 1, 2027, the
Chief Actuary of the Centers for Medicare & Medicaid Services
shall determine whether the Program has resulted in an increase
in total expenditures under this title with respect to the
period beginning on January 1, 2022, and ending on December 31,
2026, compared to what such expenditures would have been during
such period had the Program not been in operation.
``(2) Termination.--If the Chief Actuary makes a
determination under paragraph (1) that the Program has resulted
in an increase in total expenditures under this title, the
Secretary shall terminate the Program as of January 1 of the
first year beginning after such determination.''.
<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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